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Case Report
Revised

Case Report: Smoking as the risk factor of persistent STEMI after primary percutaneous coronary intervention: how it could be happen?

[version 3; peer review: 2 approved, 1 not approved]
PUBLISHED 29 Oct 2024
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Abstract

Background

Acute coronary syndrome (ACS) remains one of the leading causes of death worldwide. Smoking may also increase the risk of developing ACS. The most advantageous therapy is percutaneous coronary intervention. However, this therapy may fail because of the no-reflow phenomenon. This case report describes a young male patient admitted to the emergency department due to ST-segment elevation of myocardial infarction (STEMI), with smoking as the only risk factor.

Case description

A 37-year-old male presented to our hospital with a typical chest pain. He was a heavy smoker. Electrocardiography (ECG) revealed extensive anterior STEMI. Coronary angiography revealed total occlusion of the proximal left anterior descending artery (LAD) with a high-burden thrombus. The no-reflow phenomenon occurs during Percutaneous Coronary intervention (PCI). After two days of hospitalization, the patient developed cardiogenic shock and acute decompensated heart failure. The patient was administered ticagrelor, acetylsalicylic acid, enoxaparin for three days, high-dose statins, and optimized heart failure treatment. The patient was discharged on the 7th day after admission.

Discussion

Cigarette smoke chemicals may induce atherosclerosis and thickened blood in the arteries. Lipid oxidation leads to plaque formation. If plaque ruptures, it will cause thrombus occlusion. A high-burden thrombus can induce a no-reflow phenomenon, leading to heart failure and cardiogenic shock.

Conclusion

Smoking may induce STEMI and tends to result in a high-burden thrombus. The no-reflow phenomenon is an evidence of miscarriage during PCI, which may increase because of smoking.

Plain Language Summary

This paper describes a provisional clinical protocol for the pilot human challenge model of Mycobacterium ulcerans infection, which causes the skin disease 'Buruli ulcer' (BU). BU is typically painless and begins as a small area of redness or swelling, and is curable with antibiotics. If the diagnosis is delayed, it can result in large ulceration and disability. Side effects from antibiotics are common but rarely severe; nevertheless, preventative strategies, such as vaccination, are urgently needed. The overarching project, known as 'MuCHIM', aims to establish a safe and acceptable controlled human challenge model (CHIM) of this disease in healthy volunteers in Melbourne, Australia. This pilot protocol primarily aims to establish that it is safe and acceptable to participants, and secondarily to confirm successful establishment of infection and the infection rate amongst participants. We also aim to test less invasive diagnostic tests, assess immune responses to infection, to understand changes in the human microbiome during the trial, and explore microbiological characteristics of M. ulcerans infection. If this pilot is successful, we hope to test vaccines and other therapeutics using this model, which could blunt or reduce the rising incidence of this disease in Australia, while further informing vaccine development research.

Keywords

Smoking; no-reflow phenomenon; STEMI

Revised Amendments from Version 2

There are many changes in the text that we conducted because of the lack of English.
There is also added information in Figures 3 and 5 to make them clear.

See the authors' detailed response to the review by İbrahim Rencüzoğulları

Introduction

Since the early 1960s, the association between smoking and cardiovascular disease (CVD) has been explored in the Framingham Heart and the Seven Countries studies.1 About 26% of ACS patients were active in smoking at hospital administration until one year forward follow-up.1 Acute coronary syndrome (ACS) is one of many CVDs that commonly happens.2 Patients with ACS may develop total occlusion in coronary artery, so ST-elevation myocardial infarction (STEMI) as a result in ECG (Electrocradiogram).3 Percutaneous coronary intervention (PCI) is considered the most promising and rewarding reperfusion strategy.2 The failure in restoring myocardial reperfusion is mostly because of the no-reflow phenomenon.2 The incidence of this phenomenon is about 10–54% of procedures.2 This case report will discuss the correlation between smoking and the no-reflow phenomenon and how it can occur.

Case report

A 37-year-old male presented at our hospital with severe chest pain in the middle of the chest three hours before going to the hospital. The pain was not relieved with rest. He was a high school teacher without medical, familial, or psychosocial history. He was a heavy smoker. The patient's vital signs were as follows: temperature was 36.8°C, heart rate was 69 beats/minute, respiration rate was 23 breaths/minute, and blood pressure was 65/30 mmHg. The first electrocardiogram (ECG) was done in the hospital (Figure 1) revealed extensive anterior acute myocardial infarction (AMI). We administered oxygenation, Ringer Lactate infusion 250 mL, dopamine 4.2 mL/hour, morphine 1 mg/hours, aspirin 400 mg, and clopidogrel 300 mg as the first treatment for the patient. After several hours, his blood pressure increased to 130/80 mmHg. Chest radiography revealed no abnormalities (Figure 2). Blood examination revealed no abnormalities, and the patient was transferred for coronary angiography, which showed total occlusion with a high-burden thrombus in the proximal left anterior descending artery (LAD). Percutaneous coronary intervention (PCI) was performed (Figure 3). A drug-eluting stent (DES) was implanted in the LAD; however, the thrombus returned. The thrombus was aspirated until TIMI 3 flow was achieved.

afe430b5-8cb2-489c-907f-85962bdb46c3_figure1.gif

Figure 1. The first ECG when the patient came to the hospital.

afe430b5-8cb2-489c-907f-85962bdb46c3_figure2.gif

Figure 2. Chest radiography performed in the first hospitalization.

afe430b5-8cb2-489c-907f-85962bdb46c3_figure3.gif

Figure 3. Coronary angiography. A) Normal Right Coronary Artery (RCA); B) Total occlusion in the proximal part of Left Anterior Descending Artery (LAD) and normal Left Circumflex Artery (LCX); C) Guidewire to LAD, there was flow to distal LAD (TIMI 1); D) Suddenly no-reflow and we aspirated thrombus; E) Implanting DES 3.25 × 30 mm to proximal LAD, TIMI 3 flow.

After two days, the patient complained of typical chest pain. We then performed ECG, which showed extensive anterior STEMI (Figure 4). After several hours, the patient became unstable and experienced acute decompensated heart failure (ADHF) with cardiogenic shock. We combined 5 μg/kg/minute dopamine and 5 μg/kg/minute dobutamine to increase the blood pressure. After the hemodynamic was stable, we started to give some medicine from low dose such as bisoprolol 2.5 mg/day, ramipril 2.5 mg/day, furosemide 20 mg/day, spironolactone 25 mg/day, atorvastatin 40 mg/day, aspirin 80 mg/day, nitroglycerin 10 μg/minute, and we changed clopidogrel to ticagrelor 90 mg/12 hours. Other supporting therapies included infusion with normal saline (500 mL/day, alprazolam 0.5 mg/day, and ondansetron 4 mg/day, if needed. The echocardiography of the patient showed coronary artery disease (CAD) with anteroseptal LV hypokinetic, normal LV and mild reduce ejection fraction (EF by teach 51%) (Figure 5). After two days, the patient was in better condition, and the next day the patient was discharged from the hospital.

afe430b5-8cb2-489c-907f-85962bdb46c3_figure4.gif

Figure 4. Patient's ECG when fell into ADHF and cardiogenic shock.

afe430b5-8cb2-489c-907f-85962bdb46c3_figure5.gif

Figure 5. Patient's echocardiography after primary PCI.

Discussion

Cigarette smoke contains about 4,000 different chemical agents considered the most complex and the least understood among cardiovascular risk factors of cardiovascular disease.3 Smoking-related cardiovascular dysfunction caused by toxic components in cigarette smoke has multiple mechanisms, including increased inflammation, oxidation of low-density lipoprotein cholesterol, platelet aggregability, thromboxane production, plasma viscosity, and fibrinogen levels. Smoking also causes alteration of the function of endothelial cells and reduces oxygen supply.4,5

In addition to directly damaging the coronary arteries, smoking also increases the levels of harmful oxidized low-density lipoproteins. It reduces beneficial high-density lipoprotein, thereby contributing to an increase in fatty deposits (plaques) at the site of arterial injury. Smokers have a higher extracellular lipid content in their plaque, which renders it vulnerable to rupture. Endothelial injury and dysfunction promote platelet adhesion and lead to the formation of a blood clots, a process known as thrombosis. Tobacco smoking also induces a hypercoagulable state, which increases the risk of acute thrombosis. Smoking-mediated thrombosis appears to be a significant factor in the pathogenesis of critical cardiovascular events.4

The pathogenesis and risk factors for no-reflow are not entirely understood. Several risk factors have been associated with the risk of a no-reflow phenomenon. Smoking is a risk factor for the incidence of high thrombus burden, which induces the no-reflow phenomenon.6,7 However, several recent studies have shown that smokers experience less of a reflow phenomenon after PCI. Data from Shemirani et al., showed that the incidence of the no-reflow phenomenon was not significantly different between smokers and nonsmokers.2 This finding is still controversial. Theoretically, smoking is associated with the risk of CAD and endothelial dysfunction. Nevertheless, it has been described that the causes of no-reflow are multifactorial. Therefore, smoking cannot be judged as the only factor influencing no-reflow.6

The no-reflow phenomenon (NRP) is the hypoperfusion of myocardial tissue after an occlusion is removed, even though the epicardial coronary arteries are open and patent. NRP is quite common in patients who experience acute ST-elevation myocardial infarction (STEMI) and then receive primary percutaneous coronary intervention (PPCI).810 The process by which NRP occurs has not been clearly described. As in the present case, many factors influence it, including smoking. In addition, the presence of leukocyte infiltration, vasoconstriction, activation of inflammatory pathways, and cellular edema is associated with the phenomenon of the occurrence of NRP.9,10

According to a study by Pantea et al., one-third of patients with NRP experience various complications.8,9 The presence of anterior STEMI and lesions in the left anterior descending artery (LAD) is associated with high incidence of complications in these patients.8 Complications include hemodynamics disturbance, cardiogenic shock, myocardial rupture, pulmonary edema, heart failure, and arrhythmias.8,9 In this case, the patients develop cardiogenic shock and acute decompensated heart failure (ADHF). Cardiogenic shock results from long-term myocardial necrosis and secondary rupture of the free myocardial wall or interventricular septum.8 In addition, in NRP, heart rhythm disturbances occur, which cause ischemia in the long term, resulting in extensive necrosis of the heart myocardium. Furthermore, changes in myocardial function can occur when ejection fraction decreases due to modification of left ventricle (LV) function.8,9 This reduces contractility and increases the risk of acute pulmonary edema and acute heart failure.

Conclusion

Smoking is one of the most common habits in people all over the world. Many adverse effects may occur owing to smoking. One of these is ACS, in which STEMI is one of the diseases included. One of the many therapies that may be used is to reflow the obstruction of blood. Percutaneous coronary intervention (PCI) is one of them, and now it is claimed as the most advantageous reperfusion of the coronary arteries: Failure of this therapy may occur, with the no-reflow phenomenon being most common. Smoking may induce the no-reflow phenomenon and may lead to heart failure, increasing the risk of cardiogenic shock.

Data availability

All data underlying the results are available as part of the article and no additional source data are required.

Consent

Oral informed consent for publication of their clinical details and/or clinical images was obtained from the patient. Oral rather than written consent was obtained because of the patient’s condition and education level of the family, and was approved by the ethical review board of West Nusa Tenggara Province hospital.

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Version 3
VERSION 3 PUBLISHED 18 Jul 2022
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Pintaningrum Y, Yusuf RS, Ramdani BHA et al. Case Report: Smoking as the risk factor of persistent STEMI after primary percutaneous coronary intervention: how it could be happen? [version 3; peer review: 2 approved, 1 not approved]. F1000Research 2024, 11:801 (https://doi.org/10.12688/f1000research.109757.3)
NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.
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Key to Reviewer Statuses VIEW
ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions
Version 3
VERSION 3
PUBLISHED 29 Oct 2024
Revised
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Reviewer Report 31 Oct 2024
İbrahim Rencüzoğulları, Department of Cardiology, Kafkas University School of Medicine, Kars, Turkey 
Approved
VIEWS 2
Dear editor
The changes made and the answers given ... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Rencüzoğulları İ. Reviewer Report For: Case Report: Smoking as the risk factor of persistent STEMI after primary percutaneous coronary intervention: how it could be happen? [version 3; peer review: 2 approved, 1 not approved]. F1000Research 2024, 11:801 (https://doi.org/10.5256/f1000research.173400.r336149)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
Version 2
VERSION 2
PUBLISHED 25 Jul 2023
Revised
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Reviewer Report 03 Oct 2023
İbrahim Rencüzoğulları, Department of Cardiology, Kafkas University School of Medicine, Kars, Turkey 
Approved with Reservations
VIEWS 11
  1. No-reflow phenomenon or short-term complications were not significantly different between current smokers and non smokers in the study of Shemirani H et al (Ref: Shemirani H, Tafti FD, Amirpour A. Comparison of no-reflow phenomenon after percutaneous coronary
... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Rencüzoğulları İ. Reviewer Report For: Case Report: Smoking as the risk factor of persistent STEMI after primary percutaneous coronary intervention: how it could be happen? [version 3; peer review: 2 approved, 1 not approved]. F1000Research 2024, 11:801 (https://doi.org/10.5256/f1000research.152156.r199117)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
  • Author Response 29 Oct 2024
    Ricky Setiadi Yusuf, Cardiovascular, Mataram University, Mataram, 83126, Indonesia
    29 Oct 2024
    Author Response
    1. No-reflow phenomenon or short-term complications were not significantly different between current smokers and non smokers in the study of Shemirani H et al (Ref: Shemirani H, Tafti FD,
    ... Continue reading
COMMENTS ON THIS REPORT
  • Author Response 29 Oct 2024
    Ricky Setiadi Yusuf, Cardiovascular, Mataram University, Mataram, 83126, Indonesia
    29 Oct 2024
    Author Response
    1. No-reflow phenomenon or short-term complications were not significantly different between current smokers and non smokers in the study of Shemirani H et al (Ref: Shemirani H, Tafti FD,
    ... Continue reading
Version 1
VERSION 1
PUBLISHED 18 Jul 2022
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Reviewer Report 08 Nov 2022
Mario Enrico Canonico, Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy 
Not Approved
VIEWS 12
The Authors show the manuscript entitled "Case Report: Smoking as the risk factor of persistent STEMI after primary percutaneous coronary intervention: how it could be happen?"

Some comments:
  • How did the Authors assessed
... Continue reading
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Canonico ME. Reviewer Report For: Case Report: Smoking as the risk factor of persistent STEMI after primary percutaneous coronary intervention: how it could be happen? [version 3; peer review: 2 approved, 1 not approved]. F1000Research 2024, 11:801 (https://doi.org/10.5256/f1000research.121300.r153430)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
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Reviewer Report 13 Sep 2022
Cut Aryfa Andra, Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Sumatera Utara, Medan, Indonesia;  H. Adam Malik Hospital, Medan, Indonesia 
Approved
VIEWS 13
This case report is interesting and deserves to be studied, where it is said that many chemicals in cigarettes can cause lipid oxidation so that plaque deposits. The article explained that there can be a no-reflow phenomenon (NRP), where there ... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Andra CA. Reviewer Report For: Case Report: Smoking as the risk factor of persistent STEMI after primary percutaneous coronary intervention: how it could be happen? [version 3; peer review: 2 approved, 1 not approved]. F1000Research 2024, 11:801 (https://doi.org/10.5256/f1000research.121300.r148891)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.

Comments on this article Comments (0)

Version 3
VERSION 3 PUBLISHED 18 Jul 2022
Comment
Alongside their report, reviewers assign a status to the article:
Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions
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