Benefit of revascularization in non-infarct-related artery in multivessel disease patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention

This study compared the prognosis of ST-elevation myocardial infarction (STEMI) in patients with multivessel disease (MVD) with that of single vessel disease (SVD) and investigated the revascularization benefit of noninfarct-related artery (IRA) in MVD patients undergoing primary percutaneous coronary intervention (PCI). Between 2002 and 2009, 1278 patients with STEMI underwent primary PCI. Of these patients, 717 (56.1%) with SVD (only IRA obstruction) were placed in group A, while 561 (43.9%) with MVD (Group B) were further categorized into group 1 (PCI for IRA) and group 2 (staged PCI for IRA+non-IRA). The results demonstrated a lower degree of successful reperfusion in IRA and higher 30-day and 1-year cumulative mortality rates in group B (P < 0.001). While there was no difference in successful reperfusion in IRA between group 1 and group 2, the 30-day and one-year cumulative mortality rates were higher in group 1. Multivariate analysis identified MVD as an independent predictor of 1-year mortality (P < 0.001). In conclusion, patients with subsequent PCI for MVD had better 30-day and 1-year outcomes than those with conservative treatment.     

Comparison of five-year outcomes of patients with and without chronic total occlusion of noninfarct coronary artery after primary coronary intervention for ST-segment elevation acute myocardial infarction

The aim of the present study was to evaluate the effect of concurrent chronic total occlusion (CTO) in a noninfarct-related artery (IRA) on the long-term prognosis in patients with ST-segment elevation myocardial infarction and multivessel coronary disease. Of 1,658 consecutive patients with ST-segment elevation myocardial infarction, 666 with multivessel coronary disease who underwent percutaneous coronary intervention from 1999 to 2004 were included in the present analysis. The patients were divided into 2 groups: no CTO and CTO. The first group included 462 patients without CTO (69%) and the second group included 204 patients with CTO in a non-IRA (31%). The in-hospital mortality rate was 6.3% and 21.1% (p < 0.0001) and the 5-year mortality rate was 22.5% and 40.2% (p < 0.0001) for the no-CTO and CTO patients, respectively. Multivariate analysis revealed that after correction for baseline differences CTO in a non-IRA was a strong, independent predictor of 5-year mortality in patients undergoing percutaneous coronary intervention (hazard ratio 1.85; 95% confidence interval 1.35 to 2.53; p = 0.0001). In conclusion, the presence of CTO in a non-IRA in patients with ST-segment elevation myocardial infarction and multivessel coronary disease is a strong and independent risk factor for greater 5-year mortality.     

Comparison of left ventricular ejection fraction and exercise capacity as predictors of two- and five-year mortality following acute myocardial infarction

This study evaluated exercise capacity and left ventricular ejection fraction (LVEF) as predictors of long-term mortality in patients with ST-elevation myocardial infarction (STEMI) treated with percutaneous coronary intervention. LVEF is a well-established predictor of mortality in patients with STEMI. Exercise capacity, expressed as milliliters per kilogram per minutes or METs (1 MET = 3.5 ml/kg/min), may also serve as an independent predictor of mortality in this cohort. However, it is unclear whether these variables used together more accurately define mortality risk than either alone. In the Primary Angioplasty in Acute Myocardial Infarction-2 trial, 330 patients with long-term mortality data underwent radionuclide ventriculography at rest and cycle ergometer stress testing 6 weeks after percutaneous coronary intervention for STEMI. We used this database to evaluate the ability of LVEF at rest and exercise capacity to predict 2- and 5-year mortality. Exercise capacity <4 METs was a significant predictor of 5-year mortality (odds ratio [OR] 4.54, p = 0.0016). In contrast, decreased LVEF demonstrated a trend toward higher mortality but was not statistically significant at 2- (OR 2.22, p = 0.22) or 5-year (OR 2.04, p = 0.20) follow-up. When evaluated in combination, there was a statistically significant 2-year mortality risk for those with a decreased LVEF and decreased exercise capacity (OR 6.03, p = 0.018). Exercise capacity was a better predictor of 2- and 5-year mortality than LVEF in patients with STEMI treated with percutaneous intervention. In conclusion, when combined with LVEF, exercise capacity provides independent and additive information regarding long-term prognosis.     

Prognostic value of admission hemoglobin levels in ST-segment elevation myocardial infarction patients presenting with cardiogenic shock

Even in the era of primary percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI) complicated by cardiogenic shock (CS), mortality remains high. Whether admission hemoglobin (Hb) concentration is a predictor of mortality in patients with CS treated with primary PCI is unexplored. We assessed the relation between admission Hb concentration and 1-year mortality in patients with STEMI and CS who were treated with PCI at admission. We investigated a cohort of 265 patients with STEMI with CS on admission. Patients were categorized in 3 groups according to plasma Hb levels at admission: 9.6 g/dl (group I, n = 22), 9.6 to 12 g/dl (group II, n = 59), and >12 g/dl (group III, n = 184). All-cause mortality at 1 year was 64%, 46%, and 35% for groups I, II, and III, respectively (p = 0.007). Multivariate logistic regression analysis showed that the odds for mortality increased 17% for every 1.0 g/dl decrease in plasma Hb (odds ratio 1.17, 95% confidence interval 1.01 to 1.35, p = 0.042). In conclusion, admission Hb concentration is an independent predictor for 1-year mortality in patients with STEMI undergoing primary PCI.     

Prognostic impact of chronic total occlusion in patients with acute ST-segment elevation myocardial infarction undergoing primary percutaneous intervention

Background The presence of a chronic total occlusion(CTO)in a non-infarct-related artery might be associatedwith a worse prognosis in long term benefit for ST-segment elevation myocardial infarction(STEIMI)patients. But it still remain controversial. Methods All 383 STEMI patients underwent percutaneous intervention(PCI)from Jan 2015 to Jan 2017 in our center were enrolled in this prospective study. Baseline characteristics,medical history,biochemical findings,echocardiographic and angiographic parameters,procedures performed and complications were recorded. Factors related to worse outcome CTO in STEMI patients were analyzed by the cox logistic regression analysis for the hazard rate(HR). Results In a total of 383 patients enrolled in this study,85 cases had CTO in at least 1 coronary artery. The mean follow-up was 352 days. 1-year mortality and MACE ratesinpatients with CTO were 18.8% and 11.8%,respectively. Major adverse cardiac events(MACE)during follow-up were significantly higher in patients with CTO(HR=2.88;95%CI,1.82-4.77;P0.001). The multivariate analysis showed a significant association between CTO and MACE(HR=2.11 95%CI,1.27-3.88;P=0.014). Conclusion Chronic total occlusion is associated with higher risk of comorbidities and higher mortality,and serves as an independent predictor of MACE.     

Meta-analysis of multivessel coronary artery revascularization versus culprit-only revascularization in patients with ST-segment elevation myocardial infarction and multivessel disease

American College of Cardiology/American Heart Association guidelines for management of patients with ST-segment elevation myocardial infarction (STEMI) recommend culprit artery-only revascularization (CULPRIT) based on safety concerns during noninfarct-related artery intervention. However, the data to support this safety concern are scant. Searches were performed in PubMed/EMBASE/CENTRAL for studies evaluating multivessel revascularization versus CULPRIT in patients with STEMI and multivessel disease (MVD). A multivessel revascularization strategy had to be performed at the time of CULPRIT or during the same hospitalization. Early (≤30-day) and long-term outcomes were evaluated. Among 19 studies (23 arms) that evaluated 61,764 subjects with STEMI and MVD, multivessel revascularization was performed in a minority of patients (16%). For early outcomes, there was no significant difference for outcomes of mortality, MI, stroke, and target vessel revascularization, with a 44% decrease in risk of repeat percutaneous coronary intervention and major adverse cardiovascular events (odds ratio 0.68, 95% confidence interval 0.57 to 0.81) with multivessel revascularization compared to CULPRIT. Similarly, for long-term outcomes (follow-up 2.0 ± 1.1 years), there was no difference for outcomes of MI, target vessel revascularization, and stent thrombosis, with 33%, 43%, and 53% decreases in risk of mortality, repeat percutaneous coronary intervention, coronary artery bypass grafting, respectively, and major adverse cardiovascular events (odds ratio 0.60, 95% confidence interval 0.50 to 0.72) with multivessel revascularization compared to CULPRIT. In conclusion, in patients with STEMI and MVD, multivessel revascularization appears to be safe compared to culprit artery-only revascularization. These findings support the need for a large-scale randomized trial to evaluate revascularization strategies in patients with STEMI and MVD.     

Closer to surgery,but not to truth

Objectives: To evaluate clinical results of percutaneous coronary intervention (PCI) in ST‐elevation myocardial infarction (STEMI) in patients with multivessel disease (MVD), in relation to single or multivessel (MV)‐PCI and to patients with single vessel disease (SVD). Methods: Patients treated with PCI in the setting of <24 hr STEMI in the years 2004–2007 were considered. Results: Seven hundred forty‐five primary PCI, 346 (46%) in patients with SVD and 399 (54%) in patients with MVD were performed. Among MVD patients, 156 (39%) had infarct related artery (IRA)‐only treatment and 243 had MV‐PCI: 147 (37%) in a single session, 48 (12%) within 24 hr, and 48 (12%) predischarge. Revascularization was complete in 46% of MVD patients. At a median follow‐up of 597 days, mortality was 6.3% in SVD and 12% in MVD (P = 0.007), new revascularization 2.9% and 9%, respectively (P < 0.001). Thirty‐day mortality was 2.4% in SVD and 6.7% in MVD (P = 0.006). After exclusion of patients with cardiogenic shock or pulmonary oedema, more frequent in the MV‐PCI in single session group (P = 0.006), 30‐day mortality was SVD 1.3%, IRA‐only 6.3%, MV‐PCI 2.8% (P = 0.023), without differences if in a single (3.3%) or in staged session (2.2%). By multivariate analysis, female sex, anterior STEMI, cardiogenic shock, MVD, and procedural failure were independent predictors of 30‐day mortality. Conclusions: STEMI patients with MVD have a worse prognosis than those with SVD. MV‐PCI in patients without hemodynamic compromise yields good short‐term results, even if performed very early, with a 30‐day mortality in between that of SVD patients and that of MVD patients with IRA‐only treatment. © 2008 Wiley‐Liss, Inc.     

Comparison of late (3-year) registry data outcomes using bare metal versus drug-eluting stents for treating ST-segment elevation acute myocardial infarctions

Clinical trial data have supported the safety and efficacy of drug-eluting stents (DES) in the treatment of patients with ST-segment elevation myocardial infarctions (STEMIs), but contemporary "real-world" registry data regarding the late safety profiles of DES are limited. This prospective registry-based study included 1,569 consecutive unselected patients with STEMIs who underwent emergency primary percutaneous coronary intervention from January 2001 to December 2009. Of the study cohort, 200 patients (12.7%) received DES, while 1,369 patients (87.3%) underwent bare-metal stent (BMS) placement. The primary end points of the study were all-cause mortality and target vessel revascularization at 1, 2, and 3 years. Survival status was assessed by municipal civil registries. Repeat revascularization procedures were prospectively collected in the hospital database. All-cause mortality was significantly lower in the DES group at 3 years (4.2% vs 13.5%, p = 0.007) compared to BMS-treated patients, but DES use was not an independent predictor of all-cause mortality (adjusted odds ratio 0.5, 95% confidence interval 0.2 to 1.2, p = 0.10). Target vessel revascularization was significantly lower in the DES group compared to the BMS group at 3 years (10.5% vs 21%, p = 0.001). DES use was an independent predictor of reduced target vessel revascularization (adjusted odds ratio 0.44, 95% confidence interval 0.25 to 0.77, p = 0.004). Late definite stent thrombosis occurring after 1 year occurred in 4 (2.5%) patients in the DES group compared to 6 (0.7%) in the BMS group (p = 0.05). DES use was an independent predictor of late stent thrombosis (adjusted odds ratio 8.6, 95% confidence interval 1.9 to 38, p = 0.004). In conclusion, this contemporary registry-based study of patients who underwent primary percutaneous coronary intervention for STEMI demonstrated improved revascularization rates without increased 3-year hazard of adverse clinical outcomes in DES-treated patients.     

Prognostic value of admission myeloperoxidase levels in patients with ST-segment elevation myocardial infarction and cardiogenic shock

Inflammation plays a critical role in acute myocardial infarction. One inflammatory marker is myeloperoxidase (MPO). Its role as a predictor of in-hospital death in patients with ST-segment elevation myocardial infarction (STEMI) presenting with cardiogenic shock (CS) is unclear. Therefore, the aim of this study was to investigate the role of MPO as a predictor of in-hospital death in patients with STEMIs presenting with CS and treated with primary percutaneous coronary intervention. In 38 consecutive patients with CS complicating STEMIs who were treated with primary percutaneous coronary intervention, serum MPO levels were measured at coronary care unit admission using a commercially available enzyme-linked immunosorbent assay. The primary study end point was in-hospital cardiac death. Among the 38 patients included in the study, 20 died during their coronary care unit stays, whereas 18 survived. Compared with patients who survived, patients who died showed, at coronary care unit admission, higher serum MPO levels (81 +/- 28 vs 56 +/- 23 ng/ml, p <0.006). After controlling for different baseline clinical, laboratory, and angiographic variables, baseline serum MPO level was an independent predictor of in-hospital mortality on multivariate analysis (odds ratio 3.9, 95% confidence interval 1.8 to 7.5, p <0.001). In conclusion, admission MPO concentration is an independent predictor of in-hospital mortality in patients with STEMIs presenting with CS.     

Comparison of differences in outcome after percutaneous coronary intervention in men versus women <40 years of age

We evaluated the outcomes of 177 consecutive patients (43 women, 134 men) <40 years of age with premature atherosclerosis who underwent percutaneous coronary intervention. Women were younger, had more diabetes mellitus (37% vs 10%; p <0.001), but less hyperlipidemia (58% vs 75%; p <0.001) compared with men. In-hospital vascular complications and 1-year mortality rate or Q-wave myocardial infarction (7.9% vs 0.08%, p <0.01) were higher in women. By multivariable regression analysis, female gender was the only independent predictor of vascular complications (odds ratio, 14.1; 95% confidence intervals, 1.59 to 125, p = 0.01) and of 1-year mortality rate or nonfatal myocardial infarction (odds ratio, 12.5; 95% confidence interval, 1.14 to 111, p = 0.03). Women with premature coronary disease had a distinctive risk factor profile relative to men, with a predominance of diabetes and hypercholesterolemia, and were at higher risk of developing vascular and ischemic complications after percutaneous coronary intervention, warranting aggressive risk factor modification and vigilance in this population.     

Does Proximal Location of Culprit Lesion Confer Worse Prognosis in Patients Undergoing Primary Percutaneous Coronary Intervention for ST Elevation Myocardial Infarction?

ST segment elevation myocardial infarction (STEMI) from proximally located culprit lesion is associated with greater myocardium at jeopardy. In STEMI patients treated with thrombolytics, proximal culprit lesions are known to have worse prognosis. This relation has not been studied in patients undergoing primary percutaneous coronary intervention (PCI). In 3,535 STEMI patients with native coronary artery occlusion pooled from the primary angioplasty in myocardial infarction database, we compared in-hospital and 1-year outcomes between those with proximal (n = 1,606) versus non-proximal (n = 1,929) culprit lesions. Patients with proximal culprits were more likely to die and suffer major adverse cardiovascular events (MACE) during the index hospital stay (3.8% vs 2.2%, P = 0.006; 8.2% vs 5.8%, P = 0.0066, respectively) as well as during 1-year follow-up (6.9% vs 4.5%, P = 0.0013; 22% vs 17%, P = 0.003, respectively) compared to those with non-proximal culprits. After adjustment for baseline differences, proximal culprit was independently predictive of in-hospital death (adjusted odds ratio% 1.58, 95% confidence intervals, CI 1.05-2.40) and MACE (OR 1.41, CI 1.06-1.86), but not 1-year death or MACE. In addition, proximal culprit was independently associated with higher incidence of ventricular arrhythmias and sustained hypotension during the index hospitalization. The univariate impact of proximal culprit lesion on in-hospital death and MACE was comparable to other adverse angiographic characteristics, such as multivessel disease and poor initial thrombolysis in myocardial infarction flow, and greater than that of anterior wall STEMI. In conclusion, proximal location of the culprit lesion is a strong independent predictor of worse in-hospital outcomes in patients with STEMI undergoing primary PCI.     

Mortality in patients with ST-segment elevation myocardial infarction who do not undergo reperfusion

Reperfusion therapy reduces mortality in patients presenting with ST-segment elevation myocardial infarctions (STEMI). However, some patients may not receive thrombolytic therapy or undergo primary percutaneous coronary intervention. The decision making and clinical outcomes of these patients have not been well described. In this study, 139 patients were identified from a total of 1,126 patients with STEMI who did not undergo reperfusion therapy at a high-volume percutaneous coronary intervention center from October 2006 to March 2011. Clinical data, reasons for no reperfusion, management, and mortality were obtained by chart review. The mean age was 80 ± 13 years (61% women, 31% diabetic, and 37% known coronary artery disease). Of the 139 patients, 72 (52%) presented with primary diagnoses other than STEMI, and 39 (28%) developed STEMI >24 hours after admission. The most common reasons for no reperfusion were advanced age, co-morbid conditions, acute or chronic kidney injury, delayed presentation, advance directives precluding reperfusion, patient preference, and dementia. Eighty-four patients (60%) had ≥ 3 reasons for no reperfusion. Factors associated with hospital mortality were cardiogenic shock, intubation, and advance directives prohibiting reperfusion after physician consultation. In hospital and 1-year mortality were 53% and 69%, respectively. In conclusion, at a high-volume percutaneous coronary intervention center, most patients presenting with STEMI underwent immediate catheterization. The decision for no reperfusion was multifactorial, with advanced age reported as the most common factor. Outcomes were poor in this population, and fewer than half of these patients survived to hospital discharge.     

Patients with Tombstoning Pattern on the Admission Electrocardiography Who Have Undergone Primary Percutaneous Coronary Intervention for Anterior Wall ST‐Elevation Myocardial Infarction: In‐Hospital and Midterm Clinical Outcomes

Background: A tombstoning pattern (T‐pattern) is associated with in‐hospital poor outcomes patients with ST‐segment elevation myocardial infarction (STEMI), but no data are available for midterm follow‐up. We sought to determine the prognostic value of a T‐pattern on admission electrocardiography (ECG) for in‐hospital and midterm mortality in patients with anterior wall STEMI treated with primary percutaneous coronary intervention (PCI). Methods: After exclusion, 169 consecutive patients with anterior wall STEMI (mean age: 55 ± 12.9 years; 145 men) undergoing primary PCI were prospectively enrolled in this study. Patients were classified as a T‐pattern (n = 32) or non–T‐pattern (n = 137) based upon the admission ECG. Follow‐up to 6 months was performed. Results: In‐hospital mortality tended to be higher in the T‐pattern group compared with non–T‐pattern group (9.3% vs 2.1% respectively, P = 0.05). All‐cause mortality was higher in the T‐pattern group than non–T‐pattern group for 6 month (P = 0.004). After adjusting the baseline characteristics, the T‐pattern remained an independent predictor of 6‐month all‐cause mortality (odds ratio: 5.18; 95% confidence interval: 1.25–21.47, P = 0.02). Conclusion: A T‐pattern is a strong independent predictor of 6‐month all‐cause mortality in anterior STEMI treated with primary PCI. Therefore, it may be an indicator of high risk among patients with anterior wall STEMI.     

Left circumflex occlusion in acute myocardial infarction (from the National Cardiovascular Data Registry)

Compared to occlusions of other major coronary arteries, patients presenting with acute left circumflex (LCx) occlusion usually have ST-segment elevation on the electrocardiogram <50% of the time, potentially delaying treatment and resulting in worse outcomes. In contemporary practice, little is known about the clinical outcomes of patients with LCx territory occlusion without ST-segment elevation myocardial infarction (STEMI). We identified patients with myocardial infarction from April 2004 to June 2009 in the CathPCI Registry treated with percutaneous coronary intervention for culprit LCx territory occlusion, excluding those with previous coronary artery bypass grafting. Logistic generalized estimating equation modeling was used to compare the outcomes, including in-hospital mortality between patients with STEMI and non-STEMI (NSTEMI) adjusting for differences in the baseline characteristics. Of the 27,711 patients with myocardial infarction and acute LCx territory occlusion, 18,548 (67%) presented with STEMI and 9,163 (33%) with NSTEMI. With the exception of a greater proportion of cardiac risk factors and cardiac history in the NSTEMI group, the demographic and baseline characteristics were clinically similar between the 2 groups, despite the statistical significance resulting from the large population. The patients with STEMI were more likely to have a proximal LCx culprit lesion (63% vs 27%, p <0.0001) and had greater risk-adjusted in-hospital mortality (odds ratio 1.36, 95% confidence interval 1.12 to 1.65, p = 0.002) compared to patients with NSTEMI. In conclusion, acute LCx territory occlusion often presents as NSTEMI, but patients with NSTEMI and occlusion have a lower mortality risk than those with STEMI, possibly because of factors such as the amount of myocardium involved, the lesion location along the vessel, and/or a dual blood supply.     

Renal insufficiency is an independent predictor of mortality after percutaneous coronary intervention

The present study was designed to evaluate whether the presence of renal disease during percutaneous coronary intervention (PCI) is associated with worse outcomes at 1 year in a multicenter study. The incidence of death, myocardial infarction, coronary artery bypass grafting, repeat PCI, and repeat revascularization were prospectively collected on 4,602 patients (6,542 lesions) in 2 waves of patients who underwent PCI in 17 centers between July 1997 and June 1999. Renal disease was defined as the presence of an increased creatinine level in a patient with a history or presence of renal failure treated with low protein diet or dialysis. Patients with renal disease (n = 192) were older and more likely to have diabetes, heart failure, reduced ejection fraction, known coronary disease, and multivessel disease than patients without renal disease (n = 4,410). Rates of stenting were equivalent (68.2% vs 73.0%, p = NS). Patients with renal disease had lower angiographic success (84.9% vs 92.8%, p <0.001) and higher mortality, both in-hospital (5.7% vs 1.2%, p <0.001) and at 1 year (19.7% vs 4.4%, p <0.0001). After adjusting for clinical, demographic, and angiographic differences, renal disease remained an independent predictor of in-hospital (odds ratio 3.81, 95% confidence interval 1.70 to 8.58) and 1-year (risk ratio 2.46, 95% confidence interval 1.64 to 3.68) mortality. Renal disease conferred additional mortality risk in established high-risk clinical subgroups. In conclusion, after adjusting for a higher frequency of co-morbidities, renal disease remains a strong and independent predictor of increased in-hospital and 1-year mortality after PCI and is additive to other clinical markers of worse outcome.     

Usefulness of prehospital triage in patients with cardiogenic shock complicating ST-elevation myocardial infarction treated with primary percutaneous coronary intervention

We investigated the impact of ambulance-based prehospital triage on treatment delay and all-cause mortality (in hospital and long term) in patients with ST-elevation myocardial infarction (STEMI) complicated by cardiogenic shock referred for primary percutaneous coronary intervention in a prospectively collected registry. During the study period (January 2003 to December 2005), a total of 121 patients was referred for primary percutaneous coronary intervention at our intervention laboratory through 2 main triage groups: (1) after prehospital, ambulance-telemedicine-based triage (42 patients) and (2) by more conventional routes (79 patients) represented by the institutional S. Orsola-Malpighi hospital emergency department triage (44 patients) and spoke hospital triage (35 patients). Total ischemic time was shorter in the prehospital triage (142 minutes, range 106 to 187, vs 212 minutes, range 150 to 366, p = 0.003). Patients with prehospital triage showed a lower rate (29% vs 54%, p = 0.01) of severely depressed (相似文献   

Mean platelet volume on admission predicts impaired reperfusion and long-term mortality in acute myocardial infarction treated with primary percutaneous coronary intervention

OBJECTIVES: We sought to determine the prognostic value of mean platelet volume (MPV) for angiographic reperfusion and six-month mortality in patients with acute ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI). BACKGROUND: Mean platelet volume is predictive of unfavorable outcome among survivors of STEMI when measured after the index event. No data are available for the value of admission MPV in patients with STEMI treated with primary PCI. METHODS: Blood samples for MPV estimation, obtained on admission in 398 consecutive patients presenting with STEMI, were measured before primary PCI. Follow-up up to six months was performed. RESULTS: No-reflow was significantly more frequent in patients with high MPV (> or =10.3 fl) compared with those with low MPV (<10.3 fl) (21.2% vs. 5.5%, p < 0.0001). The MPV was correlated strongly with corrected Thrombolysis In Myocardial Infarction frame count (CTFC) (r = 0.698, p < 0.0001). Kaplan-Meier survival analysis showed six-month mortality rate of 12.1% in patients with high MPV versus 5.1% in low MPV group (log rank = 6.235, p = 0.0125). After adjusting for baseline characteristics, high MPV remained a strong independent predictor of no-reflow (odds ratio [OR] 4.7, 95% confidence interval [CI] 2.3 to 9.9, p < 0.0001), CTFC > or =40 (OR 10.1, 95% CI 5.7 to 18.1, p < 0.0001), and mortality (OR 3.2, 95% CI 1.1 to 9.3, p = 0.0084). Abciximab administration resulted in significant mortality reduction only in patients with high MPV values (OR 0.02, 95% CI 0.01 to 0.48, p = 0.0165). CONCLUSIONS: Mean platelet volume is a strong, independent predictor of impaired angiographic reperfusion and six-month mortality in STEMI treated with primary PCI. Apart from prognostic value, admission MPV may also carry further practical, therapeutic implications.     

Hyperglycemia is an important predictor of impaired coronary flow before reperfusion therapy in ST-segment elevation myocardial infarction

OBJECTIVES: This study was designed to investigate whether elevated glucose is associated with impaired Thrombolysis In Myocardial Infarction (TIMI) flow before primary percutaneous coronary intervention (PCI). BACKGROUND: Reperfusion before primary PCI in patients with ST-segment elevation myocardial infarction (STEMI) is associated with an improved outcome. Hyperglycemia in patients with STEMI is associated with an adverse prognosis. Hyperglycemia may induce a pro-thrombotic state and therefore be of influence on TIMI flow before PCI. METHODS: A total of 460 consecutive patients with STEMI treated with primary PCI were included in this analysis. Hyperglycemia was defined as a glucose > or =7.8 mmol/l (140 mg/dl). RESULTS: Hyperglycemia was observed in 70% and TIMI flow grade 3 before primary PCI in 17% of the patients. Patients with hyperglycemia less often had TIMI flow grade 3 before primary PCI (12% vs. 28%, p < 0.001). After adjustment for differences in baseline variables, hyperglycemia was a strong predictor of absence of reperfusion before primary PCI (odds ratio 2.6, 95% confidence interval 1.5 to 4.5). CONCLUSIONS: Hyperglycemia in patients with STEMI is an important predictor of impaired epicardial flow before reperfusion therapy has been initiated. Investigation of methods improving coronary flow before primary PCI in these patients is warranted.     

急性ST段抬高型心肌梗死合并多支冠状动脉病变血运重建策略研究进展

急性ST段抬高型心肌梗死(STEMI)合并多支冠状动脉病变比较常见,对患者死亡率及预后产生不良影响。与单支冠状动脉病变相比,多支冠状动脉病变患者临床预后差。随着医学发展以及指南更新,STEMI合并多支冠状动脉病变血运重建策略有了新的变化。对于血流动力学稳定的STEMI患者,急诊经皮冠状动脉介入(PCI)治疗时可同时或另行分期处理非梗死相关动脉;对于血流动力学不稳定的STEMI患者,完全血运重建可能增加手术并发症、心力衰竭恶化、对比剂肾病的风险,急性期仅处理梗死相关动脉(IRA)是合理的。本文就STEMI合并多支冠状动脉病变血运重建策略作一综述。     

Creatine kinase-MB fraction elevation after percutaneous coronary intervention in patients with chronic renal failure

We evaluated the short- and long-term clinical outcomes of 326 consecutive patients with chronic renal failure, not on dialysis, who had creatine kinase (CK)-myocardial band (MB) fraction elevation after successful percutaneous coronary intervention in a native coronary artery. Based on peak CK-MB levels measured after intervention, patients were divided into 3 groups: no elevation (group 1, N = 184), 1 to 3 × upper normal levels (group 2, N = 72), and >3 × upper normal levels (group 3, N = 70). Baseline clinical and angiographic characteristics were similar among the 3 groups. Angiographic success was similar among the 3 groups, although there was a significantly higher use of intra-aortic balloon pump in patients who had postprocedural CK-MB >3 × normal values and a higher rate of in-hospital complications, i.e., repeat catheterization, repeat target lesion intervention, pulmonary edema, renal function deterioration, emergency dialysis, and major bleeding complications. At 1-year follow-up, mortality rates were significantly higher in these patients (35.4% vs 22.0% for patients with CK-MB 1 to 3 × normal values and 16.7% for patients without CK-MB elevation, P = 0.007). Multivariate analysis showed that CK-MB >3 × normal (odds ratio 3.04; 95% confidence interval 1.41 to 6.57, P = 0.005) and intra-aortic balloon pump (odds ratio 1.49; confidence interval 1.15 to 1.93, P = 0.002) were independent predictors of late mortality. Therefore, patients with chronic renal failure who had CK-MB elevation >3 × the upper normal limit after a successful percutaneous coronary intervention had a higher incidence of in-hospital complications and a significantly higher mortality rate at 1-year follow-up than patients without CK-MB elevation or with <3 × normal CK-MB elevation.