Long-term prognosis of patients with acute myocardial infarction due to unprotected left main coronary artery disease: a single-centre experience over 14 years

Twelve-year trends in unprotected left main coronary artery occlusion: insights from a real-world multicentre study

AIMS

Acute myocardial infarction (AMI) resulting from unprotected left main coronary artery (LMCA) occlusion and subtotal occlusion is a life-threatening condition. Although AMI management has improved in the past two decades, there is limited information on recent trends in patient characteristics, management, and outcomes for acute unprotected LMCA-related AMI. This study aims to assess such trends over a 12 year period.

METHODS AND RESULTS

This retrospective multicentre study includes patients with unprotected LMCA occlusion/subtotal occlusion admitted to three tertiary hospitals between 2008 and 2020. The patients were divided into two groups based on the chronology of presentation: a 'past group' (January 2008 to December 2014) and a 'contemporary group' (January 2015 to December 2020). The study compares clinical characteristics, management approaches, and outcomes between the two groups. The study includes 128 patients, with 51 (40%) in the 'past group' and 77 (60%) in the 'contemporary group'. Baseline risk factors did not show statistically significant differences between the two groups, except for hypertension (49% vs. 74%; P = 0.005). Chest pain was more frequent in the 'past group' (98% vs. 89%; P = 0.014), and a trend towards more cardiac arrests was observed in the 'contemporary group' (18% vs. 31%; P = 0.087). Revascularization type did not differ significantly (P = 0.419), but manual thrombectomy was less frequently used (41% vs. 23%; P = 0.032) and stent implantation showed a trend towards higher rates (66% vs. 78%; P = 0.150) in the 'contemporary cohort'. There was a gradual shift from bare-metal to drug-eluting stents, with a significantly higher percentage of ticagrelor/prasugrel loading in the 'contemporary cohort' (5% vs. 79%; P < 0.001). The use of mechanical circulatory support (MCS), although not statistically significant, was higher among patients in the 'past group' (67% vs. 51%; P = 0.073). The type of MCS differed significantly between groups, with a decrease in intra-aortic balloon pump use (67% vs. 42%; P = 0.005) and an increase in veno-arterial extracorporeal membrane oxygenation (4% vs. 22%; P = 0.005) and Impella system (0% vs. 3%) over time. Survival analysis showed no significant differences (P = 0.599; log-rank test) in all-cause mortality between the different time groups, with the long-term survival rate being approximately 30%.

CONCLUSIONS

In our real-world population, despite the progressive use of newer drugs and more advanced devices over time, patients with unprotected LMCA occlusion/subtotal occlusion remain a subpopulation with poor prognosis.

Clinical Outcomes after Percutaneous Coronary Intervention for Cardiogenic Shock Secondary to Total Occlusive Unprotected Left Main Coronary Artery Lesion-Related Acute Myocardial Infarction

BACKGROUND

Acute myocardial infarction (AMI) with occlusion of an unprotected left main coronary artery (ULMCA) is a rare condition with a high mortality. The literature on clinical outcomes after percutaneous coronary intervention (PCI) for cardiogenic shock secondary to ULMCA-related AMI is scarce.

METHODS

In this retrospective analysis, all consecutive patients undergoing PCI for cardiogenic shock secondary to total occlusive ULMCA-related AMI were included between January 1998 and January 2017. The primary endpoint was 30-day mortality. The secondary endpoints were long-term mortality and 30-day and long-term major adverse cardiovascular and cerebrovascular events. The differences in clinical and procedural variables were assessed. A multivariable model was created to search for independent predictors of survival.

RESULTS

Forty-nine patients were included, and the mean age was 62 ± 11 years. The majority of patients suffered cardiac arrest prior or during PCI (51%). Thirty-day mortality was 78%, of which 55% died within 24 h. The median follow-up of patients who survived 30 days (n = 11) was 9.9 years (interquartile range 4.7-13.6), and long-term mortality was 84%. Long-term all-cause mortality was independently associated with cardiac arrest prior or during PCI (hazard ratio [HR] 2.02, 95% confidence interval 1.02-4.01, p = 0.043). Patients who survived to the 30-day follow-up with severe left ventricular dysfunction had a significantly higher risk of mortality compared to patients with moderate to mild dysfunction (p = 0.007).

CONCLUSIONS

Cardiogenic shock secondary to total occlusive ULMCA-related AMI carries a very high 30-day all-cause mortality. Thirty-day survivors with a severe left ventricular dysfunction have a poor long-term prognosis.

Association of collateral flow with clinical outcomes in patients with acute myocardial infarction

Coronary collateral flow is an important prognostic marker in percutaneous coronary intervention (PCI) for chronic total occlusion. However, the role of collateral flow to the culprit lesion of acute myocardial infarction (AMI) has not been fully established yet. The purpose of this retrospective study was to examine the association between collateral flow and long-term clinical outcomes in patients with AMI. We included 937 patients with AMI, and divided those into the no-collateral group (n = 704) and the collateral group (n = 233) according to the presence or absence of collateral flow to the culprit lesion of AMI. The primary endpoint was the incidence of major adverse cardiac events (MACE), which was defined as a composite of all-cause death, non-fatal MI, re-admission for heart failure, and ischemia driven target vessel revascularization. The median follow-up duration was 473 days (Q1: 184 days- Q3: 1027 days), and a total of 263 MACE was observed during the study period. The incidence of MACE was significantly greater in the no-collateral group than in the collateral group (29.8% vs. 22.3%, p = 0.027). In the multivariate COX hazard model, the presence of collateral flow was inversely associated with MACE (HR 0.636, 95% CI 0.461-0.878, p = 0.006) after controlling multiple confounding factors. In conclusion, the presence of collateral flow to the culprit lesion of AMI was inversely associated with long-term adverse outcomes. Careful observation of collateral flow may be important in emergent coronary angiography to stratify a high-risk group among various patients with AMI.

Survival rate after acute myocardial infarction in patients treated with percutaneous coronary intervention within the left main coronary artery according to time of admission

The relationship regarding time of percutaneous coronary intervention (PCI) and clinical outcomes in patients with acute myocardial infarction (AMI) treated within the left main coronary artery (LMCA) is less investigated compared to the overall group of patients with AMI.Therefore, we aimed to assess the relationship between time of PCI (day- vs night-time) and overall mortality rate in patients treated due to AMI within the LMCA.This cross-sectional study included 443,805 AMI patients hospitalized between 2006 and 2018 enrolled in the Polish Registry of Acute Coronary Syndromes. We extracted 5,404 patients treated within the LMCA. The number of patients were treated during daytime hours (7:00 am-10:59 pm) was 2809 while 473 patients underwent treatment during night-time hours (11:00 pm-6:59 am). Differences in cardiac mortality rates between night- and day-hours among patients treated with PCI during the follow-up period were assessed via the Kaplan-Meier method.The 30-day (20.3% vs 14.9%, P = .003) and 12-month (31.7% vs 26.2%, P = .001) overall mortality rates were significantly greater among patients treated during night-time, which was confirmed by comparison using Kaplan-Maier survival curves (P = .001). The time of PCI was not found among predictors of survival in multiple regression analysis (hazard ratio: 1.22; 95% confidence interval: 0.96-1.55, P = .099).Patients treated during night-time in comparison to the day-time are related to higher in-hospital, 30-day and 12-month mortality. This is probably largely a consequence that the night-time, in comparison to the day-time, of treatment of patients with AMI with PCI within the LMCA is and indicator of higher comorbidity and clinical acuity of patients undergoing therapy. Therefore, the night-time was not found to be an independent predictor of greater mortality rate during the 12-months follow-up period.

The functional effect of atorvastatin dose-dependent via inflammation factors on acute ST segment elevation myocardial infarction after emergency percutaneous coronary intervention

OBJECTIVE

To investigate the effect of different doses of atorvastatin on patients with acute ST segment elevation myocardial infarction (MI) after emergency percutaneous coronary intervention (PCI).

METHODS

A total of 265 patients with acute ST segment elevation MI who underwent emergency PCI were enrolled, 133 in high-dose atorvastatin administration (40 mg/day) and 132 in moderate-dose atorvastatin administration (20 mg/day). All the patients continued treatment for 1 year. The incidences of major adverse cardiovascular events (MACE) were recorded, including cardiovascular death, spontaneous MI, and unplanned revascularization. The association between clinical incidences and different doses of atorvastatin treatment was studied.

RESULTS

Through tracking 1 year's treatment, the level of low-density lipoprotein cholesterol was lower in high-dose atorvastatin administration than in moderate treatment (1.6 ± 0.6 vs. 1.8 ± 0.6, P = 0.041). MACE significantly decreased in high-dose atorvastatin administration than in moderate treatment (9.8 vs. 18.2%, P = 0.03). Spontaneous MI was significantly more attenuated in high-dose treatment than in moderate treatment (6.8 vs. 12.8%, P = 0.03). Unplanned revascularization robustly decreased in patients with high-dose administration than those with moderate-dose treatment (5.2 vs. 8.3%, P = 0.03). There was no difference in the rate of adverse events between the two groups.

CONCLUSION

For patients with acute ST segment elevation MI who underwent emergency PCI, high-dose atorvastatin could provide better performance than moderate-dose in our long-term tracking.

New Predictors of Early and Late Outcomes after Primary Percutaneous Coronary Intervention in Patients with ST-Segment Elevation Myocardial Infarction and Unprotected Left Main Coronary Artery Culprit Lesion

Objectives

The study evaluated the correlation between baseline SYNTAX Score, Residual SYNTAX Score, and SYNTAX Revascularization Index and long-term outcomes in ST-elevation myocardial infarction (STEMI) patients with primary percutaneous coronary intervention (PCI) on an unprotected left main coronary artery lesion (UPLMCA).

Background

Previous studies on primary PCI in UPLMCA have identified cardiogenic shock, TIMI 0/1 flow, and cardiac arrest, as prognostic factors of an unfavourable outcome, but the complexity of coronary artery disease and the extent of revascularization have not been thoroughly investigated in these high-risk patients.

Methods

30-day, 1-year, and long-term outcomes were analyzed in a cohort of retrospectively selected, 81 consecutive patients with STEMI, and primary PCI on UPLMCA.

Results

Cardiogenic shock (p=0.001), age (p=0.008), baseline SYNTAX Score II (p=0.006), and SYNTAX Revascularization Index (p=0.046) were independent mortality predictors at one-year follow-up. Besides cardiogenic shock (HR 3.28, p<0.001), TIMI 0/1 flow (HR 2.17, p=0.021) and age (HR 1.03, p=0.006), baseline SYNTAX Score II (HR 1.06, p=0.006), residual SYNTAX Score (HR 1.03, p=0.041), and SYNTAX Revascularization Index (HR 0.9, p=0.011) were independent predictors of mortality at three years of follow-up. In patients with TIMI 0/1 flow, the presence of Rentrop collaterals was an independent predictor for long-term survival (HR 0.24; p=0.049).

Conclusions

In this study, the complexity of coronary artery disease and the extent of revascularization represent independent mortality predictors at long-term follow-up.