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Percutaneous coronary intervention is the main strategy of revascularization and has been shown to improve outcomes in some patients with ST-segment elevation myocardial infarction (STEMI). However, multivessel disease (MVD), a common condition in these patients, is associated with worse clinical outcomes compared to single-vessel disease. Despite intervention being a standard treatment for coronary artery disease, optimal strategies and timings for patients with STEMI and MVD remain unclear. Numerous studies and meta-analyses have investigated this topic; however, many current conclusions are based on observational studies. Furthermore, clinical guidelines regarding the management of patients with STEMI and MVD contain conflicting recommendations. Therefore, we aimed to compile relevant studies and newly available evidence-based medicines to explore the most effective approach.

Background and Objective: Non-ST segment elevation myocardial infarction (NSTEMI) may be associated with multivessel disease (MVD) and total coronary artery occlusion (TO); hallmarks of occlusive myocardial infarction (OMI). The study aimed to determine the frequency and predictors of MVD and TO in NSTEMI patients with OMI at a tertiary care center in Pakistan. Methodology: This retrospective observational study analyzed the medical records of NSTEMI patients aged > 18 years, who underwent PCI at Indus Hospital and Health Network, Karachi, Pakistan, during 2022. Clinical features, electrocardiograph (ECG) and echocardiographic findings were reviewed. Univariate and multivariate logistic regression identified independent predictors of MVD and TO. Adjusted odds ratio (aORs) and 95% confidence intervals (CIs) were reported. Results: Among the 671 NSTEMI patients (mean age 56.92 ± 11.29 years, 64% male), MVD and TO was detected in 35.42% and 33.72% respectively. Independent predictors for MVD included age >60 years (aOR 1.44, 95% CI: 1.01-2.04; p=0.045), chest pain at presentation (aOR 1.71, 95% CI: 1.18-2.49; p=0.005) and T-wave inversion (aOR 3.00, 95% CI: 1.92-4.67; p=<0.001). Predictors of TO included age < 60 years (aOR 0.68, 95% CI: 0.48-0.97; p=0.033), ST depression (aOR 1.70, 95% CI: 1.16-2.49; p=0.006) and absence of T-wave inversion (aOR 0.41, 95% CI: 0.27-0.62; p<0.001). Conclusion: A significant subset of NSETMI patients in Pakistan present with underlying OMI. Simple clinical and ECG features may be helpful in identification of such high-risk cases in resource-limited settings; enabling timely intervention and improved outcome.

CMV infection is a common complication in patients undergoing hematopoietic-cell transplantation. The incidence of CMV infection was 23 percentage points lower with prophylactic letermovir, a CMV–terminase complex inhibitor, than with placebo, with only low-level toxic effects.

Background Multivessel coronary disease (MVCD) is the common type of coronary artery disease in acute coronary syndrome (ACS). Coronary artery calcification (CAC) has been confirmed the strong predictor of major adverse cardiovascular events (MACEs). Several studies have validated that triglyceride glucose (TyG) index can reflect the degree of coronary calcification or predict MACEs. However, no evidence to date has elucidated and compared the predictive intensity of TyG index or/and coronary artery calcification score (CACS) on multi-vascular disease and MACEs in ACS patients. Methods A total of 935 patients, diagnosed with ACS and experienced coronary computed tomography angiography (CCTA) from August 2015 to March 2022 in the Second Hospital of Shandong University, were selected for retrospective analysis. The subjects were divided into TyG index quartile 1–4 groups (Q1-Q4 groups), non-multivessel coronary disease (non-MVCD) and multivessel coronary disease (MVCD) groups, respectively. The general data, past medical or medication history, laboratory indicators, cardiac color Doppler ultrasound, CACS, and TyG indexes were respectively compared among these groups. The ROC curve preliminarily calculated and analyzed the diagnostic value of TyG index, CACS, and the combination of the two indicators for MVCD. Univariate and multivariate logistic regression analysis discriminated the independent hazard factors for forecasting MVCD. Results Compared with the lower TyG index and non-MVCD groups, the higher TyG index and MVCD groups had higher values of age, smoking history, waist circumference, systolic blood pressure, low-density lipoprotein cholesterol(LDL-C), fasting blood glucose and glycosylated hemoglobin, and CACS, but lower values of high-density lipoprotein cholesterol(HDL-C) (all P  < 0.01). Coronary artery calcification is more common in the left anterior descending artery. Compared with non-MVCD, each unit increase in TyG index was associated with a 1.213-fold increased risk of MVCD. Logistic regression analysis adjusted for potential confounders indicated that TyG index is an independent risk factor for MVCD. With the increase of TyG index, the incidence of MACEs, apart from all-cause death, cardiac death, unexpected re-hospitalization of heart failure, recurrent ACS or unplanned revascularization, and non-fatal stroke in coronary artery increased ( P log-rank < 0.001). Conclusion TyG index could completely substitute for CACS as a reliable, practical, and independent indicator for predicting the severity and prognosis of MVCD in patients with ACS.

IntroductionTrials showed that multivessel disease (MVD) was associated with increased cardiovascular morbidity and mortality in STEMI patients. There is no available evidence on the validity of non-invasive clinical parameters to predict the presence of MVD in the available literature. We aimed to find the relationship between acute heart failure (AHF) at the time of presentation of STEMI patients to the emergency department and the number of diseased coronary arteries on the angiogram. The latter is vital in determining those patients' morbidity and mortality during hospitalisation.MethodsWe ran a retrospective cohort study that included 210 consecutive STEMI patients who presented to a single PPCI centre. We excluded post-fibrinolysis patients, patients with old stents, and those who presented more than 24 hours after the onset of pain. We divided the studied cohort into two subgroups based on the presence of AHF on presentation to the emergency department, the AHF and the no-HF groups. We obtained Informed consent from all patients, and all procedures were done in compliance with the Helsinki declaration for research on human beings. Two blinded interventional cardiology consultants assessed the number of diseased coronaries in the angiograms of the patients before the PPCI was done. A diseased vessel was defined as one that showed 70% stenosis in the left anterior descending, left circumflex, and right coronary artery, or 50% stenosis in the case of the left main coronary artery.ResultsThe baseline characteristics of the studied groups are presented in table 1. The HF group represented 9.5% of the studied patients. The modal of the number of diseased coronaries was significantly higher in the AHF group compared to the no-HF group (3 vs one vessel, respectively, p=0.036). (figure 1) A point biserial correlation analysis illustrated a positive correlation between the presence of AHF and the number of diseased coronary arteries ( rpb=0.16, p=0.02). A multivariate logistic regression analysis confirmed that admission AHF was an independent predictor of having three-vessel coronary artery disease in STEMI patients (OR= 3.79, 95% CI 1.38-10.37, p=0.01).ConclusionAHF in STEMI patients is associated with a higher risk of multivessel disease (MVD) on angiography. This information is crucial in managing those patients, as studies showed higher morbidity and mortality in MVD patients.Abstract 67 Table 1The baseline characteristics of the studied groups Parameter No-HF group AHF group p Number of patients (%)190 (90.5%)20(9.5%)-Age (years; mean±SD)54.99 ±11.359.95± 7.62-Sex (n;%)Males170 (89%)17(85%)0.24Females20 (11%)3 (15%)Hypertension (n;%)73 (38%)8 (40%)0.98IDDM (n;%)6 (3%)0 (0%)0.41NIDDM (n;%)70 (37%)10 (50%)0.33Smoking (n;%)113 (59%)13 (65%)0.83Dyslipidemia (n;%)112 (59%)14 (70%)0.49Previous MI (n;%)7(3.7%)1 (5%)0.81Previous CVA (n;%)1 (0.5%)0 (0%)0.74Abstract 67 Figure 1Raincloud plot showing the relationship between the presence of AHF and the number of diseased coronaries on the angiogramConflict of InterestNone

Observational data have demonstrated that patients presenting with acute coronary syndromes (ACS) and multivessel coronary artery disease (MV-CAD) experience improved 1-year outcomes including lower rates of death, rehospitalization, and repeat ACS when treated with coronary artery bypass graft (CABG) compared with percutaneous coronary intervention (PCI) and medical management (MM). However, limited data exists that studies these practices in adults over the age of 75. This retrospective, multi-centered, observational study from 2018 to 2022 from a healthcare center in Texas compared outcomes among patients with ACS and MV-CAD, stratified by revascularization strategy and age group (<75 vs ≥75 years). The primary endpoint was 1 year mortality, and secondary endpoints include readmission or myocardial infarction (MI) within 1 year, index length of stay, and repeat revascularization within 30 days and 1 year. Cox proportional hazards modeling was used to evaluate the effect of age on mortality outcomes. A total of 2161 patients met inclusion criteria (n = 1559 CABG, n = 295 PCI, and n = 307 MM). There were 1547 patients under the age of 75 (median age 63.82, IQR = 57.24, 69.44) and 614 over the age of 75 (median age 80.43, IQR = 77.62-84.58). Patients who underwent CABG had significantly reduced mortality compared with PCI or MM (RR = 0.324, CI 0.172 to 0.612, p <0.0001). In conclusion, CABG was associated with improved and comparable outcomes in patients with ACS and MV-CAD both under and over 75 years of age compared with PCI and MM.

An increased total stent length (TSL) might be associated with a higher risk of clinical events; however, in patients with multivessel disease (MVD), a considerable TSL is often required. In patients presenting with acute coronary syndrome and MVD, immediate complete revascularization was associated with shorter TSL in the BIOVASC (Immediate versus staged complete revascularisation in patients presenting with acute coronary syndrome and multivessel coronary disease) Trial. This is a subanalysis of the BIOVASC trial comparing clinical outcomes in patients with either <60 or ≥60 mm TSL. The primary outcome was a composite of all-cause mortality, myocardial infarction, any unplanned ischemia driven revascularization, or cerebrovascular events at 2 years after the index procedure. A total of 1,525 patients were enrolled in the BIOVASC trial, of whom 855 had a TSL of ≥60 mm (long TSL). No significant difference was established when comparing patients treated with either long or short TSL in terms of the primary outcome at 2-year follow-up, which occurred in 117 patients (13.7%) in the ≥60 mm group and 69 patients (10.3%) in the <60 mm group (adjusted hazard ratio 1.25, 95% confidence interval 0.92 to 1.69, p = 0.16). Furthermore, no significant differences were observed in the secondary end points. In conclusion, in patients with acute coronary syndrome and MVD, long stenting did not show a significant difference in clinical event rate compared with short stenting.

In acute coronary syndromes (ACS), revascularization is the standard of care. However, trials comparing contemporary coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) are limited. Optimal revascularization in patients with multivessel coronary artery disease (MV-CAD) presenting with ACS is unclear. This is a multicentered, retrospective observational study from a large hospital system in the United States. We abstracted data in patients with MV-CAD and ACS from 2018 to 2022 who underwent revascularization with PCI, CABG, or medical management (MM). We evaluated multivariate statistics comparing categorical variables and outcomes, including all-cause mortality and myocardial infarction (MI) at 1 year. All logistic and Cox proportional-hazard models were balanced using inverse probability treatment weights accounting for age and gender. There were 295 patients with CABG (median age 66 years [interquartile range 59.7 to 73.1]; 73% male), 1,559 patients with PCI (median age 68.3 years [interquartile range 60 to 76.6]; 69.1% male], and 307 patients with MM (median age 70 years [60.9 to 77.1] 74% male]. Patients revascularized with PCI had greater all-cause mortality at 1 year (14.1% vs 5.1%; hazard ratio 2.4, confidence interval [1.5 to 3.8], p <0.001) and similar mortality to MM (13.4%). CABG also showed a reduced 1-year MI rate compared with PCI (1.7% vs 3.9%; hazard ratio 0.36, confidence interval 0.21 to 0.61, p ≤0.001), with a similar 1-year rate of MI to MM (3.9%). In conclusion, CABG is associated with lower mortality than are PCI and MM, and repeat ACS events at 1 year in patients with ACS and MV-CAD.

This article details a correction to: Sustersic M, Mrak M, Svegl P, Kodre AR, Kranjec I, Fras Z, et al. Complete Revascularization and Survival in STEMI. Global Heart. 2021; 16(1): 64. DOI: http://doi.org/10.5334/gh.1040

The benefit of mechanical circulatory support with Impella (Abiomed, Inc., Danvers, Massachusetts) for high-risk percutaneous coronary intervention (HR-PCI) is uncertain. PROTECT III registry data showed improved outcomes with Impella compared with historical data (PROTECT II) but lack a direct comparison with the HR-PCI cohort without Impella support. We retrospectively identified patients meeting the PROTECT III inclusion criteria for HR-PCI and compared this group (non-Impella cohort [NonIMP]) with the outcomes data from the PROTECT III registry (Impella cohort). Baseline differences were balanced using inverse propensity weighting. The coprimary outcome was major adverse cardiac events (MACE) in-hospital and at 90 days. A total of 283 patients at great risk did not receive Impella support; 200 patients had 90-day event ascertainment and were included in the inverse propensity weighting analysis and compared with 504 patients in the Impella cohort group. After calibration, few residual differences remained between groups. The primary outcome was not different in-hospital (3.0% vs 4.8%, p = 0.403) but less in NonIMP at 90 days (7.5% vs 13.8%, p = 0.033). Periprocedural vascular complications, bleeding, and transfusion rate did not differ between groups; however, acute kidney injury occurred more frequently in the NonIMP group (10.5% vs 5.4%, p = 0.023). In conclusion, under identical HR-PCI inclusion criteria for Impella use in PROTECT III, an institutional non–Impella-supported HR-PCI cohort showed similar MACE in-hospital but fewer MACE at 90 days, whereas there was no signal for periprocedural harm with Impella use. These results do not support routine usage of Impella for patients with HR-PCI.