Effectiveness and safety of routine primary angioplasty in patients aged > or =85 years with acute myocardial infarction

BACKGROUND: Although octogenarians constitute a fast growing portion of cardiovascular patients, few data are available on the outcome of very old patients (age >80 years) with ST-segment elevation myocardial infarction (STEMI) undergoing primary angioplasty. METHODS AND RESULTS: Short- and long-term outcomes of 88 consecutive very old (age > or =85 years) patients with STEMI undergoing primary angioplasty were evaluated. In-hospital mortality was 17%, significantly higher in patients with cardiogenic shock (90%; p<0.001), with failure of percutaneous coronary intervention (PCI; p=0.016), with Killip class > or =III on admission (p=0.018), or with chronic renal failure (p=0.033). Major bleeding complications occurred in 11 patients (12%). Multivariable logistic regression analysis identified 3 independent predictors of in-hospital death: age > or =90 years (p=0.018), Killip > or =III on admission (p=0.018), and PCI failure (p=0.025). Multivariable logistic regression analysis identified age > or =90 years (p=0.008), Killip > or =III on admission (p=0.015), and time from symptoms to PCI >12 h (p=0.04) as independent predictors of mortality at long-term follow-up. CONCLUSIONS: The low incidence of procedural complications, together with good long term survival, suggest that primary PCI in STEMI patients > or =85 years is safe and efficacious, with a low rate of PCI failure in the presence of a low Killip class on admission, whereas primary PCI is unable to affect the poor prognosis for very old patients with cardiogenic shock.     

Mitral regurgitation is an independent predictor of 1-year mortality in ST-elevation myocardial infarction patients presenting in cardiogenic shock on admission.

Abstract

Background: Cardiogenic shock (CS) remains the most serious complication of acute ST-elevation myocardial infarction (STEMI). Mitral regurgitation (MR) is a frequent complication of STEMI and a well-known predictor of mortality in STEMI without CS. The purpose of this study was to determine the prognostic significance of MR in STEMI patients with CS on admission. Methods: Mitral regurgitation was assessed in 147 consecutive STEMI patients with CS on admission and treated by primary percutaneous coronary intervention (PCI). Color Doppler of MR was graded with a 0 to 3 scale (none, n = 26; 1 = mild, n = 62; 2 = moderate, n = 40; 3 = severe, n = 19). Results: Overall one-year mortality in the study cohort was 27%. One-year mortality was 8%, 23%, 30% and 58% for patients with no, mild, moderate and severe MR respectively (P <0.001). For each grade of MR increase, the odds for mortality increased with 71% (OR: 1.71; 95% CI: 1.02–2.87; P = 0.043) when adjusted for age, gender, previous myocardial infarction, left ventricular ejection fraction (LVEF) <40%, multivessel disease and no-reflow. Conclusions: The presence of MR on early echocardiography is an important independent predictor of one-year mortality in STEMI patients with CS on admission treated by primary PCI.     

Primary percutaneous coronary intervention for acute myocardial infarction in the elderly aged ≥75 years

Objectives : We aimed to see whether primary percutaneous coronary intervention (PCI) benefits for ST‐segment elevation myocardial infarction (STEMI) in the aged could be validated. Background : Primary PCI benefits in elderly patients with STEMI remain uncertain. Methods : We reviewed 947 consecutive patients treated with primary PCI for STEMI: 331 were aged ≥75 years (older) and 616 <75 years (younger). Results : The older group had higher percentage of renal insufficiency (7.9% vs. 3.1%, P = 0.0010), prior stroke (9.4% vs. 3.9%, P = 0.0006), 30‐day mortality rate (7.6% vs. 3.9%, P = 0.015), and cardiac mortality rate (6.6% vs. 3.7%, P = 0.045). Successful reperfusion rates were similarly high in both groups (90.0% and 92.7%, P = 0.16), despite the higher proportion of patients with door‐to‐balloon time >90 min (15% vs. 8.4%, P = 0.0016) in older patients. Successful compared with unsuccessful PCI significantly decreased 30‐day mortality rates in the older group (6.0% vs. 21%, P = 0.0018) and in the younger group (2.8% vs. 18%, P < 0.0001). When reperfusion was successful, cardiac mortality rate in older patients was not significantly greater than in younger patients (5.4% vs. 2.8%, P = 0.057). By multivariate analysis, unsuccessful reperfusion independently predicted 30‐day mortality (odds ratio, 4.04; 95% confidence interval, 1.79–9.12; P = 0.0008), whereas age ≥75 years (odds ratio, 1.00; 95% confidence interval, 0.41–2.41; P = 0.99) and door‐to‐balloon time >90 min (odds ratio, 1.78; 95% confidence interval, 0.76–4.20; P = 0.19) did not. Conclusions : Pre‐existing comorbidities characterize older patients developing STEMI. Aggressive PCI in older patients improves prognosis, and short door‐to‐balloon time is an important parameter conditioning the prognosis. © 2011 Wiley Periodicals, Inc.     

Incidence,predictors, and prognostic value of intramyocardial hemorrhage lesions in ST elevation myocardial infarction

Background: Intra myocardial hemorrhage lesions (IMH) are underdiagnosed complication of ST elevation myocardial infarction (STEMI). We sought to determine the incidence, predictors and the prognostic value of IMH in STEMI using cardiac MR imaging (CMR) techniques. Methods: We screened for inclusion consecutive patients with STEMI treated by percutaneous coronary intervention (PCI) within the first 12 hr of evolution. IMH lesions were identified on T2‐weighted sequences on CMR between days 4 and 8 after PCI. Adverse cardiac events were defined as a composite of death + severe ventricular arrhythmias + acute coronary syndrome + acute heart failure. Results: N = 114 patients were included and n = 11 patients (10%) presented IMH lesions. Patients with IMH lesions had a larger myocardial infarction extent (25.6 ± 1.8 vs. 13.5 ± 1.0 % LV mass, P < 0.01), microvascular obstructive lesions extent (4.6 ± 1.0 vs. 1.3 ± 0.3% LV mass, P < 0.01) and lower LV ejection fraction (40.7 ± 2.3% vs. 50.7 ± 1.3%, P < 0.01). The value of glycemia at admission was an independent predictor of IMH development (Odd ratio 1.8 [1.1–2.8] per mmol l^?1, P = 0.01). The incidence of adverse cardiac events was higher in the IMH group than in the non‐IMH group during the first year following STEMI (P = 0.01, log‐rank analysis). Cox regression analysis identified the presence of IMH lesions as an independent predictor of adverse clinical outcome (Hazard Ratio = 2.8 [1.2–6.8], P = 0.02). Conclusion: Our study indicates that IMH is a rare but severe finding in STEMI, associated with a larger myocardial infarction and a worse clinical outcome. Per‐PCI glycemia might influence IMH development. © 2011 Wiley Periodicals, Inc.     

Prognostic Significance of T‐Wave Amplitude in Lead aVR on the Admission Electrocardiography in Patients with Anterior Wall ST‐Elevation Myocardial Infarction Treated by Primary Percutaneous Intervention

Background: T‐wave positivity in aVR lead patients with heart failure and anterior wall old ST‐segment elevation myocardial infarction (STEMI) are shown to have a higher frequency of cardiovascular mortality, although the effects on patients with STEMI treated with primary percutaneous coronary intervention (PCI) has not been investigated. In this study, we sought to determine the prognostic value of T wave in lead aVR on admission electrocardiography (ECG) for in‐hospital mortality in patients with anterior wall STEMI treated with primary 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‐wave positive (n = 53, group 1) or T‐wave negative (n = 116, group 2) in aVR based upon the admission ECG. All patients were evaluated with respect to clinical features, primary PCI findings, and in‐hospital clinical results. Results: T‐wave positive patients who received primary PCI were older, multivessel disease was significantly more frequent and the duration of the patient's hospital stay was longer than T‐wave negative patients. In‐hospital mortality tended to be higher in the group 1 when compared with group 2 (7.5% vs 1.7% respectively, P = 0.05). After adjusting the baseline characteristics, positive T wave remained an independent predictor of in hospital mortality (odds ratio: 4.41; 95% confidence interval 1.2–22.1, P = 0.05). Conclusions: T‐wave positivity in lead aVR among patients with an anterior wall STEMI treated with primary PCI is associated with an increase in hospital cardiovascular mortality.     

The prognostic role of mitral regurgitation after primary percutaneous coronary intervention for acute ST-Elevation myocardial infarction

Objectives : The aim of this study was to elucidate the prognostic significance of mitral regurgitation (MR) after primary percutaneous coronary intervention (PCI) for acute ST‐elevation myocardial infarction (STEMI). Background : MR has prognostic implications after myocardial infarction (MI). However, for STEMI patients receiving primary PCI, the influence of MR on long‐term (3–5 years) outcome is unknown. Methods : We examined 888 STEMI patients receiving primary PCI enrolled in a prospective database at a regional STEMI center, who had an echocardiogram within 72 hr following successful primary PCI. MR was graded by color Doppler as none/trace vs. mild vs. moderate/severe. Mean ± SD follow‐up was 3.1 ± 1.4 years. Results : For patients with none/trace (n = 469), mild (n = 325), and moderate/severe (n = 94) MR, mortality at 3 years was 8.1%, 13.6%, and 25.7% and at 5 years was 12.7%, 18.3%, and 33.5%, respectively (P < 0.0001, log‐rank test). Patients with moderate/severe MR tended to be older (P < 0.0001) with lower ejection fraction (P < 0.0001) and were less likely to have had an anterior MI (P < 0.001). Independent predictors of mortality included age, creatinine, and heart rate. Conclusions : Following primary PCI for STEMI, echocardiographic detected MR in the first 72 hr following PCI stratifies mortality risk. However, when accounting for age, MR is not an independent predictor of mortality. © 2011 Wiley Periodicals, Inc.     

Outcomes of primary percutaneous coronary intervention in acute myocardial infarction due to unprotected left main thrombosis: The Asia‐Pacific Left Main ST‐Elevation Registry (ASTER)

Introduction

Prior studies of ULM STEMI have been confined to small cohorts. Recent registry data with larger patient cohorts have shown contrasting results. We aim to study the outcomes of patients with unprotected left main (ULM) ST‐elevation myocardial infarction (STEMI) who underwent primary percutaneous coronary intervention (PCI).

Methods

The Asia‐pacific left main ST‐Elevation Registry (ASTER) is a multicenter retrospective registry involving 4 sites in Singapore, South Korea, and the United States. The registry included patients presenting with STEMI due to an ULM coronary artery culprit lesion who underwent emergency PCI. The primary outcome was in‐hospital mortality. Secondary outcomes included major adverse cardiovascular events.

Results

A total of 67 patients (mean age 64.2 ± 12.8 years, 53 [79.1%] males) were included. The distal left main bifurcation was most commonly involved (85%, n = 57). Fifty one (76%) patients had TIMI 3 flow post‐PCI. The in‐hospital mortality rate was 47.8% (n = 32); 61% (n = 41) had cardiac failure, 4% (n = 3) had emergency coronary artery bypass grafting, 1% (n = 1) had a re‐infarction, 3% (n = 2) had stroke and 55% (n = 37) had malignant ventricular arrhythmias. On multivariate analysis, predictors of in‐hospital mortality included older age (odds ratio (OR) 1.085 (95% confidence interval (CI) 1.002‐1.175), P = 0.044), diabetes mellitus (OR 10.882 (95%CI 11.074‐110.287), P = 0.043) and absence of post‐PCI TIMI 3 flow (OR 71.429 (95%CI 2.985‐1000), P = 0.008).

Conclusions

STEMI from culprit unprotected left main coronary artery stenosis is associated with significant mortality and morbidity. Emergency PCI provides an important treatment option in this high‐risk group, but in‐hospital mortality remains high.     

Bleeding complications in primary percutaneous coronary intervention of ST-elevation myocardial infarction in a radial center

Objectives : We evaluated the incidence, types, and prognostic impact of bleeding complications in a non‐selected patient population with ongoing STEMI treated with aggressive antithrombotic treatment and routine radial primary PCI. Background : Bleeding complications remain frequent and deleterious in primary PCI through femoral approach. Methods : STEMI patients (n = 671) were evaluated for bleeding complications using a web‐based registry (e‐PARIS). In‐hospital bleeding was adjudicated using the TIMI definition. Results : In this non‐selected, high risk population, 6.1% had cardiogenic shock on admission, 3.9% out‐of‐hospital cardiac arrest. Radial access (88%) was the default strategy as was abciximab (78%). Clopidogrel loading dose ranged from 300 to 900 mg. Pre‐hospital fibrinolysis was rare (7.1%). Hemodynamic support devices (IABP, ECMO, Tandem Heart) were needed in 7.0%. In‐hospital TIMI Major and TIMI Major/minor bleedings occurred in 2.5 and 5.7% of the population, respectively. In‐hospital and 1‐year mortality rates were 5.5 and 8.2%, respectively. Patients with in‐hospital TIMI Major/minor bleeding had a higher 1‐year mortality rate (31.6% vs. 3.8%, P < 0.001). The most frequent bleeding site was gastro‐intestinal. Radial access was a strong predictor of survival (OR 0.33; 95%CI 0.17–0.56; P = 0.002). Conclusions : In the setting of radial primary PCI, the rates and types of bleeding complications are somewhat different from those observed with femoral primary PCI. The gastro‐intestinal tract has become the most frequent site of bleeding after radial primary PCI. The use of radial access appears independently associated with survival. © 2011 Wiley Periodicals, Inc     

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.     

Early and mid-term clinical outcome of emergency PCI in patients with STEMI due to unprotected left main coronary artery disease

Objectives: Evaluation of acute and mid‐term outcomes of patients with ST‐elevation myocardial infarction (STEMI) undergoing emergency PCI due to unprotected left main coronary artery (ULMCA) disease. Background: STEMI patients due to ULMCA disease represent a rare, high risk group. Percutaneous coronary intervention (PCI) may be the preferred strategy of myocardial revascularization but there are few data about this topic. Methods: We analyzed 30‐day and mid‐term mortality of 58 patients with STEMI and ULMCA disease as culprit lesion treated in our centre by emergency PCI between 2000 to 2010. Results: Mean age was 67.3 ± 11.5 years. Thirty (51.7%) patients had cardiogenic shock on admission. PCI success was achieved in 54 patients (93.1%). Mean follow‐up was 15.8 ± 10.9 months (median 14, range 6–45). Thirty‐day and mid‐term mortality rates were 39.7% and 44%. Backward binary logistic regression model identified cardiogenic shock at presentation (OR 12.6, 95% CI 2.97–53.6, P < 0.001), age ≥75 years (OR 5.9, 95% CI 1.3–26.5, P = 0.019) and post‐PCI TIMI flow grade <3 (OR 2.9, 95% CI 1.8–5.7 P = 0.02) as independent predictors of 30‐day mortality. Cox proportional hazard ratio (HR) identified shock at presentation (HR 5.2, 95% CI 1.8–14.3, P < 0.002), age ≥75 years (HR 3.9, 95% CI 1.8–8.7, P < 0.001), post‐PCI TIMI flow grade <3 (HR 4.9, 95% CI 1.6–14.6; P < 0.005) as independent predictors of mid‐term mortality. Conclusions: In patients with STEMI and ULMCA as culprit lesion, emergency PCI is a valuable therapeutic strategy. Early and mid‐term survival depends on cardiogenic shock, advanced age, and PCI failure. Patients surviving the first month have good mid‐term prognosis. (J Interven Cardiol 2012;25:215–222)     

Lower long-term mortality within a regional system of care for ST-elevation myocardial infarction

Abstract

Introduction: Organization of regional systems of care (RSC) with an emphasis on pre-hospital triage and primary percutaneous coronary intervention (PCI) has been recommended to implement guidelines and improve clinical outcome in ST-segment elevation myocardial infarction (STEMI). Patients and methods: All STEMI patients (n = 1,823) admitted to any of the 13 hospitals of the province of Bologna, Italy, before (pre-RSC, n = 858) and after (RSC, n = 965) the implementation of a RSC were enrolled in the study. Primary evaluation was mortality. Secondary outcomes included death, myocardial infarction, stroke, and coronary revascularization procedures up to three-year follow-up. Results: Among patients admitted <12 h from symptom onset, reperfusion was performed in 68.7% pre-RSC versus 89.8% RSC, P <0.001. Within the RSC, primary PCI became the main reperfusion treatment (34.5% pre-RSC versus 85.9% RSC; P <0.001 for both), and one-year mortality was lower (23.9% pre-RSC versus 18.8% RSC; P = 0.0015). At three-year, this advantage was maintained and actually increased (31.7% pre-RSC versus 24.8% RSC; P = 0.0031). Independent predictors of mortality at three-years were RSC, age, heart failure, cerebrovascular disease, renal disease, shock, peripheral vascular disease, and malignancies. Conclusions: In this study, RSC for the treatment of STEMI was associated with increased rates of reperfusion and reduction of long-term mortality.     

Angiographic perfusion score in patients treated with PCI at late angiography following fibrinolytic administration for ST-segment elevation myocardial infarction is associated with morbidity and mortality at 30 days

Background  Among patients with ST-segment elevation myocardial infarction (STEMI), evidence of restoration of both normal epicardial arterial flow and myocardial perfusion early after the administration of fibrinolytic agents has been associated with improved clinical outcomes. In STEMI patients treated with fibrinolytic therapy and scheduled for angiography later during hospital admission, however, the association of later indices of flow and perfusion with clinical outcomes has not been assessed. Methods  Clopidogrel as Adjunctive Reperfusion Therapy-Thrombolysis in Myocardial Infarction (CLARITY-TIMI) 28 enrolled 3,491 STEMI patients treated with fibrinolytic therapy. Angiography was scheduled 48–192 h (median 84) after randomization. The Angiographic Perfusion Score (APS) (the sum of the TIMI Flow Grade and Myocardial Perfusion Grade before and after percutaneous coronary intervention (PCI), range of 0–12) was assessed in the 1,460 patients treated with PCI at late angiography, and its association with morbidity and mortality at 30 days was examined. Results  Full perfusion, defined as an APS of 10–12, was associated with the lowest mortality (0.8%), while partial perfusion (APS 4–9) (2.3%) and failed perfusion (APS 0–3) (18.0%) were associated with a higher incidence of mortality at 30 days (P < 0.001 for full perfusion vs. partial perfusion, P < 0.0001 for overall trend). In addition, full perfusion was associated with a lower incidence of recurrent myocardial infarction (MI), a composite of death and MI, recurrent myocardial ischemia, ventricular tachyarrhythmia, congestive heart failure and shock (P < 0.05 for all trends). Conclusion  Among STEMI patients treated with late PCI following fibrinolytic therapy, higher APS is associated with reduced morbidity and mortality.     

生长停滞特异性基因6蛋白可预测老年急性ST段抬高型心肌梗死患者PCI术后发生心力衰竭

摘要 目的：探讨血清生长停滞特异性基因6（GAS6）蛋白对老年急性ST段抬高型心肌梗死（STEMI）患者经皮冠状动脉介入（PCI）术后住院期间发生心力衰竭的预测价值。方法：回顾性分析168例行急诊PCI治疗的老年STEMI患者的临床资料，根据患者PCI术后住院期间是否发生心力衰竭，分为无心力衰竭组（127例）和心力衰竭组（41例），比较2组患者一般资料。用酶联免疫吸附试验（ELISA）检测患者急诊入院时血清GAS6蛋白、血清B-型脑钠肽前体(BNP)、心肌肌钙蛋白 I（cTnI）、C反应蛋白（CRP）表达水平。用Pearson相关性分析、Logistic回归分析心力衰竭发生的影响因素；绘制受试者工作特征（ROC）曲线分析血清GAS6蛋白预测心力衰竭的价值，计算曲线下面积（AUC）。结果：心力衰竭组PCI术后TIMI血流3级患者比例和术前左室射血分数（LVEF）低于同时点无心力衰竭组（P均＜0.05）。心力衰竭组患者PCI术前BNP、cTnI和CRP水平高于无心力衰竭组（P均＜0.05）。心力衰竭组患者PCI术前血清GAS6蛋白水平与BNP、cTnI和CRP呈正相关，与LVEF呈负相关（P均＜0.05）。多因素分析显示，PCI术前血清GAS6蛋白、BNP、cTnI、CRP、LVEF和PCI术后TIMI血流3级是STEMI患者PCI术后发生心力衰竭的独立影响因素（P均＜0.05）。PCI术前血清GAS6蛋白水平预测STEMI患者PCI术后发生心力衰竭的AUC为0.832（P＜0.001）。当血清GAS6蛋白水平为26.09ng/mL时，约登指数最大（0.509），预测价值最高，此时灵敏度和特异性分别为70.65%和80.33%。结论：血清GAS6蛋白水平与患者心功能密切相关，血清GAS6蛋白表达水平的上升可能意味着心功能的下降，PCI术前血清GAS6蛋白水平对预测老年STEMI患者PCI术后发生心力衰竭有一定价值。.     

The ratio of contrast volume to glomerular filtration rate predicts outcomes after percutaneous coronary intervention for ST‐segment elevation acute myocardial infarction

Objective: To assess the value of the ratio between contrast medium volume and glomerular filtration rate (CMGFRr) for prediction of development of contrast‐induced nephropathy (CIN) and mortality in patients with ST‐segment elevation acute myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). Background: Renal function is a strong predictor of outcome in patients with STEMI. CIN may complicate the course of primary PCI in these patients. Methods: The study population included all 871 consecutive patients with STEMI without cardiogenic shock who underwent primary PCI at our center from January 1, 2001, to October 30, 2006. CIN was defined as an absolute increase in serum creatinine > 0.5 mg/dL or a relative increase >25% within 48 hr after PCI. Results: In‐hospital CIN developed in 72 (8.3%) patients. On linear regression analysis, the following variables were independently associated with CIN: male sex (odds ratio [OR] = 0.42, 95% confidence interval [CI], 0.18–0.97, P = 0.04), GFR < 60 (OR = 3.6, 95% CI, 2.79–4.78, P < 0.0001), multivessel coronary artery disease (OR = 1.67, 95% CI, 1.08–2.58, P = 0.02), CMGFRr (OR = 1.53, 95% CI, 1.01–2.31, P = 0.04, for upper tertile vs. lower two tertiles), and Killip class > 1 (OR = 1.35, 95% CI, 1.03–1.76, P = 0.03). CMGFRr > 3.7 was a strong independent predictor of CIN (OR = 3.87, 95% CI, 1.72–8.68, P = 0.001). Twenty‐six (2.9%) patients died at 1 month after PCI. The following variables were independently predictive of 1‐month mortality: CMGFRr > 3.7 (OR = 3.3, 95% CI, 1.22–9.04, P = 0.018) and multivessel coronary artery disease (OR = 2.3, 95% CI, 1.28–4.07, P = 0.005). Conclusion: The contrast medium‐to‐GFR ratio is a strong predictor of CIN and of 1‐month mortality in patients undergoing primary PCI for STEMI. © 2010 Wiley‐Liss, Inc.     

Outcome in high risk patients with unprotected left main coronary artery stenosis treated with percutaneous coronary intervention

Objective : We examined mortality, risk of myocardial infarction (MI), and target lesion revascularization (TLR) in high‐risk patients with unprotected left main (LM) percutaneous coronary intervention (PCI) in Western Denmark. Background : PCI of left main coronary artery lesions may be an alternative to coronary artery bypass grafting in high‐risk surgical patients. Methods : From January 2005 to May 2007, all patients who had unprotected LM PCI with stent implantation were identified in the Western Denmark Heart Registry. The indications for PCI were: (1) ST segment elevation MI (STEMI), (2) non‐STEMI (NSTEMI) or unstable angina, and (3) stable angina. All patients were followed up for 18 months. Results : A total of 344 patients were treated with LM PCI (STEMI: 71, NSTEMI/unstable angina: 157, and stable angina: 116). In STEMI patients, the median logistic EuroSCORE was 22.5 (interquartile range 12.5–39.5), in non‐STEMI (NSTEMI)/unstable angina patients 13.8 (4.8–23.9), and in stable angina patients 4.8 (2.2–10.4). Mortality after 18 months 38.0, 18.5, and 11.2% (P < 0.001) in patients with STEMI, NSTEMI/unstable angina, and stable angina, respectively. MI after 18 months was 9.9, 6.4, and 6.0% (P = ns), respectively. Four subacute and one late definite stent thrombosis were seen. TLR occurred in 5.6, 4.5, and 6.9% (P = ns) of patients, respectively. Conclusion : After PCI, patients with STEMI and LM culprit lesion have a high‐mortality risk, whereas long‐term outcome for patients with NSTEMI and stable angina pectoris is comparable with other high surgical risk patients with unprotected left main lesion. Further, TLR rates and risk of stent thrombosis were low. © 2009 Wiley‐Liss, Inc.     

The impact of unsuccessful percutaneous coronary intervention on short‐ and long‐term prognosis in STEMI and NSTEMI

Objectives: To compare the impact of the efficacy of percutaneous coronary intervention (PCI) on prognosis in ST and non‐ST elevation myocardial infarction (STEMI and NSTEMI) patients with respect to infarct‐related artery (IRA). Background: The significance of the efficacy of PCI in STEMI and NSTEMI depending on the type of IRA has yet to be clarified. Methods: Study population consisted of 2,179 STEMI and 554 NSTEMI consecutive patients treated with urgent PCI. The efficacy of PCI (TIMI [thrombolysis in myocardial infarction] 3 vs. TIMI < 3) was assessed with regard to the type of IRA (left anterior descending artery, circumflex artery [Cx] or right coronary artery). The mean follow‐up was 37.5 months. Results: The rate of unsuccessful PCI was similar in STEMI and NSTEMI irrespectively of IRA (14.1 vs. 17.7%; P = 0.062). In STEMI, unsuccessful PCI was associated with significantly higher early (23.1 vs. 5.6%; P < 0.001) and late (29.9 vs. 12.8%; P < 0.001) mortality regardless of IRA. In NSTEMI, the inefficacious PCI significantly increased early (19.0% vs. 0.9%; P < 0.001) and late (27.3% vs. 6.3%; P < 0.001) mortality only in patients with Cx‐related infarction. Unsuccessful PCI of IRA was an independent risk factor for death in STEMI (HR 1.64; P < 0.05), but not in NSTEMI (P = 0.64). Further analysis showed that whilst unsuccessful PCI of any vessel in STEMI is an independent risk factor for death, in NSTEMI this applies to unsuccessful PCI of Cx only. Conclusions: The significance of unsuccessful PCI of IRA seems to be different in STEMI and NSTEMI. Unsuccessful PCI is an independent risk factor for death in STEMI regardless of IRA and in NSTEMI with the involvement of Cx. © 2010 Wiley‐Liss, Inc.     

Percutaneous Coronary Intervention,Comorbidities, and Mortality among Emergency Department–Admitted ST‐Elevation Myocardial Infarction Patients in Florida

Background: Risk of mortality following an ST‐elevation myocardial infarction (STEMI) can be significantly reduced by prompt percutaneous coronary intervention (PCI). National guidelines specify primary PCI as the preferred recommended treatment for STEMI. In this study, we examined same‐day PCI as an independent predictor of in‐hospital mortality, after adjustment for comorbidities, other patient factors, and hospital PCI‐volume using unselected surveillance data from Florida. Methods: We analyzed hospital discharge data for adults, 18+ years old, with a primary diagnosis of STEMI who were admitted to PCI‐capable hospitals through the emergency department during 2001–2005 (n = 43,849). Hierarchical (multilevel) logistic regression models were used for analysis. Results: Overall, 4,143 STEMI patients (9.4%) did not survive to hospital discharge. In late 2005, the in‐hospital mortality rates were 1.9% for those who received same‐day PCI versus 13.0% for those who did not. After adjustment for multiple patient factors, same‐day PCI was a significant predictor of in‐hospital survival with a strong protective effect (adjusted OR = 0.35, 95% CI 0.31–0.38 P < 0.0001). Restriction of the analysis to those patients who survived the first day of admission did not appreciably change this result (adjust OR = 0.37, 95% CI 0.33–0.42, P < 0.0001). Hospital PCI‐volume did not significantly impact mortality risk. Conclusions: Same‐day PCI markedly reduced the risk of in‐hospital mortality among STEMI patients after multivariate adjustment. Serious comorbidities and complications, older age, and female gender continued to predict elevated risk of mortality after control for treatment status. Our results provide additional evidence in support of national clinical recommendations and aggressive treatment of STEMI. (J Interven Cardiol 2010;23:205–215)     

Prognosis and high-risk complication identification in unselected patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention

Abstract

Aims: The aim of this study was to evaluate treatment with primary percutaneous coronary intervention (PCI) in unselected patients with ST-segment elevation myocardial infarction (STEMI). Methods: We registered complication and mortality rates in all patients with STEMI admitted for primary PCI at a high-volume center over a two-year period (2004 to 2006). Results: We included 1022 consecutive patients (mean age 64 years; 69% men). In-hospital and one-year mortality were 8% and 12%, respectively. Cardiac arrest, cardiogenic shock, left ventricular ejection fraction ≤40% and atrioventricular block significantly predicted increased one-year mortality in univariate analysis (P < 0.001 for all) and were considered high-risk complications. 65% of patients had no high-risk complications. One-year mortality for patients without high-risk complications was 4% compared with 28% for those with high-risk complications (P < 0.001). Conclusion: Unselected patients with STEMI treated with primary PCI have mortality rates corresponding to those reported in randomized clinical studies including transport of patients. Mortality is strongly related to high-risk complications developed during admission. Thus, patients with high-risk complications should receive special attention. The majority of patients (65%) without high-risk complications have an excellent short- and long-term prognosis following primary PCI.     

Syndrome coronarien aigu avec sus-décalage du segment ST chez les patients de 85 ans et plus. Prise en charge invasive versus traitement médical exclusif : étude départementale

IntroductionPercutaneous coronary intervention (PCI) and/or fibrinolysis for management of an ST elevation myocardial infarction (STEMI) are at high risk in the elderly. Is there any place for an invasive management in this particular population?MethodsIt is a single-center retrospective study (CHD Vendée, La Roche-sur-Yon) including patients aged 85 and over who had STEMI between January 2008 and December 2013, divided into two groups: coronary angiogram/fibrinolysis (“invasive”) versus exclusive medical treatment (“non-invasive”), comparing mortality, morbidity, complications and loss of independence.ResultsAmong the 1373 patients hospitalized for STEMI, 118 (8.6%) were included: 71 (60.2%) underwent an invasive procedure for reperfusion whereas 47 had “non-invasive” management. All cause mortality rate was higher in the “non-invasive” group (28% versus 45%; P = 0.077 NS). The identified pejorative criteria are age, female gender, past history of severe valvular disease, and delay for primary care. No difference was found in intrahospital complication rate (23 vs 21; P = 0.21) nor in loss of independence.ConclusionThe invasive management of STEMI in the elderly may reduce the one-year mortality rate without increasing morbidity.     

Integrilin in patients undergoing primary percutaneous coronary intervention for ST-elevation myocardial infarction

Background: The adjunctive use of eptifibatide in patients undergoing primary percutaneous coronary intervention (PCI) for ST‐elevation myocardial infarction (STEMI) remains controversial. We therefore set out to determine the safety and efficacy of eptifibatide in this population. Methods: The study comprised 857 consecutive patients who underwent primary PCI for STEMI at the Washington Hospital Center. Three hundred eighteen patients also received adjunctive therapy with eptifibatide. Patients who had received thrombolysis prior to undergoing cardiac catheterization were excluded. The primary end‐point was all‐cause mortality and the composite of all‐cause mortality or Q‐wave MI. The primary safety end‐point was the rate of thrombolysis in myocardial infarction (TIMI) major bleeding. Results: The eptifibatide group was younger, had a higher body mass index, and a lower proportion of patients with systemic hypertension, diabetes mellitus, previous history of ischemic heart disease, coronary revascularization, and congestive heart failure. This cohort also used bivalirudin less often (23.3% vs. 72%; P < 0.001). Following multivariable analysis, the eptifibatide group had a significantly lower rate of all‐cause mortality (hazard ratio 0.55; 95% confidence interval 0.34–0.89; P = 0.01) and the composite of all‐cause mortality or Q‐wave MI (hazard ratio 0.59; 95% confidence interval 0.37–0.95; P = 0.03) at 6 months. The rate of TIMI major bleeding was similar in both groups (hazard ratio 0.54; 95% confidence interval 0.25–1.17; P = 0.12). Conclusion: The adjunctive use of eptifibatide in patients presenting with STEMI may be associated with improved clinical outcomes. (J Interven Cardiol 2011;24:351–356)