The development of pathological Q waves has long been correlated with worsened outcome in patients with ST elevation myocardial infarction (STEMI). In this study, we investigated long-term mortality of STEMI patients treated by primary percutaneous coronary intervention (PPCI) and compared predictive values of Q waves and of Selvester score for infarct volume estimation. Data of 283 consecutive STEMI patients (103 females) treated by PPCI were analysed. The presence of pathological Q wave was evaluated in pre-discharge electrocardiograms (ECGs) recorded ≥72 h after the chest pain onset (72 h Q). The Selvester score was evaluated in acute ECGs (acute Selvester score) and in the pre-discharge ECGs (72 h Selvester score). The results were related to total mortality and to clinical and laboratory variables. A 72 h Q presence and 72 h Selvester score ≥6 was observed in 184 (65.02%) and 143 (50.53%) patients, respectively. During a follow-up of 5.69 ± 0.66 years, 36 (12.7%) patients died. Multivariably, 72 h Selvester score ≥6 was a strong independent predictor of death, while a predictive value of the 72 h Q wave was absent. In high-risk subpopulations defined by clinical and laboratory variables, the differences in total mortality were highly significant (p < 0.01 for all subgroups) when stratified by 72 h Selvester score ≥6. On the contrary, the additional risk-prediction by 72 h Q presence was either absent or only borderline. In contemporarily treated STEMI patients, Selvester score is a strong independent predictor of long-term all-cause mortality. On the contrary, the prognostic value of Q-wave presence appears limited in contemporarily treated STEMI patients.

• Klíčová slova
• Q wave, ST elevation myocardial infarction, Selvester score, primary percutaneous coronary intervention,
• Publikační typ
• časopisecké články MeSH

OBJECTIVE: The introduction of primary percutaneous coronary intervention (PPCI) has modified the profile of ST elevation myocardial infarction (STEMI) patients. Occurrence and prognostic significance of hypotension episodes are not known in PPCI treated STEMI patients. It is also not known whether and/or how the hypotension episodes correlate with the degree of myocardial damage and whether there are any sex differences. METHODS: Data of 293 consecutive STEMI patients (189 males) treated by PPCI and without cardiogenic shock were analyzed. Blood pressure was measured noninvasively. A hypotensive episode was defined as a systolic blood pressure below 90 mmHg over a period of at least 30 minutes. RESULTS: A hypotensive episode was observed in 92 patients (31.4%). Female sex was the strongest independent predictor of hypotension episodes (p < 0.0001), while there was no relationship to electrocardiographic STEMI localization. Hypotensive patients had significantly higher levels of troponin T and brain natriuretic peptide; hypotensive episodes were particularly frequent in women with increased troponin T. Treatment with angiotensin-converting enzyme inhibitor (ACEI), angiotensin receptor blocker (ARB) and betablockers was less frequent in hypotensive patients. After a mean 20-month follow-up, all-cause mortality did not differ between hypotensive patients and others. However, mortality in hypotensive patients who did not tolerate ACEI/ARB therapy was significantly higher compared to other hypotensive patients (p = 0.016). CONCLUSION: Hypotension episodes are not uncommon in the sub-acute phase of contemporarily treated STEMI patients with a striking difference between sexes-female sex was the strongest independent predictor of hypotension episodes. Hypotensive episodes may lead to a delay in pharmacotherapy which influences prognosis. Higher incidence of hypotension in women could at least partially explain the sex-related differences in the use of cardiovascular pharmacotherapy which was repeatedly observed in various studies.

• MeSH
• dospělí MeSH
• hypotenze epidemiologie   etiologie   MeSH
• infarkt myokardu s elevacemi ST úseků patofyziologie   MeSH
• kardiogenní šok patofyziologie   MeSH
• koronární angioplastika škodlivé účinky   MeSH
• lidé středního věku MeSH
• lidé MeSH
• prognóza MeSH
• rizikové faktory MeSH
• senioři nad 80 let MeSH
• senioři MeSH
• Check Tag
• dospělí MeSH
• lidé středního věku MeSH
• lidé MeSH
• mužské pohlaví MeSH
• senioři nad 80 let MeSH
• senioři MeSH
• ženské pohlaví MeSH
• Publikační typ
• časopisecké články MeSH

AIMS: Thrombectomy during primary percutaneous coronary intervention (PPCI) for ST elevation myocardial infarction (STEMI) has been thought to be an effective therapy to prevent distal embolization and improve microvascular perfusion. The TOTAL trial (N = 10 732), a randomized trial of routine manual thrombectomy vs. PCI alone in STEMI, showed no difference in the primary efficacy outcome. This angiographic sub-study was performed to determine if thrombectomy improved microvascular perfusion as measured by myocardial blush grade (MBG). METHODS AND RESULTS: Of the 10 732 patients randomized, 1610 randomly selected angiograms were analysable by the angiographic core laboratory. Primary outcomes included MBG and post-PCI thrombolysis in myocardial infarction (TIMI) flow grade. Secondary outcomes included distal embolization, PPCI complications, and each component of the complications. The primary end point of final myocardial blush (221 [28%] 0/1 for thrombectomy vs. 246 {30%} 0/1 for PCI alone group, P = 0.38) and TIMI flow (712 [90%] TIMI 3 for thrombectomy vs. 733 [89.5%] TIMI 3 for PCI alone arm, P = 0.73) was similar in the two groups. Thrombectomy was associated with a significantly reduced incidence of distal embolization compared with PCI alone (56 [7.1%] vs. 87 [10.7%], P = 0.01). In multivariable analysis, distal embolization was an independent predictor of mortality (HR 3.00, 95% CI 1.19-7.58) while MBG was not (HR 2.73, 95% CI 0.94-5.3). CONCLUSIONS: Routine thrombectomy during PPCI did not result in improved MBG or post-PCI TIMI flow grade but did reduce distal embolization compared with PCI alone. Distal embolization and not blush grade is independently associated with mortality.

• Klíčová slova
• Myocardial Blush Grade *, STEMI *, Thrombectomy *,
• MeSH
• balónková koronární angioplastika MeSH
• infarkt myokardu s elevacemi ST úseků * MeSH
• infarkt myokardu MeSH
• koronární angiografie MeSH
• koronární angioplastika MeSH
• lidé MeSH
• trombektomie * MeSH
• výsledek terapie MeSH
• Check Tag
• lidé MeSH
• Publikační typ
• časopisecké články MeSH
• randomizované kontrolované studie MeSH

BACKGROUND: Two large trials have reported contradictory results at 1 year after thrombus aspiration in ST elevation myocardial infarction (STEMI). In a 1-year follow-up of the largest randomised trial of thrombus aspiration, we aimed to clarify the longer-term benefits, to help guide clinical practice. METHODS: The trial of routine aspiration ThrOmbecTomy with PCI versus PCI ALone in Patients with STEMI (TOTAL) was a prospective, randomised, investigator-initiated trial of routine manual thrombectomy versus percutaneous coronary intervention (PCI) alone in 10,732 patients with STEMI. Eligible adult patients (aged ≥18 years) from 87 hospitals in 20 countries were enrolled and randomly assigned (1:1) within 12 h of symptom onset to receive routine manual thrombectomy with PCI or PCI alone. Permuted block randomisation (with variable block size) was done by a 24 h computerised central system, and was stratified by centre. Participants and investigators were not masked to treatment assignment. The trial did not show a difference at 180 days in the primary outcome of cardiovascular death, myocardial infarction, cardiogenic shock, or heart failure. However, the results showed improvements in the surrogate outcomes of ST segment resolution and distal embolisation, but whether or not this finding would translate into a longer term benefit remained unclear. In this longer-term follow-up of the TOTAL study, we report the results on the primary outcome (cardiovascular death, myocardial infarction, cardiogenic shock, or heart failure) and secondary outcomes at 1 year. Analyses of the primary outcome were by modified intention to treat and only included patients who underwent index PCI. This trial is registered with ClinicalTrials.gov, number NCT01149044. FINDINGS: Between Aug 5, 2010, and July 25, 2014, 10,732 eligible patients were enrolled and randomly assigned to thrombectomy followed by PCI (n=5372) or to PCI alone (n=5360). After exclusions of patients who did not undergo PCI in each group (337 in the PCI and thrombectomy group and 331 in the PCI alone group), the final study population comprised 10,064 patients (5035 thrombectomy and 5029 PCI alone). The primary outcome at 1 year occurred in 395 (8%) of 5035 patients in the thrombectomy group compared with 394 (8%) of 5029 in the PCI alone group (hazard ratio [HR] 1·00 [95% CI 0·87-1·15], p=0·99). Cardiovascular death within 1 year occurred in 179 (4%) of the thrombectomy group and in 192 (4%) of 5029 in the PCI alone group (HR 0·93 [95% CI 0·76-1·14], p=0·48). The key safety outcome, stroke within 1 year, occurred in 60 patients (1·2%) in the thrombectomy group compared with 36 (0·7%) in the PCI alone group (HR 1·66 [95% CI 1·10-2·51], p=0·015). INTERPRETATION: Routine thrombus aspiration during PCI for STEMI did not reduce longer-term clinical outcomes and might be associated with an increase in stroke. As a result, thrombus aspiration can no longer be recommended as a routine strategy in STEMI. FUNDING: Canadian Institutes of Health Research, Canadian Network and Centre for Trials Internationally, and Medtronic Inc.

• MeSH
• cévní mozková příhoda epidemiologie   MeSH
• infarkt myokardu terapie   MeSH
• kardiovaskulární nemoci mortalita   MeSH
• kombinovaná terapie MeSH
• koronární angioplastika * MeSH
• koronární trombóza terapie   MeSH
• lidé MeSH
• následné studie MeSH
• prospektivní studie MeSH
• senioři MeSH
• šok epidemiologie   MeSH
• srdeční selhání epidemiologie   MeSH
• trombektomie * MeSH
• Check Tag
• lidé MeSH
• mužské pohlaví MeSH
• senioři MeSH
• ženské pohlaví MeSH
• Publikační typ
• časopisecké články MeSH
• multicentrická studie MeSH
• práce podpořená grantem MeSH
• randomizované kontrolované studie MeSH

BACKGROUND: During primary percutaneous coronary intervention (PCI), manual thrombectomy may reduce distal embolization and thus improve microvascular perfusion. Small trials have suggested that thrombectomy improves surrogate and clinical outcomes, but a larger trial has reported conflicting results. METHODS: We randomly assigned 10,732 patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary PCI to a strategy of routine upfront manual thrombectomy versus PCI alone. The primary outcome was a composite of death from cardiovascular causes, recurrent myocardial infarction, cardiogenic shock, or New York Heart Association (NYHA) class IV heart failure within 180 days. The key safety outcome was stroke within 30 days. RESULTS: The primary outcome occurred in 347 of 5033 patients (6.9%) in the thrombectomy group versus 351 of 5030 patients (7.0%) in the PCI-alone group (hazard ratio in the thrombectomy group, 0.99; 95% confidence interval [CI], 0.85 to 1.15; P=0.86). The rates of cardiovascular death (3.1% with thrombectomy vs. 3.5% with PCI alone; hazard ratio, 0.90; 95% CI, 0.73 to 1.12; P=0.34) and the primary outcome plus stent thrombosis or target-vessel revascularization (9.9% vs. 9.8%; hazard ratio, 1.00; 95% CI, 0.89 to 1.14; P=0.95) were also similar. Stroke within 30 days occurred in 33 patients (0.7%) in the thrombectomy group versus 16 patients (0.3%) in the PCI-alone group (hazard ratio, 2.06; 95% CI, 1.13 to 3.75; P=0.02). CONCLUSIONS: In patients with STEMI who were undergoing primary PCI, routine manual thrombectomy, as compared with PCI alone, did not reduce the risk of cardiovascular death, recurrent myocardial infarction, cardiogenic shock, or NYHA class IV heart failure within 180 days but was associated with an increased rate of stroke within 30 days. (Funded by Medtronic and the Canadian Institutes of Health Research; TOTAL ClinicalTrials.gov number, NCT01149044.).

• MeSH
• cévní mozková příhoda etiologie   MeSH
• elektrokardiografie MeSH
• infarkt myokardu komplikace   terapie   MeSH
• Kaplanův-Meierův odhad MeSH
• kardiovaskulární nemoci mortalita   prevence a kontrola   MeSH
• kombinovaná terapie škodlivé účinky   MeSH
• koronární angioplastika * škodlivé účinky   MeSH
• koronární trombóza komplikace   terapie   MeSH
• lidé středního věku MeSH
• lidé MeSH
• mikrocévy MeSH
• senioři MeSH
• srdeční selhání etiologie   MeSH
• trombektomie * škodlivé účinky   MeSH
• Check Tag
• lidé středního věku MeSH
• lidé MeSH
• mužské pohlaví MeSH
• senioři MeSH
• ženské pohlaví MeSH
• Publikační typ
• časopisecké články MeSH
• multicentrická studie MeSH
• práce podpořená grantem MeSH
• randomizované kontrolované studie MeSH

We briefly and comprehensively present some of the novel findings in the field of revascularization therapy and management of ST-segment-elevation myocardial infarction (STEMI). We highlight the latest evidence-based advancements in the pharmacological and mechanical treatment of patients who presented with STEMI. Since the last updates to the international guidelines (American College of Cardiology/American Heart Association and the European Society of Cardiology) were published in 2011 and 2012, there have been changes and several important studies have presented their final outcomes. We also highlight some controversial approaches as part of the current debates in the cardiology community. In addition, we share our recent experience in the field of biodegradable scaffold stents as a treatment strategy in STEMI.

• MeSH
• antikoagulancia terapeutické užití   MeSH
• infarkt myokardu terapie   MeSH
• inhibitory agregace trombocytů terapeutické užití   MeSH
• lidé MeSH
• revaskularizace myokardu * metody   MeSH
• rizikové faktory MeSH
• stenty * MeSH
• výsledek terapie MeSH
• Check Tag
• lidé MeSH
• Publikační typ
• časopisecké články MeSH
• přehledy MeSH
• Názvy látek
• antikoagulancia MeSH
• inhibitory agregace trombocytů 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.

• Klíčová slova
• Acute stroke, Catheter intervention, Myocardial infarction, Primary angioplasty, Reperfusion, Thrombectomy, Thrombolysis,
• MeSH
• akutní nemoc MeSH
• cévní mozková příhoda terapie   MeSH
• fibrinolytika terapeutické užití   MeSH
• infarkt myokardu terapie   MeSH
• intravenózní infuze MeSH
• klinické zkoušky jako téma MeSH
• kombinovaná terapie MeSH
• koronární angioplastika metody   MeSH
• lidé MeSH
• reperfuze metody   MeSH
• trombektomie metody   MeSH
• trombolytická terapie metody   MeSH
• Check Tag
• lidé MeSH
• Publikační typ
• časopisecké články MeSH
• práce podpořená grantem MeSH
• přehledy MeSH
• Názvy látek
• fibrinolytika MeSH

Over 50% of ST-segment elevation myocardial infarction (STEMI) patients suffer multi-vessel coronary artery disease, which is known to be associated with worse prognosis. Treatment strategies used in clinical practice vary from acute multi-vessel percutaneous coronary intervention (PCI), through staged PCI procedures to a conservative approach with primary PCI of only the infarct-related artery (IRA) and subsequent medical therapy unless recurrent ischaemia occurs. Each approach has advantages and disadvantages. This review paper summarizes the international experience and authors' opinion on this clinically important question. Multi-vessel disease in STEMI is not a single entity and thus the treatment approach should be individualized. However, the following general rules can be proposed till future large randomized trials prove otherwise: (i) Single-vessel acute PCI should be the default strategy (to treat only the IRA during the acute phase of STEMI). (ii) Acute multi-vessel PCI can be justified only in exceptional patients with multiple critical (>90%) and potentially unstable lesions. (iii) Significant lesions of the non-infarct arteries should be treated either medically or by staged revascularization procedures-both options are currently acceptable.

• MeSH
• balónková koronární angioplastika metody   mortalita   MeSH
• infarkt myokardu komplikace   mortalita   terapie   MeSH
• Kaplanův-Meierův odhad MeSH
• koronární bypass metody   mortalita   MeSH
• lidé MeSH
• mortalita v nemocnicích MeSH
• nemoci koronárních tepen komplikace   mortalita   terapie   MeSH
• výsledek terapie MeSH
• zátěžový test MeSH
• Check Tag
• lidé MeSH
• Publikační typ
• časopisecké články MeSH
• práce podpořená grantem MeSH
• přehledy 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
• balónková koronární angioplastika statistika a číselné údaje   MeSH
• časové faktory MeSH
• charakteristiky bydlení MeSH
• dostupnost zdravotnických služeb MeSH
• hospitalizace statistika a číselné údaje   MeSH
• incidence MeSH
• infarkt myokardu epidemiologie   terapie   MeSH
• lidé MeSH
• mortalita v nemocnicích MeSH
• odhad potřeb MeSH
• reperfuze myokardu metody   statistika a číselné údaje   MeSH
• Check Tag
• lidé MeSH
• Publikační typ
• časopisecké články MeSH
• práce podpořená grantem MeSH
• Geografické názvy
• Evropa epidemiologie   MeSH