Contrast-induced nephropathy in patients undergoing primary angioplasty for acute myocardial infarction

OBJECTIVES: The aim of this research was to assess the incidence, clinical predictors, and outcome of contrast-induced nephropathy (CIN) after primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI). BACKGROUND: Contrast-induced nephropathy is associated with significant morbidity and mortality after PCI. Patients undergoing primary PCI may be at higher risk of CIN because of hemodynamic instability and unfeasibility of adequate prophylaxis. METHODS: In 208 consecutive AMI patients undergoing primary PCI, we measured serum creatinine concentration (Cr) at baseline and each day for the following three days. Contrast-induced nephropathy was defined as a rise in Cr >0.5 mg/dl. RESULTS: Overall, CIN occurred in 40 (19%) patients. Of the 160 patients with baseline Cr clearance >/=60 ml/min, only 21 (13%) developed CIN, whereas it occurred in 19 (40%) of those with Cr clearance <60 ml/min (p < 0.0001). In multivariate analysis, age >75 years (odds ratio [OR] 5.28, 95% confidence interval [CI] 1.98 to 14.05; p = 0.0009), anterior infarction (OR 2.17, 95% CI 0.88 to 5.34; p = 0.09), time-to-reperfusion >6 h (OR 2.51, 95% CI 1.01 to 6.16; p = 0.04), contrast agent volume >300 ml (OR 2.80, 95% CI 1.17 to 6.68; p = 0.02) and use of intraaortic balloon (OR 15.51, 95% CI 4.65 to 51.64; p < 0.0001) were independent correlates of CIN. Patients developing CIN had longer hospital stay (13 +/- 7 days vs. 8 +/- 3 days; p < 0.001), more complicated clinical course, and significantly higher mortality rate (31% vs. 0.6%; p < 0.001). CONCLUSIONS: Contrast-induced nephropathy frequently complicates primary PCI, even in patients with normal renal function. It is associated with higher in-hospital complication rate and mortality. Thus, preventive strategies are needed, particularly in high-risk patients.     

Short- and long-term mortality for patients undergoing primary angioplasty for acute myocardial infarction

OBJECTIVES: The goal of this study was to learn more about the risk factors and short- and long-term outcomes for primary angioplasty. BACKGROUND: Primary angioplasty (direct angioplasty without antecedent thrombolytic therapy) has been an effective alternative to thrombolytic therapy for patients with acute myocardial infarction (AMI). However, most reported studies have been compromised by small sample sizes and short observation times. METHODS: New York's coronary angioplasty registry was used to identify New York patients undergoing angioplasty within 6 h of AMI between January 1, 1993 and December 31, 1996. Statistical models were used to identify significant risk factors for in-patient and long-term survival and to estimate long-term survival for all patients as well as various subsets of patients undergoing primary angioplasty. RESULTS: The in-hospital mortality rate for all primary angioplasty patients was 5.81%. When patients in preprocedural shock (who had a mortality rate of 45%) were excluded, the in-hospital mortality rate dropped to 2.60%. Mortality rates for all primary angioplasty patients at one year, two years and three years were 9.3%, 11.3% and 12.6%, respectively. Patients treated with stent placement did not have significantly lower risk-adjusted in-patient or two-year mortality rates. CONCLUSIONS: Primary angioplasty is a highly effective option for AMI.     

Impact of stenting and abciximab in patients with diabetes mellitus undergoing primary angioplasty in acute myocardial infarction (the CADILLAC trial)

We sought to determine the benefits of stent implantation and abciximab in patients with diabetes mellitus and acute myocardial infarction (AMI) who underwent primary angioplasty. In a 2-by-2 factorial design, 2,082 patients with AMI were randomly assigned to balloon angioplasty versus stenting, with or without abciximab. Diabetes was present in 346 patients (16.6%). The primary end point was the composite incidence of death, disabling stroke, reinfarction, and ischemic target vessel revascularization (TVR). The primary end point at 1 year occurred significantly more frequently in diabetic than nondiabetic patients (21.9% vs 16.8%, p <0.02), driven by increased rates of death (6.1% vs 3.9%, p = 0.04) and TVR (16.4% vs 12.7%, p = 0.07). Among patients with diabetes, TVR at 1 year was significantly reduced with routine stenting compared with balloon angioplasty (10.3% vs 22.4%, p = 0.004), with no differences in death, reinfarction, or stroke. Angiographic restenosis was also greatly reduced in diabetics randomized to stenting (21.1% vs 47.6%, p = 0.009). No beneficial effects were apparent with abciximab in diabetic patients at 1 year. Despite the improved outcomes with stenting in patients with diabetes, 1-year mortality remained increased in diabetic patients who received stents compared with nondiabetics (8.2% vs 3.6%, p = 0.005). Thus, routine stent implantation in diabetic patients with AMI significantly reduces restenosis and enhances survival free from TVR, independent of abciximab use, although survival remains reduced compared with survival in nondiabetic patients regardless of reperfusion modality.     

Correlates of bundle-branch block in patients undergoing primary angioplasty for acute myocardial infarction.

BACKGROUND: Early reperfusion therapy has reduced the infarct size and mortality rate in patients with acute myocardial infarction (AMI). The occurrence of bundle-branch block in AMI is related to the amount of myocardial damage and the insult to the conduction system. HYPOTHESIS: To evaluate the clinical and angiographic factors related to the occurrence of bundle-branch block (BBB) in patients with primary percutaneous transluminal coronary angioplasty (PTCA), we investigated consecutive series of patients with their first Q-wave AMI and successful PTCA. METHODS: Coronary angiogram at the time of admission, electrocardiogram, and echocardiogram were evaluated in 279 patients with their first Q-wave AMI and successful PTCA. RESULTS: Bundle-branch block was detected in 26 patients (9%); 16 patients had transient and 10 patients had persistent block, while 16 patients had bifascicular block and 10 patients had right BBB. The patients with BBB had a significantly larger number of left ventricular asynergic segments, higher incidence of total occlusion of infarct-related artery, angiographic no reflow, and pericardial rub than those without BBB. When the multivariate analysis was performed using five clinical markers of infarct severity, angiographic no reflow (F = 20.2, p < 0.001) and total occlusion of infarct-re-lated artery (F = 4.2, p = 0.04) were found to be the significant variables related to BBB. CONCLUSIONS: Despite successful primary PTCA, absence of antegrade flow in the infarct-related artery at the onset of AMI and/or angiographic no reflow resulted in more severe transmural myocardial damage and, hence, the occurrence of BBB.     

Impact of in-hospital acquired thrombocytopenia in patients undergoing primary angioplasty for acute myocardial infarction

Thrombocytopenia that develops after percutaneous coronary intervention (PCI) may result in hemorrhagic complications, requirement for blood product transfusions, and potentially thrombotic or ischemic complications. The incidence and prognostic significance of thrombocytopenia, in patients with acute myocardial infarction (AMI) who undergo primary PCI have not been evaluated. In the CADILLAC trial 2,082 patients who had AMI within 12 hours of onset without shock were prospectively randomized to receive balloon angioplasty with or without abciximab versus stenting with or without abciximab. Acquired thrombocytopenia, defined as a nadir platelet count <100 x 10(9)/L in patients who did not have baseline thrombocytopenia, developed in 50 of 1,975 qualifying patients (2.5%) after primary PCI. By multivariate analysis, acquired thrombocytopenia developed more frequently in patients who had non-insulin-requiring diabetes mellitus (odds ratio 3.88 [OR], p = 0.0002), previous statin administration (OR 3.28, p = 0.002), and use of abciximab (OR 2.06, p = 0.02) and less frequently in patients who had previous aspirin use (OR 0.26, p = 0.002), a higher baseline platelet count (OR 1.20, p < 0.0001), and greater body mass index (OR 0.90, p = 0.006). Patients who developed thrombocytopenia versus those who did not had higher in-hospital rates of major hemorrhagic complications (10.0% vs 2.7%, p = 0.01), greater requirement for blood transfusions (10.0% vs 3.9%, p = 0.05), longer hospital stay (median 4.8 vs 3.6 days, p = 0.008), and increased costs (median dollar 14,466 vs dollar 11,629, p = 0.001). All-cause mortality was markedly increased at 30 days (8.0% vs 1.6%, p = 0.0008) and at 1 year (10.0% vs 3.9%, p = 0.03) in patients who developed thrombocytopenia. In conclusion, thrombocytopenia that develops after primary PCI for AMI, although uncommon, is associated with increased hemorrhagic complications and decreased survival.     

急性心肌梗死患者经皮冠状动脉介入治疗术后早期再发心肌梗死的预测及分析

目的分析老年急性心肌梗死患者PCI术后早期再发心肌梗死的预测危险因素。方法连续选取行PCI术的老年急性心肌梗死患者共2 252例,将未发生心肌再梗死的患者2 176例作为无再梗死组,发生早期再发心肌梗死患者76例作为再梗死组,对再发心肌梗死的危险因素进行分析。结果 PCI术后早期再发心肌梗死发生率为3.4%,且以男性为主。与无再梗死组比较,再梗死组糖尿病患病率和入院时血糖水平较高,心功能较差、血管狭窄程度较重,PCI术前、术后TIMI血流分级较差,术后血栓形成和夹层发生率较高,差异有统计学意义(P<0.05,P<0.01)。多因素回归分析显示,老年、血糖增高、糖尿病、心功能(Killip分级)、多支血管病变和PCI术后血栓及夹层形成与早期再发心肌梗死密切相关。结论高龄、血糖增高、糖尿病、心功能、多支血管病变和PCI术后血栓及夹层形成是早期再梗死的高危因素。针对合并这些因素的高危患者应进行积极有效防治。     

Heart rate variability in patients with acute myocardial infarction undergoing primary coronary angioplasty

Depressed heart rate variability (HRV) has been associated with adverse outcome during and after acute myocardial infarction (AMI). The effects of reperfusion in AMI on the course of HRV have not been well characterized as yet. We analyzed 123 consecutive patients with a first AMI who underwent successful reperfusion (Thrombolysis In Myocardial Infarction grades 2 and 3) by primary percutaneous transluminal coronary angioplasty (PTCA). Time- and frequency-domain HRV was measured from 24-hour Holter monitoring, which began at hospital admission. Mean RR interval increased significantly after successful PTCA. Reperfusion immediately caused an immediate transient depression of HRV, which was followed by a significant increase of HRV. Quantitative markers of sympathetic activity and sympathovagal balance, such as SD of the averages of NN intervals in all 5-minute segments, and low- and/or high-frequency ratio continuously decreased within the observation period. Patients with anterior AMI exhibited the same pattern of temporal changes of HRV, with, however, lower absolute values for HRV and mean RR interval than patients with non-anterior AMI. Subgroup analysis in 21 patients with reperfusion > 12 hours after onset of pain showed that the biphasic profile of HRV and the marked increase of mean RR interval was absent. Furthermore, in patients with late reperfusion, HRV was significantly lower compared with those with early reperfusion. Thus, timely reperfusion in AMI leads to a biphasic effect on autonomic tone, characterized by a transient suppression, followed by a significant activation of the vagal tone, as well as an attenuation of sympathetic activity. Recovery of HRV may contribute to the benefits of early reperfusion in AMI.     

Relation of time to treatment and mortality in patients with acute myocardial infarction undergoing primary coronary angioplasty

The benefit of thrombolysis is dependent on time to treatment, but there is lack of evidence of this relation in patients undergoing primary percutaneous transluminal coronary angioplasty (PTCA). The hypothesis that the relation of time to treatment to mortality is dependent on patient risk was tested in a series of 1,336 patients who underwent successful primary PTCA and were stratified into "low-risk" and "not low-risk" patient groups according to the Thrombolysis In Myocardial Infarction criteria. After stratification, 942 patients (71%) were at not low risk, and 394 (29%) were at low risk. The 6-month mortality rate was 9.3% for not low-risk patients and 1.3% for low-risk patients (p <0.001). Among not low-risk patients, longer time to treatment was associated with increased age and a greater incidence of cardiogenic shock. Unadjusted mortality of the not low-risk patients increased from 4.8% to 12.9%, with increasing time to reperfusion up to 6 hours, whereas mortality of the low-risk group was constant, with an increased time to reperfusion. For the not low-risk group, the univariate analysis revealed a relation between time to treatment and mortality (odds ratio 1.35; 95% confidence interval 1.06 to 1.73, p = 0.017). Time to reperfusion was not an independent predictor of mortality at multivariate analysis. Mortality for not low-risk patients who undergo successful primary PTCA is related to the delay from symptom onset to treatment. The effects of other variables associated with a longer time to reperfusion may have a stronger impact on mortality, obscuring the incremental value of time to reperfusion at multivariate analysis.     

Comparison of outcomes of diabetic and nondiabetic patients undergoing primary angioplasty for acute myocardial infarction

We sought to determine whether diabetes mellitus independently conferred poor prognosis in patients with acute myocardial infarction (AMI) undergoing primary percutaneous coronary intervention (PCI). In 3,742 patients enrolled in the Primary Angioplasty in Myocardial Infarction (PAMI) studies with the intention of undergoing primary PCI, we compared in-hospital mortality, 6-month mortality, and 6-month major adverse cardiovascular events (MACEs), i.e., composite of death, reinfarction, or ischemic target vessel revascularization (TVR), between diabetics (n = 626, 17%) and nondiabetics (n = 3,116, 83%). We evaluated the independent impact of diabetes on outcomes after adjustment for baseline clinical and angiographic differences. Diabetics had worse baseline clinical characteristics, longer pain onset-to-hospital arrival time, and longer door-to-balloon time. They had more multivessel coronary disease and lower left ventricular ejection fractions, but better baseline Thrombolysis In Myocardial Infarction (TIMI) flow. Diabetics underwent primary PCI less often (88% vs 91%, p = 0.01). During the index hospitalization, diabetics were more likely to die (4.6% vs 2.6%, p = 0.005). During 6-month follow-up, diabetics had higher incidences of death (8.1% vs 4.2%, p <0.0001) and MACEs (18% vs 14%, p = 0.036). In multivariate analysis, diabetes was independently associated with 6-month mortality (hazard ratio 1.53, 95% confidence interval 1.03 to 2.26, p = 0.03), but not with in-hospital mortality or 6-month MACEs. We conclude that diabetics with AMI have less favorable baseline characteristics and are less likely to undergo primary PCI than nondiabetics. Despite excellent angiographic results, diabetics had significantly worse 6-month mortality.     

Gender differences in epicardial and tissue-level reperfusion in patients undergoing primary angioplasty for acute myocardial infarction

ObjectivePregnancy associated plasma protein-A (PAPP-A) is a potential new marker for vulnerable plaques in the coronary arteries only examined in stable coronary disease (CAD) in patients undergoing coronary angiography. Here we address the prognostic value of serum PAPP-A in unselected stable CAD patients.MethodBlood samples were drawn at study entry. Serum PAPP-A values ≥4 mIU/L were considered elevated. Mortality and non-fatal myocardial infarction was prospectively registered. The primary outcome was the composite outcome of myocardial infarction and all-cause mortality, secondary outcomes were all-cause mortality and myocardial infarction.ResultsPatients (n = 4243) were followed for a median of 2.8 years. In a Cox analysis, elevated PAPP-A was significantly related to the composite outcome of myocardial infarction and death (HR 1.99, 95% CI 1.62–2.45, p < 0.0005), all-cause mortality (HR 2.42, 1.92–3.06, p < 0.0005), and myocardial infarction (HR 1.40, 1.01–1.94, p = 0.046). After Holm's correction, the latter significance disappeared. After adjustment for risk factors and medication at entry, elevated PAPP-A remained significantly related to the composite outcome (HR 1.51, 1.22–1.86, p < 0.0005) and all-cause mortality (HR 1.68, 1.32–2.13, p < 0.0005).ConclusionIn patients with stable CAD elevated serum PAPP-A seems promising as aid in identifying patients at high risk for death.     

Effectiveness of primary angioplasty for acute myocardial infarction in patients on dialysis

We sought to characterize the outcome in patients who were on long-term dialysis and who underwent primary percutaneous transluminal coronary angioplasty (PTCA) for acute myocardial infarction. Of 2,831 consecutive patients who underwent primary PTCA for acute myocardial infarction from 1993 to 2001, 15 patients on long-term dialysis were identified. This small cohort had a 40% incidence of cardiogenic shock on admission. Despite the angiographic success rate for primary PTCA of 80%, in-hospital mortality was 53%.     

Cardioprotective effects of magnesium sulfate in patients undergoing primary coronary angioplasty for acute myocardial infarction.

BACKGROUND: Experimental evidence indicates that magnesium sulfate may have potential cardioprotective properties as an adjunct to coronary reperfusion. The present study was designed to examine the hypothesis that magnesium might have beneficial effects on left ventricular (LV) function and coronary microvascular function in patients with acute myocardial infarction (AMI). METHODS AND RESULTS: The study population of 180 consecutive patients with a first AMI (anterior or inferior) underwent successful primary coronary intervention. Patients were randomized to treatment with either intravenous magnesium (magnesium group, n=89) or normal saline (control group, n=91). Pre-discharge left ventriculograms were used to assess LV ejection fraction (LVEF), regional wall motion (RWM) within the infarct-zone and LV end-diastolic volume index. The Doppler guidewire was used to assess coronary flow velocity reserve (CFVR) as an index of coronary microvascular function. Magnesium group subjects showed significantly better LV systolic function (LVEF 63+/-9% vs 55+/-13%, p<0.001; RWM: -1.01+/-1.29 SD/chord vs -1.65+/-1.11 SD/chord, p=0.004), significantly smaller LV end-diastolic volume index (63+/-17 ml/m(2) vs 76+/-20 ml/m(2), p<0.001), and significantly higher CFVR (2.95+/-0.76 vs 2.50+/-0.99, p=0.023) than controls. CONCLUSION: Magnesium sulfate as an adjunct to primary coronary intervention shows favorable functional outcomes in patients with AMI.     

Transfer for primary angioplasty in elderly patients with acute myocardial infarction

A 52‐year‐old asymptomatic man, with cardiac risk factors of hypertension, Type II diabetes, hypertriglyceridemia, low HDL, obesity, and positive family history for early coronary artery disease (CAD), was referred to nuclear stress test. He exercised for 14 minutes, achieved his target heart rate, without any symptoms or ECG changes. Nuclear images were entirely normal. However, the patient was still concerned and anxious so he underwent CT angiography that revealed coronary narrowings. Next, he underwent coronary angiography with similar findings. The lesions were treated with stents. We present a case report to illustrate how newer technology such as CT angiography alters the way in which we diagnose CAD and decide on whether to pursue further invasive therapy.     

Intracoronary thrombectomy improves myocardial reperfusion in patients undergoing direct angioplasty for acute myocardial infarction

OBJECTIVES: We sought to evaluate the effects of mechanical thrombectomy on myocardial reperfusion during direct angioplasty for acute myocardial infarction (AMI). BACKGROUND: Embolization of thrombus and plaque debris may occur during direct angioplasty for AMI. This may lead to distal vessel or side branch occlusion and to obstructions in the microvascular system, resulting in impaired myocardial reperfusion. Mechanical thrombectomy is used to reduce distal embolization. METHODS: Ninety-two patients with AMI and angiographic evidence of intraluminal thrombus were randomized to either intracoronary thrombectomy followed by stenting or to a conventional strategy of stenting. Thrombectomy was performed using the X-Sizer catheter (EndiCOR Inc., San Clemente, California). Myocardial reperfusion was assessed by myocardial blush and ST resolution. RESULTS: Postprocedure Thrombolysis in Myocardial Infarction-3 flow was not different between groups (93.5% vs. 95.7%, p = 0.39). Myocardial blush-3 was observed in 71.7% of patients undergoing thrombectomy and in 36.9% of patients undergoing conventional strategy (p = 0.006). ST-segment resolution >or=50% occurred more often in patients undergoing thrombectomy (82.6% vs. 52.2%, p = 0.001). By multivariate analysis, adjunctive thrombectomy was an independent predictor of blush-3 (odds ratio, 3.27; 95% confidence interval, 1.06 to 10.05; p = 0.039). CONCLUSIONS: Intracoronary thrombectomy as adjunct to stenting during direct angioplasty for AMI improves myocardial reperfusion as assessed by myocardial blush and ST resolution.