The outcomes in STEMI patients with high thrombus burden treated by deferred versus immediate stent implantation in primary percutaneous coronary intervention: a prospective cohort study

Luo, Dong Hua; Hu, Xiangming; Sun, Shuo; Wang, Chenyang; Yang, Xing; Ye, Jingguang; Guo, Xiaosheng; Xu, Shenghui; Sun, Boyu; Dong, Haojian; Zhou, Yingling

doi:10.21037/atm-21-1130

Cited by 8 publications

(11 citation statements)

References 28 publications

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“…What's more, a substantial number of patients had slow or no-reflow before stenting in this study. In our follow-up study ( 29 ), we found that the no-/slow-reflow event guided by thrombolysis in myocardial infarction (TIMI) flow grade occurred in 38 (15.5%) of the 245 STEMI patients. It was quite a high rate, so the influence of slow reflow cannot be ignored.…”

Section: Discussionmentioning

confidence: 94%

“…Firstly, this study reflected the experience with a limited number of patients. Since IVUS is not routinely used in pPCI of STEMI in clinical work, the sample sizes of previous studies that focused on IVUS, vascular physiology, and STEMI are generally small ( n = 117, Geng; n = 51, Luo, D) ( 27 , 29 ). To increase the sample size, minimize the bias, and improve reliability, this study was designed as a multicenter clinical trial.…”

Section: Discussionmentioning

confidence: 99%

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Microvascular and Prognostic Effect in Lesions With Different Stent Expansion During Primary PCI for STEMI: Insights From Coronary Physiology and Intravascular Ultrasound

Sun

Luo

et al. 2022

Front. Cardiovasc. Med.

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BackgroundWhile coronary stent implantation in ST-elevation myocardial infarction (STEMI) can mechanically revascularize culprit epicardial vessels, it might also cause distal embolization. The relationship between geometrical and functional results of stent expansion during the primary percutaneous coronary intervention (pPCI) is unclear.ObjectiveWe sought to determine the optimal stent expansion strategy in pPCI using novel angiography-based approaches including angiography-derived quantitative flow ratio (QFR)/microcirculatory resistance (MR) and intravascular ultrasound (IVUS).MethodsPost-hoc analysis was performed in patients with acute STEMI and high thrombus burden from our prior multicenter, prospective cohort study (ChiCTR1800019923). Patients aged 18 years or older with STEMI were eligible. IVUS imaging, QFR, and MR were performed during pPCI, while stent expansion was quantified on IVUS images. The patients were divided into three subgroups depending on the degree of stent expansion as follows: overexpansion (>100%), optimal expansion (80%−100%), and underexpansion (<80%). The patients were followed up for 12 months after PCI. The primary endpoint included sudden cardiac death, myocardial infarction, stroke, unexpected hospitalization or unplanned revascularization, and all-cause death.ResultsA total of 87 patients were enrolled. The average stent expansion degree was 82% (in all patients), 117% (in overexpansion group), 88% (in optimal expansion), and 75% (in under-expansion). QFR, MR, and flow speed increased in all groups after stenting. The overall stent expansion did not affect the final QFR (p = 0.08) or MR (p = 0.09), but it reduced the final flow speed (−0.14 cm/s per 1%, p = 0.02). Under- and overexpansion did not affect final QFR (p = 0.17), MR (p = 0.16), and flow speed (p = 0.10). Multivariable Cox analysis showed that stent expansion was not the risk factor for MACE (hazard ratio, HR = 0.97, p = 0.13); however, stent expansion reduced the risk of MACE (HR = 0.95, p = 0.03) after excluding overexpansion patients. Overexpansion was an independent risk factor for no-reflow (HR = 1.27, p = 0.02) and MACE (HR = 1.45, p = 0.007). Subgroup analysis shows that mild underexpansion of 70%−80% was not a risk factor for MACE (HR = 1.11, p = 0.08) and no-reflow (HR = 1.4, p = 0.08); however, stent expansion <70% increased the risk of MACE (HR = 1.36, p = 0.04).ConclusionsStent expansion does not affect final QFR and MR, but it reduces flow speed in STEMI. Appropriate stent underexpansion of 70–80% does not seem to be associated with short-term prognosis, so it may be tolerable as noninferior compared with optimal expansion. Meanwhile, overexpansion and underexpansion of <70% should be avoided due to the independent risk of MACEs and no-reflow events.

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Section: Discussionmentioning

confidence: 94%

Section: Discussionmentioning

confidence: 99%

Microvascular and Prognostic Effect in Lesions With Different Stent Expansion During Primary PCI for STEMI: Insights From Coronary Physiology and Intravascular Ultrasound

Sun

Luo

et al. 2022

Front. Cardiovasc. Med.

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“…The study was a multicentre prospective cohort study, and the design of this study was previously described ( 19 ). The study was registered at the Chinese Clinical Trial Registry (registration number: ChiCTR1800019923).…”

Section: Methodsmentioning

confidence: 99%

Association between the insufficient improvement of the quantitative flow ratio and worsening outcomes in ST-segment elevated myocardial infarction: a multicentre prospective cohort study

Guo,

Chen,

et al. 2024

Quant Imaging Med Surg

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Background Improved coronary physiological function after percutaneous coronary intervention (PCI) has been shown to improve prognosis in stable ischaemic heart disease, but has not yet been explored in ST-segment elevated myocardial infarction (STEMI). The study sought to determine whether an improvement in the quantitative flow ratio (QFR) could improve the prognosis of STEMI patients undergoing primary PCI. Methods Patients diagnosed with STEMI who were receiving primary PCI were recruited for the study. Those with thrombolysis in myocardial infarction (TIMI) flow <2 after wiring were excluded. The ΔQFR was calculated using the following formula: ΔQFR = post-PCI QFR – pre-stent QFR. The primary endpoint was the composite event, including recurrent myocardial infarction (MI) and acute heart failure (AHF). Results In total, 515 STEMI patients with a median follow-up of 364 days were enrolled in the study. Based on the cut-off value from the receiver operator characteristic (ROC) curve, the patients were divided into the following two groups: the lower ΔQFR group (≤0.25, N=332); and the normal ΔQFR group (>0.25, N=183). Patients with a lower ΔQFR had a relatively higher rate of MI/AHF (10.5% vs. 4.4%, P=0.019) and AHF (7.2% vs. 2.7%, P=0.044). A lower ΔQFR was significantly associated with a higher incidence of MI/AHF [hazard ratio (HR) =2.962, 95% confidence interval (CI): 1.358–6.459, P=0.006, respectively] after adjusting for potential confounders. Pre-stent angiographic microvascular resistance [odds ratio (OR) =1.027, 95% CI: 1.022–1.033, P<0.001] and the stent-to-vessel diameter ratio <1.13 (OR =1.766, 95% CI: 1.027–3.071, P=0.04) were independent predictors of a lower ΔQFR. Conclusions An insufficient improvement in the QFR contributes to worsening outcomes and might be a useful tool for risk stratification in STEMI.

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“…Основные характеристики 17 исследований приведены в таблице [8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25]. Изучаемые исследования различались по общему количеству пациентов.…”

Section: характеристика исследований и оценка общего риска смещенияunclassified

The role of deferred stenting in the treatment of ST-elevation myocardial infarction: a systematic review and meta-analysis

Азаров

Глезер

Журавлев

et al. 2022

Almanac of Clinical Medicine

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Background: There have been a big number of studies assessing the efficacy of delayed coronary artery stenting (DCAS) in the prevention of no-reflow microvasculature injury compared to the standard immediate coronary artery stenting (ICAS) in ST-segment elevation myocardial infarction (STEMI). However, the results of these studies are contradictory in a lot of ways. Aim: To summarize studies on the assessment of DCAS in the prevention of no-reflow compared to the standard ICAS. Materials and methods: We performed a systematic literature search in PubMed, Google Scholar, and eLIBRARY.RU databases. The analysis included 17 studies with a total sample of 3505 patients. The comparative analysis included angiography-based endpoints prevalence of no-reflow (thrombolysis in myocardial infarction, TIMI 3 and myocardial blush grade, MBG 2, corrected TIMI frame count, CTFC) and clinical endpoints of all-cause mortality, cardiovascular mortality, major adverse cardiac events (MACE), recurrent myocardial infarction and recurrent revascularization. In addition, the analysis included the assessment of ST-elevation resolution, left ventricular ejection fraction values in the delayed post-intervention period and between-group differences. Results: The no-reflow phenomenon was significantly less frequent in the DCAS groups for the following parameters: epicardial flow TIMI 3 (odds ratio (OR) 2.00; 95% confidence interval (CI) 1.492.69; p 0.00001; I = 16%), myocardial perfusion MBG 2 (OR 4.69; 95% CI 1.9811.14; p = 0.0005; I = 59%), CTFC (mean difference (MD) 10.29; 95% CI 0.9619.62; p = 0.03; I = 96%). The analysis of secondary endpoints showed that MACE were less frequent in the DCAS groups (OR 1.29; 95% CI 1.041.60; p = 0.02; I = 42%), the difference becoming more significant in the studies with high initial thrombotic burden (TTG 3) (OR 1.83; 95% CI 1.282.62; p = 0.0009; I = 41%). The most clinically significant decrease of the MACE rate was found in 5 studies (n = 656) with high initial thrombotic burden (TTG 3) and mean time to repeated intervention from 4 to 7 days (OR 3.15; 95% CI 1.865.32; p 0.0001; I = 0%). The reverse trend for a benefit in the ICAS group was observed in the studies with a high initial thrombotic burden (TTG 3) and mean time to recurrent intervention of 48 hours (OR 0.60; 95% CI 0.301.19; p = 0.14; I = 20%). The ICAS and DCAS groups did not differ in overall mortality (p = 0.31), cardiovascular mortality (p = 0.49), repeated revascularization (p = 0.66), and ST resolution of 70% (p = 0.65). In the DCAS groups, there was an obvious trend to lower incidence of recurrent myocardial infarction (OR 1.28; 95% CI 0.951.73; p = 0.10; I = 0%), as well as to higher myocardial mass during the deferred analysis of left ventricular ejection fraction (OR -0.79; 95% CI -1.61 -0.04; p = 0.06; I = 36%). Conclusion: Deferred coronary artery stenting is an effective method for prevention of no-reflow. In patients with extended coronary thrombosis (TTG 3) and STEMI, the DCAS technique with time to recurrent intervention of 4 to 7 days decreases the probability of MACE compared to that with immediate stenting of the index coronary artery.

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The outcomes in STEMI patients with high thrombus burden treated by deferred versus immediate stent implantation in primary percutaneous coronary intervention: a prospective cohort study

Cited by 8 publications

References 28 publications

Microvascular and Prognostic Effect in Lesions With Different Stent Expansion During Primary PCI for STEMI: Insights From Coronary Physiology and Intravascular Ultrasound

Microvascular and Prognostic Effect in Lesions With Different Stent Expansion During Primary PCI for STEMI: Insights From Coronary Physiology and Intravascular Ultrasound

Association between the insufficient improvement of the quantitative flow ratio and worsening outcomes in ST-segment elevated myocardial infarction: a multicentre prospective cohort study

The role of deferred stenting in the treatment of ST-elevation myocardial infarction: a systematic review and meta-analysis

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