Gentian Memisha

Abciximab-Supported Infarct Artery Stent Implantation for Acute Myocardial Infarction and Long-Term Survival A Prospective, Multicenter, Randomized Trial Comparing Infarct Artery Stenting Plus Abciximab With Stenting Alone

Background—The impact on survival of routine use of abciximab as adjunctive treatment to routine infarct artery stenting for acute myocardial infarction is not defined. We sought to determine the effect of abciximab on 1-year survival and other major adverse cardiac events of patients with acute myocardial infarction undergoing routine infarct artery stenting. Methods and Results—The Abciximab and Carbostent Evaluation (ACE) Trial is an unblinded, randomized, controlled trial that compared abciximab with placebo in patients undergoing routine infarct artery stent implantation for acute myocardial infarction. At 1 year, the survival rate was 95±2% in the abciximab group and 88±2% in the stent-alone group (P =0.017). The reinfarction rate was 1% in the abciximab group and 6.0% in the stent-alone group, whereas there were no differences between groups in target vessel revascularization rate (16.5% in the abciximab group, 17.5% in the stent-alone group). Conclusions—Abciximab as adjunctive treatment to routine infarct artery stenting for acute myocardial infarction resulted in improved 1-year survival and lower reinfarction rates.

Five year outcome after primary coronary intervention for acute ST elevation myocardial infarction : results from a single centre experience

Objectives: To analyse the five year outcome of unselected patients with acute myocardial infarction (AMI) treated by primary percutaneous coronary intervention (PCI). Setting: High volume PCI tertiary centre. Design and results: The study was based on a sample of 1009 consecutive patients with ST elevation AMI treated by primary PCI. The mean (SD) clinical follow up was 51 (21) months and the follow up rate was 97.8%. The overall mortality was 20% and cardiac mortality was 16%. Non-fatal reinfarction rate was 5% and additional revascularisation procedure rate was 19%. Hospitalisation for heart failure was needed by 42 patients (4%). The variables related to mortality in multivariate Cox analysis were age (hazard ratio (HR) 1.054, 95% confidence interval (CI) 1.039 to 1.069, p < 0.0001), cardiogenic shock (HR 2.985, 95% CI 2.157 to 4.129, p < 0.0001), previous myocardial infarction (HR 1.696, 95% CI 1.199 to 2.398, p  =  0.0003), and the presence of multivessel coronary artery disease (HR 1.820, 95% CI 1.317 to 2.514, p  =  0.0003). Each additional high risk feature was associated with a relative risk for five year death of 2.328 (95% CI 2.048 to 2.646, p < 0.0001). Conclusions: The satisfactory results of routine mechanical revascularisation strategy in AMI were maintained during several years of follow up. Patients at risk of death during long term follow up may be identified by simple clinical and angiographic characteristics, such as old age, cardiogenic shock, previous myocardial infarction, and multivessel coronary artery disease. The risk of death progressively increases with the number of these high risk features.

Heart Failure and Left Ventricular Remodeling After Reperfused Acute Myocardial Infarction in Patients With Hypertension

In the thrombolytic era, hypertension has been shown to adversely affect the development of heart failure after acute myocardial infarction (AMI). We sought to examine the relation between antecedent hypertension and heart failure after mechanical reperfusion and to test the impact of postinfarction left ventricular remodeling on heart failure in hypertensive patients. A series of 953 patients (324 hypertensives) with AMI treated with successful primary percutaneous coronary intervention underwent a 5-year follow-up. A subgroup of 325 subjects underwent 2D echocardiography at admission, 1 month, and 6 months. From day 1 to 6 months, despite similar improvement in regional and global left ventricular function and similar 6-month infarct artery patency rate, left ventricular end-diastolic volume increased in the normotensives (122±36 mL to 131±47 mL; P<0.001) but not in the hypertensives (127±41 mL to 128±31 mL; P=0.768). At 6 months, the incidence of left ventricular remodeling in hypertensive and normotensive patients was not different (22% versus 28%; P=0.210). However, at 5 years, the incidences of hospitalization for heart failure (7% versus 3%; P=0.014) and of New York Heart Association functional class ≥2 (53% versus 40%; P<0.001) were higher in hypertensive as compared with normotensive patients. Hypertension was found to be a predictor of heart failure (hazard ratio, 2.23; P=0.015). In conclusion, patients with antecedent hypertension are at higher risk to develop heart failure after AMI, even when successfully reperfused by primary percutaneous coronary intervention. However, the increased incidence of heart failure in hypertensive patients is not associated with a greater propensity to postinfarction left ventricular remodeling.

Heart rate as an independent prognostic risk factor in patients with acute myocardial infarction undergoing primary percutaneous coronary intervention

BACKGROUND It has been shown that elevated heart rate identified patients with coronary artery disease and left ventricular dysfunction at increased risk of cardiovascular outcomes. OBJECTIVE We sought to assess the prognostic impact of heart rate at presentation in patients with ST-elevation acute myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). METHODS AND RESULTS We collected 6-month follow-up data in 2477 consecutive patients with STEMI treated by primary PCI. Patients with atrio-ventricular block (n=64) and atrial fibrillation (n=34) were excluded from the analysis. The association of baseline heart rate with cardiovascular outcomes was analysed using Cox proportional hazard models for groups with a heart rate of 80 beats per min (bpm) or greater (n=799) versus those with a heart rate between 60 and 79 bpm (n=1192) and those with a heart rate less than 60 bpm (n=388). The variables related to mortality were: age (hazard ratio (HR) 1.072, 95% confidence interval (CI) 1.052-1.092, p<0.0001), cardiogenic shock (HR 4.622, 95% CI 2.892-7.387, p<0.0001), previous myocardial infarction (HR 1.724, 95% CI 1.036-2.869, p=0.036), peak creatine-kinase value (HR 1.227, 95% CI 1.142-1.318, p<0.0001), heart rate 80 bpm or greater (HR 2.170, 95% CI 1.414-3.332, p=0.0001), and optimal PCI result (HR 0.126, 95% CI 0.065-0.244, p=0.0001). For every increase of 5 bpm, there were increases in mortality (HR 1.321, 95% CI 1.232-1.415, p=0.0001), but not in reinfarction or in coronary revascularization rates. CONCLUSION In patients with acute myocardial infarction undergoing primary PCI, elevated heart rate (80 bpm or greater) identifies those at increased risk of death. It is unknown whether heart rate reduction will result in improved outcome in this setting of patients.

Effectiveness of Primary Percutaneous Coronary Interventions for Stent Thrombosis

There are very few (and conflicting) data about the effectiveness of primary percutaneous coronary interventions (PCIs) for stent thrombosis (ST) treatment. We sought to evaluate the prevalence, efficacy, and outcomes of primary PCI in patients with ST-elevation acute myocardial infarction (STEMI) due to ST in 2,464 consecutive patients treated by primary PCI. ST was the cause of STEMI in 67 patients (3%). Patients with ST showed a lower rate of significant collateral circulation (0% vs 6%, p = 0.034) and a higher peak creatine kinase value (2,678 +/- 3,221 vs 2,375 +/- 2,189 U/L, p = 0.003) compared with the other 2,397 patients with STEMI. PCI was successful in 64 patients (96%) in the ST group and consisted of additional stenting (78%) or only balloon angioplasty (22%). Abciximab and rheolytic thrombectomy were used in 75% and 31% of patients, respectively. Procedure (39 +/- 26 vs 32 +/- 19 minutes, p = 0.0001) and fluoroscopy (13 +/- 10 vs 10 +/- 8 minutes, p = 0.0001) times were longer, and contrast medium amount (221 +/- 89 vs 194 +/- 103 ml, p = 0.034) larger in patients with ST compared with patients with de novo STEMI. Six-month death (12% vs 8%, p = 0.216) and nonfatal reinfarction (10% vs 1%, p = 0.0001) rates were higher in patients with ST compared with those without. At 6-month angiographic follow-up (n = 1,843 of 2,269), the restenosis/reocclusion rate was 54% versus 17% (p = 0.0001) in patients with and without ST. In conclusion, the prevalence of primary PCI for ST is low. Additional stenting with or without thrombectomy is effective in restoring vessel patency in patients with ST, but restenosis and reocclusion are frequent. ST treated with successful PCI is associated with a large infarct and poor outcome.

Long-term prognostic implications of nonoptimal primary angioplasty for acute myocardial infarction†

Aim: To evaluate the long‐term outcome of a nonoptimal result of a primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI). Methods and Results: An optimal PCI result was defined as TIMI flow grade 3 and residual stenosis ≤≤≤≤20%. Long‐term clinical follow‐up (51 ±± 21 months) data were collected from 1,009 consecutive patients with ST‐elevation AMI who underwent primary PCI. Overall, an optimal primary PCI result was achieved in 958 patients (95%). At 5‐year follow‐up, patients with nonoptimal PCI had a higher rate of all‐cause mortality (47% vs 19%; P < 0.00001 by log‐rank test) than those with an optimal mechanical reperfusion. Fifty‐two percent of the deaths in the nonoptimal PCI group occurred within the first month. Interestingly, after this period, estimated survival of 30‐day alive patients was not significantly different to that of patients with an optimal PCI (P = 0.06 by log‐rank test). Nonoptimal PCI result emerged as an independent predictor of 1‐month mortality (OR = 3.030, 95% CI = 1.265–7.254; P = 0.013), but not of 5‐year mortality. At long‐term follow‐up, comulative rates of nonfatal reinfarction, hospitalization for heart failure, and additional revascularization procedures were similar between patients with nonoptimal and optimal primary PCI (4% vs 5%, P = 0.695; 4% vs 5%, P = 921; and 22% vs 20%, P = 0.816, respectively). Conclusion: A nonoptimal primary PCI result represents a strong predictor of early mortality. However, in patients surviving the early phase, the incidence of clinical events at long‐term follow‐up seems to be similar to successfully reperfused AMI patients.

Clinical Implications of Early Mitral Regurgitation in Patients With Reperfused Acute Myocardial Infarction

BACKGROUND The mechanisms by which mitral regurgitation (MR) may lead to an adverse prognosis after reperfused acute myocardial infarction (AMI) have not been fully investigated. We hypothesized that in the early phase of ST-elevation AMI, MR may lead to progressive left ventricular (LV) remodeling and subsequent heart failure. METHODS AND RESULTS A series of 184 patients with AMI successfully treated with primary angioplasty underwent serial two-dimensional echocardiography at admission, at 1 and 6 months, and at 6-month angiography. The mean follow-up was 18 +/- 7 months. On the basis of color Doppler, MR was graded from 0 (none) to 4 (severe). Patients were divided into group 1 (n = 146) with an MR grade of < or = 1 and group 2 (n = 38) with an MR grade of > or = 2. The regurgitant volume and effective regurgitant orifice area of MR were significantly higher in group 2 than in group 1 (36.7 +/- 12.9 mL/beat vs 4.67 +/- 3.2 mL/beat, P < .0001; 22.5 +/- 7.6 mm(2) vs 5.8 +/- 5.7 mm(2), P < .0001, respectively). LV end-diastolic volume progressively increased in group 2 and was significantly higher than in group 1 at 6 months (113.8 +/- 31.8 mL vs 96.9 +/- 34.1 mL, P = .0002), with a higher prevalence of LV remodeling (66% vs 22%, P < .0001). At 2 years, the incidence of heart failure was higher in group 2 than in group 1 (39% vs 12%, P < .0002). A significant correlation was found between effective regurgitant orifice area of MR and baseline to 6-month change of LV end-diastolic volume (P = .001). By stepwise multivariate regression analysis effective regurgitant orifice area of early MR was an independent predictor of LV remodeling (P = .001) and late heart failure (hazard ratio: 1.069, 95% confidence interval 1.033-1.106, P < .0001, Cox analysis). CONCLUSION In reperfused AMI, early high-degree MR is an important predictor of both LV dilation and subsequent heart failure.

829-6 A randomized trial comparing rheolytic thrombectomy before infarct artery stenting with stenting alone in patients undergoing percutaneous coronary intervention for acute myocardial infarction

M yo ca rd ia l I sc he m ia a nd In fa rc tio n Single center registries have shown that distal protection with the Medtronic (PercuSurge) GuardWire balloon occlusion and aspiration system is capable of retrieving embolic particulate debris in a large percentage of patients undergoing primary PCI. Whether this translates into improved reperfusion success and enhanced outcomes has not been determined. Methods. In the EMERALD trial, 500 pts within 6 hrs onset of chest pain with >2 mm ST elevation in 2 or more contiguous leads, or LBBB, undergoing primary or rescue PCI are being prospectively randomized at 40 sites to angioplasty with vs. without distal protection with the 0.028” GuardWire Plus system. The primary endpoints include STR 30 mins post procedure (measured by 24 hour continuous ECG monitoring) and infarct size assessed by tc-99m-sestamibi imaging at day 5-14. The study is powered to show an improvement in complete STR from 50% with control to 65% with distal protection (a 30% relative increase), and a reduction in mean infarct size from 13.1% of the left ventricle to 8.8%. (a 33% relative decrease). Secondary efficacy endpoints include achievement of normal (grade 3) myocardial blush by core lab analysis, and the composite clinical rate of death, new onset sustained hypotension or severe heart failure, and readmission for left ventricular failure within 30 days. Results. To date, more than 415 pts have been randomized; enrollment will be complete by November 2003. Conclusions. A large-scale, prospective, randomized multicenter trial has been performed to: 1) Examine whether prevention of distal embolization in patients undergoing primary PCI for AMI improves indices of myocardial reperfusion and resolution of ongoing injury, reduces infarct size and improves clinical outcomes, and 2) Evaluate the safety, feasibility and efficacy of the GuardWire balloon occlusion and aspiration system for this application. The principal results will be reported for the first time in March 2004.