Igal Teplitsky

Comparison of the Predictive Value of Four Different Risk Scores for Outcomes of Patients With ST-Elevation Acute Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

Accurate risk stratification has an important role in the management of patients with acute coronary syndromes. Even in patients with ST-elevation acute myocardial infarction (STEMI), for whom early therapeutic options are well defined, risk stratification has an impact on early and late therapeutic decision making. We aimed to compare the prognostic value of 4 risk scores used to evaluate patients with STEMI. We conducted a prospective registry of all patients treated with primary percutaneous coronary intervention for STEMI from January 2001 to June 2006. Excluded were patients with cardiogenic shock. A total of 855 consecutive patients were included in the analysis (age 60.5 +/- 13 years, 19% women, 28% with diabetes, and 48% with anterior wall myocardial infarction). For each patient, the Thrombolysis In Myocardial Infarction (TIMI), Controlled Abciximab and Device Investigation to Lower Late Angioplasty complications (CADILLAC), Primary Angioplasty in Myocardial Infarction (PAMI), and Global Registry for Acute Coronary Events (GRACE) risk scores were calculated using specific clinical variables and angiographic characteristics. Thirty-day and 1-year clinical outcomes were assessed. The predictive accuracy of the 4 risk scores was evaluated using the area under the curve or C statistic method. The CADILLAC, TIMI, and PAMI risk scores all had relatively high predictive accuracy for 30-day and 1-year mortality (C statistic range 0.72 to 0.82), with slight superiority of the CADILLAC score. These 3 risk scores also performed well for prediction of reinfarction at 30 days (C statistic range 0.6 to 0.7). The GRACE score did not perform as well and had low predictive accuracy for mortality (C statistic 0.47). In conclusion, risk stratification of patients with STEMI undergoing primary percutaneous coronary intervention using the CADILLAC, TIMI, or PAMI risk scores provide important prognostic information and enables accurate identification of high-risk patients.

Major bleeding complicating contemporary primary percutaneous coronary interventions-incidence, predictors, and prognostic implications.

BACKGROUND Major bleeding is one of the most frequent procedural-related complications of primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infraction (STEMI). We investigated the incidence, predictors, and prognostic impact of peri-procedural bleeding in a cohort of unselected patients undergoing contemporary primary PCI. METHODS A total of 831 consecutive patients who underwent primary PCI between 1/2001 and 6/2005 were studied. Major bleeding was defined as hemorrhagic stroke, hemoglobin (Hb) drop of >5 g%, or 3-5 g% with a need for blood transfusion. Clinical outcomes were evaluated at 30 days and 6 months. RESULTS Major bleeding occurred in 27 patients (3.5%). Those who experienced major bleeding were older (66+/-15 vs. 61+/-13, P=.02), more frequently female gender (48% vs. 27%, P=.0001), presented more often with cardiogenic shock (37% vs. 8%, P=.0001), and had higher CADILLAC score (7.8+/-4.5 vs. 5.1+/-4.0, P=.002) and activated clotting time (ACT) levels (284+/-63 vs. 248+/-57 s, P=.007). In multivariate analysis, significant predictors of major bleeding were female gender (OR 5.1, 95% CI 1.7-15.2, P=.004), ACT levels >250 s (OR 3.6, 95% CI 1.1-12.1, P=.04), and use of intra-aortic balloon pump (IABP) (OR 3.5, 95% CI 1.0-12.1, P=.047). Major bleeding was associated with increased 6-month mortality rates (37% vs. 10%, P=.0001), which remained significant after adjustment for baseline CADILLAC score (37% vs. 19.4%, P=.05). CONCLUSIONS Major bleeding complicating primary PCI is associated with increased 6-month mortality. Women and those who need IABP support are at particularly high risk. Tight monitoring of anticoagulation may reduce the risk of bleeding.

Beneficial 2-years results of drug-eluting stents in saphenous vein graft lesions.

AIMS There are limited data regarding clinical outcomes of drug-eluting stents (DES) in saphenous vein grafts (SVGs) compared to bare metal stents (BMS). Here we compared outcomes of DES in de novo SVG lesions versus BMS in contemporary percutaneous coronary intervention (PCI). METHODS AND RESULTS We compared in-hospital, 6-month, 1-year and two years outcomes in 68 patients (72 grafts) who underwent PCI of SVG lesions using DES and a control BMS group composed of 43 patients (46 grafts) who underwent angioplasty in de novo SVG lesions. Major adverse cardiac events (MACE) included death, myocardial infarction (MI), target lesion revascularisation (TLR), and target vessel revascularisation (TVR). The rates of TLR and TVR at the 1-year evaluation were lower in the DES group than the BMS group (TLR per patient, 7.4% vs. 21%, P=0.04; TVR per patient, 10.3% vs. 23.3%, P=0.1). MACE-free survival was 88.2% in the DES group and 69.8% in the BMS group (P=0.02). At two years clinical follow-up: death 2.9% vs. 4.7% (P=0.6); MI: 8.8% vs. 7% (P=0.6). The rates of TLR and TVR were significantly lower in the DES group compared to the BMS group (TLR per patient, 14.7% vs. 32.6%, P=0.03; TVR per patient, 10.3% vs. 27.9%, P=0.02). The rate of MACE-free survival was 79.4% in the DES group and 58.1% in the BMS group (P=0.02). Between one to two years after PCI, no cases of angiographic stent thrombosis were recorded in either group. CONCLUSIONS DES implantation in SVG lesions was safe and had favourable outcomes after two years without excess cardiac mortality.

The risk of cardiac complications following noncardiac surgery in patients with drug eluting stents implanted at least six months before surgery.

Aims: Given the anecdotal reports and case series suggesting that drug‐eluting coronary stents [DES] may be still vulnerable to coronary thrombosis after six months, we sought to assess this risk in patients undergoing non‐cardiac surgery six months after stenting. Methods and Results: Linking the Rabin Medical Centre interventional cardiology database with its non‐cardiac surgical database, we identified 78 patients who underwent DES placement and subsequently [after six months] had noncardiac surgery [15‐vascular, 37‐ abdominal and genitourinary and 26‐others, excluding ophthalmic surgery]. Outcome measures included 30‐day rate of postoperative myocardial infarction (MI), DES‐related thrombosis, and cardiac mortality. Major adverse cardiac events [death and non‐fatal MI] occurred in 6 (7.7%) patients including 2 cardiac deaths (2.6%), 4 (5.1%) non‐fatal myocardial infarctions (MIs). Two patients (2.6%) sustained stent thrombosis [one patient had ‘definite’ and one ‘probable’ stent thrombosis]. All MIs [including stent thrombosis] occurred in the vascular and abdominal surgery group. Two of the MIs events occurred while the patients were on dual antiplatelet agents. In conclusions: Perioperative cardiac events during non cardiac surgery after six months of DES deployment still occur. These cardiac complications [not entirely prevented by continued dual antiplatelet agents] remain a matter of diagnostic and therapeutic challenge and concern.

Hematocrit Level as a Marker of Outcome in ST-Segment Elevation Myocardial Infarction

Anemia is a well-known predictor of a poor outcome in patients with ST-segment elevation myocardial infarction (STEMI). In contrast, data relating erythrocytosis to clinical outcomes in patients with STEMI are limited. Because erythrocytosis predisposes to a prothrombotic state, we hypothesized it would be associated with an increased risk of thrombotic complications in patients with STEMI undergoing primary percutaneous coronary intervention. We studied 1,042 consecutive patients with STEMI who underwent primary percutaneous coronary intervention and were a part of our primary percutaneous coronary intervention registry from 2001 to 2007. Patients with cardiogenic shock and late arrival were excluded. Patients were allocated into 3 groups according to their baseline hematocrit: anemia (<36% for women and <39% for men), normal, erythrocytosis (>46% for women and >47% for men). The clinical outcomes were assessed at 1, 6, and 12 months. The patients with anemia had the greatest clinical risk profile. Patients with erythrocytosis had a lower risk profile than the other 2 groups, except for greater rates of smoking. The mortality rates were greatest among the patients with anemia, followed by the patients with erythrocytosis, who in turn had greater short-term mortality than patients with normal hematocrit. Multivariate analysis, which included patients with erythrocytosis and those with normal hematocrit (excluding the patients with anemia), revealed that erythrocytosis was associated with an odds ratio of 4.3 (95% confidence interval 1.4 to 13, p = 0.01) for 1-month mortality. In conclusion, although not as strong a predictor of mortality as anemia, erythrocytosis might be associated with increased short-term mortality compared to a normal hematocrit. The measurement of hematocrit can be used as a useful prognostic marker in patients with STEMI.

Results of percutaneous coronary interventions in patients ≥90 years of age

There are few data about percutaneous coronary interventions (PCI) in nonagenarians (patients aged ≥90 years). This study aimed to assess acute and intermediate term clinical outcomes among nonagenarian patients undergoing PCI.

The impact of circadian variation on outcomes in emergency acute anterior myocardial infarction percutaneous coronary intervention

Objectives: We investigated the impact of primary coronary angioplasty performed during night and compared to the impact of that performed during day‐time on outcomes of patients with acute ST elevation anterior wall myocardial infarction (AMI). Methods: We prospectively followed 273 consecutive patients of whom 160 (58.6%) were treated during day time (8:00 a.m. to 6 p.m.) and 113 (41.4%) were treated “off hours”/at night (6 p.m. to 8 a.m.). Baseline demographics, angiographic factors, and clinical outcomes (death, recurrent AMI, and need for repeat revascularization) were compared between the groups. Results: Baseline clinical characteristics were similar between the two groups. Unadjusted mortality at one‐month was significantly higher among patients who were treated during night compared with those treated at day‐time (9.7% vs. 3.1% P = 0.03), as was adverse cardiac event rate (15.9% vs. 6.9%; P = 0.02). Multiple logistic regression analysis adjusted for the CADILLAC risk score demonstrated that this score, which includes baseline LVEF, renal failure, Killip class, final TIMI flow, age>65 years, anemia, and the number of coronary vessel diseases, is a significant predictor of one‐month mortality, while the effect of time of treatment was borderline (night vs. day; odds ratio 2.7; 95% confidence interval, 0.8–9.4; P = 0.095). Conclusions: The results of this study indicate that patients with anterior myocardial infarction treated during night time have worse unadjusted short‐term clinical outcomes despite no delay from onset of symptoms to actual treatment. Larger studies are needed in order to identify potential contributors to this phenomenon.

The ACIST power injection system reduces the amount of contrast media delivered to the patient, as well as fluoroscopy time, during diagnostic and interventional cardiac procedures

The ACIST injection system is an automatic power injection device that allows for online control of injection rate and volume of contrast. Limited data is available whether this technology allows reducing use of contrast and fluoroscopy time. Accordingly, we compared the use of this system to manual injection among 450 consecutive patients who underwent diagnostic coronary angiography and/or angioplasty who were randomly assigned to either manual contrast injection (control; n = 198) or to the ACIST system (study group; n = 252). The amount of contrast, fluoroscopy and total procedural times were recorded for each patient. In the diagnostic group, the mean total amount of contrast (including wasted) was reduced by 63% when the ACIST was used compared to control (100±42 ml versus 163±56 ml; P<0.001, respectively). When only the net amount of contrast delivered to the patient was considered, the differences were smaller (20%, P = 0.004). During angioplasty, the amount of contrast was also lower in the ACIST group (206±65 versus 230±69, P = 0.008), whereas no difference were noted in net amount of contrast. Fluoroscopy time was significantly shorter in the ACIST group compared to control both during diagnostic catheterization (4.7±3.5 min versus 6.3±5.5 min, respectively; P = 0.014), and angioplasty (16.7±9.1 min versus 19.6±12.4 min, respectively; P = 0.05). Routine utilization of the ACIST system during diagnostic and interventional procedure significantly reduced the total amount of contrast media used and fluoroscopy time.

The impact of renal insufficiency on patients outcomes in emergent angioplasty for acute myocardial infarction

Background: Renal insufficiency (RF) was shown to be associated with a worsened prognosis following acute myocardial infarction (AMI). Objectives: The authors analyzed the outcomes of AMI patients with impaired renal function tests treated using primary percutaneous coronary intervention (PCI), to determine factors associated with increased mortality risk. Methods: This study included 558 consecutive AMI patients treated using primary PCI between January 2001 and June 2005. The authors compared outcome results according to glomerular filtration rate (GFR). An abbreviated equation was used to calculate GFR. Patients were grouped as follow: normal (≥90 mL/min/1.73 m2), mildly impaired (60–89 mL/min/1.73 m2), moderately impaired (30–59 mL/min/1.73 m2), and severely impaired GFR (< 30 mL/min/1.73 m2). Results: There was a stepwise increase in 30‐day mortality among patients with normal, mildly, moderately, and severely impaired RF: 2.1%, 3.7%, 8.2%, and 22.2%, respectively (P = 0.004). Seventeen out of the 324 with any degree of RF died within 1 month [5.3%] of these nine patients [53%] died because of cardiac cause. Univariate correlation analysis, factors associated with an increased risk of 1 month mortality included: age > 75 years, left ventricular ejection fraction < 35%, lower GFR, killip class > 1, multivessel coronary artery disease, failure to achieve TIMI flow grade = 3, the occurrence of no‐reflow, IABP use, lack of administration of anti GP 2b/3a. The amount of contrast media used during the procedure [mL/Kg] as well as renal function deterioration were also associated with increased mortality. Conclusions: Clinical and angiographic parameters collected before and during PCI can be used to predict 30‐day mortality among AMI patients with RF. Findings indicate that in the setting of contemporary catheter‐based reperfusion strategy for AMI, the extent of coronary artery disease, measures of PCI complexity, and degree of renal impairment prior/following the procedure are altogether related to mortality.

Acute and intermediate‐term results of percutaneous coronary stenting in octogenarian patients

BACKGROUND: Percutaneous coronary intervention (PCI) in octogenarian patients has been associated with increased cardiovascular morbidity and mortality. This study aimed to assess acute and intermediate‐term clinical outcomes among octogenarians undergoing PCI. METHODS: The authors identified 97 consecutive patients aged ≥80 years who underwent PCI using stents between November 2000 and February 2002 at their institution. The patients were divided into three groups according to clinical presentation: (1) acute myocardial infarction (AMI, n = 31); (2) unstable angina pectoris (UAP, n = 28); and (3) stable angina pectoris (SAP, n = 38). Procedural data, and in‐hospital and six‐month clinical outcomes were obtained and adjudicated for all patients. RESULTS: Overall mean age was 84 ± 3 years, 67% of patients were males and 73% had multivessel coronary disease. In‐hospital outcomes varied according to clinical presentation: procedural success was 78% in AMI patients (including shock patients), 93% in UAP, and 95% in SAP patients. Likewise, hospital mortality was 26% in AMI, 3.6% in UAP, and 0% in SAP patients (p = 0.0003). Among AMI patients, hospital mortality was extremely high in patients with cardiogenic shock (67% versus 4.6% in AMI without shock, p < 0.0001). Cumulative event rate at six months also varied according to clinical presentation: mortality/MI and target vessel revascularization (TVR) rates were 29%, 3.6%, and 0% in AMI, 7.1%, 7.4%, and 11% in UAP and 0%, 5.3%, and 7.9% in SAP patients. Multivariate analysis identified cardiogenic shock as the most powerful risk factor for predicting mortality (odds ratio = 42, p = 0.03). CONCLUSIONS: These results show that clinically stable octogenarian patients undergoing PCI have favorable procedural and intermediate‐term prognosis. In contrast, cardiogenic shock has a profound negative prognostic impact on octogenarians despite ‘aggressive’ PCI attempts. (Int J Cardiovasc Intervent 2003; 5: 195–199)