The effectiveness of primary percutaneous coronary interventions in patients with ST-elevation acute coronary syndrome, with consideration of life-threatening signs that occur before or during the procedure

The study objective was to evaluate the effectiveness of primary percutaneous coronary interventions (PCIs) in patients with ST-elevation acute coronary syndrome (ST↑ ACS), taking into account the life-threatening signs that occur before and during early or delayed procedures, and the characteristics of myocardial infarction (MI) morphogenesis after restoring the epicardial blood flow.

Materials and methods. A total of 337 patients with ST↑ ACS admitted to the regional vascular center (RVC) from 01.03.2023 to 31.08.2023, were studied, their age being from 26–99 years old. Group I consisted of 192 patients who underwent PCI in the first 6 hours from the onset of disease, Group II included 47 patients with PCI performed within 6–12 hours, and Group III included 82 patients in whom PCI was performed after 12–72 hours of the onset of the disease. We took into consideration a decreased blood pressure (BP) <90 mmHg, decreased heart rate (HR) <50 bpm, and ventricular fibrillation (VF) that occurred at the prehospital stage and during PCI; the baseline mortality risk by TIMI Risk Score. In 39 patients who died after PCI, the characteristics of MI morphogenesis were assessed after the infarct-related artery (IRA) had been restored.

Results. In a comparative analysis of the PCI results, 79 % of deceased patients had no ECG signs of reperfusion; and the blood flow in IRA was assessed as TIMI 0 or TIMI III in 26 and 74 %, respectively; in 71 % of cases, the target artery was the left anterior descending (LAD) artery with acute occlusion in the proximal third in triple-vessel disease, more often present in older age groups. In all cases, a decrease in blood pressure <90 mm Hg, a heart rate fall <50 bpm and VF either preceded PCI or occurred during the PCI procedure; cases of Killip Class II, III, and IV acute heart failure (AHF) made 33, 26, and 41 %, respectively. In patients with a favorable outcome, ECG signs of reperfusion were achieved in 72.5 %, the blood flow was assessed as TIMI III in all cases, IRA was represented by LAD artery in 48 % more often in the form of an isolated lesion among individuals under 65 years of age; life-threatening signs occurred in isolated cases; AHF cases of Killip Class I, II, III, and IV accounted for 47, 48, 4 and 1 %, respectively.

Conclusion. The presented data have indicated that primary PCI does not prevent fatal outcome in patients admitted with cardiogenic shock on prolonged CPR. Extensive MI area with proximal LAD occlusion and triple-vessel disease is accompanied by AHF of varying severity degree. Interventions for this condition in older age groups require practical skills to ensure success. Microcirculation disturbances, such as multiple spasms and thromboses as identified by morphological examination are associated with life-threatening symptoms that arise both in cardiogenic shock, and during procedures accompanied by the acute heart failure progression, which can develop into multiple organ failure in patients with associated pathology. The differences in the acute heart failure development, which underlie the characteristics of thanatogenesis, make possible the assessment of mechanical reperfusion effectiveness and the possibility of preventing death.

1. Larsen A. I., Løland K. H., Hovland S. et al. Guideline-recommended time less than 90 minutes from ECG to primary percutaneous coronary intervention for ST-segment-elevation myocardial infarction is associated with major survival benefits, especially in octogenarians: a contemporary report in 11226 patients from NORIC. J Am Heart Assoc. 2022; 11 (17): e024849. https://doi.org/10.1161/jaha.122.024849

2. Byrne R. A., Rossello X., Coughlan J. J. et al. 2023 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J. 2023; 44 (38): 3720–3826. https://doi.org/10.1093/eurheartj/ehad191

3. Shpektor A. V., Vasilieva E. Yu. Acute myocardial infarction with the rise of the ST segment: from the «heart attack network» to shock centers. Creative cardiology. 2021; 15 (4): 435–439. (In Russ.). https://doi.org/10.24022/1997-3187-2021-15-4-435-439

4. Gazaryan G. A., Askerova L. M., Nefedova G. A. et al. The efficiency of percutaneous coronary interventions in a regional vascular center with regard to baseline risk, the significance of infarction-related artery and the number of affected arteries. Medalfavit. 2024; (23): 78–83. (In Russ.). https://doi.org/10.33667/2078-5631-2024-23-78-83

5. Morrow D., Antman E., Charlesworth A. et al. TIMI risk score for ST elevation myocardial infarction: A convenient, beside, clinical score for risk assessment at presentation: An intravenous tnPA for treatment of infracting myocardium early II trial substudy. Circulation. 2000; 102 (17): 2031–2037. https://doi.org/10.1161/circ.102.17.2031

6. Zeymer U., Ludman P., Danchin N. et al. Reperfusion therapies and in-hospital outcomes for ST-elevation myocardial infarction in Europe: the ACVC-EAPCI EORP STEMI Registry of the European Society of Cardiology. Eur Heart J. 2021; 42 (44): 4536–4549. https://doi.org/10.1093/eurheartj/ehab342

7. Thrane P. G., Olesen K. K.W., Thim T. et al. Mortality Trends After Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction. J Am Coll Cardiol. 2023; 82 (10): 999–1010. https://doi.org/10.1016/j.jacc.2023.06.025

8. Henry T. D., Tomey M. I., Tamis-Holland J.E., et al. Invasive management of acute myocardial infarction complicated by cardiogenic shock: a scientific statement from the American Heart Association. Circulation. 2021; 143 (15): e815–29. https://doi.org/10.1161/CIR.0000000000000959

9. Thiele H., Ohman E. M., Waha-Thiele S. et al. Management of cardiogenic shock complicating myocardial infarction: an update 2019. Eur Heart J. 2019; 40 (32): 2671–2683. https://doi.org/10.1093/eurheartj/ehz363

10. Gazaryan G. A., Nefedova G. A., Gazaryan G. G. et al. The initial risk, time window and indications for delayed percutaneous coronary interventions, their value in the treatment of myocardial infarction with elevation of the ST segment. Medical alphabet. 2023; (25): 7–13. (In Russ.). https://doi.org/10.33667/2078-5631-2023-25-7-13

11. Tumminello G., D’Errico A., Maruccio A. et al. Age-Related Mortality in STEMI Patients: Insight from One Year of HUB Centre Experience during the Pandemic. J Cardiovasc Dev Dis. 2022; 9 (12): 432. https://doi.org/10.3390/jcdd9120432

12. Nefedova G. A., Galankina I. E. Features of tanatogenesis and the vastness of myocardial infarction, depending on the prevalence of atherosclerotic stenosis of the coronary arteries. Archive of pathology. 2004; (4): 17–20. (In Russ.).