Coronary Thrombosis – ABC CARDIOL

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Editorial

Are We Reaching the End of the Evolutionary Road to Metallic Drug-Eluting Stents? Which 4th Generation Stents Do We Need?

Stents are the cornerstone of current PCI. It guarantees safety, a predictable acute angiographic upshot, and long-term acceptable clinical outcomes.

Its current accomplishment is, undoubtedly, linked to a successful evolutionary road driven by continuous unmet medical needs endured by device companies eager to gain market shares.

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Editorial

In Search of the Perfect Coronary Perfusion

Carlos Eduardo Lucena Montenegro

Since medical school, we always heard that “time is muscle” and that the faster we reperfuse a culprit artery in acute coronary syndrome (ACS), the better for the patient. Over time, evidence-based cardiology has taught us that not every patent artery is the same. The fact that we have an artery with a “TIMI 3” flow seemed enough to define the patient’s prognosis, but after the concept of microvascular ischemia, we also started to care about small-vessel perfusion.^,

Based on this concern, came the concept of ‘no reflow’, which means that even after the recanalization of a culprit artery, the tissue flow related to that myocardial territory might not be reestablished. Going back in time, the phenomenon of slow flow has been described since 1972, defined as delayed coronary opacification in the absence of epicardial obstructive coronary disease, while maintaining myocardial perfusion. Slow flow seems to be more common in patients with metabolic syndrome, in the male gender and smokers. Both the phenomenon of no reflow and slow flow are associated with significant cardiovascular outcomes, the first being related to ventricular dysfunction and cardiac remodeling^, and the latter, to cases of ventricular arrhythmias or sudden death,^, in addition to refractory angina.

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Case Report

Beyond Atherothrombotic Disease in Acute Coronary Syndrome

Mayra Alejandra Mora et al. Manuela Molano-Perez Cristian Orlando Becerra-Gonzalez Kenny Buitrago-Toro … Silvana Jimenez-Salazar Carlos Ortiz

Abstract

Half of the global population over 20 years of age will be affected by cardiovascular disease. Cardiovascular events in young people is challenging. Spontaneous coronary artery dissection is a non-traumatic and non-iatrogenic separation of the coronary arterial wall and is an uncommon and underdiagnosed cause of acute myocardial infarction predominately found in young women. Medical management has been more widely accepted, with percutaneous and surgery treatment reserved for precise indications. Optimal control of individual risk factors is essential in order to avoid recurrences.

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Acute Myocardial Infarction with Coronary Thrombosis in a Covid-19 Patient without Risk Factors for Cardiovascular Disease

Tainá Viana et al. Mariana Lins Baptista Guedes Bezerra Rodrigo Morel Vieira de Melo Cristiano Guedes Bezerra … Vítor Mamédio Gabriela Pio Dourado Clara Salles Figueiredo Luiz Carlos Santana Passos

Case Report

A 32-year-old young man, without cardiovascular risk factors, sought an Emergency Unit due to severe chest pain 30 minutes before admission, without irradiation. Admission vital signs: T 36.1°C, heart rate of 89 bpm and peripheral O₂ saturation of 96% in room air. During systematic interrogation, anosmia and ageusia were reported two days ago and fever or any other respiratory symptom was denied.

He was previously healthy and denied use of illicit drugs or previous history of angina. He denies a family history of acute myocardial infarction or coronary artery disease.

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Original Article

Outcomes in Coronary No-Reflow Phenomenon Patients and the Relationship between Kidney Injury Molecule-1 and Coronary No-Reflow Phenomenon

Mustafa Ahmet Huyut et al. Aylin Hatice Yamac

Abstract

Background

Coronary no-reflow phenomenon (CNP) is associated with an increased risk of major cardiovascular adverse events (MACE).

Objective

This study aimed to evaluate the relationship between serum Kidney Injury Molecule-1 (KIM-1) levels and CNP in patients with acute ST-segment elevation myocardial infarction (STEMI).

Methods

This study included a total of 160 patients (113 males and 47 females; mean age: 61.65±12.14 years) who were diagnosed with STEMI. The patients were divided into two groups, the reflow group (RG) (n=140) and the no-reflow group (NRG) (n=20). Patients were followed during one year. A p-value of <0.05 was considered significant.

Results

CNP was observed in 12.50% of the patients. Serum KIM-1 was significantly higher in the NRG than in the RG (20.26±7,32 vs. 13.45±6.40, p<0.001). Body mass index (BMI) was significantly higher in the NRG than in the RG (29.41 (28.48-31.23) vs. 27.56 (25.44-31.03), p=0.047). Heart rate (HR) was significantly lower in the NRG than in the RG (61.6±8.04 vs. 80.37±14.61, p<0.001). The European System for Cardiac Operative Risk Evaluation II (EuroSCORE II) was significantly higher in the NRG than in the RG (3.06±2.22 vs. 2.36±2.85, p=0.016). The incidence of stroke was significantly higher in the NRG than in the RG (15% vs. 2.90%, p=0.013). The baseline KIM-1 level (OR=1.19, 95% CI:1.07 to 1.34, p=0.002) and HR (OR=0.784, 95% CI:0.69 to 0.88, p<0.001) were the independent predictors of CNP.

Conclusion

In conclusion, baseline serum KIM-1 concentrations and lower HR are independently associated with CNP in STEMI patients and the incidence of stroke was significantly higher in the NRG in the one-year follow-up. (Arq Bras Cardiol. 2021; 116(2):238-247)

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Original Article

Clinical Significance of Platelet Volume and Other Platelet Parameters in Acute Myocardial Infarction and Stable Coronary Artery Disease

Liumei Ding et al. Lihua Sun Feng Wang Liejun Zhu … Ting Zhang Fanli Hua

Abstract

Background:

Platelets are important in the initiation of thrombosis, and their morphological and functional changes are closely related with the occurrence and development of coronary artery thrombosis. Platelet parameters might be valuable in distinguishing between acute myocardial infarction (AMI) and stable coronary artery disease (SCAD).

Objective:

This study was designed to detect and compare changes in platelet parameters, such as mean platelet volume (MPV) in patients with acute myocardial infarction (AMI) and stable coronary artery disease (SCAD) and to investigate their roles in these diseases.

Methods:

Specimen collection: Between January 2011 and December 2013, 2 mL of elbow vein blood was drawn from each of 31 patients primarily diagnosed with AMI, 34 SCAD patients and 50 healthy subjects; and placed in EDTA-K2 anticoagulant tubes. Platelet count (PLT), MPV, plateletcrit (PCT), platelet distribution width (PDW), white blood cell (WBC) and neutrophil (NEU) counts were determined using an STKS automated hematology analyzer (Beckman Courter).

Results:

Compared with the control group, MPV levels were significantly higher in the AMI and SCAD groups (p < 0.05), while PLT was significantly lower (p < 0.05).

Conclusion:

These results suggest that MPV and other related parameters have a certain value in the diagnosis of SCAD and AMI.

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Artigo Original

Clinical significance of histological features of thrombi in patients with myocardial infarction

Juliana Canedo Sebben et al. Eduardo Cambruzzi Luisa Martins Avena Cristina do Amaral Gazeta … Carlos Antonio Mascia Gottschall Alexandre Schaan de Quadros

BACKGROUND: Percutaneous Coronary Intervention (PCI) is the most common strategy for the treatment of Acute ST segment elevation Myocardia Infarction (STEMI), and thromboaspiration has been increasingly utilized for removal of occlusive thrombi. OBJECTIVES: To analyze the influence of histopathological features of coronary thrombi in clinical outcomes of patients with STEMI, and the association of these variables with clinical, angiographic, and laboratory features and medications used in hospitalization. METHODS: Prospective cohort study. All patients were monitored during hospitalization and thirty days after the event. Aspirated thrombi were preserved in formalin and subsequently stained with hematoxylin-eosin and embedded in paraffin. Thrombi were classified as recent and old. The primary outcome was the occurrence of major cardiovascular events within thirty days. RESULTS: During the study period, 1,149 patients were evaluated with STEMI, and 331 patients underwent thrombi aspiration, leaving 199 patients available for analysis. It was identified recent thrombi in 116 patients (58%) and old thrombi in 83 patients (42%). Recent thrombi have greater infiltration of red blood cells than old thrombi (p = 0.02), but there were no statistically significant differences between other clinical, angiographic, laboratory, and histopathological features and medications in both group of patients. The rates of clinical outcomes were similar in both groups. CONCLUSIONS: Recent thrombi were identified in 58% of patients with STEMI and it was observed an association with infiltration of red blood cells. There was no association between histopathological features of thrombi and clinical variables and cardiovascular outcomes.

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Artigo Original

High on-treatment platelet reactivity predicts cardiac events in patients with drug-eluting stents

Aline Sterque Villacorta et al. Humberto Villacorta Junior Marcos J. S. Batista Renato Villela Gomes … Luiz Augusto Macedo Bruno Helmuth Evandro Tinoco Mesquita

BACKGROUND: The role of platelet reactivity (PR) tests in the prediction of long-term events in Latin-American patients treated with drug-eluting stents (DES) has not been established. OBJECTIVES: To assess the role of PR tests in the prediction of events after DES implantation. METHODS: From May 2006 through January 2008, 209 Brazilian patients who underwent elective treatment with DES were included. PR was assessed 12 to 18h after the procedure by light transmittance aggregometry with 5µM of ADP. Patients were prospectively followed for up to 4.8 years. Seventeen (8%) individuals were lost to follow-up and the final cohort comprised 192 patients. Receiver operating curve (ROC) was used to determine the best 5µM of ADP cutoff to predict events. The primary endpoint was a combination of cardiovascular death, acute myocardial infarction, definite stent thrombosis, and target-artery revascularization. Cox proportional hazard models were used to determine the variables independently associated with the time to the first event. RESULTS: The best ADP 5µM cutoff was 33%. One hundred and seven (55.7%) patients had ADP 5µM >33%. Event-free survival rate at 1,800 days was 55% vs. 70% for individuals with ADP5 above and below such cutoff, respectively (p=0.001). Independent predictors of time to first event were current smoking (HR 3.49; 95% CI 1.76-6.9; p=0.0003), ADP 5µM >33% (HR 1.95; 95% CI 1.09-3.51; p=0.025) and age (HR 1.03; 95% CI 1.0-1.06; p=0.041). CONCLUSIONS: In this study, 55.7% of the patients had high on-treatment platelet reactivity. ADP 5µM >33% was an independent predictor of long-term events.

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Case Report

Coronary thrombosis as the first complication of antiphospholipid syndrome

Carlos Henrique Miranda et al. Luís Gustavo Gali José Antônio Marin-Neto Paulo Louzada-Júnior Antônio Pazin-Filho

The antiphospholipid syndrome (APS) is an autoimmune thrombophilia, characterized by the presence of plasma antibodies against phospholipids, associated with recurrent episodes of venous and/or arterial thrombosis and gestational morbidity (especially recurrent miscarriage). We report the case of a young female patient diagnosed with systemic lupus erythematosus (SLE) associated with the presence of antiphospholipid antibodies for a long time, presenting with acute myocardial infarction (AMI) due to proximal thrombosis of the anterior descending artery as the first clinical complication of APS.

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Case Report

Late coronary thrombosis secondary to implantation of paclitaxel-eluting stent without restenosis of conventional stents

Luciano Maurício de Abreu et al. George César Ximenes Meireles Marcos Kiyoshi Sumita Antonio Artur da Cruz Forte … Jose Del Carmen Solano Aliaga Jorge Hayashi

A male 39 year-old patient with post-infarction angina. The coronary angiography showed total proximal obstruction of right coronary artery (RCA), obstructive lesions of 95% of the anterior descending artery (ADA), 80% of the second left marginal branch (LM2), and 95% of the circumflex artery (CXA). The patient was successfully implanted with a Taxus 3.0 x 24 mm stent and an Express 2.75 x 24 mm stent in the proximal and distal thirds of the RCA, respectively, and with an Infinnium 3.0 x 24 mm stent in the ADA. After seven months, the patient had an anterior acute myocardial infarct (AMI) due to thrombosis of the Infinnium stent and restenosis of the Taxus stent, with no loss of results in the conventional stents.

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