The impact of primary percutaneous coronary intervention strategies during st-elevation myocardial infarction on the prevalence of coronary microvascular dysfunction
Authors: Aldujeli A , Unikas R , Grabauskyte I , Tatarunas V , Jarasuniene D , Pranculis A , Patel R , Khalifeh H , Briedis K , Hamadeh A , Ordiene R , Braukyliene R , Haq A 
Published: November 2023

Abstract

Introduction
Up to 20% of ST-elevation myocardial infarction (STEMI) patients who undergo primary percutaneous coronary intervention (PCI) continue to have persistent angina, which is considered to be a significant side effect of reperfusion therapy and is associated with coronary microvascular dysfunction (CMD).

Purpose
To determine if there is a correlation between the technique employed in primary PCI in STEMI patients and the prevalence of CMD after reperfusion.

Methods
This is a prospective single-blinded observational cohort study conducted in a tertiary cardiac care center in the republic of Lithuania. The study enrolled STEMI patients with multivessel coronary artery disease who underwent primary PCI. Three months later, participants underwent staged PCI of their non-culprit vessels and evaluation for CMD. CMD was defined as an index of microcirculatory resistance (IMR) value ≥ 25 U and a coronary flow reserve (CFR) value &lt; 2.5 U. PCI technique, such as direct stenting or conventional stenting (balloon angioplasty followed by stenting), aspiration thrombectomy, and intracoronary glycoprotein IIb/IIIa inhibitor administration, were prospectively documented. We tested for overall differences in patient characteristics and outcomes between groups using Chi-Square (or Kruskal-Wallis) tests and used the Holm-Bonferroni adjustment (or Dunn's tests) for subsequent pairwise tests. We also performed logistic regression.

Results
200 patients were enrolled, with 96 (48%) and 104 (52%), respectively, undergoing direct and conventional stenting. The median age was 65.5 [58, 76] years, most patients were men (59.5%) and 46 patients (23%) met criteria for CMD. Baseline characteristics and risk factors were similar between those with and without CMD. Patients who underwent direct stenting were less likely to suffer from CMD compared to those who underwent conventional stenting (10 (10.4%) vs 36 (34.6%); p &lt; 0.001). In the logistic multivariable analysis, direct stenting, aspiration thrombectomy, and administrations of glycoprotein IIb/IIIa had a ROC AUC of 0.765, indicating good predictive ability. In this particular model, direct stenting, aspiration thrombectomy, and the administration of an intracoronary glycoprotein IIb/IIIa inhibitor were associated with decreased odds of the presence of CMD (OR: 0.193, 95% CI: 0.087-0.430, p &lt; 0.001), (OR: 0.243, 95% CI: 0.086-0.688, p = 0.008), and (OR: 0.200, 95% CI: 0.065-0.620, p = 0.005), respectively.

Conclusion
In STEMI patients undergoing primary PCI, direct stenting is associated with reduced prevalence of CMD compared with conventional stenting. Furthermore, performing aspiration thrombectomy and administering a glycoprotein IIb/IIIa inhibitor was also associated with a lower prevalence of CMD.Forest plot for the outcome of CMDROC for the model of CMD