BACKGROUND: Sex- and gender-associated differences determine the disease response to treatment. AIM: The study aimed to explore the hypothesis that progress in the management of STE-myocardial infarction (STEMI) overcomes the worse outcome in women. METHODS AND RESULTS: We performed an analysis of three randomized trials enrolling patients treated with primary PCI more than 10 years apart. PRAGUE-1,-2 validated the preference of transport for primary PCI over on-site fibrinolysis. PRAGUE-18 enrollment was ongoing at the time of the functional network of 24/7PCI centers, and the intervention was supported by intensive antiplatelets. The proportion of patients with an initial Killip ≥ 3 was substantially higher in the more recent study (0.6 vs. 6.7%, p = 0.004). Median time from symptom onset to the door of the PCI center shortened from 3.8 to 3.0 h, p < 0.001. The proportion of women having total ischemic time ≤3 h was higher in the PRAGUE-18 (OR [95% C.I.] 2.65 [2.03-3.47]). However, the percentage of patients with time-to-reperfusion >6 h was still significant (22.3 vs. 27.2% in PRAGUE-18). There was an increase in probability for an initial TIMI flow >0 in the later study (1.49 [1.0-2.23]), and also for an optimal procedural result (4.24 [2.12-8.49], p < 0.001). The risk of 30-day mortality decreased by 61% (0.39 [0.17-0.91], p = 0.029). CONCLUSION: The prognosis of women with MI treated with primary PCI improved substantially with 24/7 regional availability of mechanical reperfusion, performance-enhancing technical progress, and intensive adjuvant antithrombotic therapy. A major modifiable hindrance to achieving this benefit in a broad population of women is the timely diagnosis by health professional services.

• Keywords
• mortality, myocardial infarction, outcome, primary PCI, therapy management, trends, women,
• Publication type
• Journal Article MeSH

Defining the risk factors affecting the prognosis of patients with acute coronary syndrome (ACS) has been a challenge. Many individual biomarkers and risk scores that predict outcomes during different periods following ACS have been proposed. This review evaluates known outcome predictors supported by clinical data in light of the development of new treatment strategies for ACS patients during the last three decades.

• Keywords
• acute coronary syndrome, percutaneous coronary intervention, prognosis, risk score, risk stratification,
• Publication type
• Journal Article MeSH
• Review MeSH

The evolution of reperfusion therapy in acute myocardial infarction and acute ischaemic stroke has many similarities: thrombolysis is superior to placebo, intra-arterial thrombolysis is not superior to intravenous (i.v.), facilitated intervention is of questionable value, and direct mechanical recanalization without thrombolysis is proven (myocardial infarction) or promising (stroke) to be superior to thrombolysis-but only when started with no or minimal delay. However, there are also substantial differences. Direct catheter-based thrombectomy in acute ischaemic stroke is more difficult than primary angioplasty (in ST-elevation myocardial infarction [STEMI]) in many ways: complex pre-intervention diagnostic workup, shorter time window for clinically effective reperfusion, need for an emergent multidisciplinary approach from the first medical contact, vessel tortuosity, vessel fragility, no evidence available about dosage and combination of peri-procedural antithrombotic drugs, risk of intracranial bleeding, unclear respective roles of thrombolysis and mechanical intervention, lower number of suitable patients, and thus longer learning curves of the staff. Thus, starting acute stroke interventional programme requires a lot of learning, discipline, and humility. Randomized trials comparing different reperfusion strategies provided similar results in acute ischaemic stroke as in STEMI. Thus, it might be expected that also a future randomized trial comparing direct (primary) catheter-based thrombectomy vs. i.v. thrombolysis could show superiority of the mechanical intervention if it would be initiated without delay. Such randomized trial is needed to define the role of mechanical intervention alone in acute stroke treatment.

• Keywords
• Acute stroke, Catheter intervention, Myocardial infarction, Primary angioplasty, Reperfusion, Thrombectomy, Thrombolysis,
• MeSH
• Acute Disease MeSH
• Stroke therapy   MeSH
• Fibrinolytic Agents therapeutic use   MeSH
• Myocardial Infarction therapy   MeSH
• Infusions, Intravenous MeSH
• Clinical Trials as Topic MeSH
• Combined Modality Therapy MeSH
• Percutaneous Coronary Intervention methods   MeSH
• Humans MeSH
• Reperfusion methods   MeSH
• Thrombectomy methods   MeSH
• Thrombolytic Therapy methods   MeSH
• Check Tag
• Humans MeSH
• Publication type
• Journal Article MeSH
• Research Support, Non-U.S. Gov't MeSH
• Review MeSH
• Names of Substances
• Fibrinolytic Agents MeSH

BACKGROUND: Traditionally, acute myocardial infarction (AMI) has been described as either STEMI (ST-elevation myocardial infarction) or non-STEMI myocardial infarction. This classification is historically related to the use of thrombolytic therapy, which is effective in STEMI. The current era of widespread use of coronary angiography (CAG), usually followed by primary percutaneous coronary intervention (PCI) puts this classification system into question. OBJECTIVES: To compare the outcomes of patients with STEMI and ST-depression myocardial infarction (STDMI) who were treated with emergency PCI. METHODS: This multicentre registry enrolled a total of 6 602 consecutive patients with AMI. Patients were divided into the following subgroups: STEMI (n = 3446), STDMI (n = 907), left bundle branch block (LBBB) AMI (n = 241), right bundle branch block (RBBB) AMI (n = 338) and other electrocardiographic (ECG) AMI (n = 1670). Baseline and angiographic characteristics were studied, and revascularisation therapies and in-hospital mortality were analysed. RESULTS: Acute heart failure was present in 29.5% of the STDMI vs 27.4% of the STEMI patients (p < 0.001). STDMI patients had more extensive coronary atherosclerosis than patients with STEMI (three-vessel disease: 53.1 vs 30%, p < 0.001). The left main coronary artery was an infract-related artery (IRA) in 6.0% of STDMI vs 1.1% of STEMI patients (p < 0.001). TIMI flow 0-1 was found in 35.0% of STDMI vs 66.0% of STEMI patients (p < 0.001). Primary PCI was performed in 88.1% of STEMI (with a success rate of 90.8%) vs 61.8% of STDMI patients (with a success rate of 94.5%) (p = 0.012 for PCI success rates). In-hospital mortality was not significantly different (STDMI 6.3 vs STEMI 5.4%, p = 0.330). CONCLUSION: These data suggest that similar strategies (emergency CAG with PCI whenever feasible) should be applied to both these types of AMI.

• MeSH
• Survival Analysis MeSH
• Electrocardiography MeSH
• Myocardial Infarction mortality   physiopathology   surgery   MeSH
• Percutaneous Coronary Intervention * MeSH
• Coronary Vessels surgery   MeSH
• Middle Aged MeSH
• Humans MeSH
• Follow-Up Studies MeSH
• Registries MeSH
• Aged, 80 and over MeSH
• Aged MeSH
• Emergency Medical Services MeSH
• Treatment Outcome MeSH
• Check Tag
• Middle Aged MeSH
• Humans MeSH
• Male MeSH
• Aged, 80 and over MeSH
• Aged MeSH
• Female MeSH
• Publication type
• Journal Article MeSH
• Multicenter Study MeSH
• Research Support, Non-U.S. Gov't MeSH
• Comparative Study MeSH

AIMS: Patient access to reperfusion therapy and the use of primary percutaneous coronary intervention (p-PCI) or thrombolysis (TL) varies considerably between European countries. The aim of this study was to obtain a realistic contemporary picture of how patients with ST elevation myocardial infarction (STEMI) are treated in different European countries. METHODS AND RESULTS: The chairpersons of the national working groups/societies of interventional cardiology in European countries and selected experts known to be involved in the national registries joined the writing group upon invitation. Data were collected about the country and any existing national STEMI or PCI registries, about STEMI epidemiology, and treatment in each given country and about PCI and p-PCI centres and procedures in each country. Results from the national and/or regional registries in 30 countries were included in this analysis. The annual incidence of hospital admission for any acute myocardial infarction (AMI) varied between 90-312/100 thousand/year, the incidence of STEMI alone ranging from 44 to 142. Primary PCI was the dominant reperfusion strategy in 16 countries and TL in 8 countries. The use of a p-PCI strategy varied between 5 and 92% (of all STEMI patients) and the use of TL between 0 and 55%. Any reperfusion treatment (p-PCI or TL) was used in 37-93% of STEMI patients. Significantly less reperfusion therapy was used in those countries where TL was the dominant strategy. The number of p-PCI procedures per million per year varied among countries between 20 and 970. The mean population served by a single p-PCI centre varied between 0.3 and 7.4 million inhabitants. In those countries offering p-PCI services to the majority of their STEMI patients, this population varied between 0.3 and 1.1 million per centre. In-hospital mortality of all consecutive STEMI patients varied between 4.2 and 13.5%, for patients treated by TL between 3.5 and 14% and for patients treated by p-PCI between 2.7 and 8%. The time reported from symptom onset to the first medical contact (FMC) varied between 60 and 210 min, FMC-needle time for TL between 30 and 110 min, and FMC-balloon time for p-PCI between 60 and 177 min. CONCLUSION: Most North, West, and Central European countries used p-PCI for the majority of their STEMI patients. The lack of organized p-PCI networks was associated with fewer patients overall receiving some form of reperfusion therapy.

• MeSH
• Angioplasty, Balloon, Coronary statistics & numerical data   MeSH
• Time Factors MeSH
• Residence Characteristics MeSH
• Health Services Accessibility MeSH
• Hospitalization statistics & numerical data   MeSH
• Incidence MeSH
• Myocardial Infarction epidemiology   therapy   MeSH
• Humans MeSH
• Hospital Mortality MeSH
• Needs Assessment MeSH
• Myocardial Reperfusion methods   statistics & numerical data   MeSH
• Check Tag
• Humans MeSH
• Publication type
• Journal Article MeSH
• Research Support, Non-U.S. Gov't MeSH
• Geographicals
• Europe epidemiology   MeSH

BACKGROUND: Acute ST-elevation myocardial infarction in patients with normal coronary arteries has previously been described, but coronary angiography in these patients was performed after the acute phase of the infarction. It is possible that these patients did not have normal angiograms during the acute phase (transient coronary thrombosis or spasm were usually suspected to be the cause). Information on the prevalence of truly normal coronary angiograms during the acute phase of a suspected ST-elevation myocardial infarction is lacking. PATIENTS AND METHODS: The Primary Angioplasty in patients transferred from General community hospitals to specialized PTCA Units with or without Emergency thrombolysis-1 (PRAGUE-1) and PRAGUE-2 studies enrolled 1150 patients with ST-elevation acute myocardial infarction, in whom 625 coronary angiograms were performed within 2 h of the initial electrocardiogram. A simultaneous registry included an additional 379 coronary angiograms performed during the ST-elevation phase of a suspected myocardial infarction. Thus, a total of 1004 angiograms were retrospectively analyzed. A normal coronary angiogram was defined as one with the absence of any visible angiographic signs of atherosclerosis, thrombosis or spontaneous spasm. RESULTS: Normal coronary angiograms were obtained for 26 patients (2.6%). Among these, the diagnosis at discharge was a small myocardial infarction in seven patients (0.7%), acute (peri)myocarditis in five patients, dilated cardiomyopathy in four patients, hypertension with left ventricular hypertrophy in three patients, pulmonary embolism in two patients and misinterpretation of the electrocardiogram (ie, no cardiac disease) in five patients. Seven patients with small infarctions underwent angiography within 30 min to 90 min of complete relief of the signs of acute ischemia, and thus, angiograms during pain were not taken. None of the 898 patients catheterized during ongoing symptoms of ischemia had a normal coronary angiogram. Spontaneous coronary spasm as the only cause (without underlying coronary atherosclerosis) for the evolving infarction was not seen among these 898 patients. Thus, the causes of the seven small infarcts in patients with normal angiograms remain uncertain. CONCLUSIONS: The observed prevalence of normal coronary angiography in patients presenting with acute chest pain and ST elevations was 2.6%. Most of these cases were misdiagnoses, not infarctions. A normal angiogram during a biochemically confirmed infarction is extremely rare (0.7%) and was not seen during the ongoing symptoms of ischemia.

HISTORIQUE: On a déjà décrit des infarctus du myocarde avec surélévation du segment ST chez des patients aux artères coronaires saines, mais la coronarographie avait été effectuée après la phase aiguë de l’infarctus. Estil possible que la coronarographie n’ait pas été normale pendant la phase aiguë (on présumait généralement une thrombose coronaire transitoire ou des spasmes). On ne possède pas d’information sur la prévalence d’une coronarographie vraiment normale pendant la phase aiguë d’une présomption d'infarctus du myocarde avec surélévation du segment ST. PATIENTS ET MÉTHODOLOGIE: Dans le cadre des études PRAGUE-1 et PRAGUE-2 sur l’angioplastie primaire de patients transférés d’un hôpital général à une unité spécialisée de coronaropathie percutanée transluminale, on a enrôlé 1 150 patients ayant un infarctus aigu du myocarde avec surélévation du segment ST, chez qui 625 coronarographies ont été effectuées dans les deux heures suivant le premier électrocardiogramme. Un registre simultané contenait 379 autres coronarographies exécutées pendant la phase de surélévation du segment ST d’une présomption d’infarctus du myocarde. Ainsi, au total, 1 004 coronarographies ont fait l’objet d’une analyse rétrospective. Une coronarographie normale était définie comme un examen ne comportant aucun signe angiographique visible d’artériosclérose, de thrombose ou de spasme spontané. RÉSULTATS: On a obtenu des coronarographies normales auprès de 26 patients (2,6 %). De ce nombre, à leur congé, sept patients avaient un diagnostic de petit infarctus du myocarde (0,7 %) au congé, cinq patients, une (péri)myocardite, quatre patients, une myocardiopathie dilatée, trois patients, une hypertension accompagnée d’une hypertrophie ventriculaire gauche, deux patients, une embolie pulmonaire et cinq patients, une mauvaise interprétation de l’électrocardiogramme (c'est-à-dire, pas de maladie cardiaque). Les sept patients ayant un petit infarctus ont subi une angiographie de 30 à 90 minutes après le soulagement complet des signes d’ischémie aiguë, et non pendant la douleur. Aucun des 898 patients ayant subi un cathétérisme pendant des symptômes d’ischémie ne présentait de coronarographie normale. Chez ces 898 patients, on n’a observé aucun cas de spasme coronaire spontané (sans artériosclérose coronarienne sous-jacente) expliquant l’infarctus en évolution. Ainsi, les causes des petits infarctus chez les sept patients ayant une angiographie normale ne sont pas claires. CONCLUSIONS: On a observé une prévalence de 2,6 % de coronarographies normales chez les patients ayant des douleurs thoraciques aiguës et une surélévation du segment ST. La plupart de ces cas étaient des mauvais diagnostics et non des infarctus. Il est extrêmement rare de constater une coronarographie normale pendant un infarctus confirmé biologiquement (0,7 %), et on n’en a pas observé pendant les symptômes continus d’ischémie.

• MeSH
• Angioplasty, Balloon, Coronary MeSH
• Biomarkers blood   MeSH
• Adult MeSH
• Echocardiography MeSH
• Electrocardiography MeSH
• Ventricular Function, Left MeSH
• Myocardial Infarction diagnosis   diagnostic imaging   physiopathology   therapy   MeSH
• Coronary Angiography * MeSH
• Creatine Kinase, MB Form blood   MeSH
• Middle Aged MeSH
• Humans MeSH
• Prevalence MeSH
• Heart Conduction System diagnostic imaging   pathology   physiopathology   MeSH
• Retrospective Studies MeSH
• Aged, 80 and over MeSH
• Aged MeSH
• Stroke Volume MeSH
• Troponin blood   MeSH
• Treatment Outcome MeSH
• Check Tag
• Adult MeSH
• Middle Aged MeSH
• Humans MeSH
• Male MeSH
• Aged, 80 and over MeSH
• Aged MeSH
• Female MeSH
• Publication type
• Journal Article MeSH
• Research Support, Non-U.S. Gov't MeSH
• Geographicals
• Czech Republic MeSH
• Names of Substances
• Biomarkers MeSH
• Creatine Kinase, MB Form MeSH
• Troponin MeSH

• Publication type
• Journal Article MeSH