The determinants and prognostic value of recurrent myocardial infarction (MI) in a contemporary cohort of ST-segment elevation MI patients treated with primary percutaneous coronary intervention ...(PPCI) and stenting are currently unknown. We investigated the predictors and prognostic impact of recurrent MI on subsequent clinical outcome in 1,700 ST-segment elevation MI patients treated with PPCI and stenting between January 1, 2003, and July 31, 2008. Two hundred forty patients had a recurrent MI during a median follow-up of 4 years and 7 months (Kaplan Meier estimate 21.2%). By multivariable analysis, recurrent MI was associated with a higher risk of subsequent cardiac mortality (hazard ratio HR 6.86, 95% confidence interval CI 4.24 to 8.72), noncardiac mortality (HR 2.02, 95% CI 1.10 to 3.69), stroke (HR 3.68, 95% CI 2.02 to 6.72), and Global Use of Strategies to Open Occluded Coronary Arteries criteria severe or moderate bleeding (HR 3.17, 95% CI 1.79 to 5.60). Early recurrent MI (within 1 day of the initial PPCI) was associated with higher unadjusted cardiac mortality rates (64.4%) compared with recurrent MIs occurring ≥1 day after PPCI. However, after multivariable adjustment, late recurrent MI (occurring >1 year after PPCI) was associated with the highest risk of subsequent cardiac mortality (HR 7.98, 95% CI 5.05 to 12.6). The risk of cardiac death was irrespective of the presence of persistent ST-segment elevation during the recurrent MI. In conclusion, recurrent MI after PPCI remains a relatively common complication in contemporary practice and confers a significantly increased risk of death, stroke, and bleeding.
Objectives The aim of this study was to evaluate the effect of a concurrent chronic total occlusion (CTO) in patients with ST-segment elevation myocardial infarction (STEMI) on long-term mortality ...and left ventricular ejection fraction (LVEF). Background The impact of a CTO in a non–infarct-related artery (IRA) on prognosis after STEMI is unknown. Methods Between 1997 and 2005, we admitted 3,277 STEMI patients treated with primary percutaneous coronary intervention. Patients were categorized as single-vessel disease (SVD), multivessel disease (MVD) without CTO, and MVD with a CTO in a non-IRA. We performed a “landmark survival analysis” to 5 years follow-up with a landmark set at 30 days. Additionally, we analyzed the evolution of LVEF within 1 year. Results Of the patients, 2,115 (65%) had SVD, 742 patients (23%) had MVD without CTO, and 420 patients (13%) had a concurrent CTO. Presence of a CTO was a strong and independent predictor for 30-day mortality (hazard ratio HR: 3.6, 95% confidence interval CI: 2.6 to 4.7, p < 0.01), whereas MVD without CTO was a weak predictor (HR: 1.6, 95% CI: 1.2 to 2.2, p = 0.01). In 30-day survivors, CTO remained a strong predictor (HR: 1.9, 95% CI: 1.4 to 2.8, p < 0.01), and MVD lost its independent prognostic value (HR: 1.1, 95% CI: 0.8 to 1.5, p = 0.45). Furthermore, CTO was associated with LVEF ≤40% immediately after STEMI (odds ratio: 1.9, 95% CI: 1.3 to 2.8, p < 0.01) and a further decrease in LVEF within the first year (odds ratio: 3.5, 95% CI: 1.6 to 7.8, p < 0.01). Conclusions The presence of a CTO and not MVD alone is associated with long-term mortality even when early deaths are excluded from analysis. The presence of a CTO is associated with reduced LVEF and further deterioration of LVEF.
In ST-segment elevation myocardial infarction (STEMI) patients with a concurrent chronic total occlusion (CTO), the EXPLORE (Evaluating Xience and Left Ventricular Function in Percutaneous Coronary ...Intervention on Occlusions After ST-Elevation Myocardial Infarction) trial (n = 302) was the first randomized trial comparing CTO percutaneous coronary intervention (PCI) versus no-CTO PCI.
Despite early revascularization, mortality remains high in patients with ST-segment elevation myocardial infarction (STEMI) complicated by cardiogenic shock. It has been shown that the effect of ...multivessel disease (MVD) on mortality in patients with STEMI treated with primary percutaneous coronary intervention is mainly caused by the presence of chronic total occlusion (CTO) in a noninfarct-related coronary artery. Whether this association also exists in patients with STEMI with cardiogenic shock is unknown. In our institution, 292 consecutive patients with STEMI complicated by cardiogenic shock were admitted from 1997 to 2005 and treated with primary percutaneous coronary intervention. Patients were classified as having single vessel disease, MVD without CTO, and CTO. Cox regression analysis was used for multivariate analysis. The 1-year mortality rate of patients with single-vessel disease, MVD, and CTO was 31%, 47%, and 63%, respectively. After adjustment for possible confounders, MVD alone was not an independent predictor of 1-year mortality (hazard ratio 1.5, 95% confidence interval 0.98 to 2.3, p = 0.07). In contrast, CTO in a noninfarct-related artery was an independent predictor of 1-year mortality (hazard ratio 2.1, 95% confidence interval 1.5 to 3.1, p <0.01). In conclusion, the presence of CTO in a non–infarct-related artery was an independent predictor of 1-year mortality. In contrast, MVD alone lost its predictive significance after multivariate analysis.
Abstract Objectives This study sought to compare long-term clinical outcome in ST-segment elevation myocardial infarction (STEMI) patients with a concomitant chronic total occlusion (CTO) with ...well-developed versus poorly developed collaterals toward the CTO. Background In STEMI patients, presence of a CTO is associated with increased morbidity and mortality. CTOs are often (partially) perfused by collateral vessels. Therefore, when the infarct-related artery (IRA) is the main donor vessel for the collateral blood supply of the CTO, infarct size may increase significantly. Well-developed collaterals to the infarct related vessel have been associated with improved clinical outcome after STEMI. However, the impact of well-developed collaterals toward a concomitant CTO in STEMI patients is unknown. Methods Consecutive STEMI patients with a CTO in a non-IRA presenting for primary percutaneous coronary intervention (PCI) were divided according to the presence of angiographic, well-developed (grade 2 to 3) or poorly developed collaterals (grade 0 to 1). Results Between 2000 and 2012 we included 413 STEMI patients with a single concomitant CTO. Well-developed collaterals to the CTO were present in 53%. Associated with poorly developed collaterals to the CTO were cardiogenic shock (hazard ratio HR: 1.8; 95% confidence interval CI: 1.11 to 3.07; p = 0.02), CTO located in the left circumflex artery (HR: 1.9; 95% CI: 1.00 to 3.43; p = 0.05), CTO diameter ≤2.5 mm (HR: 2.1; 95% CI: 1.07 to 4.12; p = 0.03), and CTO tapering (HR: 1.9; 95% CI: 1.21 to 2.85; p < 0.001). Patients with well-developed collaterals to the CTO had a better 5-year survival compared to those with poorly developed collaterals (74% vs. 63%; p = 0.01). The presence of well-developed collaterals to the CTO was independently associated with improved survival (HR: 1.5; 95% CI: 1.03 to 2.10; p = 0.04). Conclusions In STEMI patients with a CTO in a non-IRA, the presence of well-developed collaterals to the CTO is associated with improved survival.
A periprocedural myocardial infarction, defined as the advent of new Q-waves or a creatine kinase-MB elevation >8× normal has been previously validated as predictive of subsequent mortality. We ...examined the effects of using this clinically relevant definition of periprocedural myocardial infarction instead of the original protocol definition on outcomes in the recent PROTECT II A Prospective, Multi-center, Randomized Controlled Trial of the IMPELLA RECOVER LP 2.5 System Versus Intra Aortic Balloon Pump (IABP) in Patients Undergoing Non Emergent High Risk PCI trial. In this trial, patients who were undergoing high-risk percutaneous coronary intervention (PCI) were randomized to either an intra-aortic balloon pump (IABP, n = 211) or a left ventricular assist device (Impella, n = 216). All eligible patients per study protocol were included in the analysis. Patient outcomes were compared up to 90 days, the longest available follow-up, on the composite end points of major adverse events (MAE) and major adverse cardiac and cerebral events (MACCE = death, stroke, myocardial infarction, and repeat revascularization). At 90 days, the rates of both composite end points were lower in the Impella group compared with the IABP group (MAE, 37% vs 49%, p = 0.014 respectively; MACCE, 22% vs 31%, p = 0.034 respectively). There were no differences in death or large myocardial infarction between the 2 arms. By multivariable analysis, treatment with Impella as opposed to IABP was an independent predictor for freedom from MAE (odds ratio = 0.75 95% confidence interval 0.61 to 0.92, p = 0.007) and MACCE (odds ratio = 0.76 95% confidence interval 0.61 to 0.96, p = 0.020) at 90 days postprocedure. In conclusion, hemodynamic support with Impella compared with IABP during high-risk PCI in the PROTECT-II trial resulted in improved event-free survival at 3-month follow-up; this finding was further supported by multivariate analyses.
Objectives The aim of this study was to evaluate long-term clinical outcomes after percutaneous coronary intervention (PCI) for chronic total occlusions (CTO). Background Despite technical ...advancements, there is a paucity of data on long-term outcomes after PCI of CTO. Methods We evaluated long-term clinical outcomes in 1,791 patients who underwent PCI of 1,852 CTO at 3 tertiary care centers in the United States, South Korea, and Italy between 1998 and 2007. Median follow-up was 2.9 years (interquartile range: 1.5 to 4.6 years). Results Procedural success was obtained in 1,226 (68%) patients. Stents were implanted in 1,160 patients (95%); 396 patients (34%) received bare-metal stents (BMS), and 764 patients (66%) received drug-eluting stents (DES). After multivariable analysis, successful CTO PCI was an independent predictor of a lower cardiac mortality (hazard ratio HR: 0.40, 95% confidence interval CI: 0.21 to 0.75, p < 0.01) and reduced need for coronary artery bypass graft surgery (HR: 0.21, 95% CI: 0.13 to 0.40, p < 0.01); it also correlated with a strong trend toward lower all-cause mortality (HR: 0.63, 95% CI: 0.40 to 1.00, p = 0.05) at 5-year follow-up. Among patients who underwent stent implantation, treatment with DES rather than BMS resulted in less target vessel revascularization at long-term follow-up (17.2% vs. 31.1%, p < 0.01); definite/probable stent thrombosis rates were similar (DES 1.7%, BMS 2.3%, p = 0.58). Within the DES subgroup, patients treated with paclitaxel-eluting stents and sirolimus-eluting stents had similar clinical outcomes. Conclusions Successful CTO PCI is associated with reduced long-term cardiac mortality and need for coronary artery bypass graft surgery. Treatment of CTO with DES rather than BMS is associated with a significant reduction in target vessel revascularization with similar rates of stent thrombosis. Paclitaxel-eluting stents and sirolimus-eluting stents had similar long-term safety and efficacy outcomes.
Objectives This study sought to develop a practical risk score to predict the risk of stent thrombosis (ST) after percutaneous coronary intervention (PCI) for acute coronary syndromes (ACS). ...Background ST is a rare, yet feared complication after PCI with stent implantation. A risk score for ST after PCI in ACS can be a helpful tool to personalize risk assessment. Methods This study represents a patient-level pooled analysis of 6,139 patients undergoing PCI with stent implantation for ACS in the HORIZONS-AMI (Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction) and ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy) trials who were randomized to treatment with bivalirudin versus heparin plus a glycoprotein IIb/IIIa inhibitor. The cohort was randomly divided into a risk score development cohort (n = 4,093) and a validation cohort (n = 2,046). Cox regression methods were used to identify clinical, angiographic, and procedural characteristics associated with Academic Research Consortium–defined definite/probable ST at 1 year. Each covariate in this model was assigned an integer score based on the regression coefficients. Results Variables included in the risk score were type of ACS (ST-segment elevation myocardial infarction, non-ST-segment elevation ACS with ST deviation, or non–ST-segment elevation ACS without ST changes), current smoking, insulin-dependent diabetes mellitus, prior PCI, baseline platelet count, absence of early (pre-PCI) anticoagulant therapy, aneurysmal/ulcerated lesion, baseline TIMI (Thrombolysis In Myocardial Infarction) flow grade 0/1, final TIMI flow grade <3, and number of treated vessels. Risk scores 1 to 6 were considered low risk, 7 to 9 intermediate risk, and 10 or greater high risk for ST. Rates of ST at 1 year in low-, intermediate-, and high-risk categories were 1.36%, 3.06%, and 9.18%, respectively, in the development cohort (p for trend <0.001), and 1.65%, 2.77%, and 6.45% in the validation cohort (p for trend = 0.006). The C-statistic for this risk score was over 0.65 in both cohorts. Conclusions The individual risk of ST can be predicted using a simple risk score based on clinical, angiographic, and procedural variables. (Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction HORIZONS-AMI; NCT00433966 ) (Comparison of Angiomax Versus Heparin in Acute Coronary Syndromes ACUITY; NCT00093158 )
Published reports describe a strong association between plasma glucose levels on admission and mortality in patients who undergo primary percutaneous coronary intervention for ST-segment elevation ...myocardial infarction. The aim of this study was to assess the predictive value of admission glucose levels for early and late mortality. From 2005 to 2007, 1,646 patients underwent primary percutaneous coronary intervention for ST-segment elevation myocardial infarction and were stratified according to admission plasma glucose level in category 1 (<7.8 mmol/L; n = 747), category 2 (7.8 to 11.0 mmol/L; n = 620), or category 3 (>11 mmol/L; n = 279). Event rates were estimated using the Kaplan-Meier method. A landmark survival analysis to 3-year follow-up was performed, with a landmark set at 30 days. Time-extended Cox regression was used to assess the predictive value of admission glucose levels. Furthermore, a stratified analysis was performed for known diabetes mellitus status at admission. Thirty-day mortality was 2.4% in category 1, 6% in category 2, and 22% in category 3 (p <0.01). Three-year mortality in 30-day survivors was 5.9% in category 1, 8.2% in category 2, and 7.1% in category 3 (p = 0.27). Glucose level on admission was a strong predictor of 30-day mortality: for every 1 mmol/L increase, the hazard increased by 14% (hazard ratio 1.14, 95% confidence interval 1.09 to 1.19, p <0.01) in patients without diabetes, by 12% (hazard ratio 1.12, 95% confidence interval 1.05 to 1.19, p <0.01) in those with diabetes, and by 13% (hazard ratio 1.13, 95% confidence interval 1.09 to 1.17, p <0.01) in the total cohort. After 30 days, glucose level at admission lost its predictive value. In conclusion, in patients with and those without diabetes, glucose level at admission is an independent predictor of early but not late mortality.
Objectives The study sought to determine whether rapid access to medical care and reperfusion results in a better prognosis in patients with in-hospital compared with out-of-hospital stent thrombosis ...(ST) in patients with ST-segment elevation myocardial infarction (STEMI) in the HORIZONS-AMI (Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction) trial. Background Whether the prognosis of in-hospital and out-of-hospital ST are similar is uncertain, with conflicting data reported from prior studies. Methods A total of 3,602 STEMI patients undergoing primary percutaneous coronary intervention (PCI) were randomized to bivalirudin (n = 1,800) versus unfractionated heparin (UFH) plus a glycoprotein IIb/IIIa inhibitor (GPI) (UFH+GPI; n = 1,802). Stents were implanted in 3,202 patients, 156 (4.9%) of whom developed Academic Research Consortium definite/probable ST during 3-year follow-up. We investigated the 1-year clinical outcomes after ST in 54 patients with in-hospital ST compared with 102 patients with out-of-hospital ST. Results One year after the ST event, patients with in-hospital compared with out-of-hospital ST had significantly greater mortality (27.8% vs. 10.8%, p < 0.01); most deaths in both groups occurred within 1 week of the ST event. Patients with in-hospital ST also had higher rates of major bleeding (21.2% vs. 6.0%, p < 0.01), but a lower rate of myocardial infarction (56.6% vs. 77.5%, p < 0.01). Subgroup analysis within both in-hospital and out-of-hospital ST groups indicated that subacute ST had the highest mortality. By multivariable analysis, 1-year mortality was significantly increased in patients with in-hospital compared with out-of-hospital ST (adjusted hazard ratio: 4.62, 95% confidence interval: 1.98 to 10.77, p < 0.01). Additional correlates of increased mortality after an ST event included diabetes and randomization to UFH+GPI (vs. bivalirudin). Conclusions Following primary PCI for STEMI, more than one-third of all ST events during 3-year follow-up occurred during the index hospital phase. Mortality and major bleeding were significantly higher after in-hospital ST compared with out-of-hospital ST. (Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction; NCT00433966 )
PDF
