Coronary microcirculation and peripheral endothelial function evaluation after acute ST elevation myocardial infarction treated with primary angioplasty

ABSTRACT: Introduction: Despite achieving normal epicardial coronary artery flow after primary percutaneous coronary intervention (P-PCI), a significant proportion of patients with acute ST elevation myocardial infarction has a poorer outcome because of microvascular coronary damage and/or dysfunction. Endothelial dysfunction may play a role in this microvascular coronary damage after STEMI, and its evaluation by peripheral arterial tonometry may be useful to predict the extent of microvascular coronary damage and the extent of myocardial infarction. Objectives: To evaluate the relation of early peripheral endothelial dysfunction, as measured by the reactive hyperemia index (RHI, obtained by peripheral arterial tonometry) and the index of microcirculatory resistance (IMR) immediately after P-PCI and to access the relation between RHI and IMR values and: 1) the extent of myocardial infarct evaluated by contrast enhanced cardiac magnetic resonance (ceCMR) and troponin release; 2) the extent of microvascular obstruction (MVO), evaluated by ceCMR and by other available indirect indicators; 3) late (3 months) left ventricular remodelling, measured by echocardiography. Methods: Observational, prospective cohort study. Patients with a first STEMI successfully treated with P-PCI, hemodynamically stable and without contra-indications for adenosine administration were included. After successful P-PCI, IMR was determined, using a pressure-wire. RHI was evaluated acutely and after 24 hours, using EndoPAT; endothelial dysfunction was defined as RHI24 had significantly worse ST resolution and angiographic indicators of microvascular dysfunction. IMR also correlated with infarct mass (r=0.70, p24 had significantly higher peak (p=0.013) and AUC (p=0.003) TnI. LVEF improved significantly only in patients with IMR24, a resolução do ST foi significativamente menor e os indicadores angiográficos de reperfusão foram significativamente piores. O IRM também se correlacionou com a massa de enfarte (r=0,70, p24 tiveram valores significativamente mais elevados de TnI máxima (p=0,013) e ASC de TnI (p=0,003). A FEVE melhorou de forma significativa apenas nos doentes com IMR<24 (p=0,01). Os preditores independentes do IRH foram a idade, a glicemia na admissão e a HbA1c na admissão. Conclusões: Não parece ser possível avaliar de forma fidedigna o IHR na fase aguda do EAMcST após ICP-P. O IHR medido 24h após a ICP-P é mensurável de forma adequada e prevê a dimensão do enfarte e da OMV, confirmando a disfunção endotelial como um mecanismo importante na disfunção microvascular em doentes com EAMcST. O IRM correlaciona-se fortemente com a OMV e permite prever a dimensão do enfarte e o risco de remodelagem ventricular esquerda

Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

Background Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks. Methods The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned. Results A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P &lt; 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31). Conclusion Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov)