Prognostic implications of atrio-ventricular block in patients undergoing primary coronary angioplasty in the stent era

Prognostic Implications of High-Degree Atrio-Ventricular Block in Patients with Acute Myocardial Infarction in the Contemporary Era

BACKGROUND

High-degree atrioventricular block (HAVB) is a known complication of ST-segment elevation myocardial infarction (STEMI). We aimed to determine the prevalence and prognostic impact of HAVB in a contemporary cohort of STEMI.

METHODS

Data were collected from the DIAMANTE registry that included STEMI patients admitted to our cardiac intensive care unit treated with urgent reperfusion. We studied the clinical characteristics and evolution in patients with and without HAVB at admission.

RESULTS

From 1109 consecutive patients, HAVB was documented in 95 (8.6%). The right coronary artery was the culprit vessel in 84 patients with HAVB (88.4%). The independent predictors of HAVB were: male sex (OR 1.9, 95% CI 1.2-2.9), age (OR 1.03, 95% CI 1.01-1.05), involvement of right coronary artery (OR 12.4, 95% CI 7.6-20.2), and creatinine value (OR 1.5, 95% CI 1.1-2.0). A transient percutaneous pacemaker was used in 37 patients with HAVB (38.9%). Patients with HAVB had higher mortality that patients without HAVB (15.8% vs. 4.1%, p < 0.001); however, in multivariate analysis, HAVB was not an independent predictor of in-hospital mortality.

CONCLUSIONS

HAVB was seen in 9% of STEMI patients and was particularly frequent in elderly males with renal failure. Patients with HAVB had a poor prognosis during hospitalization, but HAVB was not an independent predictor of in-hospital mortality.

Factors associated with temporary pacing insertion in patients with inferior ST-segment elevation myocardial infarction

Background

High-degree atrioventricular block (HAVB) is a prognostic factor for survival in patients with inferior ST-segment elevation myocardial infarction (STEMI). However, there is little information about factors associated with temporary pacing (TP). The aim of this study was to find factors associated with TP in patients with inferior STEMI.

Methods

We included 232 inferior STEMI patients, and divided those into the TP group (n = 46) and the non-TP group (n = 186). Factors associated with TP were retrospectively investigated using multivariate logistic regression model.

Results

The incidence of right ventricular (RV) infarction was significantly higher in the TP group (19.6%) than in the non-TP group (7.5%) (p = 0.024), but the incidence of in-hospital death was similar between the 2 groups (4.3% vs. 4.8%, p = 1.000). Long-term major adverse cardiovascular events (MACE), which were defined as a composite of all-cause death, non-fatal myocardial infarction (MI), target vessel revascularization (TVR) and readmission for heart failure, were not different between the 2 groups (p = 0.100). In the multivariate logistic regression analysis, statin at admission [odds ratio (OR) 0.230, 95% confidence interval (CI) 0.062–0.860, p = 0.029], HAVB at admission (OR 9.950, 95% CI 4.099–24.152, p<0.001), and TIMI-thrombus grade ≥3 (OR 10.762, 95% CI 1.385–83.635, p = 0.023) were significantly associated with TP.

Conclusion

Statin at admission, HAVB at admission, and TIMI-thrombus grade ≥3 were associated with TP in patients with inferior STEMI. Although the patients with TP had the higher incidence of RV infarction, the incidence of in-hospital death and long-term MACE was not different between patients with TP and those without.

First-degree atrioventricular block in acute anterior myocardial infarction

BACKGROUND

There is paucity of data regarding the prognostic implications of first-degree atrioventricular block in patients with acute anterior myocardial infarction as a distinct group. The aim of this study was to elucidate the association of prolonged PR interval with hospital clinical outcomes in patients with treated with thrombolysis.

METHODS

Three hundred consecutive patients with a first acute anterior ST-segment elevation myocardial infarction undergoing thrombolysis between October 2017 and March 2018, were retrospectively enrolled in this study. They were divided into two groups based on PR interval on admission: PR interval ≤200 ms, and PR interval > 200 ms. Hospital mortality and complications were compared between the 2 groups.

RESULTS

Of the 300 patients, 26 (8.66%) had first-degree atrioventricular block on initial presentation. Overall, hospital death occurred in 20 (6.66%) patients. Patients with PR interval > 200 ms had a higher hospital mortality rate (26.9%) than those without (4.7%, p < 0.001). In multivariate Cox regression analysis, only left ventricular systolic function and PR interval were independent predictors of hospital mortality (odds ratio = 1.031; 95% confidence interval: 1.008-1.056, p = 0.009 for PR interval).

CONCLUSION

In patients with a first acute anterior ST-segment elevation myocardial infarction treated with thrombolysis, first-degree atrioventricular block was associated with increased hospital mortality and a worse prognosis.

Prognostic of Interatrial Block after an Acute ST-Segment Elevation Myocardial Infarction

BACKGROUND

The influence of interatrial block (IAB) in the prognosis after an acute ST-segment elevation myocardial infarction (STEMI) is unknown.

OBJECTIVES

To assess the prognostic impact of IAB after an acute STEMI regarding long-term mortality, development of atrial fibrillation, and stroke.

METHODS

Registry of 972 consecutive patients with STEMI and sinus rhythm at discharge, with a long-term follow-up (49.6 ± 24.9 months). P wave duration was analyzed using digital calipers, and patients were divided into three groups: normal P wave duration (<120 ms), partial IAB (pIAB) (P wave ≥120 ms and positive in inferior leads), and advanced IAB (aIAB) (P wave ≥120 ms plus biphasic [positive/negative] morphology in inferior leads).

RESULTS

Mean age was 62.6 ± 13.5 years. A total of 708 patients had normal P wave (72.8%), 207 pIAB (21.3%), and 57 aIAB (5.9%). Patients with aIAB were older (mean age 73 years) than the rest (62 years in the other two groups, p < 0.001). They also had a higher rate of hypertension (70 vs. 55% in pIAB and 49% in normal P wave, p = 0.006) and higher all-cause mortality (26.3 vs. 12.6% in pIAB and 10.3% in normal P wave, p = 0.001). However, multivariable analysis did not show an independent association between IAB and prognosis.

CONCLUSION

About a quarter of patients discharged in sinus rhythm after an acute STEMI have IAB. Patients with aIAB have a poor prognosis, although this is explained mainly by the association of aIAB with age and other variables.

Incidence, Predictors, and Outcomes of High-Grade Atrioventricular Block in Patients With ST-Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention (from the HORIZONS-AMI Trial)

High-grade atrioventricular block (HAVB) is historically considered a marker of worse outcomes in patients with ST-segment elevation myocardial infarction (STEMI). However, the predictors and prognostic impact of HAVB in the primary percutaneous coronary intervention (PCI) era remain poorly understood. We sought to describe the characteristics and predictors of HAVB in patients undergoing primary PCI in STEMI and to assess the prognostic significance of HAVB in the contemporary reperfusion era. The present analysis includes 3,115 patients presenting with STEMI from the Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction trial who underwent primary PCI. Outcomes were examined according to the presence of HAVB on a presenting electrocardiogram, as interpreted by an independent electrocardiography core laboratory. HAVB (second-degree Mobitz II or third-degree atrioventricular block) was present at baseline in 46 patients (1.5%). Independent predictors of HAVB included increased age, diabetes mellitus, right coronary artery occlusion, sum of ST-segment deviation, and baseline Thrombolysis In Myocardial Infarction flow 0/1. Thrombolysis In Myocardial Infarction flow 3 was restored in 83.7% and 91.5% of patients with versus without baseline HAVB respectively (p = 0.06). Mortality rate was significantly higher in patients with versus without HAVB at 30-day, 1-, and 3-year follow-ups (unadjusted hazard ratio [HR] 3.83, 95% CI 1.40 to 10.48; unadjusted HR 4.37, 95% CI 2.09 to 9.38 and unadjusted HR 2.78, 95% CI 1.31 to 5.91, respectively). After covariate adjustment, mortality rate was significantly higher in patients with HAVB at 1 year (adjusted HR 2.45, 95% CI 1.09 to 5.50, p = 0.03) but not at 30 days (adjusted HR 1.70, 95% CI 0.58 to 5.01, p = 0.33) or 3 years (adjusted HR 0.71 to 3.41, p = 0.27). In conclusion, HAVB is a rare complication of STEMI but remains associated with increased mortality, even after primary PCI.

Periprocedural temporary pacing in primary percutaneous coronary intervention for patients with acute inferior myocardial infarction

OBJECTIVE

High-degree atrioventricular block (AVB), including complete AVB in acute inferior ST-elevation myocardial infarction (STEMI), is not uncommon. However, there is no study evaluating the clinical differences between patients who have undergone temporary pacing (TP) and patients who have not. The present study was designed to investigate whether TP has any prognostic significance in inferior STEMI complicated by complete AVB.

METHODS

From January 2009 to December 2014, 295 consecutive patients diagnosed with inferior wall STEMI in a university hospital were reviewed. All of them underwent primary percutaneous coronary intervention (PCI). Among the 295 patients, there were 72 patients with complete AVB. The clinical characteristics, procedural data, and long-term major adverse cardiocerebrovascular events were compared in patients with and without TP.

RESULTS

Baseline clinical and procedural characteristics were similar between patients with and without TP. Patients with TP were more likely to present with cardiogenic shock; thus, additional interventions were attempted via a femoral approach, as patients received further treatment with intra-aortic balloon pumps and were subjected to additional cardiopulmonary resuscitation. Most cases of complete AVB were primarily caused by right coronary artery occlusion. After a median follow-up period of 344 (range, 105.5-641) days, major adverse cardiocerebrovascular events did not differ between the groups (P=0.528).

CONCLUSION

We conclude that primary PCI without TP is acceptable in complete AVB-complicated acute inferior STEMI. To avoid delay in reperfusion, we suggest that primary PCI should be the first priority therapy rather than treating patients initially with TP.