Long-term prognosis after primary PCI in unselected patients with ST-elevation myocardial infarction

Prognostic implications for patients after myocardial infarction: an integrative literature review and in-depth interviews with patients and experts

Background

As patients with myocardial infarction (MI) survive for a long time after acute treatment, it is necessary to pay attention to the prevention of poor prognosis such as heart failure (HF). To identify the influencing factors of adverse clinical outcomes through a review of prospective cohort studies of post-MI patients, and to draw prognostic implications through in-depth interviews with post-MI patients who progressed to HF and clinical experts.

Methods

A mixed-method design was used that combined a scoping review of 21 prospective cohort studies, in-depth interviews with Korean post-MI patients with HF, and focus group interviews with cardiologists and nurses.

Results

A literature review showed that old age, diabetes, high Killip class, low left ventricular ejection fraction, recurrent MI, comorbidity of chronic disease and current smoking, and low socioeconomic status were identified as influencing factors of poor prognosis. Through interviews with post-MI patients, these influencing factors identified in the literature as well as a lack of disease awareness and lack of self-care were confirmed. Experts emphasized the importance of maintaining a healthy lifestyle after acute treatment with the recognition that it is a chronic disease that must go together for a lifetime.

Conclusion

This study confirmed the factors influencing poor prognosis after MI and the educational needs of post-MI patients with transition to HF. Healthcare providers should continue to monitor the risk group, which is expected to have a poor prognosis, along with education emphasizing the importance of self-care such as medication and lifestyle modification.

Ten-Year Mortality in Patients With ST-Elevation Myocardial Infarction

Knowledge of the long-term prognosis (>10 years) and mortality predictors of ST-elevation myocardial infarction (STEMI) patients who have undergone primary percutaneous coronary intervention (p-PCI) is scarce. Therefore, this study evaluated the long-term prognosis and determined the predictors of long-term outcomes for STEMI patients after p-PCI. Between January, 2006 and December, 2010, we collected data and analyzed 459 consecutive patients with acute STEMI who underwent p-PCI and were discharged from the hospital (mean age, 66.8 years; male, 75.2%; peak creatine phosphokinase level, 2,292.5 IU/L). The primary endpoint was 10-year all-cause mortality. The cumulative 10-year incidence of all-cause death was 23.8%. The Cox multivariate regression analysis identified age ≥ 65 years (adjusted hazard ratio [aHR], p <0.001), body mass index (aHR, 0.93, p = 0.033), presence of atrial fibrillation (aHR, 1.69, p = 0.038), mineralocorticoid receptor antagonist use (aHR, 1.95, p = 0.008), ejection fraction <40% (aHR, 2.14, p = 0.005), and albumin <3.5 g/dL (aHR, 2.01, p = 0.005) as independent predictors of all-cause mortality. In conclusion, a post-discharge 10-year survival rate of 76.2% was identified for STEMI patients who underwent p-PCI.

[Percutaneous Coronary Interventions in Patients With ST-Elevation Myocardial Infarction: 10-Years Follow-up]

Aim      To study long-term results and to identify predictors of death in patients with ST-segment elevation acute myocardial infarction (STEMI) who underwent endovascular revascularization.Materials and methods This study included 283 patients registered in the hospital registry of percutaneous coronary interventions (PCI) for STEMI from 2006 through 2009. Analysis of 10-year results included all-cause and cardiovascular death rate, incidence of recurrent myocardial infarction (MI), repeated revascularization, stroke, stent restenosis and thrombosis. Also, a composite endpoint МАССЕ (Major Adverse Cardiovascular and Cerebrovascular Events) was evaluated, which included death, recurrent MI, repeated PCI, stent restenosis and thrombosis, coronary bypass, and stroke.Results Information about the health condition was provided by 204 (72.1 %) patients. Mean follow-up period was 120.1±9.5 months. All-cause mortality was 25.5 % with cardiovascular death determined in 19.1 % of cases. Recurrent MI developed in 21.6 % of patients; in 1.5 % of cases, recurrent MI resulted from thrombosis of previously implanted stents. Repeated PCI was performed for 31.9 % of patients; in 13.7 % of cases, the PCI was performed for stent restenosis. Coronary bypass was performed for 5.4 % of patients. Incidence of stroke was 10.3 %. Major cardiovascular and cerebrovascular complications (МАССЕ) during the follow-up period were determined in 60.3 % patients. According to the Cox proportional hazards regression model, age ≥65 years (odds ratio (OR), 3.75 at 95 % confidence interval (CI) from 1.75 to 8.03; р=0.001) and incomplete coronary revascularization (OR, 3.09 at 95 % CI from 1.52 to 6.30; р=0.002) were independent predictors of death based on data of the 10-year observation.Conclusion      Therefore, at 10 years following endovascular revascularization, STEMI patients showed a moderate death rate with a high incidence of major cardiovascular and cerebrovascular complications. The leading causes for fatal outcomes were recurrent cardiovascular complications. The major predictors of death for the coming 10-year period included age ≥65 years and incomplete myocardial revascularization.

Toward a geriatric approach to patients with advanced age and cardiovascular diseases: position statement of the EuGMS Special Interest Group on Cardiovascular Medicine

Cardiovascular diseases (CVD) are highly prevalent in older adults and represent a major geriatric health-care concern. Management of CVD in older patients may be challenging due to specific geriatric issues, such as frailty and multi-morbidity, which may influence patients' outcomes. In this clinical context, diagnostic and therapeutic strategies should target those outcomes that have higher priority in geriatric health care, including disability prevention and quality of life. Older adults with CVD should be offered a reasonably optimized treatment, customized to the individual's frailty level and functional status. Yet, most clinical trials excluded comorbid and frail patients and evidence to support CVD management in this vulnerable population is lacking. Therefore, a geriatric approach is needed in cardiovascular medicine, characterized by a holistic, patient-centered perspective focusing on functional status and quality of life. With a view to promote the geriatric approach in the management of older patients with CVD, the EuGMS Special Interest Group (SIG) on Cardiovascular Medicine was founded in 2018, consisting of a network of geriatricians with an extensive expertise in geriatric cardiovascular medicine. The present position paper aims to present the Cardiovascular SIG and illustrate its main purposes and action programs.

Using the RISK-PCI Score in the Long-Term Prediction of Major Adverse Cardiovascular Events and Mortality after Primary Percutaneous Coronary Intervention

Background/Aim

The RISK-PCI is a simple score for the prediction of 30-day major adverse cardiovascular events (MACE) and mortality in patients treated with primary PCI (pPCI). The aim of the present study is to evaluate the prognostic performance of the RISK-PCI score in predicting MACE and mortality in the long-term follow-up of STEMI patients treated with pPCI.

Method

The present study enrolled 2,096 STEMI patients treated with pPCI included in the RISK-PCI trial. Patients presenting with cardiogenic shock were excluded. The composite end-point MACE comprising cardiovascular mortality, nonfatal reinfarction and stroke. Patients were followed up at 6 years after enrollment.

Results

One-year and 6-year MACE occurred in 229 (10.9%) and 285 (13.6%) patients, respectively; and 1-year and 6-year mortality occurred in 128 (6.2%) and 151 (7.2%) patients, respectively. The RISK-PCI score was an independent predictor for 1-year MACE (HR 1.24, 95% CI 1, 18–1.31, p < 0.001), 6-year MACE (HR 1.22, 95% CI 1.16–1.28, p < 0.001), 1-year mortality (HR 1.21, 95% CI 1.13–1.29, p < 0.001), and 6-year mortality (HR 1.23, 95% CI 1.15–1.31, p < 0.001). The discrimination of the RISK-PCI score to predict 1-year and 6-year MACE and mortality was good: for 1-year MACE c-statistic 0.78, for 6-year MACE c-statistic 0.75, for 1-year mortality c-statistic 0.87, and for 6-year mortality c-statistic 0.83. The nonsignificant Hosmer–Lemeshow goodness-of-fit estimates for 1-year MACE (p=0.619), 6-year MACE (p=0.319), 1-year mortality (p=0.258), and 6-year mortality (p=0.540) indicated a good calibration of the model.

Conclusion

The RISK-PCI score demonstrates good characteristics in the assessment of the risk for the occurrence of MACE and mortality during long-term follow-up after pPCI.

Poor long-term outcome in acute coronary syndrome in a real-life setting: Ten-year outcome of the TACOS study

BACKGROUND

Long-term outcome of the three categories of acute coronary syndrome (ACS) in real-life patient cohorts is not well known. The objective of this study was to survey the 10-year outcome of an ACS patient cohort admitted to a university hospital and to explore factors affecting the outcome.

METHODS

A total of 1188 consecutive patients (median age 73 years) with ST-elevation myocardial infarction (STEMI), non-ST-elevation myocardial infarction (NSTEMI) or unstable angina pectoris (UA) in 2002-2003 were included and followed up for ≥ 10 years.

RESULTS

Mortality for STEMI, NSTEMI and UA patients during the follow-up period was 52.5%, 69.9% and 41.0% (p < 0.001), respectively. In multivariable Cox regression analysis, only age and creatinine level at admission were independently associated with patient outcome in all the three ACS categories when analyzed separately.

CONCLUSIONS

All the three ACS categories proved to have high mortality rates during long-term followup in a real-life patient cohort. NSTEMI patients had worse outcome than STEMI and UA patients during the whole follow-up period. Our study results indicate clear differences in the prognostic significance of various demographic and therapeutic parameters within the three ACS categories.

Serum YKL-40 predicts long-term outcome in patients undergoing primary percutaneous coronary intervention for ST-segment elevation myocardial infarction

Serum YKL-40, a potential inflammatory marker, is greatly increased at the early stage of ST-segment elevation myocardial infarction (STEMI). Here, we hypothesized that YKL-40 levels at admission could predict the long-term outcomes after STEMI.A total of 324 patients with acute STEMI undergoing primary percutaneous coronary intervention (PCI) were consecutively enrolled and followed for 24 months. The baseline clinical and procedural data were recorded, and serum YKL-40 levels at admission were measured using ELISA method. The endpoint of interest was major adverse cardiac event (MACE), including all-cause death, recurrent myocardial infarction, and hospitalization for heart failure.Patients with elevated serum YKL-40 levels (≥126.8 ng/mL) were more likely to be older and smoker and to present with type 2 diabetes, advanced Killip class, multivessel disease and intra-aortic balloon pump, with increased levels of admission glucose, triglyceride, and high-sensitivity C-reactive protein and decreased level of high-density lipoprotein cholesterol. During the follow-up period, the incidence of MACE was notably higher in the high than in the low YKL-40 groups (28.4% vs 11.1%, P < .001). Kaplan-Meier curve showed that elevated YKL-40 levels were associated with reduced MACE-free survivals (log-rank P < .001). In multivariate Cox regression analysis, we found that high serum YKL-40 level was an independent predictor of MACE after controlling for clinical and angiographic variables (hazard ratio: 1.65, 95% confidence interval: 1.14-2.39, P = .008).The results of our study indicate that serum YKL-40 may be used as a biomarker to predict the long-term outcome after PCI in patients with STEMI.

Recurrent Cardiovascular Events in Survivors of Myocardial Infarction With ST-Segment Elevation (from the AMI-QUEBEC Study)

The characteristics and predictors of long-term recurrent ischemic cardiovascular events (RICEs) after myocardial infarction with ST-segment elevation (STEMI) have not yet been clarified. We aimed to characterize the 10-year incidence, types, and predictors of RICE. We obtained 10-year follow-up of STEMI survivors at 17 Quebec hospitals in Canada (the AMI-QUEBEC Study) in 2003. There were 858 patients; mean age was 60 years and 73% were male. The majority of patients receive reperfusion therapy; 53.3% and 39.2% of patients received primary percutaneous coronary intervention (PCI) and fibrinolytic therapy, respectively. Seventy-five percent of patients underwent in-hospital PCI (elective, rescue, and primary). At 10 years, 42% of patients suffered a RICE, with most RICEs (88%) caused by recurrent cardiac ischemia. The risk of RICE was the highest during the first year (23.5 per patient-year). At 10 years, the all-cause mortality was 19.3%, with 1/3 of deaths being RICE-related. Previous cardiovascular event, heart failure during the index STEMI hospitalization, discharge prescription of calcium blocker increased the risk of RICE by almost twofold. Each point increase in TIMI (Thrombolysis In Myocardial Infarction) score augmented the risk of RICE by 6%, whereas discharge prescription of dual antiplatelets reduced the risk of RICE by 23%. Our findings suggested that survivors of STEMI remain at high long-term risk of RICE despite high rate of reperfusion therapy and in-hospital PCI. Patients with previous cardiovascular event, in-hospital heart failure, and high TIMI score were particularly susceptible to RICE. Future studies are needed to confirm the impacts of calcium blocker and dual antiplatelets on long-term risk of RICE.

Thirty-day readmission rates after PCI in a metropolitan center in Europe: incidence and impact on prognosis

INTRODUCTION

Thirty-day readmission rates after percutaneous coronary intervention (PCI) have been related to adverse prognosis, and represent one of the most investigated indicators of quality of care. These data, however, derive from non-European centers evaluating all-cause readmissions, without stratification for diagnosis.

METHODS

All consecutive patients undergoing PCI at our center from January 2009 to December 2011 were enrolled. Thirty-day readmissions related to postinfarction angina, myocardial infarction, unstable angina or heart failure were defined as acute coronary syndrome (ACS) or heart failure rehospitalizations. Major cardiac adverse event (MACE) was the primary outcome, and its single components (death, myocardial infarction and repeated revascularization) the secondary ones.

RESULTS

A total of 1192 patients were included; among them, 53 (4.7%) were readmitted within 30 days, and 25 (2.1%) were classified as ACS/heart failure related. During hospitalization, patients with ACS/heart failure readmissions were more likely to suffer a periprocedural myocardial infarction (22 vs. 4%; P = 0.012), and to undergo PCI at 30 days (52 vs. 0.5%; P < 0.001). Logistic regression analysis indicated that periprocedural myocardial infarction represented the only independent predictor of an ACS/heart failure readmission [odds ratio (OR) 4.5; 1.1-16.8; P = 0.047]. After a median follow-up of 787 days (434-1027; first and third quartiles), patients with a 30-day ACS/heart failure readmission experienced higher rates of MACE, all-cause death and myocardial infarction (64 vs. 21%, P < 0.001; 28 vs. 6%, P = 0.017; and 20 vs. 2.7%, P < 0.001, respectively). Cox multivariate analysis indicated that ACS/heart failure 30-day readmissions were independently related to an increased risk of all-cause death (OR 3.3; 1.1-8.8; P = 0.02), differently from 30-day non-ACS/heart failure readmissions (OR 3.1; 0.7-12.9; P = 0.12).

CONCLUSION

Thirty-day readmissions after PCI in an Italian center are infrequent, and only those patients with ACS/heart failure show a detrimental impact on prognosis who have periprocedural myocardial infarction as the only independent predictor.

Serum apelin level predicts the major adverse cardiac events in patients with ST elevation myocardial infarction receiving percutaneous coronary intervention

The cardiovascular profile of the apelin makes it a promising therapeutic target for heart failure and ischemic heart disease. However, it remains unknown whether apelin affect the clinical outcome of patients with ST elevation myocardial infarction (STEMI) and received percutaneous coronary intervention (PCI). We enrolled a total of 120 patients with acute STEMI who underwent primary PCI. Serum apelin was detected. After PCI procedure, all patients were followed for 12 months. The follow-up end-point was occurrence of major adverse cardiovascular event (MACE). Lower serum apelin levels (<0.54 ng/mL) was significantly associated with higher serum low density lipoprotein-cholesterol level, higher peak creatine kinase MB fraction (CK-MB) and peak troponin-I (TNI) levels, the number of obstructed vessels, and need for inotropic support. The incidence of MACE was significantly higher in the low apelin group (23 patients out of 67) than in the high apelin group (10 patients out of 75, P < 0.001). Kaplan-Meier analysis revealed that the MACE-free rate was significantly lower in the patients with low apelin than those with high apelin (P < 0.001, log rank test). The multivariate Cox proportional hazard analysis adjusted with the clinical and angiographic characteristic reveals that the serum low apelin is a predictor for MACE incidence (hazard ratio = 2.36, 95% confidence interval: 1.83-3.87, P = 0.004). The finding of this study suggests that the serum apelin may be used as a marker to predict the MACE after PCI in patients with STEMI.