Клинико-гемодинамические особенности пациентов с острым инфарктом миокарда с подъемом сегмента ST, подлежащих позднему интервенционному лечению

To save the viability of the ischemic myocardium in a patient with ST-segment elevation myocardial infarction and improve the survival, coronary blood flow must be restored as soon as possible, preferably within the first 12 hours after the onset of pain. The current dilemma of interventional cardiologists is the decision about the possibility of performing interventional myocardial reperfusion in the patients with delayed presentation (more than 12 hours from the onset) and establishing the predictive factors of the procedures performed in this category of patients. In ths study 63 patients with STEMI were included, divided into 2 groups: the first one included 33 patients presentetd at the emergency department within the first 12 hours after the onset of STEMI, and the second group consited of 30 subjects with STEMI in whom the first medical contact was more than 12 hours after the onset of symptoms. The groups were compared with each other according to the well-established criteria. The primary end points were the assessment of major cardiovascular events (MACE), as well of ventricular myocardium remodeling/reverse-remodeling and predictors of interventional procedures. The improvement of left ventricular myocardial contractile function (LVEF), seems to be associated with early myocardial revascularization. Early presentation in STEMI can be considered an independent predictor of the improvement of the regional kinetics affected by AMI. The contractile function of the LV myocardium represented by the ejection fraction is considered an independent predictor of long-term and short-term mortality in patients with STEMI. The preliminary results of the research highlight the applicative value of PCI procedures also for patients with delayed presentation more than 12 hours from the onset of the disease and the first medical contact.Pentru a salva viabilitatea miocardului ischemizat la un pacient cu infarct miocardic acut cu supradenivelarea de segment ST și pentru a îmbunătăți supraviețuirea, fluxul sanguin coronarian trebuie restabilit cât mai curând posibil, de preferință în primele 12 ore de la debutul bolii. Dilema actuală a cardiologilor intervenţionişti este decizia cu privire la posibilitatea efectuării reperfuziei miocardice intervenţionale la pacienţii cu prezentare întârziată (mai mult de 12 ore de la debut) şi stabilirea factorilor predictivi ai procedurilor efectuate la această categorie de pacienţi. În acest studiu au fost incluși 63 de pacienți cu STEMI, împărțiți în 2 grupe: primul a inclus 33 de pacienți prezentați la serviciul de urgență în primele 12 ore de la debutul STEMI, iar al doilea grup a fost format din 30 de subiecți cu STEMI la care primul contact medical a fost la mai mult de 12 ore de la apariția durerilor. Grupurile au fost comparate între ele conform criteriilor bine stabilite. Obiectivele principale au fost evaluarea evenimentelor cardiovasculare majore (MACE), remodelarării/ invers-remodelării miocardului ventricular și predictorii procedurilor intervenționale. Îmbunătățirea funcției contractile miocardice a ventriculului stâng (FEVS) pare să fie asociată cu revascularizarea miocardică precoce. Prezentarea precoce în STEMI poate fi considerată un predictor independent al îmbunătățirii cineticii regionale afectate de IMA. Funcția contractilă a miocardului VS reprezentată de fracția de ejecție este considerată un predictor independent al mortalității pe termen lung și pe termen scurt la pacienții cu STEMI. Rezultatele preliminare ale cercetării evidențiază valoarea aplicativă a procedurilor PCI și pentru pacienții cu prezentare întârziată peste 12 ore de la debutul bolii și primului contact medical.Для сохранения жизнеспособности миокарда у больного с острым инфарктом миокарда с подъемом сегмента ST и улучшения выживаемости необходимо как можно быстрее восстановить коронарный кровоток, лучше всего в течение первых 12 часов. Актуальной дилеммой интервенционных кардиологов является решение вопроса о возможности выполнения интервенционной реперфузии миокарда у больных с отсроченным обращением (более 12 часов от начала заболевания) и установление прогностических факторов выполняемых у данной категории больных интервенционных вмешательств. В исследование были включены 63 пациента с с острым инфарктом миокарда с подъемом сегмента ST, разделенные на 2 группы: в первую вошли 33 пациента, поступивших в отделение неотложной помощи в течение первых 12 часов от начала заболевания, во вторую группу вошли 30 пациентов, у которых первый медицинский контакт был более чем через 12 часов после появления симптомов. Группы сравнивались между собой по хорошо определенным критериям. Первичными конечными точками (end points) были оценка больших сердечно-сосудистых событий (MACE), а также ремоделирования/обратного ремоделирования миокарда желудочков и предикторы интервенционных процедур. Улучшение сократительной функции миокарда левого желудочка (ФВЛЖ), по-видимому, связано с ранней реваскуляризацией миокарда. Раннее обращение больных с острым инфарктом миокарда с подъемом сегмента ST можно рассматривать как независимый предиктор улучшения кинетики миокарда левого желудочка, вызванной острой ишемией миокарда. Сократительная функция миокарда, представленная фракцией выброса, считается независимым предиктором отдаленной и краткосрочной смертности у больных с острым инфарктом миокарда с подъемом сегмента ST. Предварительные результаты исследования подчеркивают практическую ценность интервенционных процедур также у пациентов с поздним обращением более 12 часов от начала заболевания и первого медицинского контакта

Assessment of the impact of late myocardial revascularization in patients with acute myocardial infarction with ST-segment elevation

Introduction. Early reperfusion therapy is considered a percutaneous coronary intervention (PCI) performed within the first 12h from symptoms onset in acute myocardial infarction with ST segment elevation (STEMI). There is a tendency to extend the “therapeutic window” for STEMI stable patients: the European’s Society of Cardiology (ESC) guideline on myocardial revascularization from 2012 and 2015 emphasized an extension of PCI to 24h and in 2017’s edition to 48 h. Delayed revascularization procedure remains a dilemma for hemodynamically stable patients who missed the reperfusion window. Aim of study. Assessment of the impact of late myocardial revascularization on left ventricular systolic function, reinfarction rate, and major cardiovascular events (MACE) referring to PCI in different periods of time from symptoms onset. Methods and materials. Our clinical research represents a retrospective study based on data from 40 patients treated with PCI within the Institute of Cardiology from 2020 to 2022. All subjects were divided into 3 groups: I group - includes 15 patients with PCI performed within the first 12h from symptoms onset, II group - includes 12 patients with PCI performed within 12-24h and III group - includes 13 patients with PCI performed after 48h. All participants were examined after 30 days and 6 months from the PCI. Results. None of the subjects developed reinfarction or MACE during all follow-up stages. Only one subject was reexamined via PCI after 6 months due to the recurrence of angina, but there hasn’t been any progressive residual lesion and the drug-eluting stent has been completely permeable. Improvement of left ventricle systolic function (initial baseline >40 %) was associated with early revascularization: in group I, the mean of EF (ejection fraction) increased from 40,2 to 46,1%, P < 0,001, followed by group III, where the mean of EF increased from 37,07 to 39,53%, P< 0,001, and followed by patients from the group II, where the mean of EF increased from 44,3 to 45,1%. According to NYHA classes of heart failure, patients who have undergone a reperfusion within the first 12h have a lower rate to develop heart failure than latecomers (group II and III). Most of the subjects were assigned NYHA class II: 10 subjects (73,3 %) from group I, 11 subjects (91,6 %) from group II and 6 subjects (46,1 %) from group III. Conclusion. Early reperfusion therapy is associated with low reinfarction rate as well as few major cardiovascular events. However, late reperfusion therapy hasn’t been associated with high reinfarction rate or major cardiovascular events