Optimizing the treatment approach for ST-segment elevation myocardial infarction in the chest leads

BACKGROUND: The treatment of ST-segment elevation myocardial infarction (STEMI) in both chest and other leads chose a single course of mandatory use of percutaneous coronary interventions (PCI) in the first 12 h from the onset of pain. However, a significant proportion of patients, often older age groups, are hospitalized at later terms. Thus, studying the efficiency of primary PCIs in different age groups is of interest, considering the terms of hospitalization and characteristics of thanatogenesis in the absence of reperfusion therapy and with its use.

AIM: This study aimed to optimize the treatment approach of patients with STEMI in the chest leads using the primary percutaneous coronary interventions (PCI) during hospitalization in the first 12 h and subsequent 12–72 h, taking into account the initial risk of death at different ages groups.

MATERIALS AND METHODS: The study included 804 patients with anterior STEMI, who were admitted to the institute from 2008 to 2017. Early PCI was performed in the first 12 h in 311 patients, whereas 272 patients underwent delayed interventions at hospitalization after 12–72 h; additionally, 221 patients, including 124 cases with coronary angiography with late hospitalization, received drug therapy. In early PCI, the ratio of individuals under 65 years, 65–75 years, and over 75 years were 176, 73, and 62, whereas 164, 66, and 42 in delayed PCI, and 126, 47, and 48 without intervention, respectively. In 26 deceased patients after PCI and 39 patients without interventions, the state of the coronary arteries (CA), the area of left ventricular (LV) lesion, and the cause of death were determined.

RESULTS: The absence of reperfusion therapy in the form of PCI in anterior STEMI was established to lead to a progressive decreased myocardial contractile function and formation of an extensive LV aneurysm and high mortality rate, especially in older age groups. Early PCI preserves the contractile function, prevents the LV aneurysm, and significantly reduces mortality. The use of delayed PCI prevents LV dysfunction progression, limits the formation of LV aneurysm, and reduces mortality, which remains high in the absence of PCI. However, delayed PCI, contrary to early used interventions without age restrictions, is mainly performed for isolated lesions, much less often for multiple lesions that are more often present in elderly and senile people. Severe CA disease in these categories of patients increases the risk of intraprocedural complications. Nevertheless, without PCI, a lethal outcome is inevitable in many of them. Thanatogenesis in anterior STEMI is based on the proximal lesion of the anterior interventricular branch in combination with three-vessel CA disease, which causes an extensive infarction area with fatal complications.

CONCLUSIONS: The delayed PCI, by analogy with early used procedures without limitations, optimizes the treatment approach of MI with ST-segment elevation in the chest leads and minimizes mortality in all age groups.