Primary angioplasty for acute myocardial infarction in 1,000 consecutive patients: Results in an unselected population and high-risk subgroups

Primary angtoplasty (direct angioplasty without antecedent thrombolytic therapy) has remained an exclusive and consistent method of infarct intervention at our institution over the past 13 years. A total of 1,000 consecutive patients were prospectively enrolled in our primary angioplasty database. Of patients presenting to our group with an acute myocardial infarction, 96% of those eligible received immediate angioplasty. Cardiogenic shock was noted in 79 patients (7.9%). The mean time from pain onset to reperfusion was 5.4 ± 4.0 hours. Infarct-vessel recanalizatton was accomplished in 94% of patients. Recanalization rates were similar among the 3 native epicardial coronary systems but were lower in bypass grafts (86%; p < 0.0001). Overall in-hospital mortality was 7.8%; mortality with cardiogenic shock was 44%. Global ejection fraction increased from 49.7% preangloplasty to 57.4% at the time of dismissal. The amount of myocardial salvage was highly dependent on the size of the initial infarction (the largest infarctions benefiting the most). Patients reperfused in <2 hours experienced a very low mortality (4%) and impressive myocardial salvage. Complications included stroke in 0.5%, significant bleeding in 2.8%, and early reocclusion of the infarct vessel in 13%. Primary angioplasty is broadly applicable to patients presenting with acute myocardial infarction and results in a very high rate of infarct vessel recanalization, with a mortality rate of 7.8%. This strategy may be uniquely effective in patients presenting with cardiogenic shock, large infarctions, contraindications to thrombolytic therapy, and prior bypass surgery.     

Cardiogenic shock: single center experience with and without on-site catheterization facilities

BACKGROUND: The beneficial effect of on-site catheterization facilities on the survival of all patients with myocardial infarction complicated by cardiogenic shock has been questioned. Our objective was to evaluate the impact of the availability of on-site catheterization facilities on the outcome of unselected patients with cardiogenic shock. METHODS AND RESULTS: We studied the hospital records of 70 consecutive patients with cardiogenic shock admitted to our intensive coronary care unit during 1990-1996, and compared two groups of patients: those admitted before (n = 34) and after (n = 36) the opening of our catheterization laboratory. Patients admitted when the catheterization laboratory was available were of similar age, but included fewer males and fewer patients with prior myocardial infarction. Following the activation of the catheterization laboratory, utilization rates of coronary angiography, percutaneous transluminal coronary angioplasty and intra-aortic balloon pump increased, compared with the previous period. However, there was no improvement in in-hospital (88 vs. 83%; p = 0.7) and 30-day mortality (91 vs. 86%; p = 0.7) before versus after the activation of our catheterization laboratory. Twelve patients selected to cardiac catheterization (9 underwent percutaneous transluminal coronary angioplasty) experienced lower in-hospital and 30-day mortality compared with patients who were not selected (58 vs. 96, and 67 vs. 96%, respectively; p < 0.02). CONCLUSIONS: Following the activation of the catheterization laboratory, the mortality of the entire population of cardiogenic shock patients remained relatively unchanged. Still, a small subgroup of these patients selected for urgent cardiac catheterization had a lower mortality compared with patients who were not selected.     

Percutaneous transluminal coronary angioplasty for treatment of acute myocardial infarction: comparison with percutaneous transluminal coronary recanalization

Percutaneous transluminal coronary angioplasty (PTCA) was evaluated as a means of reperfusion of the infarct-related coronary artery, and the results were compared with those of percutaneous transluminal coronary recanalization (PTCR). There were no difference in sex, age, infarct location and time from the onset to start of treatment between 135 patients with evolving acute myocardial infarction treated with PTCA (PTCA group) and 113 patients treated with PTCR alone (PTCR group). Fifty-nine patients in the PTCA group underwent PTCA following PTCR; the remaining 76 patients were without prior PTCR. Successful PTCA, defined as a 20% or more reduction in percent luminal stenosis diameter, was achieved in 123 (90%) of the 135 patients in the PTCA group. The reperfusion rate was 93% in the PTCA group and 77% in the PTCR group (p less than 0.01). Residual stenosis immediately after the treatment was 30 +/- 13% in the PTCA group and 70 +/- 16% in the PTCR group (p less than 0.01). In the PTCA group, three cases developed serious complications which were associated with angioplasty: coronary perforation, side branch occlusion resulting in cardiogenic shock and exacerbation of cardiogenic shock. The latter two patients died, however, there was no difference in hospital mortality rate: 6% in the PTCA group versus 11% in the PTCR group. At follow-up angiography performed four weeks after admission, reocclusion of the successfully recanalized arteries was observed in 3% of the PTCA group and in 14% of the PTCR group (p less than 0.01). Regional wall motion was evaluated by left ventriculography using a wall motion score system which consisted of six grades; from normal counted as 0, to dyskinesis counted as 5. There was no difference in the wall motion score between the successful PTCA group and the successful PTCR group (2.6 +/- 1.4 versus 2.8 +/- 1.4), but the scores of both groups were better than those of the non-recanalized group (3.4 +/- 1.0: p less than 0.01). In conclusion, PTCA and PTCR have the same effect on hospital mortality rate and regional wall motion, but PTCA has a higher reperfusion rate and a lower reocclusion rate than does PTCR. Although PTCA has a potential disadvantage inducing serious complications, it appears to be a useful treatment for acute myocardial infarction.     

PRimary coronary angioplasty versus thrombolytic therapy. Comparison of mortality in the acute phase of myocardial infarction - a single centre experience

BACKGROUND: Patency of an infarct-related artery may be achieved by the use of primary coronary angioplasty or thrombolysis. In spite of the growing number of reports dealing with this topic, controversies exist as to the superiority of either of these therapeutic options. Moreover, the role of primary angioplasty has not yet been clearly defined in the guidelines of the Polish Cardiac Society. AIM: To compare mortality in the acute phase of myocardial infarction (MI) in patients treated with primary angioplasty versus patients receiving thrombolytic treatment. METHODS: Using prospectively collected data from all consecutive patients with acute MI admitted to our institution, we analysed retrospectively mortality in patients treated with primary angioplasty versus those who received thrombolysis. RESULTS: Between May 1996 and October 2000, 657 patients with acute MI were hospitalised. Of this group, in 66 (10%) patients primary angioplasty was performed, and 278 (42.3%) received thrombolysis. Cardiogenic shock complicated MI in 20 (30%) patients treated with angioplasty and in 19 (7%) thrombolysed patients. Total mortality in the acute phase of MI was 12 (18.2%) patients in the angioplasty group versus 26 (9.4%) patients in the medically treated group (p<0.05). Mortality among patients with cardiogenic shock was significantly higher in those who received thrombolysis than in those who underwent angioplasty [17 (89.5%) patients versus 11 (55%) patients (p<0.05)] and tended to be higher among patients without cardiogenic shock [9 (3%) thrombolysed patients versus 1 (2.2%) patient who underwent angioplasty, NS]. CONCLUSIONS: Primary coronary angioplasty improves the outcome in patients with acute MI complicated by cardiogenic shock and tends to decrease mortality among patients without cardiogenic shock.     

Myocardial revascularization at the acute phase of myocardial infarction in the octogenarian

Elderly patients are at high risk of complications in acute myocardial infarction (AMI). In this population, myocardial reperfusion at the acute phase improves the prognostic. The mortality rate is above 50% in the absence of reperfusion strategy, and decreases at less than 20% in case of such treatment. The thrombolytic use is limited in those patients, coronary angioplasty is taking an important place in this reperfusion therapy, but is not well evaluated in patients older than 80 years. Prospective registry of patients older than 80 years admitted in H?pital Bichat for acute myocardial infarction within the first 6 hours (n = 92), between 1990 january to 1999 december. Eight patients (10%) received a thrombolytic therapy. Coronary angiogram was achieved in eighty patients (87%). In 58 (63%) patients a coronary angioplasty was performed. The success rate of the coronary angioplasty was 86%. In-hospital mortality rate was 26% (death in 24 patients), 20% in the absence of cardiogenic shock and 62% when this complication was noted. Two patients (2%) were treated by emergent coronary artery bypass surgery. The results comparison between the periods of 1990 to 95 and 1955 to 99 showed, a real trend of decrease mortality rate (28 to 13% in the absence of cardiogenic shock, p = 0.10), an increase of the proportion of patients treated by angioplasty. These results are more and more encouraging. Coronary reperfusion by primary angioplasty in possible in patients older than 80 years with a low rate of complications. Technical progress such as stents and GpIIb/IIIa inhibitors must be evaluated in this population.     

Primary angioplasty for cardiogenic shock complicating acute myocardial infarction.

To evaluate the role of primary percutaneous transluminal coronary angioplasty in cardiogenic shock, 53 patients admitted with the diagnosis of acute myocardial infarction and cardiogenic shock were studied. Thirty-five (66.0%) patients received intravenous thrombolytic therapy (streptokinase 15 lac units) and 18 (34.0%) underwent primary percutaneous transluminal coronary angioplasty. There was no significant difference in the mean age, risk factor profile, presence of prior myocardial infarction, site of myocardial infarction and cardiac enzyme levels at presentation between the two groups. More male patients were present in the group undergoing primary percutaneous transluminal coronary angioplasty (94.44% vs 68.57%; p = 0.04). The time delay between the onset of symptoms and presentation to the hospital did not differ significantly between the two groups (318.9 vs 320.0 minutes; p = NS). In the primary percutaneous transluminal coronary angioplasty group, 17 patients had a single infarct-related artery and one had both left anterior descending and right coronary artery occlusion. Thus in 18 patients, 19 vessels were attempted. Angiographic success (< 50% residual stenosis) was achieved in 15 (78.94%) vessels of which TIMI III flow was achieved in 10 (52.63%) vessels and TIMI II flow in five (26.31%). Intra-aortic balloon pump was needed in five (27.77%) patients undergoing coronary angioplasty. In-hospital mortality was 27.77 percent in patients undergoing primary percutaneous transluminal coronary angioplasty and 57.14 percent in patients receiving intravenous thrombolytic therapy (p = 0.04). In the thrombolytic therapy group, mortality was higher (85.91%) in patients presenting six hours or later after the onset of symptoms as compared to those presenting in less than six hours of the onset of symptoms (50%). In primary percutaneous transluminal coronary angioplasty group, mortality was 21.42 percent in patients with successful and 50 percent in patients with failed angioplasty. Thus, in patients with acute myocardial infarction and cardiogenic shock, an aggressive invasive strategy with primary percutaneous transluminal coronary angioplasty, as compared to intravenous thrombolytic therapy, is helpful in reducing in-hospital 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.     

Cardiogenic shock complicating acute myocardial infarction in elderly patients: does admission to a tertiary center improve survival?

Background The role of early revascularization among patients with acute myocardial infarction complicated by cardiogenic shock remains controversial. Angioplasty registries, while suggesting a benefit, are subject to selection bias, and clinical trials have been underpowered to detect early benefits. If an invasive strategy is beneficial in this population, patients admitted to hospitals with onsite coronary revascularization might be expected to have a better prognosis. We sought to determine whether access to cardiovascular resources at the admitting hospital influenced the prognosis of patients with acute myocardial infarction complicated by cardiogenic shock. Methods By use of the Cooperative Cardiovascular Project database (a retrospective medical record review of Medicare patients discharged with acute myocardial infarction), we identified patients aged ≥65 years whose myocardial infarction was complicated by cardiogenic shock. Results Of the 601 patients with cardiogenic shock, 287 (47.8%) were admitted to hospitals without revascularization services and 314 (52.2%) were admitted to hospitals with coronary angioplasty and coronary artery bypass surgery facilities. Clinical characteristics were similar across the subgroups. Patients admitted to hospitals with revascularization services were more likely to undergo coronary revascularization during the index hospitalization and during the first month after acute myocardial infarction. After adjustment for demographic, clinical, hospital, and treatment strategies, the presence of onsite revascularization services was not associated with a significantly lower 30-day (odds ratio 0.83, 95% CI 0.47, 1.45) or 1-year mortality (odds ratio 0.91, 95% CI 0.49, 1.72). Conclusions In a community-based cohort, patients with acute myocardial infarction complicated by cardiogenic shock did not have significantly different adjusted 30-day and 1-year mortality, irrespective of the revascularization capabilities of the admitting hospital. (Am Heart J 2002;143:768-76.)     

Emergency percutaneous transluminal coronary angioplasty in acute myocardial infarction: a 3 year experience

In 151 patients experiencing acute myocardial infarction, emergency coronary angioplasty was performed as primary therapy. Overall, angioplasty was successful in 132 patients (87%); it was successful in 91 (85%) of 107 patients with a totally occluded infarct-related artery and in 41 (93%) of 44 patients with a subtotally occluded infarct-related artery. After successful angioplasty, mean residual stenosis was 29% (range 0 to 70). Eighteen patients were in cardiogenic shock (12%) including four patients receiving cardiopulmonary resuscitation during the angioplasty procedure. Hospital mortality was 9%, with 7 of 13 deaths occurring in patients presenting with cardiogenic shock or intractable ventricular arrhythmia. Hospital mortality was 5% in patients with successful angioplasty versus 37% in those with unsuccessful angioplasty (p less than 0.001). In the immediate period after angioplasty, left ventricular ejection fraction was significantly lower for patients with lesions of the left anterior descending artery (34 +/- 10%) than for patients with lesions of the left circumflex or right coronary artery (43 +/- 11%). In patients with successful angioplasty, significant improvement in left ventricular ejection fraction averaged 13 +/- 12% (p less than 0.001) for those with lesions of the left anterior descending artery and 10 +/- 12% (p less than 0.001) for those with lesions of the left circumflex or right coronary artery. Repeat coronary angiography was performed in 85 (70%) of 121 patients who had successful angioplasty and survived hospitalization without requiring bypass surgery; restenosis was found in 26 (31%), and angioplasty was repeated in 22 patients, successfully in each.(ABSTRACT TRUNCATED AT 250 WORDS)     

One-Week and Six-Month Angiographic Controls of Stent Implantation After Occlusive and Nonocclusive Dissection During Primary Balloon Angioplasty for Acute Myocardial Infarction

We prospectively assessed in 124 consecutive patients by means of 1-week and 6-month follow-up angiograms the rate of reocclusion and restenosis of coronary stenting with Palmaz-Schatz stents after occlusive and nonocclusive dissection during primary balloon angioplasty for acute myocardial infarction (AMI). Patients were further evaluated clinically at 1 year. Stenting was performed on large (>3.2 mm) coronary arteries for suboptimal results (47%), occlusive (8%), or nonocclusive dissections (45%) after balloon angioplasty. Stents were delivered using the bare stent technique and high pressure inflations (>12 atm). All patients received ticlopidine 250 mg (500 mg if weight was >80 kg) and aspirin 100 mg for 1 month. No patient received warfarin. At 1 week, 6 patients died of cardiogenic shock and 2 of right ventricular infarction. One subacute occlusion occurred at day 14. At 6 months, in 95 patients, the angiographic restenosis rate (>50% diameter stenosis) was 19%. One-year clinical follow-up, available in 55 patients, indicated cardiac death in 5, and repeat revascularization in 3. Thus, coronary stenting on large (>3.2 mm) coronary arteries after occlusive and nonocclusive dissection during primary balloon angioplasty for AMI using bare Palmaz-Schatz stents, high pressures, ticlopidine, and aspirin is safe. Our reocclusion and restenosis rates are similar to those of trials on elective stenting in stable patients.

The reocclusion and restenosis rates of coronary Palmaz-Schatz stenting after occlusive and nonocclusive dissection during primary balloon angioplasty for acute myocardial infarction were assessed in 124 consecutive patients by performing 1-week and 6-month angiographic controls. No reocclusion was noted at 1 week, 1 subacute occlusion occurred at day 14, and the angiographic 6-month restenosis rate was 19%.     

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.     

Thrombolysis in acute myocardial infarction complicated by cardiogenic shock

The adverse impact of the development of cardiogenic shock in the setting of acute myocardial infarction was first described by Killip and Kimball in 1967. While the inhospital mortality rate in patients with myocardial infarction and no evidence of heart failure was only 6%, the mortality rate in those patients who developed cardiogenic shock was 81%. Despite advances in cardiovascular care and therapy since that initial report, including universal institution of cardiac care units, advances in hemodynamic monitoring, new inotropic and vasodilating agents, and even increasing utilization of thrornbolytic therapy, the mortality from acute myocardial infarction, when complicated by cardiogenic shock, remains disturbingly high, and cardiogenic shock remains the leading cause of death of hospitalized patients following acute myocardial infarction.The grave prognosis associated with this condition has resulted in increased interest in potential therapeutic interventions, particularly in the area of reperfusion therapy. Several studies suggest that, in contrast to the beneficial effects of thrombolytic therapy in most patient populations suffering acute myocardial infarction, mortality rates are not decreased in those patients with cardiogenic shock at the time of lytic administration. Thrombolytic administration does, however, appear to lead to a modest reduction in the percent of patients with myocardial infarction who will subsequently develop cardiogenic shock during hospitalization.Reperfusion rates with lytic therapy in patients with cardiogenic shock are disappointingly low, in the range of 42–48%, significantly lower than those achieved in patients without cardiogenic shock. These low perfusion rates may, in part, be explained by decreased coronary blood flow and perfusion pressure in patients with left ventricular pump failure.Although promising as adjunctive therapy, it is unclear whether institution of balloon counterpulsation has any long-term benefit in patients with cardiogenic shock treated with thrombolytic therapy. Whether other or additional interventions, such as coronary angioplasty and coronary artery bypass graft (CABG), decrease mortality rates in patients with cardiogenic shock remains to be determined.     

Aspirin and percutaneous coronary angioplasty are associated with a decline in mortality from cardiogenic shock. Results from a national Israeli survey, 1992--1998

BACKGROUND AND METHODS: Despite the significant progress in the care and outcome of patients with acute myocardial infarction (AMI), the impact of evolving therapies on the incidence and outcome of patients with cardiogenic shock complicating AMI has been questioned. We analyzed trends in the incidence, care and outcome of cardiogenic shock from four national surveys conducted during 1992--1998. RESULTS: Of the 5,351 AMI patients admitted to all coronary care units in Israel, 254 (4.7%) developed cardiogenic shock. The incidence of cardiogenic shock decreased over time (5.8, 5.1, 4.3 and 4.4% for the years 1992, 1994, 1996 and 1998, respectively, p = 0.08). Concomitantly, there was an increase in utilization of coronary angiography, urgent angioplasty and intra-aortic balloon counterpulsation. In addition, there was an increase in hospital use of aspirin, nitrates, ACE inhibitors and beta-blockers. Patients with shock were more likely to die within 7 days compared with AMI patients not having shock (65 vs. 4%; p < 0.001). During the study period, the mortality of patients with shock decreased: at 7 days (72% in 1992 to 60% in 1998; p = 0.09), at 30 days (87 to 70%, respectively; p = 0.01) and at 6 months (89 to 77%, respectively; p = 0.02). Both aspirin and angioplasty were independently associated with improved outcome after adjustment for baseline characteristics and study period. CONCLUSIONS: Although the mortality rate of cardiogenic shock complicating AMI remains high, the increased utilization of aspirin and angioplasty is associated with improved outcome.     

Efficacy of invasive strategy for the management of acute myocardial infarction complicated by cardiogenic shock

This retrospective study evaluates the influence of an invasive strategy of urgent coronary revascularization on the in-hospital mortality of patients with acute myocardial infarction (AMI) complicated early by cardiogenic shock. Among 1,981 patients with AMI admitted to our institution from 1994 to 1997, 162 patients (8.2%) developed cardiogenic shock unrelated to mechanical complications. The strategy of management was considered invasive if an urgent coronary angiography was indicated within 24 hours of symptom onset. Every other strategy was considered conservative. Fifty-seven patients who developed the shock late or after a revascularization procedure, or who died on admission, were excluded. The strategy was invasive in 73 patients (70%). Five of them died before angiography could be performed and 65 underwent angioplasty (success rate 72%). By univariate analysis the invasive strategy was associated with a lower mortality than conservative strategy (71% vs 91%, p = 0.03), but this association disappeared after adjustment for baseline characteristics. Older age, nonsmoking, and previous ischemic heart disease were independent predictors of mortality. In conclusion, we have failed to demonstrate that a strategy of urgent coronary revascularization within 24 hours of symptom onset for patients with AMI complicated by cardiogenic shock is independently associated with a lower in-hospital mortality. This strategy was limited by the high mortality within 1 hour of admission in patients with cardiogenic shock, the modest success rate of angioplasty in this setting, and the powerful influence of some adverse baseline characteristics on prognosis.     

Emergency percutaneous transluminal coronary angioplasty for acute myocardial infarction in patients 70 years of age and older

Direct percutaneous transluminal coronary angioplasty (PTCA) was performed as the primary means of establishing reperfusion during acute myocardial infarction in 105 elderly patients (mean age +/- standard deviation 75 +/- 4 years) at a mean of 5.5 +/- 4.0 hours from symptom onset. Fifty-two patients (50%) had anterior infarctions, 70 (67%) had significant narrowing in greater than 1 vessel, and 12 (11%) were in cardiogenic shock. Primary success was achieved in 91% of the infarct-related arteries. Four patients with failed PTCA underwent emergency bypass surgery; 10 had early symptomatic reocclusion of the dilated vessel. There was 1 death acutely in the catheterization laboratory. The overall in-hospital mortality was 18%. Three-vessel coronary artery disease and cardiogenic shock on presentation were the strongest predictors of in-hospital death. Global ejection fraction improved from 54 +/- 13 to 61 +/- 15% (p less than 0.001). The 1- and 5-year survival rates, including in-hospital deaths, were 73 and 67%, respectively. It is concluded that direct PTCA is an effective means of salvaging ischemic myocardium during acute myocardial infarction in the elderly patient. It is associated with a high success rate and low complication rate. The short- and long-term survival in this high-risk group of patients are improved compared with survival rates in historical controls.     

Primary coronary angioplasty in ST-elevation myocardial infarction: prediction of the thirty-day mortality risk in an unselected population of patients.

BACKGROUND: The 30-day mortality in catheter-based reperfusion therapy in patients with acute myocardial infarction varies widely in the literature and only some factors, such as cardiogenic shock, are clearly associated with the risk. This non-randomized, single center study investigates the potential factors influencing the 30-day mortality in 586 consecutive patients with ST-elevation myocardial infarction, treated with primary coronary angioplasty (PTCA). METHODS: In the whole series and in two subgroups (with and without cardiogenic shock) the clinical, angiographic and procedural variables were used to develop multivariate statistical models for the prediction of the endpoint. RESULTS: The overall 30-day mortality was 7.3%: 35.8 and 4.5% in patients with and without cardiogenic shock, respectively (p < 0.001). Independent predictors of the 30-day mortality included: a) in the entire series: shock, PTCA angiographic success, time to treatment, age, and coronary artery disease extension; b) in patients with cardiogenic shock: PTCA angiographic success, time to treatment, coronary artery disease extension, and use of abciximab; c) in patients without cardiogenic shock: time to treatment, age, and coronary artery disease extension. CONCLUSIONS: In patients with ST-elevation myocardial infarction submitted to primary PTCA, the 30-day mortality rate is a highly predictable endpoint. The role of abciximab therapy and of other independent predictors varies according to the presence or otherwise of cardiogenic shock.     

Emergency surgery of acute coronary insufficiency]

In our centre, during the last five years, emergency operations (within 6 hours) and urgent operations (within 72 hours) have represented 1/4 of all coronary surgery. 295 patients (pts) have been operated on since 1972: of these, 279 with simple revascularization, 5 with combined major surgery, and 11 as a consequence of mechanical complications of acute myocardial infarction. These last were all in cardiogenic shock: the overall 30-day mortality rate was 5.4% (3.6% in those pts with simple revascularization, 20% in those with combined major surgery, and 45.4% in pts with cardiogenic shock). In the subgroup with simple revascularization, the incidence of non fatal perioperative acute myocardial infarction (AMI) was 4.7% in 253 pts with unstable angina, 52.2% in 23 pts with abrupt closure during coronary angioplasty, and obviously 100% in 3 pts surgically treated during evolving AMI. We were able to identify in the univariate analysis as the only 30-day risk mortality factors: 1) a reduced ejection fraction (< 30%) and 2) the combination with endarterectomy. Other factors (female sex, age > 70, severity of angina, diffuse coronary artery disease and more than 3 by pass grafts) have shown a tendency to increase the mortality rate without statistical significance. No deaths occurred in pts revascularized in emergency situations due to coronary angioplasty complications. In recent years emergency and urgent coronary surgical operations have been increasing, with an increase in pts with higher risk factors. In pts with simple revascularization, 30-day mortality and incidence of myocardial infarction are similar to those of elective surgery. In pts with abrupt closure as a consequence of coronary angioplasty the mortality rate seems very low, while the incidence of infarction remains extremely high. These observations have allowed the development of an integrated protocol of intervention in acute unstable coronary syndromes.     

Percutaneous coronary revascularization in patients over eighty: acute and long-term results]

BACKGROUND: As a consequence of prolonged life expectancy the number of older patients with symptomatic coronary artery disease is constantly increasing. The aim of the study was to evaluate procedural success, immediate and long-term outcomes and the predictive factors of prognosis in patients aged > 80 years with high-risk coronary artery disease treated with coronary angioplasty. METHODS: In this retrospective study, we report the diagnostic and therapeutic strategies adopted in patients aged > 80 years admitted to our institution for acute coronary syndrome with or without ST-segment elevation or disabling angina (CCS class 3-4) and the immediate and long-term results of patients treated with coronary angioplasty. RESULTS: A conservative approach was adopted in 180 patients (33%, group 1) out of the total number of 545 patients, while 365 patients (67%, group 2) underwent coronary angiography. Among these, 85% underwent revascularization. Relevant comorbidities were significantly higher in group 1 (59 vs 16%, p < 0.001) while a clinical presentation with ST-elevation myocardial infarction was prevalent in group 2 (15 vs 6%, p = 0.007). The in-hospital mortality was 19% in group 1 and 7.9% in group 2 (p = 0.001). Among 198 patients treated with angioplasty, procedural success was achieved in 93% of cases, with 8% in-hospital mortality. Periprocedural myocardial infarction occurred in 3.3% and major bleeding in 5.6% of patients. At multivariate analysis ST-elevation myocardial infarction and cardiogenic shock were significantly related to the in-hospital mortality. At follow-up (mean 25 +/- 13 months) 13 patients died, 9 from cardiac causes and 4 from noncardiac events. Recurrence of ischemia requiring revascularization occurred in 15.9% of cases. Cumulative survival at follow-up was respectively 86% at 1 year and 83% at 5 years, while the event-free survival at 5 years was 59% in the entire group, without any significant difference among patients with multivessel disease in whom a complete vs an incomplete revascularization was performed. The presence of severe comorbidities appeared to be the only predictive factor of unfavorable outcome at long-term follow-up at multivariate analysis. CONCLUSIONS: In patients aged > 80 years with symptomatic ischemic heart disease at high risk, the invasive approach was prevalent. Higher mortality rates were found in patients in whom coronary angiography was not performed. Comorbidities represent an important negative prognostic factor, impairing both the possibility of an invasive approach and conditioning an unfavorable outcome of revascularized patients. Coronary angioplasty can be successfully performed even in elderly patients. The in-hospital mortality turns out significantly higher in the setting of an acute ST-elevation myocardial infarction or in cardiogenic shock patients. For patients overcoming the acute phase, high survival rates can be expected at follow-up.     

Effectiveness of percutaneous coronary interventions in nonagenarians

Data on percutaneous coronary intervention (PCI) in nonagenarians are very scarce. The investigators present a series of 26 nonagenarians who underwent PCI (29 lesions, 1.1 +/- 0.3 per patient). Most (96%) had acute coronary syndrome at presentation, 27% underwent primary PCI for acute myocardial infarctions, and 54% had multivessel disease. Angiographically successful results were obtained in 24 patients (92%), and coronary stents were used in 81%. Five patients (19%) died during hospitalization. In-hospital mortality was significantly greater in patients with Killip class III or IV at presentation (100% vs 9%, p = 0.001), in those in whom the procedure was a primary PCI for acute myocardial infarction (57% vs 5%, p = 0.010), and in the presence of angiographic failure (100% vs 13%, p = 0.031). In-hospital mortality was 0% after excluding patients in cardiogenic shock and those with primary PCI. Thus, most nonagenarians who undergo PCI have a high-risk profile. However, PCI achieves a successful angiographic result in most patients. Mortality is high but concentrated in patients in cardiogenic shock and with primary angioplasty as PCI.