ST Elevation Myocardial Infarction

IJCS

Editorial

Difference in Treatment Response Between Men and Women with Acute Myocardial Infarction with ST-segment Elevation Even When Following Well-established Protocols

The study “Comparison of Clinical and Epidemiological Profiles Between Men and Women with ST-Elevation Myocardial Infarction in Salvador from 2021 to 2023” provides an important contribution by demonstrating that, even in a setting supported by a well-structured ST-elevation myocardial infarction (STEMI) protocol, relevant differences in clinical profiles between men and women persist. Although treatment strategies were homogeneous between sexes—a noteworthy finding in a country where healthcare inequities are often the rule—the observation that women present later, are older at the time of the event, and more frequently receive potent antiplatelet agents reinforces the need to understand acute coronary syndrome in women according to their specific pathophysiological and clinical characteristics.¹

In recent years, increasing evidence has challenged the concept that myocardial infarction in women is simply “the same infarction, occurring later.” Contemporary data indicate that mechanisms such as coronary microvascular dysfunction, plaque erosion, and spontaneous coronary artery dissection are more prevalent among women, demanding greater diagnostic precision and tailored therapeutic strategies.^2,3 In parallel, atypical symptom presentation and lower perceived cardiovascular risk contribute to delays in seeking care—a phenomenon consistently observed worldwide, including in high-income countries.⁴

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Original Article

Comparison of Clinical and Epidemiological Profiles Between Men and Women with ST-Elevation Myocardial Infarction in Salvador from 2021 to 2023

Heloisa Gonzaga Menezes de Moraes et al. Mariela Gomes Botelho Carneiro Marianna Deway Andrade Dracoulakis

Abstract

Background:

ST-segment elevation myocardial infarction (STEMI) remains one of the leading causes of morbidity and mortality worldwide. Although studies indicate sex disparities in risk factors, symptomatology, and outcomes, there is a lack of local research validating these differences.

Objectives:

To compare the clinical and epidemiological profiles, treatment times, and in-hospital outcomes of men and women diagnosed with STEMI at a private hospital in Salvador, Brazil from 2021 to 2023.

Methods:

This retrospective observational study analyzed 75 patients, of whom 30.7% were women. Variables assessed included age, cardiovascular risk factors, symptom-to-door time, door-to-ECG time, door-to-reperfusion time, pharmacological therapy, and in-hospital outcomes.

Results:

Women presented STEMI at a significantly older age compared to men (median age: 73.0 versus 62.5 years; p = 0.002). There were no statistically significant differences in treatment times (symptom-to-door, door-to-ECG, and door-to-reperfusion) between sexes. Women were more frequently treated with high-potency antiplatelet agents (prasugrel and ticagrelor) than men (p = 0.047 and p = 0.012, respectively). No differences in complications or mortality rates were observed between the groups.

Conclusions:

Despite being older and using more potent antiplatelet therapy, women did not experience significant differences in treatment times or complications. The limited sample size may have affected the ability to detect more significant differences, underscoring the need for larger studies.

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Editorial

ST-Segment Elevation Myocardial Infarction: Assessment of Quality of Care Before and After the COVID-19 Pandemic

Fernando Oswaldo Dias Rangel

In this article, Tavares et al. comparatively analyze quality indicators of care for 193 patients with ST-segment elevation myocardial infarction (STEMI) and relevant clinical outcomes before and during the COVID-19 pandemic.

An increase in mortality rates associated with cardiovascular diseases was observed in Brazil after the onset of the COVID-19 pandemic. Many patients did not leave their homes to seek hospital care, contributing to increased cardiovascular mortality.

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Original Article

ST-Segment Elevation Myocardial Infarction Metrics Before and During the COVID-19 Pandemic: Experience from a Brazilian Center

Caio de Assis Moura Tavares et al. Tarso A. D. Accorsi Milena Ribeiro Paixão Tarsila Mota … Fabio Pitta Pedro Alves Lemos Marcelo Franken Karine De Amicis Lima Karen Francine Kohler José Leão de Souza Jr.

Abstract

Background:

The impact of the COVID-19 pandemic on the healthcare of patients with ST-segment elevation acute myocardial infarction (STEMI) in Brazil remains unclear.

Objective:

Provide a descriptive analysis of clinical profiles, time intervals, performance metrics, and outcomes in patients with STEMI before and during the COVID-19 pandemic.

Methods:

Among a cohort of 193 patients with STEMI diagnosed in five emergency departments within a single Brazilian healthcare network, 187 patients were included between January 2017 and April 2021 and stratified into two cohorts: Cohort I (pre-pandemic, 146 patients) and Cohort II (pandemic, 41 patients). Statistical significance was defined as a two-sided p value < 0.05.

Results:

The mean age of the participants was 62.7 years (standard deviation: 13.2); 83.4% were male, and 86.1% underwent primary percutaneous coronary intervention (PCI). Duration from symptom onset to emergency department presentation was 60 minutes in both cohorts (interquartile range, IQR: 30 to 150 in Cohort I versus 30 to 152 in Cohort II, p = 0.273). Total ischemic time was 132 minutes in Cohort I (IQR: 94 to 222), and 117 minutes in Cohort II (IQR: 76.3 to 185.6) (p = 0.159). The observed STEMI time delays and performance metrics were comparable between groups, with reperfusion rates within the recommended time frame above 90% in both cohorts. Hospital mortality was 3.4% in Cohort I and 7.3% in Cohort II (p = 0.376).

Conclusion:

In the context of the COVID-19 pandemic, within a private healthcare network system in Brazil, this study did not uncover statistically significant disparities in clinical profiles, time intervals, performance metrics, or in-hospital mortality when compared to the pre-pandemic period.

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Editorial

Challenges in Worldwide Cardiovascular Urgencies and Emergencies

Daniel Piskorz et al. Ignacio Piskorz

The Sustainable Health Agenda for the Americas 2018-2030 represents the highest level of strategic planning and policy framework in the Americas. Approved by the Pan American Sanitary Conference — the top authority of the Pan American Health Organization (PAHO) — one of its main objectives is to achieve the highest attainable standard of health care. In this context, timely, affordable, and high-quality access to urgent and emergency health care is an essential requirement. The original research by Uchimura et al. aimed to identify the various challenges that hinder the effectiveness of urgent and emergency care networks. These challenges include inadequate regulatory mechanisms, difficulties in financial management across different levels of government, a lack of evaluation and monitoring culture, and weaknesses in information systems.

Over the past decade, the mortality profile in the Americas was dominated by noncommunicable diseases, which accounted for 78% of all deaths. The leading causes of death in the region were ischemic heart diseases (I20-I25), which accounted for 14.1% of total deaths, and cerebrovascular diseases (I60-I69), which accounted for 7.2% of total deaths.

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Editorial

The COVID-19 Collateral Damage in ST-Elevation Myocardial Infarctions in Low/Middle-Income American Regions

Karen Alexandra Dueñas-Criado et al. Oscar Maurício Perez-Fernandez

For this issue of the International Journal of Cardiovascular Sciences, we would like to discuss the post-coronavirus disease 2019 (COVID-19) pandemic effects on performance measures in patients with ST-segment elevation myocardial infarction (STEMI) in a low/middle-income country.

In the Americas, cardiovascular diseases, mainly ischemic heart disease and cerebrovascular disease (stroke), are the leading causes of long-term disability and mortality. Over three quarters of heart disease and stroke-related deaths occur in low- and middle-income countries. In the Americas region, during the last 3 years, more than 190.3 million people have been diagnosed with COVID-19, and more than 2.9 million people have died, according to Pan American Health Organization statistics from March 2023. As of 12 July 2023, more than 2 billion doses of vaccination against COVID-19 had been applied in the region to about 700 million people with a 3-dose regimen.

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Editorial

Quality of Life Assessment in Patients With ST-Elevation Myocardial Infarction (STEMI): An Opportunity to Improve the Quality of Care That Should Not Be Missed

Ana Teresa Timóteo

In chronic diseases, the Quality of Life (QoL) is one of the most important patient-reported outcomes. Cardiovascular diseases are the main cause of death worldwide and ischemic heart disease represents an important health burden. In a large population-based cohort, individuals with self-reported previous myocardial infarction (MI) presented worse self-perceived health statuses in all domains, particularly in mobility and anxiety / depression. However, QoL was not independently associated with MI but instead was associated with age, sex and number of comorbidities, which were significantly higher in patients with prior MI. In this study, long-term QoL was more impaired in men, as compared to women. Nevertheless, in population-based cohorts, we have many possible pitfalls, considering that a diagnosis of MI and other chronic diseases is self-reported; therefore, it is impossible to confirm this diagnosis. It is also impossible to differentiate between ST-elevation MI (STEMI) and non-STEMI, and it is rarely possible to assess the QoL at the same point in time after MI. In fact, we can expect QoL to be much different in the first few months after MI when compared with the QoL several years later.

A more structured study was performed in Australia, in which the QoL was assessed at earlier time points (4 weeks and 6 months). The study sample consisted primarily of males (representing more than 75%), but with a mean age similar to previous studies in MI populations. Health-related QoL improved at 6 months following primary percutaneous coronary intervention for physical and mental health. All aspects of cardiac-specific health status had improved (physical limitation, anginal frequency, treatment satisfaction, and QoL), except for angina stability. Patients aged ≥ 70 years had poorer physical QoL and physical limitations, but better mental QoL at both time points. However, patients were from a specific remote geographic region and were included in 2010 and 2011. Therefore, this did not represent a contemporary sample of patients, and it does not reflect current treatment standards. All in all, those results are not comparable with current populations of STEMI patients from different regions around the world.

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Editorial

ST-Elevation Myocardial Infarction and COVID-19: Is There a Synergistic Effect?

Eduardo Martelli Moreira et al. Bernardo Augusto Rosário Pedro Felipe Gomes Nicz

The SARS-CoV-2 pandemic has widely and profoundly impacted cardiovascular care worldwide. In Brazil, a decrease in emergency department visits for chest pain has been witnessed in both public and private healthcare providers.^, There has been a 23% reduction in weekly emergency department visits for chest pain, from 13.0 to 10.1 per 100.000 habitants, in public health services in Curitiba, Paraná. Private emergency departments have reported an even higher 42% reduction in suspected acute coronary syndrome presentations. A meta-analysis of 12 international studies, conducted with50,123 patients, has shown a nearly 25% decline, from 11.0 to 8.2, in ST-elevation myocardial infarction (STEMI) daily admissions during the pandemic. Although no increase in symptom onset to first medical contact (patient delay) was reported, there was an increase in door-to-balloon time, and no change in mortality was reported.

In this edition of the International Journal of Cardiovascular Sciences, Vargas et al. report on the impact of the COVID-19 pandemic concerning the reperfusion times of 336 patients who underwent primary angioplasty for STEMI at a single, mid-sized, tertiary center in Passos, Minas Gerais, Brazil. This was a retrospective, before-and-after study carried out between January 1, 2018, and August 31, 2021.

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Original Article

Quality of Life in Patients After Acute ST-Segment Elevation Myocardial Infarction

Bárbara de Matos Santos et al. Itana Samara Santana Guimarães Katia de Miranda Avena Ivan de Mattos Paiva Filho Pollianna de Souza Roriz

Abstract

Background:

ST-segment elevation myocardial infarction (STEMI) is the acute coronary syndrome with the highest severity and mortality. It can affect physical health and well-being of patients, and consequently their quality of life (QoL).

Objective:

To describe the QoL of patients at 30 days and 180 days after STEMI, focusing on sex differences and repercussions on physical and mental dimensions.

Methods:

Observational study with 174 STEMI patients included in the study on STEMI conducted in the city of Salvador, Brazil (PERSISST). The QoL of patients at 30 days (D30) and 180 days (D180) after the coronary event was assessed using the 12-item short form health survey (SF-12). Physical and mental components of QoL were calculated using the SF-12 OrthoToolKit. Descriptive analysis of data was made using the IBM SPSS software, version 25.0.

Results:

Mean age of participants at D30 and D180 was 57.1±11.4 years and 60.5±10.9 years, respectively, with a higher prevalence of men (55.8% and 56.8%). In general, patients had a poor QoL at both time points (scores 49.1±8.9 and 49.9±8.4, respectively). Analysis by sex, however, showed that men had a good QoL at both 30D (score 51.8±7.4) and 180 D (score 51.3±7.7), whereas a poor QoL was found among women at these time points (45.7±9.6 and 48.1±9.0, respectively). Men showed higher physical and mental health scale scores than women at both D30 and D180, and there was a greater impairment of the physical component in both sexes.

Conclusion:

Patients had poor QoL at 30 days and 180 days after STEMI, with a greater impairment of the physical component and a worse QoL perception among women than men at both time points.

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Original Article

The Impact of the COVID-19 Pandemic on ST Elevation Myocardial Infarction Care Indicators at a Public Hospital in Brazil

Túlio Torres Vargas et al. Lucas Yuji Sonoda Maria da Graça Lepre Hawerroth Stefania de Figueiredo Coutinho … Gabriela Gonçalves Ferreira Mariane da Mata Morato Mendes Marilene Ribeiro Almeida Costa André Schmidt Antonio Pazin Filho

Abstract

Background

International publications have shown that the COVID-19 pandemic has negatively impacted the indicators of care for ST-segment elevation acute myocardial infarction (STEMI), with a potential increase in morbidity and mortality.

Objectives

To compare mortality, time from symptom onset to primary angioplasty (total delay [TD]), time from symptom onset to initial medical contact (patient delay [PD]), and time from initial medical contact to guidewire insertion in the hemodynamics laboratory (system delay [SD]) among patients admitted for STEMI at the Hemodynamics Service of Santa Casa de Passos, Minas Gerais, Brazil before and after the declaration of the COVID-19 pandemic by the World Health Organization, assessing the impact of the COVID-19 pandemic on STEMI care indicators.

Methods

This is a before-and-after study involving patients hospitalized with STEMI undergoing primary angioplasty. Data were collected retrospectively through medical record review. Clinical and demographic profiles and outcomes between the pre-pandemic and pandemic groups were compared using the chi-square test for categorical variables or Student’s t-test for continuous variables. A significance level of p < 0.05 was adopted.

Results

There were no differences in TD (pre-pandemic: 300 min [± 159 min], 95% CI 277.1 to 322.6; pandemic: 300 min [± 148 min], 95% CI 274.3 to 326.6, p = 0.97). However, there was an increase in SD (pre-pandemic: 145 min [± 97 min], 95% CI 122.7 to 167.9; pandemic: 178 min [± 96 min], 95% CI 157.4 to 197.9, p = 0.037). There was no increase in PD (pre-pandemic: 145 min ± 133 min; pandemic: 130 min ± 117 min, p = 0.44), and no differences in mortality were observed (pre-pandemic: 9.7%; pandemic: 12%, p = 0.49).

Conclusion

The COVID-19 pandemic increased SD in the management of STEMI in the region of Passos, Minas Gerais. There were no differences in PD, TD, and in-hospital mortality.

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Editorial

After a STEMI, is Less Sugar more Protective to Myocardium?

Rafael Willain Lopes et al. Alexandre Hohl

The infarct size reduction in acute myocardial infarction (AMI) has been studied for more than 50 years. Animal experiments were conducted in the 1970s, followed by the first clinical studies to reduce infarct size (IS), with fibrinolytic agents or with mechanical coronary angioplasty (PTCA). The clinical experience of coronary reperfusion indicated that left ventricle function was not normalized in 30% of the patients, and despite unblocking the epicardial vessel, demonstrated hemodynamically, there was no equivalent in myocardial perfusion. New concepts emerged such as reperfusion injury, microvascular dysfunction, “no-reflow” phenomenon, and stunned and hibernating myocardium, which became the focus of basic research and clinical investigation. To improve characterization, different technologies were used, such as contrast echocardiography, isotopic studies, including positron emission tomography, and magnetic resonance.

Cardioprotection (CP) aims to reduce IS and improve clinical outcomes. The translation of CP from preclinical and promising proof-of-concept studies to clinical benefit (CB) for patients has been quite unsatisfactory. Almost all these studies that did not translate into CB had infarct size reduction as the primary endpoint and used protocols selected to achieve IS reduction.

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Editorial

Association between the Average Ratio of Platelet Volume and the Presence of Mural Thrombus in Post-Myocardial Infarction

Fernando Augusto Alves da Costa

Cardiovascular disease is a serious public health problem, responsible for 31% of all deaths worldwide. Population growth, urbanization and the lack of proper policies to control modifiable risk factors lead to an increased number in cases. Associated with this, we have new factors such as stress, pollution, income, unemployment, among others, which, associated with classical factors, increase the speed of atherosclerosis development. Acute ischemic syndromes are some of the worst consequences of the evolution of atherosclerosis, with mortality rates varying according to the type of infarction, place of care and the healthcare resources available.

Among the types of infarction, those with ST segment elevation (STEMI), particularly in the anterior wall, present peculiarities in their natural history, and may lead to complications, such as sudden death, heart failure and embolic events, usually due to the formation of apical thrombus (AT) in the left ventricle.

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Case Report

The Association between Covid-19 and ST Elevation Myocardial Infarction: Variable Clinical Presentations on a Case Report Series

Vinicius Esteves et al. Cleverson Neves Zukowski Fabio Augusto de Luca Italo Bruno dos Santos Sousa … Bruno Santana Bandeira Angelina Camiletti Guilherme Arruda André Feldman Olga Ferreira de Souza

Introduction

The current global pandemic caused by the new coronavirus (COVID-19) already reaches 185 countries with approximately 3 million infected people and more than 200 thousand deaths.^, With continental dimensions and an elevated socioeconomic disparity, Brazil, by the beginning of May, presents with increasing infection rates and mortality close to 8%. The numbers may be higher considering the lack of adequate testing of the population and healthcare professionals.

According to the World Health Organization (WHO), cardiovascular diseases represent the leading cause of deaths around the world. . Recent reports confirmed that patients with cardiovascular comorbidities are at a higher risk to develop the most severe form of the COVID-19.^– The association between these two pathologies can lead to high morbidity and mortality rates and has been the object of continuous efforts by the medical community. In this sense the management of Acute Coronary Syndrome (ACS) has undergone changes in both diagnosis and treatment since the beginning of the pandemic.^– Another aggravating factor regarding the approach of ACS during this period is the multiple clinical presentations and differential diagnosis associated with COVID-19, such as myopericarditis, pulmonary embolism and arrhythmia.^–

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Brief Communication

Takotsubo Syndrome in the Context of Transmural Acute Myocardial Infarction: Prevalence and How to Differentiate?

João Paulo Soares Costa et al. Luiz Eduardo Fonteles Ritt Rafael Modesto Fernandes Felipe Alvarenga Duarte Campos … Queila Borges Eduardo Sahade Darzé

Introduction

Takotsubo syndrome (TTS) is characterized by transient left ventricular dysfunction culminating in acute cardiac dysfunction. It is frequently preceded by emotional or physical stress.^,

The most common symptoms at presentation are chest pain and dyspnea. Because the presentation of TTS is similar to that of acute coronary syndrome (ACS), the differential diagnosis is difficult, especially from ST-elevation myocardial infarction (STEMI). Absence of coronary artery disease in the affected area must be confirmed to establish the diagnosis of TTS. To facilitate the diagnosis of TTS, the European Society of Cardiology has recently developed the InterTAK diagnostic score, a promising tool that estimates the probability of a TTS event.^,

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