Predictors of in-hospital and 6-month outcome after acute myocardial infarction in the reperfusion era: the Primary Angioplasty in Myocardial Infarction (PAMI) trail

Hemoglobin A1c levels and 1-year mortality in patients with ST-elevation myocardial infarction undergoing percutaneous coronary intervention

Background: In this study, we investigated whether different levels of hemoglobin A1c (HbA1c) are associated with different short-term and 1-year mortality rates among diabetic patients undergoing percutaneous coronary intervention. Patients & methods: Clinical events including in-hospital, 1-month and 1-year mortality were compared between three groups based on HbA1c levels of patients (I: ≤5.6%, II: 5.7-6.4%, III: ≥6.5%). Results: Among 165 diabetic individuals, patients with abnormal HbA1c levels (≥6.5%) experienced significantly higher hospitalization days (7.65 ± 1.64 days) compared with those with normal HbA1c (4.94 ± 0.97 days) (p < 0.0001). In-hospital mortality was significantly higher in group III (14.5%) and II (5.5%) compared with group I (0%) (p = 0.008). Conclusion: HbA1c levels may be a reliable predictor of short-term clinical events in diabetic patients.

Exploring potent aldose reductase inhibitors for anti-diabetic (anti-hyperglycemic) therapy: integrating structure-based drug design, and MMGBSA approaches

Aldose reductase (AR) is an important target in the development of therapeutics against hyper-glycemia-induced health complications such as retinopathy, etc. In this study, we employed a combination of structure-based drug design, molecular simulation, and free energy calculation approaches to identify potential hit molecules against anti-diabetic (anti-hyperglycemic)-induced health complications. The 3D structure of aldoreductase was screened for multiple compound libraries (1,00,000 compounds) and identified as ZINC35671852, ZINC78774792 from the ZINC database, Diamino-di nitro-methyl dioctyl phthalate, and Penta-o-galloyl-glucose from the South African natural compounds database, and Bisindolylmethane thiosemi-carbazides and Bisindolylme-thane-hydrazone from the Inhouse database for this study. The mode of binding interactions of the selected compounds later predicted their aldose reductase inhibitory potential. These com-pounds interact with the key active site residues through hydrogen bonds, salt bridges, and π-π interactions. The structural dynamics and binding free energy results further revealed that these compounds possess stable dynamics with excellent binding free energy scores. The structures of the lead inhibitors can serve as templates for developing novel inhibitors, and in vitro testing to confirm their anti-diabetic potential is warranted. The current study is the first to design small molecule inhibitors for the aldoreductase protein that can be used in the development of therapeutic agents to treat diabetes.

The outcomes in STEMI patients with high thrombus burden treated by deferred versus immediate stent implantation in primary percutaneous coronary intervention: a prospective cohort study

Background

No-/slow-reflow indicates worse outcomes in ST-elevation myocardial infarction (STEMI) patients with high thrombus burden. We examined whether deferred stenting (DS) strategy reduces no-/slow-reflow or major adverse cardiovascular events (MACEs) in primary percutaneous coronary intervention (pPCI) for patients with acute STEMI and high thrombus burden.

Methods

We performed an open-label, multi-center, prospective cohort study among eligible patients with acute STEMI and high thrombus burden who further received pPCI. All participants received PCI with DS (second procedure performed within 48-72 h) or immediate-stenting (IS) strategy. The primary outcome was the incidence of no-/slow-reflow. We evaluated MACEs and bleeding events during hospitalization and at 30- and 90-day follow-ups.

Results

We recruited 245 patients to this study, including 51 with DS and 194 with IS. Baseline clinical characters were comparable between the 2 strategies. Incidence of no-/slow-reflow defined by thrombolysis in myocardial infarction (TIMI) flow grade was not significantly different between the 2 strategies [DS: 5 (9.8%), IS: 33 (17.0%), P=0.21]. No-/slow-reflow by TIMI myocardial perfusion grade (TMPG) was less prevalent in DS [20 (39.2%) vs. 107 (55.2%), P=0.04]. No significant differences were found in recurrence of myocardial infarction (P=0.56), cardiac death (P=0.37), all-cause mortality (P=0.37), heart failure-induced readmission (P=0.35), or bleeding (P=0.61) between the 2 strategies in-hospital, and at 30- and 90-day follow-up.

Conclusions

In STEMI patients with high thrombus burden who underwent pPCI, DS strategy reduced no-/slow-reflow of microcirculation. However, DS strategy did not reduce incidence of MACEs or bleeding.

Percutaneous coronary intervention of unprotected left main and bifurcation in octogenarians: Subanalysis from RAIN (veRy thin stents for patients with left mAIn or bifurcatioN in real life)

OBJECTIVE

Outcomes of complex percutaneous coronary interventions (PCIs) in older patients are still debated. The aim of the study was to evaluate clinical outcomes of Octogenarian patients treated with ultrathinstents on left main or on coronary bifurcations, compared with younger patients.

METHODS

All consecutive patients presenting a critical lesion of an unprotected left main (ULM) or a bifurcation and treated with very thin stents were included in the RAIN (veRy thin stents for patients with left mAIn or bifurcatioN in real life) registry and divided into octogenarians group (OG, 551 patients) and nonoctogenarians (NOGs, 2,453 patients). Major adverse cardiovascular event (MACE), a composite end point of all-cause death, nonfatal myocardial infarction (MI), target lesion revascularization (TLR), and stent thrombosis (ST), was the primary endpoint, while MACE components, cardiovascular (CV) death, and target vessel revascularization (TVR) were the secondary ones.

RESULTS

Indication for PCI was acute coronary syndrome in 64.7% of the OG versus 53.1% of the NOG. Severe calcifications and a diffuse disease were significantly more in OG. After a follow-up of 15.2 ± 10.3 months, MACEs were higher in the OG than in the NOG patients (OG 19.1% vs. NOG 11.2%, p < .001), along with MI (OG 6% vs. NOG 3.4%, p = .002) and all-cause death (OG 14% vs. NOG 4.3%, p < .001). In contrast, no significant difference was detected in CV-death (OG 5.1% vs. NOG 4%, p = .871), TVR/TLR, or ST. At multivariate analysis, age was not an independent predictor of MACE (OR 1.02 CI 95% 0.76-1.38), while it was for all-cause death, along with diabetes, GFR < 60 ml/min, and ULM disease.

DISCUSSION

Midterm outcomes of complex PCI in OG are similar to those of younger patients. However, due to the higher non-CV death rate, accurate patient selection is mandatory.

Comparison of effects of thrombolytic therapy and primary percutaneous coronary intervention in elderly patients with acute ST-segment elevation myocardial infarction on in-hospital, six-month, and one-year mortality

Introduction

This study aims to evaluate the effect of primary percutaneous coronary intervention (PCI) and thrombolytic therapy (TT) on the in-hospital adverse events, in-hospital and long-term mortality in patients over 65 years of age with acute ST-segment elevation myocardial infarction (STEMI).

Material and methods

A total of 111 retrospectively screened patients (73 males, mean age: 73.4 ±5.9 years) over 65 years of age with STEMI, who underwent TT or primary PCI, were included in the study. Patients' characteristics, in-hospital outcomes, and 6-month and 1-year mortalities were recorded.

Results

Our study was conducted with 111 patients over 65 years of age with STEMI (73 males, 38 females). Of the patients, 66 (59.5%) were treated with thrombolytics, and 45 (40.5%) patients underwent primary PCI. Door-to-needle time was 25.9 ±7.8 min in the TT group, whereas door-to-balloon time was 84.4 ±20.0 min in the PCI group. Time from symptom onset to hospital admission was 213.6 ±158.4 min in the thrombolytic group, and 166.8 ±112.8 min in the PCI group. Rescue PCI was performed in 7 (10.6%) patients in the TT group due to lack of reperfusion. Recurrent infarction was observed in 5 (7.6%) patients in the TT group and in 2 (4.4%) patients in the PCI group. Non-haemorrhagic stroke was observed in 1 (1.5%) patient in the thrombolytic-administered group and in 4 (8.9%) patients in the PCI group. No intracranial haemorrhage was observed in any patient. Major haemorrhage was observed in 4 (6.1%) patients in the TT group and in 4 (8.9%) patients in the PCI group. Six-month and 1-year mortalities were present in 15 (22.7%) patients and 19 patients in thrombolytic group, and 8 (17.8%) and 8 (17.8%) patients in the PCI group, respectively. Binary logistic regression analysis indicated that the patient's age was the only predictor for 1-year mortality (odds ratio (OR) = 1.1, 95% confidence interval (CI): 1.019-1.188, p = 0.015).

Conclusions

Considering the in-hospital adverse outcomes, in-hospital mortality, and 6-month mortality rates, TT and primary PCI have similar effects in STEMI patients aged 65 years and over according to the results of our study. Although 1-year mortality was higher in the TT group, it was not statistically significant.

Primary Ventricular Fibrillation in the Primary Percutaneous Coronary Intervention ST-Segment Elevation Myocardial Infarction Era (from the "Codi IAM" Multicenter Registry)

Primary ventricular fibrillation (PVF) is a dreadful complication of ST segment elevation myocardial infarction (STEMI). Scarce data are available regarding PVF prognosis since primary percutaneous coronary intervention (PPCI) became routine practice in STEMI. Our aim was to compare 30-day and 1-year mortality for patients with and without PVF (including out-of-hospital and in-hospital PVF) within a regional registry of PPCI-treated STEMI patients. This prospective multicenter registry included all consecutive STEMI patients treated with PPCI from January 2010 to December 2014. Patients were classified as non-PVF or PVF, with further subdivision into out-of-hospital and in-hospital PVF. We analyzed 30-day and 1-year all-cause mortality in groups. The registry included 10,965 patients. PVF occurred in 949 patients (8.65%), including 74.2% out-of-hospital and 25.8% in-hospital PVF. Compared with the non-PVF group, PVF patients were younger; less commonly diabetic; more frequently had anterior wall STEMI, higher Killip-Kimball class, and left main disease; and showed significantly higher 24-hour (5.1% vs 1.1%), 30-day (18.5% vs 4.7%), and 1-year mortality (23.2% vs 7.9%) (all p <0.001). Mortality did not differ in out-of-hospital versus in-hospital PVF. After multivariable adjustment, PVF remained associated with all-cause 30-day (2.32, 95% CI: 1.91 to 2.82, p <0.001) and 1-year (HR: 1.59, 95% CI: 1.13 to 2.24, p = 0.008) mortality. In conclusion, we present the largest registry of PVF patients in the era of routine PPCI in STEMI. Although overall STEMI mortality has declined, PVF emerged as a predictor of both 30-day and 1-year mortality. These data warrant prospective validation and proper identification and protection of high-risk patients.

Aldo-Keto Reductases: Multifunctional Proteins as Therapeutic Targets in Diabetes and Inflammatory Disease

Aldose reductase (AR) is an NADPH-dependent aldo-keto reductase that has been shown to be involved in the pathogenesis of several blinding diseases such as uveitis, diabetic retinopathy (DR) and cataract. However, possible mechanisms linking the action of AR to these diseases are not well understood. As DR and cataract are among the leading causes of blindness in the world, there is an urgent need to explore therapeutic strategies to prevent or delay their onset. Studies with AR inhibitors and gene-targeted mice have demonstrated that the action of AR is also linked to cancer onset and progression. In this review we examine possible mechanisms that relate AR to molecular signaling cascades and thus explain why AR inhibition is an effective strategy against colon cancer as well as diseases of the eye such as uveitis, cataract, and retinopathy.

Impact of Double Loading Regimen of Clopidogrel on Final Angiographic Results, Incidence of Upper Gastrointestinal Bleeding and Clinical Outcomes in Patients with STEMI Undergoing Primary Coronary Intervention

This study tested the therapeutic impact of double-loading dose (i.e., 600 mg) versus standard-loading dose (i.e., 300 mg) of clopidogrel on ST-segment-elevation-myocardial-infarction (STEMI) patients undergoing primary-coronary-intervention (PCI).Between January 2005 and December 2013, a total of 1461 STEMI patients undergoing PCI were consecutively enrolled into the study and categorized into group 1 (600 mg/clopidogrel; n = 508) and group 2 (300 mg/clopidogrel; n = 953). We assessed angiographic thrombolysis-in-myocardial-infarction (TIMI) flow in the infarct-related-artery, 30-day mortality and upper-gastrointestinal-bleeding (UGIB) within 30 days as primary-endpoints and later incidents of UGIB as secondary-endpoints.The results showed that the incidences of advanced Killip score (defined as ≥ score 3) upon presentation (23.8% versus 24.6%) and advanced heart failure (defined as ≥ NYHAFc-3) (10.2% versus 10.4%) did not differ between groups 1 and 2 (all P > 0.4). Primary-endpoints, which were final TIM-3 flow (91.3% versus 91.7%) in the infarct-related-artery, incidences of 30-day mortality (5.8% vs. 7.1%), and UGIB ≤ 30 day (7.8% versus 8.9%) did not differ between group 1 and group 2 (all P > 0.33). The secondary-endpoints which were incidences of ≥ 30-day < one-year (5.2% versus 4.7) and > one-year (8.9% versus 10.1%) UGIB did not differ between groups 1 and 2 (all P > 0.45). One-year mortality did not differ between two groups (10.74% versus 12.9%) (P > 0.25). Multiple-stepwise-logistic-regression analysis showed that age and advanced-Killip score were independently predictive of 30-day mortality (all P < 0.001).Double-loading dose of clopidogrel did not confer an additional benefit to the final angiograph results, 30-day/one-year clinical outcomes; and age and advanced Killip-score were powerful predictors of 30-day mortality.

In-hospital mortality after acute STEMI in patients undergoing primary PCI

BACKGROUND

Acute myocardial infarction (AMI) is the main cause of global and in-hospital mortality in patients with cardiovascular diseases. We aimed to examine the association between the coronary artery involved and the in-hospital mortality in patients who underwent primary percutaneous coronary intervention (pPCI) after ST segment elevation myocardial infarction (STEMI).

METHODS

The in-hospital mortality of STEMI patients who underwent pPCI was assessed at the Department of Cardiology, Harzklinik Goslar, Germany, which has no access to immediate mechanical circulatory support (MCS), between 2013 and 2017.

RESULTS

We enrolled 312 STEMI patients, with a mean age of 67.1 ± 13.4 years, of whom 211 (68%) were male. In-hospital mortality was documented in 31 patients (10%). In-hospital mortality was associated with pre-hospital cardiopulmonary resuscitation (CPR; n = 39/12.5%), older age, lower systolic blood pressure, Killip class > 1, triple-vessel disease (each p < 0.0001), female gender (p = 0.0158), and with the localization of the treated culprit lesion in the left main coronary artery (LMCA; p = 0.0083) and in the ramus circumflexus (RCX; p = 0.0141).

CONCLUSION

In this monocentric cohort, all-cause in-hospital mortality of STEMI patients after pPCI was significantly higher in those patients with culprit lesions in the LMCA and in the RCX, which may prove to be a substantial novel risk factor for STEMI-related mortality. Increasing age and female gender may be interdependent risk factors for mortality in this patient population. Furthermore, our data highlight the importance of the availability of MCS options in pPCI centers for patients after CPR.

Sestrin2 prevents age-related intolerance to ischemia and reperfusion injury by modulating substrate metabolism

A novel stress-inducible protein, Sestrin2 (Sesn2), declines in the heart with aging. AMPK has emerged as a pertinent stress-activated kinase that has been shown to have cardioprotective capabilities against myocardial ischemic injury. We identified the interaction between Sesn2 and AMPK in the ischemic heart. To determine whether ischemic AMPK activation-modulated by the Sesn2-AMPK complex in the heart-is impaired in aging that sensitizes the heart to ischemic insults, young C57BL/6 mice (age 3-4 mo), middle-aged mice (age 10-12 mo), and aged mice (age 24-26 mo) were subjected to left anterior descending coronary artery occlusion for in vivo regional ischemia. The ex vivo working heart system was used for measuring substrate metabolism. The protein level of Sesn2 in hearts was gradually decreased with aging. Of interest, ischemic AMPK activation was blunted in aged hearts compared with young hearts (P < 0.05); the AMPK downstream glucose uptake and the rate of glucose oxidation were significantly impaired in aged hearts during ischemia and reperfusion (P < 0.05 vs. young hearts). Myocardial infarction size was larger in aged hearts (P < 0.05 vs. young hearts). Immunoprecipitation with Sesn2 Ab revealed that cardiac Sesn2 forms a complex with AMPK and upstream liver kinase B1 (LKB1) during ischemia. Of interest, the binding affinity between Sesn2 and AMPK upstream LKB1 is impaired in aged hearts during ischemia (P < 0.05 vs. young hearts). Furthermore, Sesn2-knockout hearts demonstrate a cardiac phenotype and response to ischemic stress that is similar to wild-type aged hearts (i.e., impaired ischemic AMPK activation and higher sensitivity to ischemia- and reperfusion- induced injury). Adeno-associated virus-Sesn2 was delivered to aged hearts via a coronary delivery approach and significantly rescued the protein level of Sesn2 and the ischemic tolerance of aged hearts; therefore, Sesn2 is a scaffold protein that mediates AMPK activation in the ischemic myocardium via an interaction with AMPK upstream LKB1. Decreased Sesn2 levels in aging lead to a blunted ischemic AMPK activation, alterations in substrate metabolism, and an increased sensitivity to ischemic insults-Quan, N., Sun, W., Wang, L., Chen, X., Bogan, J. S., Zhou, X., Cates, C., Liu, Q., Zheng, Y., Li J. Sestrin2 prevents age-related intolerance to ischemia and reperfusion injury by modulating substrate metabolism.

Cardiac MR Imaging in Acute Coronary Syndrome: Application and Image Interpretation

Acute coronary syndrome (ACS) is a frequent cause of hospitalization and coronary interventions. Cardiac magnetic resonance (MR) imaging is an increasingly used technique for initial work-up of chest pain and early post-reperfusion and follow-up evaluation of ACS to identify patients at high risk of further cardiac events. Cardiac MR imaging can evaluate with accuracy a variety of prognostic indicators of myocardial damage, including regional myocardial dysfunction, infarct distribution, infarct size, myocardium at risk, microvascular obstruction, and intramyocardial hemorrhage in both acute setting and later follow-up examinations. In addition, MR imaging is useful to rule out other causes of acute chest pain in patients admitted to the emergency department. In this article, a brief explanation of the pathophysiology, classification, and treatment options for patients with ACS will be introduced. Indications of cardiac MR imaging in ACS patients will be reviewed and specific cardiac MR protocol, image interpretation, and potential diagnostic pitfalls will be discussed. ^© RSNA, 2017 Online supplemental material is available for this article.

A review of strategies for infarct size reduction during acute myocardial infarction

Advances in medical and interventional therapy over the last few decades have revolutionized the treatment of acute myocardial infarction. Despite the ability to restore epicardial coronary artery patency promptly through percutaneous coronary intervention, tissue level damage may continue. The reported 30-day mortality after all acute coronary syndromes is 2 to 3%, and around 5% following myocardial infarction. Post-infarct complications such as heart failure continue to be a major contributor to cardiovascular morbidity and mortality. Inadequate microvascular reperfusion leads to worse clinical outcomes and potentially strategies to reduce infarct size during periods of ischemia-reperfusion can improve outcomes. Many strategies have been tested, but no single strategy alone has shown a consistent result or benefit in large scale randomised clinical trials. Herein, we review the historical efforts, current strategies, and potential novel concepts that may improve myocardial protection and reduce infarct size.

Two-year prognosis of admission hemoglobin A1c following a primary percutaneous coronary intervention

OBJECTIVE

We sought to assess the effect of hemoglobin A1c (HbA1c) on the outcomes of a primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI).

BACKGROUND

Many studies have shown the diagnostic and predictive value of HbA1c levels in patients with acute myocardial infarction. We assessed the prognostic role of HbA1c in short-term and long-term mortality in 796 consecutive patients with STEMI.

METHODS AND RESULTS

A total of 796 patients with STEMI undergoing primary PCI were prospectively enrolled between December 2013 and June 2015. The patients were divided into three groups on the basis of admission HbA1c levels: group I (HbA1c≤5.6%), group II (HbA1c 5.7-6.4%), and group III (HbA1c≥6.5%). The in-hospital and 2-year cardiovascular (CV) mortality and morbidity of all three patient groups were followed up. A significant association was found between HbA1c level and 2-year primary clinical outcomes, including CV mortality, heart failure/shock, and major adverse cardiovascular event (P<0.001).

CONCLUSION

HbA1c is an independent predictor of the in-hospital and long-term mortality, nonfatal reinfarction, and target vessel revascularization in STEMI patients treated with primary PCI.

Predictors and Impact of In-Hospital Recurrent Myocardial Infarction in Patients With Acute Coronary Syndrome: Findings From Gulf RACE-2

BACKGROUND

Little is known about the predictors and prognostic impact of recurrent in-hospital ischemia and infarction in patients with acute coronary syndrome (ACS). Our objectives were to determine the baseline characteristics, risk factors, and long-term outcomes of patients with recurrent myocardial infarction (Re-MI).

METHODS

We evaluated patients with ACS who were enrolled in the second Gulf Registry of Acute Coronary Events from October 2008 to June 2009.

RESULTS

Of 7925 patients with ACS, 167 (2.1%) developed in-hospital Re-MI. Patients with Re-MI were older (mean age: 58.7 ± 13.4 vs 56.8 ± 12.6; P = .045), had higher rates of hyperlipidemia (42.5% vs 32.6%; P = .019), and were more likely to present with ST-segment elevation myocardial infarction (STEMI; 74.25% vs 43.9%; P < .001) and Killip class 4 (8.4% vs 3.2%; P < .001) than patients without Re-MI. Patients with Re-MI were less likely to receive evidence-based therapies upon admission, including aspirin (94.6% vs 98.5%; P < .001), β-blockers (59.3% vs 74.7%; P < .001), and statins (86.8% vs 94.9%; P < .001), and were less frequently assessed with coronary angiography (29.3% vs 32.5%; P = .029). Predictors of recurrent events included history of angina, hypotension on presentation, admission diagnosis of STEMI, and decreased use of evidence-based therapies including aspirin, statins, and β-blockers upon admission. Patients with Re-MI had more in-hospital complications, including congestive heart failure (44.3% vs 12.4%) and cardiogenic shock (26.4% vs 5.3%), as well as higher mortality rates during hospitalization (23.4% vs 4.1%) and after a discharge period of 30 days (27% vs 7.8%) and 1 year (30.5% vs 11.7%; P < .001 for all comparisons).

CONCLUSION

In our study, patients with Re-MI were less likely to receive evidence-based therapies and had a worse prognosis in terms of in-hospital complications and higher mortality rates. High-risk patients should be monitored and managed differently to prevent secondary attacks.

Safety and feasibility of a PAclitaxel-eluting balloon angioplasty in Primary Percutaneous coronary intervention in Amsterdam (PAPPA): one-year clinical outcome of a pilot study

AIMS

In primary percutaneous coronary intervention (PPCI), stenting has been shown to reduce the need for repeat target lesion revascularisation (TLR) compared to balloon angioplasty alone, but did not result in a reduction of recurrent myocardial infarction (MI) or cardiac death. Meanwhile, stent-related adverse events such as stent thrombosis continue to be of concern. Our aim was to evaluate the safety and feasibility of drug- coated balloon (DCB) angioplasty without stenting in PPCI.

METHODS AND RESULTS

One hundred patients presenting with ST-elevation MI were prospectively enrolled in this pilot study. They underwent PPCI with DCB angioplasty; additional stenting was allowed only in case of type C to F coronary dissection or residual stenosis >50%. All patients were treated with i.v. bivalirudin. The primary endpoint was the composite of cardiac death, recurrent MI and TLR. A total of 59 patients received treatment with DCB angioplasty alone, whereas additional stenting was required in 41 patients. One-year clinical follow-up was completed in 98 patients. A total of five major adverse cardiac events were reported (5%). Cardiac death was seen in two patients, while three patients underwent TLR.

CONCLUSIONS

This first study of a DCB angioplasty-only strategy in the setting of PPCI showed good one-year clinical results.

QT interval Independently Predicts Mortality and Heart Failure in Patients with ST-Elevation Myocardial Infarction

OBJECTIVES

Heart-rate corrected QT (QTc) interval predicts cardiovascular mortality or all-cause mortality in the general population. Little is known about the best cut-off value of QTc interval for predicting clinical events in patients with ST-elevation myocardial infarction (STEMI).

METHODS

We enrolled 264 patients with STEMI who received measurement of QTc intervals at ER (QTc-ER), on day 2 (QTc-D2), and on day 3 (QTc-D3) of hospitalization. Clinical events, including all-cause death and readmission for heart failure, were followed for 2 years.

RESULTS

Prolonged QTc-ER, but not QTc-D2 or QTc-D3, well predicted clinical events with the best cut-off value of 445 ms. Patient with QTc-ER > 445 ms had lower left ventricular ejection fraction at baseline and at 6 months. Kaplan-Meier survival curves showed that the combination of QTc-ER > 445 ms and N-terminal pro-brain natriuretic peptide (NT-pro BNP) > 936 pg/mL was a strong predictor of clinical events (p<0.001). In multivariable Cox regression analysis, the independent predictors of death and heart failure were QTc-ER (p<0.001), log NT-proBNP (p<0.001), diabetes mellitus (p<0.001), history of stroke (p=0.001), and left ventricular end diastolic volume index (p<0.001).

CONCLUSION

QTc-ER > 445 ms independently predicts clinical events in STEMI, providing incremental prognostic value to established clinical predictors and NT-proBNP.

Prognosis of primary percutaneous coronary intervention in elderly patients with ST-elevation myocardial infarction

Objective

To evaluate the prognosis of primary percutaneous coronary intervention (PPCI) and medical therapy (MT) in elderly patients presenting with ST-elevation myocardial infarction (STEMI).

Methods

A total of 238 STEMI patients aged above 80 and treated with PPCI (n = 186) and MT (n = 52) at Harefield Hospital, London were included in this study. Patients who did not have true STEMI based on non-diagnostic electrocardiogram (ECG) for STEMI and negative troponin, who presented with left bundle branch block (LBBB) and had normal coronaries were excluded from this study. Primary PCI was defined as any use of a guidewire for more than diagnostic purposes in patients with STEMI, whereas conventional MT was defined as treatment of patients with anti-platelets and anti-thrombotic medications without thrombolysis.

Results

The survival rate of PPCI patients was 86% (n = 160) at month 1 followed by 83.9% (n = 156) at month 6, and 81.2% (n = 151) at month 12. The survival rate of MT patients was 44.2% (n = 23) at month 1 followed by 36.5% (n = 19) at month 6, and 34.6% (n = 18) at month 12. Compared to MT, significantly fewer comorbidities were found in the PPCI group. Ventricular fibrillation (VF) (4.8%) and consequent admission to intensive care unit (7%) were the major complications of the PPCI group.

Conclusion

PPCI has a higher survival rate and, compared to MT, fewer comorbidities were observed in the PPCI group of elderly patients presenting with STEMI.

A review of the role of nurses and technicians in ST-elevation myocardial infarction (STEMI)

The role of nurses and technicians in the treatment of ST-elevation myocardial infarction (STEMI) by primary percutaneous coronary intervention (PPCI) is vital for the success of the multidisciplinary Heart Team. Several editorials have emphasised the importance of a holistic treatment which links each step of care to the next, a chain that is essential for quality and efficacy in the management of STEMI patients. In pre-hospital acute coronary care, the first medical contact is most commonly a nurse and/or a paramedic. The time from symptom onset to reperfusion is crucial for the long-term outcome. On arrival at the hospital, it is important for the nurse or paramedic to share an overview of what has been done to the patient so far, in a structured and evidence-based way, with the receiving nurse and physician. During PPCI, the role of nurses and technicians includes puncture site assessment, administration of pharmaceuticals and the ability to anticipate and prevent complications. In patients with cardiogenic shock and cardiac arrest, advanced knowledge of haemodynamic support systems is required. In the future, this knowledge must be extended from a limited number of individuals in a small number of centres to a standard of care which is available for all citizens throughout Europe. This review demonstrates the necessity for a multidisciplinary team approach where every person plays an equal, important role in every element of PPCI. The future role of nurses and technicians is intriguing and demands education and experience from an advanced medical and nursing point of view, where the multidisciplinary Heart Team and the knowledge of the different key players are vital.

Long-term prognostic value of admission haemoglobin A1c (HbA1c) levels in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention

Introduction

Many studies have reported the diagnostic and prognostic value of haemoglobin A_1c (HbA_1c) levels in patients with acute coronary syndrome. However, the short- and long-term prognostic value of HbA_1c level in patients with ST elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI) is controversial.

Aim

To investigate whether admission HbA_1c level has a prognostic value for in-hospital, short-, and long-term cardiovascular (CV) mortality and major adverse cardiovascular events in patients with STEMI undergoing primary PCI.

Material and methods

This prospective study included 443 consecutive patients with STEMI who underwent primary PCI between September 2010 and July 2012. The patients were divided into three groups based on admission HbA_1c levels: group I (HbA_1c ≤ 5.6%), group II (HbA_1c 5.7–6.4%), and group III (HbA_1c ≥ 6.5%). The in-hospital, 1-month, and 1-year CV events of all 3 patient groups were followed up.

Results

A significant association was found between HbA_1c level and 1-year primary clinical outcomes, including CV mortality, non-fatal reinfarction, and stroke (p = 0.037). In addition, age, Killip class > 1, and left ventricular ejection fraction were found to be independent predictors of long-term CV mortality in multivariate analysis (hazard ratios (95% confidence interval) 1.081 (1.020–1.146), 4.182 (1.171–14.935), and 0.832 (0.752–0.920); p = 0.009, p = 0.028, and p < 0.001, respectively).

Conclusions

In this study, we demonstrated that increased admission HbA_1c levels were associated with higher rates of major adverse CV events, including mortality, non-fatal reinfarction, and stroke, in patients with STEMI who underwent primary PCI.

Incidence and prognostic value of bleeding after percutaneous coronary intervention in patients older than 75 years of age

OBJECTIVES

We aimed to assess the impact of bleeding after percutaneous coronary intervention (PCI) on the outcome of patients >75 years of age.

BACKGROUND

Limited information exists on the impact of post-PCI bleeding on the outcome in elderly patients.

METHODS

This study included 3,255 patients >75 years of age. Bleeding events were assessed using the Bleeding Academic Research Consortium (BARC) criteria. The primary outcome was 1-year mortality.

RESULTS

Within 30 days after PCI, bleeding occurred in 501 patients (15.4%). Bleeding according to BARC was: class 1 (170 patients; 33.9%), class 2 (81 patients; 16.2%), class 3a (177 patients; 35.3%), class 3b (65 patients; 13.0%), class 3c (four patients; 0.8%), and class 4 (four patients; 0.8%). There were 201 deaths within the first year after PCI: 61 deaths (12.3%) among bleeders and 140 deaths (5.1%) among nonbleeders (adjusted hazard ratio = 2.03, 95% confidence interval [CI] 1.42-2.91, P < 0.001). Bleeding improved the discriminatory power of multivariable model for mortality prediction (P = 0.001). Female sex (adjusted odds ratio [OR] = 1.49 [1.17-1.88], P = 0.001) and reduced renal function (adjusted OR = 1.30 [1.04-1.63], P = 0.019 for each 30 ml/min decrease in the creatinine clearance) were independent associates of increased bleeding risk. Bivalirudin reduced the bleeding risk by 24% compared with unfractionated heparin and 33% compared with abciximab plus unfractionated heparin.

CONCLUSIONS

Post-PCI bleeding is an important prognostic factor in patients >75 years of age. The risk for bleeding in this age category is increased in women and patients with impaired renal function. Bleeding risk is reduced by bivalirudin.

Safety and feasibility of high-dose administration of nicorandil before reperfusion therapy in acute myocardial infarction

The efficacy and safety of high-dose nicorandil therapy in acute myocardial infarction (AMI) have not yet been clarified. This is a prospective study including 30 patients who received nicorandil at 0.06 mg/kg/h [standard dose nicorandil (SDN) group] and 32 patients who received a bolus injection of nicorandil 0.2 mg/kg followed by a continuous infusion at 0.2 mg/kg/h [high-dose nicorandil (HDN) group]. The benefits and adverse events were assessed during acute phase and 12-month follow-up period. There were no significant differences between the groups in blood pressure, heart rate or urine volume 2, 6 and 24 h after drug administration, although blood pressure decreased during acute phase. The percentages of patients who required dose reduction or discontinuation of nicorandil were 34.4 and 16.7 % in HDN and SDN groups, respectively (p = 0.11). In HDN group, subgroup analysis revealed that the TIMI frame count (TFC) was significantly lower in patients in whom the treatment was started within 12 h compared to those more than 12 h (17.0 vs. 21.0, p = 0.017) and in patients with baseline WBC elevation compared to those without it (16.5 vs. 22.0, p = 0.029). A TFC of >20 was significantly associated with being in HDN group [odds ratio (OR) 0.27; 95 % confidence interval, CI 0.07-0.89], onset-to-balloon time (OR 1.06; 95 % CI 1.01-1.16), and ∑creatine kinase (OR 7.27; 95 % CI 1.40-57.83). There were no significant differences in incidences of cardiovascular death, rehospitalization, and target lesion revascularization between the groups. HDN therapy may improve coronary microcirculation in patients with AMI.

The effect of statins on the no-reflow phenomenon: an observational study in patients with hyperglycemia before primary angioplasty

BACKGROUND

An association between admission plasma glucose levels and an increased risk of no-reflow has been well documented. Although HMG-CoA reductase inhibitor (statin) therapy can reduce no-reflow, little is known about its effect on no-reflow in patients with hyperglycemia. In the present study, we investigated whether pretreatment with a statin could reduce no-reflow in patients with hyperglycemia, who underwent primary coronary intervention for acute myocardial infarction (AMI).

METHODS

A total of 259 consecutive patients who underwent primary angioplasty for a first AMI were studied. Blood glucose and creatinine kinase levels were measured on admission. All patients underwent 2-dimensional echocardiography and electrocardiographic analysis just after admission. No-reflow was defined as a Thrombolysis in Myocardial Infarction (TIMI) flow grade <3. Hyperglycemia was defined as a blood glucose level >or=10 mmol/L. Statin administration prior to admission was determined by detailed interview or information in the medical records.

RESULTS

Hyperglycemia was diagnosed in 154 patients on admission. The no-reflow phenomenon was found in 31 of the 154 patients with hyperglycemia. The incidence of no-reflow was significantly greater in patients with hyperglycemia compared with no hyperglycemia. A multivariable logistic regression analysis showed that hyperglycemia on admission was an independent predictor of no-reflow. Among the 154 patients with hyperglycemia, there were no significant differences in baseline clinical characteristics between patients who received statin pretreatment and those who did not; however, hyperlipidemia occurred in a greater number of the patients who did not receive statin pretreatment. The 40 patients with hyperglycemia who received statins before admission had a lower incidence of no-reflow than those who did not receive statin pretreatment (5% and 25.4%; p < 0.05). Multivariable logistic regression analysis revealed that absence of statin pretreatment was a significant predictor of no-reflow in patients with hyperglycemia, along with ejection fraction on admission, initial TIMI 0 flow, number of Q waves, and anterior AMI.

CONCLUSION

The results of our study show that pretreatment with statins could attenuate no-reflow after AMI in patients with acute hyperglycemia.

ST Elevation Myocardial Infarction in the elderly

Acute coronary syndromes (ACS) are the leading causes of death in the elderly. The suspicion and diagnosis of ACS in this age group is more difficult, since typical angina is less frequent. The morbidity and mortality is greater in older age patients presenting ACS. Despite the higher prevalence and greater risk, elderly patients are underrepresented in major clinical trials from which evidence based recommendations are formulated. The authors describe, in this article, the challenges in the diagnosis and management of ST elevation myocardial infarction in the elderly, and discuss the available evidence.

Primary percutaneous coronary interventions in nonagenarians

BACKGROUND

The optimal treatment of very elderly patients with ST elevation myocardial infarction (STEMI) is not yet defined. The aim of this study is to present the feasibility and safety of primary percutaneous coronary interventions (PCI) in nonagenarians.

METHODS

A retrospective analysis of all patients who underwent primary PCI due to STEMI between 2004 and 2008 was performed. Patients age 90 years or older at the time of the procedure were identified and studied.

RESULTS

Twenty-two patients fulfilled the study criteria (median age 92 years; range, 90-97 years; 50% women). The procedural success rate was 82%. Bare metal stent implantation was performed in 82% of the procedures, whereas only balloon angioplasty was performed on the rest of them. One patient experienced a minor bleeding complication. Procedural mortality was 9% (2 out of 22 patients), and it was due to "no flow" phenomenon in both patients. In-hospital mortality was 27% (6/22 patients) and 30-day mortality was 32% (7/22 patients). All 3 patients with Killip class III-IV on admission died within 30 days compared with 4 of the 19 patients with Killip class I-II (P = 0.023). Furthermore, of 11 patients with anterior infarction, 7 died within 30 days compared with none of the 11 patients with infarction of other location (P = 0.004).

CONCLUSIONS

Although primary PCI is feasible in patients 90 years or older suffering from STEMI, the short-term mortality rate is high especially in patients with anterior infarct location and/or severely depressed myocardial function.

Outcome and treatment quality of transfer primary percutaneous intervention in older patients with acute ST-elevation myocardial infarction (STEMI)

The aim of this study was to evaluate the outcome and treatment quality of transfer percutaneous coronary intervention (PCI) in older patients with acute STEMI. In this prospective study all patients with diagnosed acute (pain-to-balloon≤12 h) STEMI transferred to our institution for primary PCI (n=400) between January 2005 and October 2007 were under investigation. Overall 125 older patients with age ≥70 years were included (mean age 77.5±4.9 years; 77 males). Pre-hospital delays were more common in older patients with longer pain-to-balloon: median (range)=85 (5-629) vs. 66 (1-688) p=0.031, and pain-to-first medical-contact-times: median: 206 (84-711) vs. 172 (45-720); p=0.001. A trend towards a higher (non-significant) rate of major 5/125 (5%) vs. 5/275 (1.8%), p=0.195 and minor 10/125 (8%) vs. 14/275 (5.1%). p=0.256 bleeding complications in older patients was evident. In-hospital mortality was significantly higher in older patients compared to the younger patients group: 13/125, 10.4% vs. 8/275, 2.9%, p=0.002). Overall mortality at 30-day follow-up was 11.2% in older and 3.3% in younger patients: 14/125 vs. 9/275, p=0.002. Transfer PCI is an effective treatment strategy for older patients with acute ST-elevation myocardial infarction. Overall-30-day mortality in older STEMI-patients transferred for primary PCI is comparably low.

Early extracorporeal membrane oxygenator-assisted primary percutaneous coronary intervention improved 30-day clinical outcomes in patients with ST-segment elevation myocardial infarction complicated with profound cardiogenic shock

OBJECTIVES

This study tested the hypothesis that early extracorporeal membrane oxygenator offered additional benefits in improving 30-day outcomes in patients with acute ST-segment elevation myocardial infarction complicated with profound cardiogenic shock undergoing primary percutaneous coronary intervention.

METHODS

Between May 1993 and July 2002, 920 patients with acute ST-segment elevation myocardial infarction underwent primary percutaneous coronary intervention. Of these patients, 12.5% (115) with cardiogenic shock were enrolled in this study (group 1). Between August 2002 and December 2009, 1650 patients with acute ST-segment elevation myocardial infarction underwent primary percutaneous coronary intervention. Of these patients, 13.3% (219) complicated with cardiogenic shock were enrolled (group 2).

RESULTS

The incidence of profound shock (defined as systolic blood pressure remaining < or =75 mm Hg after intra-aortic balloon pump and inotropic agent supports) was similar in both groups (21.7% vs. 21.0%, p > .5). Extracorporeal membrane oxygenator support, which was available only for patients in group 2, was performed in the catheterization room. The results demonstrated that final thrombolysis in myocardial infarction grade 3 flow in infarct-related artery was similar between the two groups (p = .678). However, total 30-day mortality and the mortality of patients with profound shock were lower in group 2 than in group 1 (all p < .04). Additionally, the hospital survival time was remarkably longer in patients in group 2 than in patients in group 1 (p = .0005). Furthermore, multivariate analysis demonstrated that unsuccessful reperfusion, presence of advanced congestive heart failure, profound shock, and age were independent predictors of 30-day mortality (all p < .02).

CONCLUSION

Early extracorporeal membrane oxygenator-assisted primary percutaneous coronary intervention improved 30-day outcomes in patients with ST-segment elevation myocardial infarction with complicated with profound cardiogenic shock.

Health-related quality of life: The impact of diagnostic angiography

BACKGROUND

Little is known regarding the effects of index angiograms on health-related quality of life related to angiographic outcome, that is, positive or negative for coronary heart disease (CHD).

METHODS

A longitudinal, comparative design was used. Ninety-three patients underwent initial angiography and completed questionnaires (Cardiac-Quality of Life Index, Short Form-36 mental and physical, and Cardiac Attitudes Index) before, 1 week and 1 year after angiography. Data were evaluated with linear regression and analysis of variance.

RESULTS

Fifty-five patients were CHD positive (age 65.3 ± 10.7 years, 49% were female), and 38 patients were CHD negative (age 59.5 ± 12 years, 53% were female). Compared with CHD-positive patients over 1 year, CHD-negative patients reported lower scores on the Cardiac-Quality of Life Index (P < .008), Short Form-36 mental and physical measures (P = .004), and Cardiac Attitudes Index (P = .05).

CONCLUSION

CHD-negative patients experienced lower health-related quality of life and lower perceived control than CHD-positive patients. After an index angiogram, a negative finding may not be sufficient to relieve negative emotions.

Temporal trends in revascularization and outcomes after acute myocardial infarction among the very elderly

BACKGROUND

Few data are available on time-related changes in use and outcomes of invasive procedures after acute myocardial infarction in very elderly patients. Our objective was to describe trends in revascularization procedures and outcomes in a provincial cohort of very elderly patients who had experienced acute myocardial infarction.

METHODS

We used a database of hospital discharge summaries to identify all patients aged 80 years or older admitted for acute myocardial infarction in Quebec. We used the provincial database of physicians' services and medication claims to assess treatment and obtain data on survival.

RESULTS

Between March 1996 and March 2007, 29 750 patients aged 80 years or older were admitted to hospital for acute myocardial infarction. During this period, use of percutaneous coronary interventions increased from 2.2% to 24.9%, and use of coronary artery bypass graft surgery increased from 0.8% to 3.1%. Evidence-based prescriptions of medication increased over time (p < 0.001). The prevalence of reported comorbidities was higher during the period of 2003-2006 than during the 1996-1999 period. One-year mortality improved over time (46.5% for 1996-1999 v. 40.9% for 2003-2006, p < 0.001) but remained unchanged in the subgroup of patients who did not undergo revascularization.

INTERPRETATION

The use of revascularization, especially percutaneous coronary interventions, in the very elderly after acute myocardial infarction has been growing at a rapid pace, while the prevalence of reported comorbidities has been increasing in this population. Revascularization procedures are no longer restricted to younger patients. In the context of an aging population, it is imperative to determine whether these changes in practice are cost-effective.

Impaired macrophage migration inhibitory factor-AMP-activated protein kinase activation and ischemic recovery in the senescent heart

BACKGROUND

Elderly patients are more sensitive than younger patients to myocardial ischemia, which results in higher mortality. We investigated how aging affects the cardioprotective AMP-activated protein kinase (AMPK) signaling pathway.

METHODS AND RESULTS

Ischemic AMPK activation was impaired in aged compared with young murine hearts. The expression and secretion of the AMPK upstream regulator, macrophage migration inhibitory factor (MIF), were lower in aged compared with young adult hearts. Additionally, the levels of hypoxia-inducible factor 1alpha, a known transcriptional activator of MIF, were reduced in aged compared with young hearts. Ischemia-induced AMPK activation in MIF knockout mice was blunted, leading to greater contractile dysfunction in MIF-deficient than in wild-type hearts. Furthermore, intramyocardial injection of adenovirus encoding MIF in aged mice increased MIF expression and ischemic AMPK activation and reduced infarct size.

CONCLUSIONS

An impaired MIF-AMPK activation response in senescence thus may be attributed to an aging-associated defect in hypoxia-inducible factor 1alpha, the transcription factor for MIF. In the clinical setting, impaired cardiac hypoxia-inducible factor 1alpha activation and consequent reduced MIF expression may play an important role in the increased susceptibility to myocardial ischemia observed in older cardiac patients.

Proceedings from the scientific symposium: Sex differences in cardiovascular disease and implications for therapies

A consortium of investigator-thought leaders was convened at the Heart Institute at Cedars-Sinai Medical Center and produced the following summary points: POINT 1: Important sex differences exist in cardiovascular disease (CVD) that affect disease initiation, diagnosis, and treatment.

IMPLICATION

Research that acknowledges these differences is needed to optimize outcomes in women and men. POINT 2: Atherosclerosis is qualitatively and quantitatively different in women and men; women demonstrate more plaque erosion and more diffuse plaque with less focal artery lumen intrusion.

IMPLICATION

Evaluation of CVD strategies that include devices should be used to explore differing anatomical shapes and surfaces as well as differing drug coating and eluting strategies. POINT 3: Bone marrow progenitor cells (PCs) engraft differently based on the sex of the donor cell and the sex of the recipient.

IMPLICATION

PC therapeutic studies need to consider the sex of cells of the source and the recipient. POINT 4: Women have a greater risk of venous but not arterial thrombosis compared with men, as well as more bleeding complications related to anticoagulant treatment. Several genes coding for proteins involved in hemostasis are regulated by sex hormones.

IMPLICATIONS

Research should be aimed at evaluation of sex-based differences in response to anticoagulation based on genotype. POINT 5: Women and men can have differences in pharmacological response.

IMPLICATION

Sex-specific pharmacogenomic studies should be included in pharmacological development. POINT 6: CVD progression results from an imbalance of cell injury and repair in part due to insufficient PC repair, which is affected by sex differences, where females have higher circulating levels of PCs with greater rates of tissue repair.

IMPLICATION

CVD regenerative strategies should be directed at learning to deliver cells that shift the recipient balance from injury toward repair. CVD repair strategies should ideally be tested first in females to have the best chance of success for proof-of-concept.

Real-world outcome from ST elevation myocardial infarction in the very elderly before and after the introduction of a 24/7 primary percutaneous coronary intervention service

BACKGROUND

It remains unclear whether the superiority of primary percutaneous coronary intervention (PPCI) over thrombolysis for the treatment of ST elevation myocardial infarction (STEMI) extends to the very elderly. Furthermore, the deliverability and efficacy of PPCI in over the 80s has not been investigated in a real-world setting. The aim of this study was to compare outcome from STEMI in patients aged > or =80 before and after the introduction of routine 24/7 PPCI.

METHODS

Retrospective observational analysis of all patients aged > or =80 presenting with STEMI to 2 neighboring hospitals in the 3-year period after the introduction of a 24/7 PPCI service and in the preceding 2 years when reperfusion therapy was by thrombolysis.

RESULTS

Two hundred fifty-six STEMI patients aged > or =80 were included. After the introduction of PPCI, 84% (136/161) received reperfusion therapy, 73% PPCI, and 12% thrombolysis, compared to 77% ([73/95] 1% PPCI, 76% thrombolysis) previously. Mortality after inception of PPCI was reduced at 12 months (29% vs 41%, P = .04) and 3 years (43% vs 58%, P = .02). Improved outcome was attributable to treatment by PPCI, which was associated with numerically lower 12-month (26% vs 37%, P = .07) and significantly reduced 3-year (42% vs 55%, P = .05) mortality compared to thrombolysis.

CONCLUSIONS

Primary PCI can be effectively delivered to very elderly patients presenting with ST elevation MI in a real-world setting and leads to a substantial reduction in mortality compared to patients treated by thrombolysis.

Acute coronary syndrome in the elderly

The spectrum of acute coronary syndrome (ACS) including unstable angina, non-ST-elevation myocardial infarction and ST-elevation myocardial infarction accounts for increasing numbers of deaths among persons age > or = 65 years in the US. This is important given demographic changes involving falling birth rates and increasing life expectancy. Elderly patients are likely to benefit the most from treatment of ACS, even though community practice still demonstrates less use of cardiac medications as an early-invasive approach among this population.

Safety and efficacy of transradial vs transfemoral arterial primary coronary angioplasty for acute myocardial infarction: single-center experience

BACKGROUND

The aim of the present study was to test the hypothesis that the transradial arterial approach (TRA) is not inferior to the transfemoral arterial approach (TFA) for <or=Killip 3 acute myocardial infarction (AMI) patients undergoing primary percutaneous coronary intervention (PCI).

METHODS AND RESULTS

This study enrolled 506 AMI patients undergoing primary PCI using the TRA (group 1) between March 2002 and May 2007, and 810 AMI patients undergoing primary PCI using TFA (group 2) between May 1993 and February 2002. The results demonstrated that puncture to first balloon-inflation time was similar in both groups; however, the procedure time was shorter in group 1 than in group 2 (P<0.0001). Additionally, the incidences of stenting, tirofiban therapy and final normal coronary blood flow of the infarct-related artery were higher, whereas the frequency of intra-aortic balloon pump support was lower in group 1 than in group 2 (all P<0.02). Although the 30-day mortality rate did not differ between the 2 groups (P=0.341), the rate of combined major vascular and bleeding complications was higher in group 2 than in group 1 (P<0.0001).

CONCLUSIONS

Initial selection of TRA is not inferior to initial selection of TFA for AMI patients undergoing primary PCI. However, in the present study, the incidence of combined vascular and bleeding complications was lower with the TRA than with the TFA approach.

Prognostic factors and outcomes in young chinese patients with acute myocardial infarction undergoing primary coronary angioplasty

We investigated the prognostic risk and the clinical outcome of young-adult patients with ST-segment elevation (ST-se) acute myocardial infarction (AMI) undergoing primary percutaneous coronary intervention (PCI). Between May 1999 and September 2007, primary PCI was performed in 1680 consecutive patients with AMI of onset < 12 hours (cardiogenic shock within 18 hours) at Kaohsiung Chang Gung Memorial Hospital. Of these patients, 163 (9.7%) young-age patients (defined as male of < 45 years old and female of < 55 years old) were enrolled into this study. A comparable number (n = 175) of patients > or = 55 years old, who presented with AMI of < 12 hours duration having undergone primary PCI between November 2004 and May 2006, were retrospectively reviewed and enrolled as control subjects. The procedural success (defined as normal blood flow achieved in the infract-related artery) was similar between the young-age and old-age patients (P = 1.0). Additionally, the incidence of an advanced Killip score (defined as > or = score 3 upon presentation), 30-day and 6-month cumulative mortality did not differ between these two groups of patients (P > 0.1). However, the 30-day major adverse clinical outcome (MACO) (defined as New York Heart Association Functional Classification > or = 3 or 30-day mortality) was significantly lower in the young-age than in the old-age patients (P < 0.001). Further, multiple stepwise logistic regression analysis showed that an advanced Killip score along with the peak level of CK-MB was independently predictive of 30-day MACO (P < 0.05) in young-age patients. In conclusion, the prognostic outcome is favorable in young-adult ST-se AMI undergoing primary PCI. Traditional risk factors remain effective for stratification of young-adult AMI patients into high- or low-risk subgroups.