Percutaneous coronary intervention for acute MI does not prevent in-hospital development of cardiogenic shock compared to fibrinolysis

BACKGROUND: It has been speculated that invasive revascularization prevents development of cardiogenic shock. Data from randomised trials comparing angioplasty with fibrinolysis on the development of cardiogenic shock are lacking. AIMS: To elucidate the effect of angioplasty on in-hospital development of cardiogenic shock compared to fibrinolysis. To evaluate whether mortality in patients who develop cardiogenic shock after treatment is dependent on revascularization strategy. METHODS AND RESULTS: DANAMI-2 randomly assigned 1572 STEMI patients to fibrinolysis (782 patients) or angioplasty (790 patients). Data on patients with in-hospital development of cardiogenic shock after randomisation were included. Of the 103 patients (6.6%) patients developing cardiogenic shock 57% were randomised to angioplasty with an unadjusted odds ratio of 1.39 (0.92-2.11, p=0.14). During the three year follow-up 58% of the total mortality was due to cardiogenic shock, and treatment strategy did not influence the risk associated with shock (hazard ratio of 1.05 (0.67-1.64) for angioplasty vs. fibrinolysis). CONCLUSIONS: Angioplasty does not prevent the in-hospital development of cardiogenic shock complicating acute MI compared to fibrinolysis. Cardiogenic shock is still the leading cause of death in patients hospitalised for acute MI. There was no difference in mortality, with regards to treatment strategy in patients developing cardiogenic shock after the initial treatment.     

Outcomes of primary coronary angioplasty and angioplasty after initial thrombolysis in the treatment of 374 consecutive patients with acute myocardial infarction

Background

In patients with acute myocardial infarction (MI), the efficacy of thrombolysis is low. Angioplasty after failed thrombolysis (rescue percutaneous coronary angioplasty [PTCA]) has been associated with an increase in the incidence of inhospital complications. It has been proposed that these complications result from the procedure itself. Thus, the aim of this study was to compare the efficacy, inhospital complications, and mortality rate of patients with MI who are treated with primary PTCA and PTCA after initial thrombolysis (rescue or immediate rescue) in an experienced clinical center specializing in percutaneous coronary interventions.

Methods and results

The study group consisted of consecutive patients with MI treated with primary PTCA (n = 195) or PTCA after initial thrombolysis (n = 179). The study was performed in a referral center with a 24-hour catheter-laboratory service. The success rate of the procedure was 90.5% and 88.2% in the PTCA after initial thrombolysis group and primary PTCA group, respectively. The groups did not differ in the frequency of reocclusion, emergency surgical revascularization (coronary artery bypass grafting), or stroke. In patients without cardiogenic shock, the inhospital mortality rates were 3.2% and 0.6% in the rescue and immediate rescue group and primary PTCA group, respectively (not significant). In a subgroup of patients with cardiogenic shock, the mortality rate was 36.0% in the initial thrombolysis PTCA group and 30.8% in the primary PTCA group. However, after successful PTCA in this subgroup, the mortality rate dropped to 18% and 10%, respectively.

Conclusions

After initial thrombolysis, PTCA is safe, effective, and likely to restore grade 3 Thrombolysis In Myocardial Infarction flow in about 90% of patients. When available, immediate rescue PTCA should be performed in all patients, including patients with cardiogenic shock.     

Anterior wall myocardial infarction in real world: Does reperfusion strategy make any differences?

Some prospective randomized trials have established the superiority of primary percutaneous coronary intervention (PCI) over fibrinolytic treatment in patients with acute myocardial infarction (MI). These excellent PCI results are not duplicated in smaller hospitals where there may be delays in getting the cardiac catheterization team to the laboratory. This study aimed to compare the outcome of patients with anterior wall MI, without cardiogenic shock on admission, treated with primary PCI or thrombolytic therapy, in everyday practice. The data of all patients with MI hospitalized in all coronary care units operating in Israel during three consecutive national surveys was analyzed. A total of 1,038 patients with anterior wall MI were treated by reperfusion (886 received thrombolytic therapy, 152 primary PCI). Overall, the outcome of patients treated using primary PCI was better compared to patients treated with thrombolysis, with 68% relative risk reduction of 30-day mortality (mortality at 30 days: 2% vs. 6.3%; P = 0.04). A subanalysis of patients according to age showed that the beneficial effect of primary PCI on mortality was mainly clustered among the younger. In our study, patients (especially younger than 75 years) with anterior wall MI allocated to primary PCI have a better clinical outcome.     

Thrombolysis Plus Aortic Counterpulsation: Improved Survival in Patients Who Present to Community Hospitals With Cardiogenic Shock

Objectives. We sought to explore the potential benefit of combining intraaortic balloon counterpulsation (IABP) with thrombolysis for acute myocardial infarction (MI) complicated by cardiogenic shock.

Background. In community hospitals, this condition is usually managed with thrombolysis alone.

Methods. We reviewed the charts of 335 patients from two community hospitals who presented with acute MI and had cardiogenic shock between 1985 and 1995.

Results. Of 46 patients who underwent thrombolysis within 12 h of acute infarction with confirmed cardiogenic shock, 27 underwent IABP and 19 did not. Age, systolic blood pressure with shock, pulmonary artery catheter use, pulmonary capillary wedge pressure and the incidence of diabetes mellitus and anterior MI did not differ between groups. Patients treated with IABP were somewhat more likely to have prior MI and had a significantly greater cardiac index (2.0 vs. 1.5 liters/min per m², p = 0.04). Although no deaths occurred within 2 h of presentation, patients not treated with IABP tended to die earlier (6.8 ± 5 vs. 23.8 ± 19 h, p = 0.13). Patients treated with IABP had a significantly higher rate of community hospital survival (93% vs. 37%, p = 0.0002), and more of them were transferred for revascularization (85% vs. 37%). Of 30 patients transferred for revascularization, 27 underwent angioplasty or bypass surgery; hospital survival was 74%. Patients treated with IABP also had a significantly higher overall hospital and 1-year survival rate (67% vs. 32%, p = 0.019).

Conclusions. Survival may be enhanced and transfer for revascularization facilitated when community hospitals use both thrombolysis and IABP to treat patients with acute MI complicated by cardiogenic shock.

(J Am Coll Cardiol 1997;29:1454–8)     

Effect of thrombolytic therapy on the risk of cardiac rupture and mortality in older patients with first acute myocardial infarction.

AIMS: To evaluate the effect of thrombolysis on mortality and its causes in older patients with acute myocardial infarction (AMI). METHODS AND RESULTS: An analysis of 706 consecutive patients > or =75 years old with a first AMI enrolled in the PPRIMM75 registry showed that although there were important differences in baseline characteristics among patients treated with thrombolysis, primary angioplasty (PA) and those who did not receive reperfusion therapy, 30 day mortality did not differ (29, 25, and 32%, respectively). The main cause of death in patients treated with thrombolysis was cardiac rupture (54%), whereas most of the other patients died in cardiogenic shock. Patients who received thrombolysis had a higher (P<0.0001) incidence of free wall rupture (FWR) (17.1%) compared with those who did not receive reperfusion therapy (7.9%) or who underwent PA (4.9%). By multivariable analysis, patients treated with thrombolytic therapy (TT) showed an excess risk of FWR (OR, 3.62; 95% CI, 1.79-7.33), a hazard not observed in patients who underwent PA. When compared with patients who did not receive reperfusion therapy, the odds ratio of 30 day mortality was 1.07 (95% CI, 0.65-1.76) for patients treated with thrombolysis and 0.78 (95% CI, 0.45-1.34) for those who underwent PA. The figures for 24 month mortality were 0.78 (95% CI, 0.65-1.76) and 0.67 (95% CI, 0.28-0.81), respectively. CONCLUSION: Treatment of first AMI with TT increases the risk of FWR in very old patients, a risk not observed in patients treated with PA.     

Prospective evaluation of early abciximab and primary percutaneous intervention for patients with ST elevation myocardial infarction complicated by cardiogenic shock: results of the REO-SHOCK trial

OBJECTIVE: Patients with acute myocardial infarction complicated by cardiogenic shock have a high mortality despite the use of early reperfusion therapies with thrombolysis or percutaneous coronary intervention (PCI). Therefore, there is still need to evaluate therapy strategies in these patients. DESIGN: The REO-SHOCK trial was a prospective, non-randomized study, aimed at evaluation of a routine strategy of early abciximab and PCI in a high-risk group of acute ST elevation myocardial infarction (STEMI) patients with cardiogenic shock. RESULTS: Patients (n = 40) planned for coronary angioplasty or stenting received abciximab (0.25 mg/kg bolus followed by 0.125 mg/kg/minute over 12 hours), heparin and aspirin. The intervention was successful in 92.5% of the patients and achieved Thrombolysis In Myocardial Infarction (TIMI) grade 3 patency in 32 patients (80%). The primary endpoint, total mortality after 30 days, was observed in 42.5% (17/40), and was significantly different between patients aged > 75 years and patients aged 75 years (91% versus 24%, respectively; p < 0.001). Major bleeding occurred in 2 patients (5%), but stroke occurred in none. CONCLUSION: A strategy of abciximab with primary PCI in high-risk patients with cardiogenic shock is safe, associated with a high procedural success rate and seems to improve outcomes in patients < 75 years old.     

« Paradoxe des fumeurs » et stratégie de reperfusion à la phase aiguë de l’infarctus du myocarde

Previous studies have shown that smokers with acute myocardial infarction (AMI) treated by thrombolysis have lower mortality rates than nonsmokers, a phenomenon often termed “smoker's paradox”. This “smoker's paradox” has been rarely studied in case of primary angioplasty.

Aim of the study

To evaluate the impact of smoking status on the early mortality of patients admitted with AMI with regard to the strategy of reperfusion (intravenous thrombolysis versus primary angioplasty).

Patients and methods

Study undertaken from the Monsatir registry of ST elevation MI including 688 patients having had either a hospital or a prehospital thrombolysis (n = 397) or a primary angioplasty (n = 291). Among those patients, 482 (70.1%) were active smokers.

Results

In the thrombolysis group, the prevalence of hypertension, diabetes and anterior location of MI was significantly less among smokers. In the group primary angioplasty, only diabetes and hypertension were less frequent. The immediate mortality was significantly less among smokers in case of thrombolysis comparatively to non-smokers (5.3 vs 13%; p = 0.008). By multivariate analysis, cardiogenic shock (p < 0.0001), anterior MI (p = 0.03) and active smoking (p = 0.03) were independent predictive factors of mortality in case of thrombolysis. A trend toward a lower mortality among smokers was observed in the primary angioplasty group (10 vs 17.6%; p = 0.07).

Conclusion

“The smoker's paradox” seems to be observed mainly among patients having had thrombolysis.     

Prim?r-Dilatation versus Thrombolyse bei Patienten mit akutem Myokardinfarkt, die nicht in randomisierte Studien eingeschlossen wurden

There have been some prospective randomized studies which compared primary angioplasty with intravenous thrombolysis in patients with an acute myocardial infarction (AMI). However, a substantial number of patients with AMI who would not have been included in those trials are treated with one of these two therapeutic options. To describe the proportions, characteristics, and outcome of these patients treated with primary angioplasty or thrombolysis we analyzed the data of the prospective "Maximal Individual Optimized Therapy for Acute Myocardial Infarction" (MITRA) trial. Out of 3308 patients treated with primary angioplasty or thrombolysis, 737 (22.3%) belonged to one of the following groups, not included in current randomized trials: Left bundle branch block, non-diagnostic first ECG, pre-hospital delay > 12 hours or unknown pre-hospital delay. Primary angioplasty was performed in 158/737 (21.4%) and thrombolysis received 579/737 (78.6%) of the patients. There were only minor differences regarding patients' characteristics and concomitant diseases between the two groups. Patients treated with primary angioplasty were 3 years younger (62 years median versus 65 years median (p < 0.036). They also more often showed overt heart failure at admission compared to patients treated with thrombolysis (primary angioplasty: 3.2% versus thrombolysis: 8.9%, OR = 0.34, 95% CI: 0.13-0.86). In-hospital time to intervention was 1 1/2 hours longer in patients treated with primary angioplasty (156 minutes median versus 47 minutes median, p = 0.001). beta-blockers were more often used with primary angioplasty compared to thrombolysis (70.31% versus 55.9%; OR = 1.87, 95% CI: 1.28-2.72), as well as ACE inhibitors (62% versus 49.9%; OR = 1.64, 95% CI: 1.14-2.35). Hospital mortality (8.2% versus 16.4%; OR = 0.46, 95% CI: 0.25-0.84), as well as a combined endpoint of death, reinfarction, postinfarction angina, advanced heart failure, and stroke (24.1% versus 42.3%, OR = 0.43, 95% CI: 0.29-0.64) were lower in patients treated with primary angioplasty compared to those treated with thrombolysis. Logistic regression analysis showed primary angioplasty to be independently associated with a lower rate of the combined endpoint (OR = 0.73, 95% CI: 0.59-0.91), after adjusting for confounding parameters. All subgroups showed a more favorable outcome in patients treated with primary angioplasty. In clinical practice, patients with AMI, not included in current randomized trials comparing primary angioplasty with thrombolysis, account for 22% of all patients with AMI treated with one of those two therapies. Primary angioplasty seems to be associated with a lower event rate compared to thrombolysis in these patients. This has to be confirmed by a prospective randomized trial.     

Emergent angioplasty prevents left ventricular dilation in patients with acute anterior wall myocardial infarction and cardiogenic shock

BACKGROUND: Percutaneous transluminal coronary angioplasty (PTCA) reduces in-hospital mortality and improves long-term outcome in patients with acute myocardial infarction (MI) complicated by cardiogenic shock. However, no study has evaluated the effects of different reperfusion therapies on left ventricular (LV) dimension and cardiac function in long-term survivors of MI with cardiogenic shock. HYPOTHESIS: We investigated the effects of PTCA on the development of LV dilation in patients who survived MI complicated by cardiogenic shock. METHODS: We studied 34 patients with a first MI and cardiogenic shock in whom two-dimensional echocardiography was performed immediately after admission and 1 month after infarction. Group A consisted of 17 patients who underwent emergent PTCA during the acute phase of MI, and Group B consisted of 17 patients who did not undergo PTCA. We also studied 119 patients with a first uncomplicated acute anterior MI, including 53 who underwent PTCA (Group C) and 66 who did not (Group D). The length and wall thickness of the infarcted and noninfarcted endocardial segments were determined immediately after MI and 1 month later, and LV ejection fraction (LVEF) was measured during the chronic phase. RESULTS: The lengths of the infarcted and noninfarcted endocardial segments were significantly greater in Group B than in the other three groups (p < 0.05). The LVEF was significantly lower in Group B than in the other three groups (p < 0.05). CONCLUSIONS: We conclude that PTCA performed in patients during the acute phase of MI complicated by cardiogenic shock lowers in-hospital mortality and prevents both LV dilation and a decrease in LVEF.     

Acute myocardial infarction complicated by cardiogenic shock treated with angioplasty of left main stenosis - two case reports

Two patients with acute myocardial infarction (MI) complicated by cardiogenic shock are described. Coronary angiography revealed subtotal left main stenosis. Both patients underwent successful primary coronary angioplasty. The role of coronary angioplasty in patients with acute MI complicated by cardiogenic shock is discussed.     

The prognosis of a first Q-wave versus non-Q-wave myocardial infarction in the reperfusion era

PURPOSE: To compare the prognosis of patients with a first Q-wave versus non-Q-wave myocardial infarction (MI) in the reperfusion era. METHODS: Patients with a first MI were compared according to type of infarct-Q-wave (n = 1,786) versus non-Q-wave (n = 722)-and by treatment with thrombolysis. RESULTS: Patients with non-Q-wave MI were more likely to be female and to have undergone previous coronary revascularization. Their 30-day mortality rate was 7%, as compared with a rate of 9% among patients with Q-wave infarction (adjusted odds ratio [OR] = 0.6, 95% confidence interval [CI]: 0.4 to 0.9). However, the subsequent 30-day to 1-year mortality rates were similar in patients with Q-wave or non-Q-wave MI. Patients who were not treated with thrombolysis and who had a non-Q-wave MI had a lower 30-day mortality rate (OR = 0.6, 95% CI: 0.3 to 0.9) but a similar 30-day to 1-year mortality rate (hazard ratio [HR] = 1.5, 95% CI: 0.9 to 2.5) as compared with their counterparts who developed Q-wave infarction. Among thrombolysis-treated patients, 30-day (OR = 0.8, 95% CI: 0.4 to 1.5) as well as 30-day to 1-year (HR = 1.2, 95% CI: 0.5 to 3.0) mortality rates were similar between patients who developed either Q-wave or non-Q-wave MI. CONCLUSIONS: Patients who received thrombolysis had similar early and late mortality rates after the index infarction regardless of whether they had a Q-wave or non-Q-wave MI. Conversely, among patients who were not treated with thrombolysis, patients with a non-Q-wave MI had lower early mortality rates but similar long-term mortality rates as those with Q-wave MI.     

The use of intra-aortic balloon counterpulsation in patients with cardiogenic shock complicating acute myocardial infarction: data from the National Registry of Myocardial Infarction 2

BACKGROUND: Cardiogenic shock complicating acute myocardial infarction (AMI) remains the leading cause of death in patients hospitalized with AMI. Although several studies have demonstrated the importance of establishing and maintaining a patent infarct-related artery, it remains unclear as to whether intra-aortic balloon counterpulsation (IABP) provides incremental benefit to reperfusion therapy. The purpose of this study was to determine whether IABP use is associated with lower in-hospital mortality rates in patients with AMI complicated by cardiogenic shock in a large AMI registry. METHODS: We evaluated patients participating in the National Registry of Myocardial Infarction 2 who had cardiogenic shock at initial examination or in whom cardiogenic shock developed during hospitalization (n = 23,180). RESULTS: The mean age of patients in the study was 72 years, 54% were men, and the majority were white. The overall mortality rate in all patients who had cardiogenic shock or in whom cardiogenic shock developed was 70%. IABP was used in 7268 (31%) patients. IABP use was associated with a significant reduction in mortality rates in patients who received thrombolytic therapy (67% vs 49%) but was not associated with any benefit in patients treated with primary angioplasty (45% vs 47%). In a multivariate model, the use of IABP in conjunction with thrombolytic therapy decreased the odds of death by 18% (odds ratio, 0.82; 95% confidence interval, 0.72 to 0.93). CONCLUSIONS: Patients with AMI complicated by cardiogenic shock may have substantial benefit from IABP when used in combination with thrombolytic therapy.     

Thrombolysis and Counterpulsation to Improve Survival in Myocardial Infarction Complicated by Hypotension and Suspected Cardiogenic Shock or Heart Failure: Results of the TACTICS Trial

Background: Sustained hypotension, cardiogenic shock, and heart failure all imply a poor prognosis in acute myocardial infarction (MI). We assessed the benefit of adding 48 hours of intra-aortic balloon counterpulsation (IABP) to standard treatment for MI, in an international trial among hospitals without primary angioplasty capabilities.Methods: We randomized 57 patients with MI complicated by sustained hypotension, possible cardiogenic shock, or possible heart failure to receive either fibrinolytic therapy and IABP or fibrinolysis alone. The primary end point was all-cause mortality at 6 months.Results: In all, IABP was inserted in 27 of 30 assigned patients a median 30 minutes after fibrinolysis began and continued for a median 34 hours. Of the 27 patients assigned to fibrinolysis alone, 9 deteriorated such that IABP was required. The IABP group was at slightly higher risk at baseline, but the incidence of the primary end point did not differ significantly between groups (34% for combined treatment versus 43% for fibrinolysis alone; adjusted P = 0.23). Patients with Killip class III or IV showed a trend toward greater benefit from IABP (6-month mortality 39% for combined therapy versus 80% for fibrinolysis alone; P = 0.05).Conclusions: While early IABP use was not associated with a definitive survival benefit when added to fibrinolysis for patients with MI and hemodynamic compromise in this small trial, its use suggested a possible benefit for patients with the most severe heart failure or hypotension.Abbreviated Abstract. We assessed the benefit of adding 48 hours of intra-aortic balloon counterpulsation to fibrinolytic therapy among 57 patients with acute myocardial infarction complicated by sustained hypotension, possible cardiogenic shock, or possible heart failure. The primary end point, mortality at 6 months, did not differ between groups (34% for combined treatment versus 43% for fibrinolysis alone [n = 27]; adjusted P = 0.23), although patients with Killip class III or IV did show a trend toward greater benefit from IABP (39% for combined therapy versus 80% for fibrinolysis; P = 0.05).     

Early coronary angioplasty for acute myocardial infarction complicated by cardiogenic shock: have novel therapies led to better results?

Patients with acute myocardial infarction (MI) and cardiogenic shock constitute a very high risk subset despite an aggressive management. The objective of this study was to evaluate if the results of early coronary angioplasty in patients with acute myocardial infarction and cardiogenic shock have changed over the last years, and to address which role the recent adjuvant therapies have played in this evolution. From 1991 to April 1999, 94 patients with acute MI and cardiogenic shock were treated with coronary angioplasty within the first 12 hours from the onset of symptoms. Temporal changes of the utilization of adjuvant therapies and operators experience were studied over these years, as well as their impact on the angiographic results and in-hospital outcome. Over the years, a progressive and significant increase on the use of coronary stents and c7E3Fab was observed, as well as an increased number of primary angioplasties performed per month. The proportion of patients treated with intraaortic balloon pump did not changed significantly over the years. An angiographic successful result (< 50% residual stenosis and TIMI flow 2 or 3) and a final TIMI grade 3 flow were obtained in 76 (80.9%) and 61 (64.9%) patients, respectively. The angiographic success rate progressively increased over the years, from 72.3% in patients treated before 1994 to 94.1% in those admitted in 1998Eth 1999 (p for trend 0.0409). The proportion of patients with a final TIMI grade 3 flow also grew progressively over the years: from 36.4% before 1994 to 76.5% after 1997 (p for trend 0. 0209). The overall in-hospital mortality rate was 63.8% (60 patients), and there was no significant change in mortality rate over the years. Therefore, apart from the growing operators experience, we have observed an incremental change in the use of coronary stents and c7E3 Fab (abciximab) in patients with acute myocardial infarction and cardiogenic shock treated with early coronary angioplasty. All these factors have led to an improvement in the angiographic results, although this change has not meant a significant reduction of mortality.     

Comparison of primary balloon angioplasty with bailout stenting strategy to primary coronary stenting strategy in the treatment of patients with ST-segment elevation myocardial infarction (STEMI)

BACKGROUND: In recent years significant progress has been made in invasive treatment of patients with acute myocardial infarction (AMI). Primary coronary stenting is currently a routine strategy which replaced primary balloon angioplasty with bailout stenting preferred in the past. Studies comparing these two strategies of stenting in AMI are scarce. AIM: To compare the immediate and long-term outcomes after primary angioplasty strategy and bailout stenting versus primary stent placement strategy in patients with AMI. METHODS: We analysed data from a single-centre registry of consecutive patients with ST segment elevation myocardial infarction admitted between January 1998 and October 2003. In our centre in years 1998-2000 stenting was used only after failed or suboptimal balloon angioplasty. Starting from year 2001 we used routine primary stenting strategy. We compared these two angioplasty strategies applied in different time intervals with regard to in-hospital outcome and long-term mortality. Patients with cardiogenic shock at admission were excluded. RESULTS: Out of a total of 1602 patients treated invasively for AMI (cardiogenic shock excluded) 479 underwent primary balloon angioplasty strategy with bailout stenting - group 1 (years 1998-2000) and 1123 were treated with primary stenting strategy - group 2 (years 2001-2003). In group 1 bailout stenting occurred in 34.4% of patients whereas in group 2 stents were implanted in 83% of patients. Patients in the balloon angioplasty group were younger, had shorter time from the onset of symptom to hospital arrival and more frequently underwent rescue coronary intervention after failed thrombolysis. In-hospital mortality was 2.9 vs. 2.4% in groups 1 and 2, respectively (p=NS). Twenty-four month mortality rate was 9.8% in group 1 and 10.06% in group 2 (p=NS). CONCLUSIONS: 1. Effectiveness of coronary angioplasty is high and comparable in both groups. 2. In-hospital and long-term mortality and procedure-related complication rate are all low and comparable with both stenting strategies. 3. Independent factors increasing long-term mortality include: culprit vessel reocclusion, multivessel coronary disease, older age and hypertension. 4. Patients with complete patency of culprit vessel restored and with higher left ventricular ejection fraction presented lower 2-year mortality rate. 5. Bailout stenting did not increase 2-year mortality.     

The role of reperfusion therapy in paced patients with acute myocardial infarction

BACKGROUND/OBJECTIVE: Our purpose was to evaluate the effectiveness of reperfusion therapy among elderly paced patients with acute myocardial infarction (MI). Current guidelines make no recommendation for the use of reperfusion therapy among patients who have a paced rhythm during MI. METHODS: We evaluated 1954 Medicare beneficiaries 65 years and older treated for acute MI between 1994 and 1996 who had a paced rhythm for use of reperfusion therapy. Use of reperfusion therapy was evaluated for associations with outcomes by logistic regression and Cox proportional hazards models incorporating propensity score analysis. RESULTS: Reperfusion therapy was used in 171 (8.8%) patients; 70 were treated with primary PTCA and 101 with thrombolytic therapy. Patients who received reperfusion therapy had 30-day mortality rates similar to those who did not receive reperfusion (26.3% vs 25.7%, P =.87). Multivariate adjustment for mortality risk factors and treatment propensity indicated no survival benefit associated with reperfusion therapy at 30 days (relative risk [RR] 1.07, 95% confidence interval [CI] 0.77-1.43) or long-term follow-up (hazard ratio [HR] 0.86, 95% CI 0.68-1.10). Mortality risks varied by type of reperfusion therapy. Patients treated with primary percutaneous transluminal coronary angioplasty were at comparable risk of mortality at 30 days (RR 0.73, 95% CI 0.40-1.23) but at lower risk at long-term follow-up (HR 0.60, 95% CI 0.40-0.88). Mortality risks were unchanged among patients treated with thrombolytics at 30 days (RR 1.32, 95% CI 0.92-1.79) and long-term follow-up (HR 1.08, 95% CI 0.82-1.43). CONCLUSION: We find suggestive evidence that primary percutaneous transluminal coronary angioplasty provides a long-term survival benefit in the treatment of elderly patients with acute MI who have a paced rhythm.     

Diabetes mellitus and cardiogenic shock in acute myocardial infarction

AIMS: Cardiogenic shock is the leading cause of in-hospital mortality after acute myocardial infarction (MI). This study investigates the importance of age and preexisting diabetes mellitus on the incidence and prognosis of cardiogenic shock in a large group of consecutive patients with MI. METHODS AND RESULTS: Baseline characteristics and in-hospital complications to the infarction were prospectively recorded in 6676 patients with MI. Ten-year mortality was collected. Diabetes was present in 10.8% of the total population. A total of 443 developed cardiogenic shock with an incidence of 6.2% among nondiabetics and 10.6% among diabetics. Age, wall motion index, reinfarction, and the absence of thrombolytic treatment were significant independent predictors of mortality in patients with cardiogenic shock. Intriguingly, diabetes was not a significant predictor for short- and long-term mortality in this population. The 30-day and 5-year mortality rate was equally poor in both diabetic and nondiabetic patients with cardiogenic shock (diabetics: 30-day 63%, 5-year 91%; nondiabetics: 30-day 62%, 5-year 86%; p>0.05). CONCLUSIONS: Cardiogenic shock develops approximately twice as often among diabetics as among nondiabetic patients with acute MI. The prognosis of diabetics with cardiogenic shock is similar to the prognosis of nondiabetic patients with cardiogenic shock.     

Cardiac rupture in acute myocardial infarction with ST segment elevation. Clinical course and prognosis

INTRODUCTION: Cardiac rupture (CR), involving left ventricular free wall, interventricular septum or papillary muscles, accounts for 15% of all deaths in the acute phase of myocardial infarction (MI). After cardiac arrhythmias and cardiogenic shock, CR is the third most common cause of death in acute MI. In spite of progress in the treatment of MI, mortality due to CR did not change in recent years.Aim. To assess the incidence, clinical course and outcome in patients with acute MI complicated by CR who were treated in our centre. METHODS: The study group consisted of 697 consecutive patients who were hospitalised due to acute MI with ST segment elevation (STEMI). The in-hospital and three-month follow-up data were analysed in 27 (3.9%) patients who developed CR. In 20 patients CR occurred in the left ventricular free wall, in 5 interventricular septum, in one both of these structures, and in one papillary muscle. The diagnosis of CR was based on clinical presentation and echocardiography. RESULTS: The overall mortality in 697 patients with STEMI was 10.5%. Mortality rate in patients with CR was 55.6% (15 patients) which accounted for 20.5% of all deaths. Nine patients with CR underwent cardiac surgery whereas 18 were treated conservatively. Two (22.2%) patients from the former group and 13 (72.2%) patients from the latter group died. CONCLUSIONS: 1. Mortality due to CR was increased in patients who were treated conservatively, who received thrombolysis and those who were females. 2. Rapid and accurate diagnosis, proper correction of hemodynamical disturbances and timely introduction of cardiac surgery improve prognosis in patients with CR complicating STEMI.     

Primary angioplasty versus intravenous thrombolysis in acute myocardial infarction: can we define subgroups of patients benefiting most from primary angioplasty? Results from the pooled data of the Maximal Individual Therapy in Acute Myocardial Infarction Registry and the Myocardial Infarction Registry

OBJECTIVES: We sought to determine the effectiveness of primary angioplasty compared with thrombolysis in clinical practice. BACKGROUND: In clinical practice, primary angioplasty for the treatment of acute myocardial infarction (AMI) has not yet been proven more effective than intravenous thrombolysis, nor have subgroups of patients been identified who would perhaps benefit from primary angioplasty. METHODS: The pooled data of two AMI registries--the Maximal Individual TheRapy in Acute myocardial infarction (MITRA) study and the Myocardial Infarction Registry (MIR)--were analyzed. A total of 9,906 lytic-eligible patients with AMI, with a pre-hospital delay of < or =12 h, were treated with either primary angioplasty (n = 1,327) or thrombolysis (n = 8,579). RESULTS: Despite differences in the patients' characteristics and concomitant diseases between the two groups, the prevalence of adverse risk factors was balanced. Univariate analysis of hospital mortality showed a more favorable course for patients treated with primary angioplasty: 6.4% versus 11.3% (odds ratio [OR] 0.54, 95% confidence interval [CI] 0.43 to 0.67). This was confirmed by logistic regression analysis (multivariate OR 0.58, 95% CI 0.44 to 0.77). Primary angioplasty was associated with a lower mortality in all subgroups analyzed. We observed a significant correlation between mortality and absolute risk reduction (r = 0.82, p < 0.0001) in the different subgroups: as mortality increased, there was an increase in absolute benefit of primary angioplasty compared with thrombolysis. CONCLUSIONS: These large registry data showed the effect of primary angioplasty to be more favorable than thrombolysis for the treatment of patients with AMI in clinical practice. This effect was not restricted to special subgroups of patients. As mortality increased, the absolute benefit of primary angioplasty also increased.     

Long-term follow-up of patients with acute myocardial infarction treated with primary angioplasty or thrombolysis. Results of the MITRA trial

Long-term follow-up after treatment with primary angioplasty compared to treatment with thrombolysis in patients with acute myocardial infarction (AMI) remains still to be determined. We therefore analyzed the data of the "Maximal Individual Therapy" in Acute Myocardial Infarction (MITRA-1) Registry. Follow-up data for a median of 17 months after discharge were available in 2090 out of 2195 (95%) AMI patients treated with thrombolysis, as well as 293 out of 312 patients (94%) treated with primary angioplasty. There were only small differences in patient characteristics between the two treatment groups. Compared to patients treated with thrombolysis, those treated with primary angioplasty had a higher prevalence of prior myocardial infarction (16.4% versus 12.2%, p = 0.04), longer prehospital delay: 10 minutes (130 minutes versus 120 minutes, p = 0.002), and a longer door-to-treatment time: 45 minutes (p < 0.001). Primary angioplasty patients were more likely to be treated with beta-blockers (primary angioplasty 79.8% versus thrombolysis 66.2%, p < 0.001) or statins (24.5% versus 16.5%, p < 0.001). There was no difference between the treatment groups for total mortality (p = 0.90) nor for the combined endpoint of death or re-infarction (p = 0.85). However, the combined endpoint of death, re-infarction or percutaneous coronary intervention or coronary bypass surgery was significantly lower in the primary angioplasty group (primary angioplasty 25.6% versus thrombolysis 32.3%, univariate odds ratio 0.72, 95% CI: 0.55-0.95, p = 0.02). This result was confirmed by multivariate analysis after adjusting for confounding parameters (multivariate odds ratio: 0.62, 95% CI: 0.42-0.91). The beneficial effect of primary angioplasty compared to thrombolysis achieved during the hospital stay after an AMI is maintained during a 17 month follow-up. AMI patients treated with thrombolysis were more likely to be treated with either percutaneous coronary intervention or coronary bypass surgery after discharge.