Survival benefit from recent changes in management of men and women with ST-segment elevation myocardial infarction treated with percutaneous coronary interventions

Temporal trends of in-hospital mortality and its determinants following percutaneous coronary intervention in patients with acute coronary syndrome in England and Wales: A population-based study between 2006 and 2021

BACKGROUND

There is limited data around drivers of changes in mortality over time. We aimed to examine the temporal changes in mortality and understand its determinants over time.

METHODS

743,149 PCI procedures for patients from the British Cardiovascular Intervention Society (BCIS) database who were aged between 18 and 100 years and underwent Percutaneous Coronary Intervention (PCI) for Acute Coronary Syndrome (ACS) in England and Wales between 2006 and 2021 were included. We decomposed the contributing factors to the difference in the observed mortality proportions between 2006 and 2021 using Fairlie decomposition method. Multiple imputation was used to address missing data.

RESULTS

Overall, there was an increase in the mortality proportion over time, from 1.7% (95% CI: 1.5% to 1.9%) in 2006 to 3.1% (95% CI: 3.0% to 3.2%) in 2021. 61.2% of this difference was explained by the variables included in the model. ACS subtypes (percentage contribution: 14.67%; 95% CI: 5.76% to 23.59%) and medical history (percentage contribution: 13.50%; 95% CI: 4.33% to 22.67%) were the strongest contributors to the difference in the observed mortality proportions between 2006 and 2021. Also, there were different drivers to mortality changes between different time periods. Specifically, ACS subtypes and severity of presentation were amongst the strongest contributors between 2006 and 2012 while access site and demographics were the strongest contributors between 2012 and 2021.

CONCLUSIONS

Patient factors and the move towards ST-elevated myocardial infarction (STEMI) PCI have driven the short-term mortality changes following PCI for ACS the most.

Mortality Trends After Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction

BACKGROUND

Observational studies have reported that mortality rates after ST-segment elevation myocardial infarction (STEMI) have been stable since 2006 to 2010.

OBJECTIVES

The aim of this study was to evaluate the temporal trends in 1-year, 30-day, and 31- to 365-day mortality after STEMI in Western Denmark where primary percutaneous coronary intervention (PCI) has been the national reperfusion strategy since 2003.

METHODS

Using the Western Denmark Heart Registry, the study identified first-time PCI-treated patients undergoing primary PCI (pPCI) for STEMI from 2003 to 2018. Based on the year of pPCI, patients were divided into 4 time-interval groups and followed up for 1 year using the Danish national health registries.

RESULTS

A total of 19,613 patients were included. Median age was 64 years, and 74% were male. One-year mortality decreased gradually from 10.8% in 2003-2006, 10.4% in 2007-2010, 9.1% in 2011-2014, to 7.7% in 2015-2018 (2015-2018 vs 2003-2006: adjusted HR [aHR]: 0.71; 95% CI: 0.62-0.82). The largest absolute mortality decline occurred in the 0- to 30-day period with a 2.3% reduction (aHR: 0.69; 95% CI: 0.59-0.82), and to a lesser extent in the 31- to 365-day period (risk reduction: 1.0%; aHR: 0.71; 95% CI: 0.56-0.90).

CONCLUSIONS

In a high-income European country with a fully implemented pPCI strategy, 1-year mortality in pPCI-treated patients with STEMI decreased substantially between 2003 and 2018. Approximately three-quarters of the absolute mortality reduction occurred within the first 30 days after pPCI. These results indicate that optimization of early management of pPCI-treated patients with STEMI offers great opportunities for improving overall survival in contemporary clinical practice.

Culprit vessel revascularization first with primary use of a dedicated transradial guiding catheter to reduce door to balloon time in primary percutaneous coronary intervention

Background

The effect of a single transradial guiding catheter (STGC) for culprit vessel percutaneous coronary intervention (PCI) first on door-to-balloon (D2B) time remains unclear.

Materials and methods

Between February 2017 and July 2019, 560 patients with ST-elevation myocardial infarction (STEMI) were randomized into either the STGC group (n = 280) or the control group (n = 280) according to direct culprit vessel PCI with a STGC. In the STGC group, a dedicated transraidal guiding catheter (6F either MAC3.5 or JL3.5) was used for the treatment of electrocardiogram (ECG)-guided culprit vessel first and later contralateral angiography. In the control group, a universal diagnostic catheter (5F Tiger II) was used for complete coronary angiography, followed by guiding catheter selection for culprit vessel PCI. The primary endpoint was D2B time, and the secondary endpoint included catheterization laboratory door-to-balloon (C2B), procedural, fluoroscopy times, and major adverse cardiac events (MACE) at 30 days.

Results

The median D2B time was significantly shorter in the STGC group compared to the control group (53.9 vs. 58.4 min; p = 0.003). The C2B, procedural, and fluoroscopy times were also shorter in the STGC group (C2B: 17.3 vs. 24.5 min, p < 0.001; procedural: 45.2 vs. 49.0 min, p = 0.012; and fluoroscopy: 9.7 vs. 11.3 min, p = 0.025). More patients achieved the goal of D2B time within 90 min (93.9% vs. 87.1%, p = 0.006) and 60 min (61.4% vs. 51.1%, p = 0.013) in the STGC group. Radial artery perforation (RAP) was significantly reduced in the STGC group compared with the control group (0.7% vs. 3.2%, P = 0.033). MACE at 30 days was similar (2.5% vs. 4.6%, P = 0.172) between the two groups.

Conclusion

ECG-guided immediate intervention on culprit vessel with a STGC can reduce D2B, C2B, procedural, and fluoroscopy times (ECG-guided Immediate Primary PCI for Culprit Vessel to Reduce Door to Device Time; NCT03272451).

Different associations between left atrial size and 2.5-year clinical outcomes in patients with anterior versus non-anterior wall ST-elevation myocardial infarction

Objective

To investigate associations between left atrial diameter (LAD) and long-term outcomes in patients with anterior or non-anterior wall ST-elevation myocardial infarction (STEMI).

Methods

Patients with STEMI were included in this secondary analysis of data from a prospective cohort study in which the primary outcome was major adverse cardiovascular event (MACE) occurrence during a 2.5-year follow-up. A LAD cut-off value was obtained through receiver operating characteristic curve analysis. Kaplan-Meier curve and Cox regression analyses were applied. Subgroup Cox regression analysis was also performed, with patients stratified based on left ventricular diastolic diameter (LVEDD, > 55 mm and ≤55 mm). The relationship between LAD and outcomes in patients with anterior or non-anterior wall STEMI was explored using restricted cubic spline functions.

Results

Out of 464 patients, adjusted Cox regression showed that dichotomous (>40 mm) LAD was significantly associated with MACE (hazard ratio 2.978, 95% confidence interval 1.763, 5.030) in patients with anterior wall but not non-anterior wall STEMI. The association was not different between normal and enlarged LVEDD groups.

Conclusions

A left atrium > 40 mm may indicate higher risk of MACE in patients with anterior wall STEMI, even in patients with normal left ventricular structure. This relationship was not observed in patients with non-anterior wall STEMI.