Long-term survival after cardiac arrest in patients undergoing emergent coronary angiography

AIM

To determine long-term survival of patients after cardiac arrest undergoing emergent coronary angiography and therapeutic hypothermia.

METHODS

We analysed data from patients treated within the regional STEMI Network from January 2015 to December 2020. The primary endpoint was all-cause mortality at median follow-up. Secondary endpoints were periprocedural complications (arrhythmias, pulmonary edema, cardiogenic shock, mechanical complication, stent thrombosis, reinfarction, bleeding) and 6-month all-cause death. A landmark analysis was performed, studying two time periods; 0-6 months and beyond 6 months.

RESULTS

From a total of 24,125 patients in the regional STEMI network, 494 patients who suffered from cardiac arrest were included and divided into two groups: treated with (n = 119) and without therapeutic hypothermia (n = 375). At median follow-up (16.0 [0.2-33.3] months), there was no difference in the adjusted mortality rate between groups (51.3 % with hypothermia vs 48.0 % without hypothermia; HRadj1.08 95%CI [0.77-1.53]; p = 0.659). There was a higher frequency of bleeding in the hypothermia group (6.7 % vs 1.1 %; ORadj 7.99 95%CI [2.05-31.2]; p = 0.002), without difference for the rest of periprocedural complications. At 6-month follow-up, adjusted all-cause mortality rate was similar between groups (46.2 % with hypothermia vs 44.5 % without hypothermia; HRadj1.02 95%CI [0.71-1.47]; p = 0.900). Also, no differences were observed in the adjusted mortality rate between 6 months and median follow-up (9.4 % with hypothermia vs 6.3 % without hypothermia; HRadj2.02 95%CI [0.69-5.92]; p = 0.200).

CONCLUSIONS

In a large cohort of patients with cardiac arrest within a regional STEMI network, those treated with therapeutic hypothermia did not improve long-term survival compared to those without hypothermia.

Clinical profile and prognosis of young patients with ST-elevation myocardial infarction managed by the emergency-intervention Codi IAM network

INTRODUCTION AND OBJECTIVES

Data on the clinical profile and outcomes of younger patients with ST-elevation myocardial infarction (STEMI) is scarce. This study compared clinical characteristics and outcomes between patients aged<45 years and those aged ≥ 45 years with STEMI managed by the acute myocardial infarction code (AMI Code) network. Sex-based differences in the younger cohort were also analyzed.

METHODS

This multicenter study collected individual data from the Catalonian AMI Code network. Between 2015 and 2020, we enrolled patients with an admission diagnosis of STEMI. Primary endpoints were all-cause mortality within 30 days, 1 year, and 2 years.

RESULTS

Overall, 18 933 patients (23% female) were enrolled. Of them, 1403 participants (7.4%) were aged<45 years. Younger patients with STEMI were more frequently smokers (P<.001) and presented with cardiac arrest and TIMI flow 0 before pPCI (P<.05), but the time from first medical contact to wire crossing was shorter than in the older group (P<.05). All-cause mortality rates were lower in patients aged<45 years (P<.001). Among younger patients, cardiogenic shock was most prevalent in women than in their male counterparts (P=.002), with the time from symptom onset to reperfusion being longer (P<.05). Compared with men aged<45 years, younger women were less likely to undergo pPCI (P=.004).

CONCLUSIONS

Despite showing high-risk features on admission, young patients exhibit better outcomes than older patients. Differences in ischemia times and treatment were observed between men and women.

Performance analysis of a STEMI network: prognostic impact of the type of first medical contact facility

INTRODUCTION AND OBJECTIVES

Prognosis in ST-elevation myocardial infarction (STEMI) is determined by delay in primary percutaneous coronary intervention (PPCI). The impact of first medical contact (FMC) facility type on reperfusion delays and mortality remains controversial.

METHODS

We performed a prospective registry of primary coronary intervention (PCI)-treated STEMI patients (2010-2020) in the Codi Infart STEMI network. We analyzed 1-year all-cause mortality depending on the FMC facility type: emergency medical service (EMS), community hospital (CH), PCI hospital (PCI-H), or primary care center (PCC).

RESULTS

We included 18 332 patients (EMS 34.3%; CH 33.5%; PCI-H 12.3%; PCC 20.0%). Patients with Killip-Kimball classes III-IV were: EMS 8.43%, CH 5.54%, PCI-H 7.51%, PCC 3.76% (P <.001). All comorbidities and first medical assistance complications were more frequent in the EMS and PCI-H groups (P <.05) and were less frequent in the PCC group (P <.05 for most variables). The PCI-H group had the shortest FMC-to-PCI delay (median 82 minutes); the EMS group achieved the shortest total ischemic time (median 151 minutes); CH had the longest reperfusion delays (P <.001). In an adjusted logistic regression model, the PCI-H and CH groups were associated with higher 1-year mortality, OR, 1.22 (95%CI, 1.00-1.48; P=.048), and OR, 1.17 (95%CI 1.02-1.36; P=.030), respectively, while the PCC group was associated with lower 1-year mortality than the EMS group, OR, 0.71 (95%CI 0.58-0.86; P <.001).

CONCLUSIONS

FMC with PCI-H and CH was associated with higher adjusted 1-year mortality than FMC with EMS. The PCC group had a much lower intrinsic risk and was associated with better outcomes despite longer revascularization delays.

Revascularized ST-segment elevation myocardial infarction. Temporal trends in contemporary therapies and impact on outcomes

INTRODUCTION AND OBJECTIVES

To assess, in patients with ST-segment elevation myocardial infarction (STEMI) who underwent primary percutaneous intervention, the pace of introduction in clinical practice (2010-2017) of drug-eluting stents (DES), ticagrelor, prasugrel, and prolonged dual antiplatelet therapy (DAPT) duration, and their potential impact on the risk of 2-year outcomes.

METHODS

Prospective and exhaustive community-wide cohort of 14 841 STEMI patients undergoing primary percutaneous intervention between 2010 and 2017. Index episodes were obtained from the Catalan Codi IAM Registry, events during follow-up from the Minimum Data Set and DAPT were defined by pharmacy dispensation. Follow-up was 24 months. The temporal trend for exposures and outcomes was assessed using regression models.

RESULTS

Age> 65 years, diabetes, renal failure, previous heart failure, and need for anticoagulation at discharge were more frequent in later periods (P <.001). From 2010 to 2017, the use of DES increased from 31.1% to 69.8%, ticagrelor from 0.1% to 28.6%, prasugrel from 1.5% to 23.8%, and the median consecutive months on DAPT from 2 to 10 (P <.001 for all). Adjusted analysis showed a temporal trend to a lower risk of the main outcome over time: the composite of death, acute myocardial infarction, stroke and repeat revascularization (absolute odds reduction 0.005% each quarter; OR, 0.995; 95%CI, 0.99-0.999; P=.028). The odds of all individual components except stroke were reduced, although significance was only reached for revascularization.

CONCLUSIONS

Despite a strong increase between 2010 and 2017 in the use and duration of DAPT and the use of ticagrelor, prasugrel and DES, there was no substantial reduction in major cardiovascular outcomes.

Predictors of primary percutaneous coronary intervention delay in cases of myocardial infarction diagnosed in hospitals without hemodynamic support systems

OBJECTIVES

The need for primary percutaneous coronary intervention in hospitals without hemodynamic support capability is associated with delays between first medical contact (FMC) and reperfusion. It is important to identify factors involved in delays, particularly if they are relevant to the organization of emergency services.

MATERIAL AND METHODS

Analysis of a registry of patients treated in hospitals without advanced hemodynamic support systems in a catchment area with an established care network for acute ST-segment elevation myocardial infarction (STEMI). The registry included care times.

RESULTS

The network served 2542 patients with a mean (SD) age of 63 (13) years. FMC-to-reperfusion time was within 120 minutes in 42% of the cases. Nine of the hospitals had a chest-pain unit in the emergency department, and this factor was an independent predictor of FMC-to-reperfusion times of 120 minutes or less (odds ratio, 0.64; 95% CI, 0.54–0.77; P < .0001); the time was shortened by 11 minutes in such hospitals. FMC-to-reperfusion was delayed beyond 120 minutes in relation to the following factors: shock and need for intubation at start of care, age, gender, FMC at night, left bundle branch block, and Killip class. One-month and 1-year mortality rates increased in hospitals without hemodynamic support systems in proportion to reperfusion delay, by 1.7% and 3.5% if the delay was 106 minutes or less and by 7.3% and 12.4% if the delay was 176 minutes or longer (P < .0001).

CONCLUSION

FMC-to-reperfusion time in STEMI exceeds recommendations in 58% of the hospitals without hemodynamic support systems and delay is inversely proportional to the availability of an emergency department chest pain unit. One-month and 1-year mortality is proportional to the degree of delay.

Impact of pre-angioplasty antithrombotic therapy administration on coronary reperfusion in ST-segment elevation myocardial infarction: Does time matter?

BACKGROUND

Optimal timing of antithrombotic therapy for patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI) is unclear. We analyzed the impact of pre-angioplasty administration of unfractionated heparin (UFH) on infarct-related artery (IRA) patency and mortality.

METHOD

Multicenter prospective observational study of 3520 STEMI patients treated with PPCI from 2016 to 2018. Subjects were divided into four groups according to the elapsed time from heparin administration to PPCI: Group 1: Upon arrival at catheterization laboratory or ≤ 30 min (n = 800; 22.7%); Group 2: 31 to 60 min (n = 994; 28.2%); Group 3: 61 to 90 min (n = 1091; 31%); Group 4: >90 min (n = 635; 18%). IRA patency was defined as thrombolysis in myocardial infarction (TIMI) flow grade 2-3. Multivariate analyses assessed factors associated with IRA patency and both 30-day and 1-year mortality.

RESULTS

UFH administration at STEMI diagnosis was an independent predictor of IRA patency especially when administered more than 60 min before the PPCI (OR 1.43; 95% CI 1.14-1.81), either an independent predictor of 30-day (HR 0.63; 95% CI 0.42-0.94) and 1-year (HR 0.57; 95% CI 0.41-0.80) mortality. The effect of UFH on IRA patency was higher when administered earlier from the symptom onset.

CONCLUSION

UFH administration at STEMI diagnosis improves coronary reperfusion prior to PPCI and this benefit seems associated with superior clinical outcomes. The presented results highlight a time-dependent effectiveness of UFH, since its reported effect is greater the sooner UFH is administered after symptom onset.

Impact of COVID-19 on ST-segment elevation myocardial infarction care. The Spanish experience

Introduction and objectives

The COVID-19 outbreak has had an unclear impact on the treatment and outcomes of patients with ST-segment elevation myocardial infarction (STEMI). The aim of this study was to assess changes in STEMI management during the COVID-19 outbreak.

Methods

Using a multicenter, nationwide, retrospective, observational registry of consecutive patients who were managed in 75 specific STEMI care centers in Spain, we compared patient and procedural characteristics and in-hospital outcomes in 2 different cohorts with 30-day follow-up according to whether the patients had been treated before or after COVID-19.

Results

Suspected STEMI patients treated in STEMI networks decreased by 27.6% and patients with confirmed STEMI fell from 1305 to 1009 (22.7%). There were no differences in reperfusion strategy (> 94% treated with primary percutaneous coronary intervention in both cohorts). Patients treated with primary percutaneous coronary intervention during the COVID-19 outbreak had a longer ischemic time (233 [150-375] vs 200 [140-332] minutes, P < .001) but showed no differences in the time from first medical contact to reperfusion. In-hospital mortality was higher during COVID-19 (7.5% vs 5.1%; unadjusted OR, 1.50; 95%CI, 1.07-2.11; P < .001); this association remained after adjustment for confounders (risk-adjusted OR, 1.88; 95%CI, 1.12-3.14; P = .017). In the 2020 cohort, there was a 6.3% incidence of confirmed SARS-CoV-2 infection during hospitalization.

Conclusions

The number of STEMI patients treated during the current COVID-19 outbreak fell vs the previous year and there was an increase in the median time from symptom onset to reperfusion and a significant 2-fold increase in the rate of in-hospital mortality. No changes in reperfusion strategy were detected, with primary percutaneous coronary intervention performed for the vast majority of patients. The co-existence of STEMI and SARS-CoV-2 infection was relatively infrequent.

Differences in 30-day complications and 1-year mortality by sex in patients with a first STEMI managed by the Codi IAM network between 2010 and 2016

INTRODUCTION AND OBJECTIVES

ST-segment elevation myocardial infarction (STEMI) emergency care networks aim to increase reperfusion rates and reduce ischemic times. The influence of sex on prognosis is still being debated. Our objective was to analyze prognosis according to sex after a first STEMI.

METHODS

This multicenter cohort study enrolled first STEMI patients from 2010 to 2016 to determine the influence of sex after adjustment for revascularization delays, age, and comorbidities. End points were 30-day mortality, the 30-day composite of mortality, ventricular fibrillation, pulmonary edema, or cardiogenic shock, and 1-year all-cause mortality.

RESULTS

From 2010 to 2016, 14 690 patients were included; 24% were women. The median [interquartile range] time from electrocardiogram to artery opening decreased throughout the study period in both sexes (119 minutes [85-160] vs 109 minutes [80-153] in 2010, 102 minutes [81-133] vs 96 minutes [74-124] in 2016, both P=.001). The rates of primary PCI within 120 minutes increased in the same period (50.4% vs 57.9% and 67.1% vs 72.1%, respectively; both P=.001). After adjustment for confounders, female sex was not associated with 30-day complications (OR, 1.06; 95%CI, 0.91-1.22). However, female 30-day survivors had a lower adjusted 1-year mortality than their male counterparts (HR,0.76; 95%CI, 0.61-0.95).

CONCLUSIONS

Compared with men, women with a first STEMI had similar 30-day mortality and complication rates but significantly lower 1-year mortality after adjustment for age and severity.

Differential features in composition of coronary thrombus of women with ST-segment elevation myocardial infarction

OBJECTIVES

To characterize sex differences in the composition of coronary thrombus in patients with ST-segment elevation myocardial infarction (STEMI), especially in the young (age ≤ 55 years).

BACKGROUND

Women have smaller coronary vessels than men and their vascular lesions can be influenced by different exposure to circulating estrogens throughout life. These factors could determine a different composition of the coronary thrombus in women with STEMI.

METHODS

A prospective, multicenter study was conducted on patients with STEMI and coronary thrombus was aspirated immediately before percutaneous coronary intervention (PCI) using a suction catheter (ProntoV3® or Export®). Histopathology, immunohistochemistry and ELISA techniques were used for the quantitative determination of fibrin, p-selectin and von Willebrand factor (vWF) within thrombi.

RESULTS

Thrombi were collected from 100 patients (50 men and 50 women; 13 women and 13 men of <55 years). Women presented similar baseline characteristics and pain-to-balloon elapsed time than men. Thrombi from women showed a trend to a lower concentration of fibrin than those from men [median = 1.2 ng/mg (IQR 3.5) vs median = 2.2 ng/mg (IQR 5.9), p = 0.102]. No differences were found between sexes in p-selectin and vWF concentration in thrombi. However, thrombi from young women showed lower levels of p-selectin [median = 2.2 ng/mg (IQR 4.5) vs 6.5 ng/mg (IQR 4.8), p = 0.004], fibrin [median = 1.1 ng/mg; (IQR: 3.4) vs 4.1 ng/mg (IQR 15.6), p = 0.014] and vWF [median = 3.2 ng/mg (IQR 10.6) vs 25.8 ng/mg (IQR 15.0), p = 0.003] than those from young men.

CONCLUSIONS

Thrombi from young women with STEMI showed a lower content of fibrin, p-selectin and vWF than those from men.

Adequate antiplatelet regimen in patients on chronic anti-vitamin K treatment undergoing percutaneous coronary intervention

AIM

To investigate the impact of dual antiplatelet therapy (DAT) in patients on anti-vitamin K (AVK) regimen requiring percutaneous coronary intervention (PCI).

METHODS

Between February 2006 and February 2008, 138 consecutive patients under chronic AVK treatment were enrolled in this registry. Of them, 122 received bare metal stent implantation and 16 received drug eluting stent implantation. The duration of DAT, on top of AVK treatment, was decided at the discretion of the clinician. Adequate duration of DAT was defined according to type of stent implanted and to its clinical indication.

RESULTS

The baseline clinical characteristics of patients reflect their high risk, with high incidence of comorbid conditions (Charlson score ≥ 3 in 89% of the patients). At a mean follow-up of 17 ± 11 mo, 22.9% of patients developed a major adverse cardiac event (MACE): 12.6% died from cardiovascular disease and almost 6% had an acute myocardial infarction. Major hemorrhagic events were observed in 7.4%. Adequate DAT was obtained in only 44% of patients. In the multivariate analysis, no adequate DAT and Charlson score were the only independent predictors of MACE (both P = 0.02).

CONCLUSION

Patients on chronic AVK therapy represent a high risk population and suffer from a high MACE rate after PCI. An adequate DAT regimen and absence of comorbid conditions are strongly associated with better clinical outcomes.

[Rescue maneuver for entrapped stent in the coronary tree]

We describe two patients in whom stents dislodged from the unexpanded balloon during angioplasty and remained trapped in the coronary tree. In one patient the stent was located in the curvature of the circumflex artery and, in the other patient, it was detected in the distal left main artery. Retrieval of the undeployed stents was accomplished in the first case after advancing a low profile balloon through the stent and, in the second case, after placing a second guidewire exterior to the stent. In both cases, the balloon was inflated distally and the stents were dislodged after pulling the balloon back towards the guiding catheter and then withdrawing the whole system.

[Neointimal tissue proliferation after coronary stent implantation without predilatation]

INTRODUCTION AND OBJECTIVES

Intravascular ultrasound (IVUS) studies in conventional stent angioplasty with predilatation have demonstrated that late luminal narrowing is caused by neointimal proliferation. In the present study, we analyzed the degree and distribution of in-stent neointimal proliferation after direct stent implantation and aimed to identify variables that predict a proliferative response.

MATERIAL AND METHOD

We studied 45 patients who underwent successful stent implantation without predilatation and 23 patients with similar clinical and angiographic characteristics who underwent conventional stent angioplasty with predilatation. IVUS imaging was performed at 7.85+/-2.81 months. The cross-sectional area was measured at five predetermined points in the stented coronary segment. The inflation pressure used in patients who underwent direct stent implantation was higher than that employed in those who underwent conventional angioplasty with predilatation (13+/-3 atm vs 10+/-2 atm; P=.005).

RESULTS

Luminal and stent cross-sectional areas were greater in the group that did not undergo predilatation than in the group that did. Neointimal proliferation in the 5 sections analyzed along the axis of the stent was similar in the 2 groups. There was a weak linear relationship between the amount of plaque outside the stent and neointimal proliferation in both the group that underwent predilatation (r=0.37; P=.005) and the group that did not (r=0.33; P=.005).

CONCLUSIONS

As with conventional angioplasty, the neointimal proliferation that occurred after direct stent implantation showed a diffuse homogeneous pattern along the length of the stent. There was a weak correlation between this proliferative response and the amount of plaque outside the stent.

[Non-invasive coronary angiography with 16 multidetector-row spiral computed tomography: a comparative study with invasive coronary angiography]

INTRODUCTION AND OBJECTIVES

Non-invasive coronary artery angiography by 16 multidetector-row spiral computed tomography is a novel diagnostic tool whose reliability is still unclear. The aim of our study was to compare this technique with invasive coronary angiography.

PATIENTS AND METHOD

A total of 31 selected patients were examined with both angiographic methods. Non-invasive studies were performed with a helical computer tomography system (Toshiba Aquilion 16-slices). A contrast agent was injected into a peripheral vein, and cross-sectional images were reconstructed with a slice thickness of 0.5 mm or 1.0 mm. Findings from both techniques were analyzed according to a predetermined segmented anatomical model of the coronary artery. The detection and relevance of coronary artery lesions were evaluated, and lesions with a reduction in diameter of more than 50% were considered significant.

RESULTS

Non-invasive coronary angiography yielded an appropriate assessment in 88.4% of the coronary artery segments. The reasons that prevented correct segment evaluation were extensive coronary calcifications, inappropriate breath-hold, motion artefacts and small vessel size. Sensitivity and specificity for the detection of significant coronary lesions with the non-invasive method were 75% and 91%, respectively. Sensitivity and specificity for individual coronary artery segments were as follows: proximal, 89% and 93%; medial, 87% and 90%; distal, 50% and 90%; and secondary branches, 62% and 92%.

CONCLUSIONS

Non-invasive coronary artery angiography with 16 multidetector-row computed tomography is a powerful diagnostic tool, especially for the evaluation of the proximal and medial segments of the major coronary arteries.

[Evaluation of the patency of left internal mammary artery graft by transcutaneous Doppler flow velocity analysis]

OBJECTIVE

To analyze the features of Doppler flow velocity curve of left internal mammary artery by-pass grafts in relation with their permeability as assessed by selective angiography.

METHODS

Twenty-five consecutive patients with a left mammary artery graft were studied by angiography and transcutaneous Doppler technique. From the Doppler tracings, peak velocity and time-velocity integral of the systolic and diastolic components were determined. Patency of the graft and the characteristics of the distal native coronary artery were evaluated at angiography.

RESULTS

Doppler flow signal was obtained in 23 (92%) of 25 analyzed patients. The graft was angiographically patent in 17 (68%) of 25 patients; in 15 (88%) of them the Doppler flow velocity signal was mainly diastolic and in only 2 (12%) it was predominantly systolic. In 8 (32%) of the 25 patients the graft was angiographically occluded, 6 (75%) of these patients showing a predominantly systolic Doppler signal, while the remaining 2 (25%) patients were those in whom the signal could not be elicited. Sensitivity and specificity of a predominantly diastolic Doppler flow pattern for the presence of graft patency was 88% and 100% respectively, with a predictive positive value of 100% and a negative one of 80%.

CONCLUSIONS

Doppler flow velocity pattern of internal mammary artery by-pass grafts is related with patency of the graft, the presence of a predominantly diastolic curve being highly indicative of a patent graft.