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.     

直接冠状动脉腔内成形术治疗急性心肌梗死

急性心肌梗死近年来大规模地推广应用静脉溶栓治疗,抢救了不少生命。直接经皮冠状动脉腔内成形术(PTCA)在急性心肌梗死的治疗上将又是一项有效的治疗措施。我科1995年8月～1998年4月,对46例急性心肌梗死病人作直接FTCA,取得满意临床效果。     

Mortality rates in patients with ST-elevation vs. non-ST-elevation acute myocardial infarction: observations from an unselected cohort.

AIMS: Acute myocardial infarction (AMI) is categorized, according to the presenting electrocardiogram, into non-ST-elevation myocardial infarction (non-STEMI), ST-elevation myocardial infarction (STEMI), or bundle branch block myocardial infarction (BBBMI). Data on the prognostic significance of these categories mainly originate from voluntary based registries or large-scale clinical trials and may be hampered by selection and information bias. The aim of this historical cohort study was to evaluate the prognostic significance of different categories of AMI in an unselected cohort. METHODS AND RESULTS: From 1 November 1999 to 31 October 2001, patient records were reviewed from all admissions to hospitals serving a study region with 139,000 inhabitants. An Endpoint Committee determined whether patients fulfilled the European Society of Cardiology criteria of AMI. A total of 654 patients with AMI were identified. The proportion having non-STEMI, STEMI, and BBBMI was 54, 39 and 6%, and the associated 1 year mortality was 31, 21, and 55%, respectively (log rank 54, P<0.001). The more favourable outcome observed in patients with STEMI remained significant according to multivariable analysis (P=0.044). CONCLUSION: In an unselected cohort of patients admitted with AMI, the mortality was considerably higher than expected from voluntary-based registries and large-scale clinical trials. The most favourable outcome is observed in patients with STEMI.     

Predicting mortality in patients with ST-elevation myocardial infarction treated with primary percutaneous coronary intervention (PAMI risk score)

We performed a pooled analysis of the Primary Angioplasty in Myocardial Infarction (PAMI) trials to examine predictors of death after primary percutaneous coronary intervention. Using these data, we developed a risk score with a range of 0 to 15 points. The PAMI risk score was found to be a strong predictor of late mortality.     

Hyperoxemic perfusion of the left anterior descending coronary artery after primary angioplasty in anterior ST-elevation myocardial infarction.

OBJECTIVES: To assess left ventricle function recovery, ST-segment changes, and enzyme kinetic in ST-elevation myocardial infarction patients treated with intracoronary hyperoxemic perfusion (IHP) after primary percutaneous coronary intervention and compare them with the results obtained in control patients. BACKGROUND: IHP has been shown to attenuate microvascular reperfusion injury, which may result in poor LV function recovery despite successful primary percutaneous coronary intervention. METHODS: Twenty seven anterior ST-elevation myocardial infarction patients treated < or = 12 hr after symptom onset by primary percutaneous coronary intervention were subjected to selective IHP into the left anterior descending coronary artery for 90 min. They were compared with 24 anterior ST-elevation myocardial infarction control patients matched in clinical and angiographic characteristics and treated with conventional primary percutaneous coronary intervention. Left ventricular function recovery was evaluated by serial 2D contrast echocardiography. RESULTS: Left anterior descending coronary artery recanalization was successful in all patients. After IHP (100% successful, duration 90 +/- 5.4 min), patients showed a 4.8 +/- 2.2 hr shorter time-to-peak creatine kinase release (P = 0.001), a shorter creatine kinase half-life period (23.4 +/- 8.9 hr vs. 30.5 +/- 5.8 hr, P = 0.006), and a higher rate of complete ST-segment resolution (78% vs. 42%, P = 0.01). A significant improvement of mean left ventricular ejection fraction (from (44 +/- 9)% to (55 +/- 11)%, P < 0.001) and wall motion score index (from 1.77 +/- 0.2 to 1.39 +/- 0.4, P < 0.001) was observed at 3 months in IHP patients only. CONCLUSION: After successful primary coronary intervention, IHP is associated with significant left ventricular function recovery when compared to conventional treatment. Enzyme kinetic and ST-segment changes suggest faster and more complete microvascular reperfusion and may explain the salutary effects of this new therapy on left ventricular function.     

Primary percutaneous coronary intervention vs. fibrinolytic therapy for acute ST-elevation myocardial infarction in the elderly

Advanced age is associated with worse prognosis among patients with acute ST-elevation myocardial infarction. Many eligible elderly patients with acute ST-elevation myocardial infarction, however, do not receive any reperfusion therapy at all. The risk of intracranial hemorrhage complicating fibrinolytic therapy increases with age. Furthermore, routine adjunctive stenting has made coronary angioplasty safer. In total, primary percutaneous coronary intervention is the preferred reperfusion strategy among elderly patients with acute ST-elevation myocardial infarction, provided that it can be performed without excessive delay. The break-even incremental delay with primary percutaneous coronary intervention compared with fibrinolytic therapy is not clear at this point and will need to be elucidated by future investigation.     

Primary coronary angioplasty in patients with ST segment elevation acute myocardial infarction and diabetes

BACKGROUND: Subjects with diabetes constitute 13-25% of patients with ST segment elevation acute myocardial infarction (STEMI). In spite of the introduction of thrombolytic therapy, patients with STEMI and diabetes continue to have worse prognosis than those without diabetes. Primary percutaneous coronary intervention (PCI) has been shown in recent years to be the most effective therapy in patients with STEMI. AIM: To compare the outcome of STEMI patients with or without diabetes who underwent primary PCI. METHODS: The study group consisted of 500 consecutive patients with STEMI. The occurrence of major adverse cardiac events (MACE) which included death, reinfarction or repeated PCI of the target vessel, was analysed peri-operatively and during a six-month follow-up period.Results. Diabetes was diagnosed in 68 (13.6%) patients. The mean time duration from the onset of STEMI symptoms to treatment was similar in patients with or without diabetes (230+/-97 min vs 231+/-139 min, NS). Patients with diabetes were older (61.9+/-8.9 vs 57.9+/-10.8 years, p=0.004), had higher body mass index (29+/-4 vs 27+/-5, p=0.002), more frequent history of coronary artery disease (57.4% vs 37.9%, p=0.002), higher prevalence of arterial hypertension (71.6% vs 56.8%, p=0.02) and more frequently the left anterior descending artery as the infarct-related artery (58.8% vs 42.1%, p=0.01). Immediately after PCI, epicardial and myocardial reperfusion rates were lower in patients with rather than without diabetes (TIMI 3: 84.9% vs 91.3%, p=NS, cTFC: 32+/-26 vs 22+/-16, p<0.0001, and MPG3: 25% vs 41.9% p=0.008). Diabetes increased the risk of MACE during in-hospital period by 2.7 times. The rate of MACE during a six-month follow-up period was almost two times higher in patients with rather than without diabetes (death: 8.8% vs 5.1%, reinfarction: 1.5% vs 1.2%, repeated PCI: 11.8% vs 6.9%). CONCLUSIONS: Primary PCI-achieved epicardial and myocardial reperfusion rate is lower in STEMI patients with rather than without diabetes. The presence of diabetes almost doubles the risk of MACE during a six-month follow-up.     

PAMI评分用于急性ST段抬高心肌梗死介入治疗患者的预后评价

目的探讨将来自于临床试验的介入治疗心肌梗死的危险评分(PAMI评分)应用于普通患有ST段抬高心肌梗死(STEMI)并接受直接PCI治疗的患者,评判其预测价值,以及冠状动脉病变程度与左心室射血分数对危险分层的意义。方法应用PAMI评分对2002年3月至2004年5月因STEMI连续行直接PCI的患者206例进行危险分层,并电话随访6个月至1年的死亡率。计数资料应用秩和检验,计量资料用独立样本t检验,并应用非条件logistic回归分析各变量与发病后6个月的死亡率的关系。结果随访到的183例患者中,PAMI评分在0~2分者有88例,3~5分者有54例,6~8分者有17例,≥9分有24例,死亡率分别为1·1%(1/88),3·7%(2/54),17·6%(3/17),41·7%(10/24),4组之间差异有统计学意义。Logistic回归分析显示冠状动脉血管病变支数是介入治疗后STEMI患者的危险因素(相对危险度10·186),而左心室射血分数(LVEF)则为保护性因素(相对危险度0·849)。PAMI评分联合冠状动脉3支病变及入院48h内的LVEF值可以增强死亡率的预测价值。结论PAMI危险评分可以作为简便易行的方法评价直接PCI治疗后STEMI患者的死亡率,同时联合冠状动脉病变程度与左心室射血分数可以增加预测价值的精确性。     

Balloon coronary angioplasty in patients with acute myocardial infarction

After successful thrombolysis, approximately 75% of all patients will have significant coronary stenosis, which can be dilated by means of percutaneous transluminal balloon angioplasty (PTCA). In a randomized control study, 95 of our patients (Group I) had thrombolysis alone, whereas 95 others (Group II) had thrombolysis and PTCA. Both groups were comparable with respect to age, sex, infarct location, and maximal creatine kinase (CK) value. The clinical outcome during the hospital phase was better in Group II, which had a reocclusion rate of 13%, a reinfarction rate of 5%, a lethal reinfarction rate of 2%, and a cardiac death rate of 7%, compared with respective rates of 20%, 13%, 7%, and 13% in Group I. Furthermore, in Group I, residual coronary stenosis immediately after thrombolysis (75% +/- 20%) did not improve significantly until the end of the hospital phase, when it decreased to 69% +/- 21%. In Group II, stenosis (78% +/- 16%) was improved by PTCA to 33% +/- 21%, and this improvement remained constant during the hospital phase (30% +/- 26%). In Group-II patients who had an unsuccessful PTCA, stenosis was approximately the same before dilatation (83% +/- 12%), after dilatation (80% +/- 17%), and at the control study (83% +/- 17%). The end-diastolic, end-systolic, and stroke volume indices, as well as the ejection fraction, also remained unchanged. In Group I, the number of pathologic wall segments (12.2 +/- 5.0) did not improve during the hospital phase (12.2 +/- 7.9), but in Group II, the improvement was significant (14.0 +/- 5.7 vs. 10.9 +/- 8.2) (p < 0.05). PTCA seems to improve the clinical outcome, reduce the infarction and mortality rates, and enhance myocardial perfusion and performance.     

Primary risk factors in patients with myocardial infarction.

A predicted probability of suffering myocardial infarction based on a multiple risk function involving serum cholesterol, systolic blood pressure, and tobacco consumption, was allocated retrospectively to 270 men who survived a primary myocardial infarction. The infarction patients were representative of all surviving, diagnosed cases of primary infarction in men in certain age groups in G?teborg, Sweden, during the years 1968-70. The patients were divided into three groups-low, moderate, and high risk. A large number of patients had suffered infarction despite relatively low risk, but the patients showed a tendency toward higher risk in comparison with the risk distribution in a representative population sample. In order to study whether other variables, not included in the risk function, could "explain" the infarction in patients with relatiely low risk, the different risk groups were compared. A high degree of mental stress, diabetes mellitus, and dyspnea on exertion, and possibly also raised triglycerides, contributed to "explain" the infarctions in the low-risk group. Low physical activity during leisure time was probably also of importance.