Renato Budzyn David

Accuracy of Dedicated Risk Scores in Patients Undergoing Primary Percutaneous Coronary Intervention in Daily Clinical Practice

BACKGROUND Comparisons between dedicated risk scores in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (pPCI) in real-world clinical practice are scarce. The aim of this study was to assess the diagnostic performance of the Global Registry of Acute Coronary Events (GRACE), Primary Angioplasty in Myocardial Infarction (PAMI), Thrombolysis in Myocardial Infarction (TIMI), and Zwolle scores in STEMI patients undergoing pPCI in contemporary clinical practice. METHODS This was a prospective cohort study of consecutive patients with STEMI undergoing pPCI between December 2009 and November 2010 in a high-volume tertiary referral centre. The outcomes assessed were major cardiovascular events (MACEs) and death within 30 days. The diagnostic accuracy of the scores was assessed using receiver operating characteristic curves, and scores were compared using the DeLong method. RESULTS During the study period, 501 patients were included. Within 30 days, 62 patients (12.4%) presented a MACE and 39 individuals (7.8%) died. All scores were statistically associated with death and MACE within 30 days (P < 0.01). The c-statistic and 95% confidence intervals for 30-day mortality were: GRACE, 0.84 (0.78-0.90); TIMI, 0.81 (0.74-0.87); Zwolle, 0.80 (0.73-0.87); and PAMI, 0.75 (0.68-0.82) (P < 0.01). There was no statistically significant difference regarding the accuracy of the TIMI, GRACE, and Zwolle scores for 30-day mortality, but the GRACE score was superior to the PAMI score (P < 0.01). CONCLUSIONS The TIMI, GRACE, and Zwolle scores performed equally well as predictors of mortality in patients who underwent pPCI in current practice. These results suggest that these scores are suitable options for risk assessment in a real-world setting.

Diabetes Mellitus and Glucose as Predictors of Mortality in Primary Coronary Percutaneous Intervention

Background Diabetes mellitus and admission blood glucose are important risk factors for mortality in ST segment elevation myocardial infarction patients, but their relative and individual role remains on debate. Objective To analyze the influence of diabetes mellitus and admission blood glucose on the mortality of ST segment elevation myocardial infarction patients submitted to primary coronary percutaneous intervention. Methods Prospective cohort study including every ST segment elevation myocardial infarction patient submitted to primary coronary percutaneous intervention in a tertiary cardiology center from December 2010 to May 2012. We collected clinical, angiographic and laboratory data during hospital stay, and performed a clinical follow-up 30 days after the ST segment elevation myocardial infarction. We adjusted the multivariate analysis of the studied risk factors using the variables from the GRACE score. Results Among the 740 patients included, reported diabetes mellitus prevalence was 18%. On the univariate analysis, both diabetes mellitus and admission blood glucose were predictors of death in 30 days. However, after adjusting for potential confounders in the multivariate analysis, the diabetes mellitus relative risk was no longer significant (relative risk: 2.41, 95% confidence interval: 0.76 - 7.59; p-value: 0.13), whereas admission blood glucose remained and independent predictor of death in 30 days (relative risk: 1.05, 95% confidence interval: 1.02 - 1.09; p-value ≤ 0.01). Conclusion In ST segment elevation myocardial infarction patients submitted to primary coronary percutaneous intervention, the admission blood glucose was a more accurate and robust independent predictor of death than the previous diagnosis of diabetes. This reinforces the important role of inflammation on the outcomes of this group of patients.

Avaliação histopatológica de trombos coronários em pacientes com infarto agudo do miocárdio e elevação do segmento ST

INTRODUCAO: A intervencao coronaria percutânea (ICP) primaria e o principal metodo de reperfusao em pacientes com infarto do miocardio com supradesnivelamento do segmento ST (IAMCSST). A trombectomia por aspiracao manual tem sido cada vez mais utilizada e possibilita a analise dos trombos aspirados. METODOS: Pacientes consecutivos submetidos a ICP primaria foram incluidos no periodo de dezembro de 2009 a junho de 2011. As caracteristicas clinicas e laboratoriais e os dados angiograficos foram coletados prospectivamente e incluidos em banco de dados dedicado. A decisao de realizar tromboaspiracao ficou a cargo dos operadores. Foram coletadas 112 amostras de trombos, armazenadas em formalina 10%, fixadas em parafina, coradas com hematoxilina-eosina, e analisadas por microscopia optica. Na avaliacao histopatologica, os trombos foram classificados em trombos recentes ou lisados/organizados. RESULTADOS: Foram identificados trombos recentes em 68 pacientes (61%) e trombos lisados/organizados em 44 pacientes (39%). Os pacientes com trombos recentes apresentaram maior infiltracao de globulos vermelhos (P = 0,03). Nao foram identificadas outras diferencas estatisticamente significantes em relacao as caracteristicas clinicas, angiograficas e laboratoriais ou aos desfechos clinicos entre os dois grupos estudados. CONCLUSOES: Em pacientes com IAMCSST submetidos a ICP primaria, dois tercos dos trombos aspirados apresentaram caracteristicas histopatologicas de trombos recentes. Nao foram observadas associacoes significativas entre essas caracteristicas e aspectos clinicos, laboratoriais e angiograficos nesta amostra contemporânea e representativa do mundo real.

Preditores de insucesso de tromboaspiração em pacientes submetidos à intervenção coronária percutânea primária

BACKGROUND: Aspiration thrombectomy is recommended as an adjunctive method in patients undergoing primary percutaneous coronary intervention (PCI), however, thrombus aspiration failure is relatively frequent. The objective of this study was to evaluate the rate and identify predictors of failed thrombus aspiration in a contemporaneous series of patients. METHODS: Prospective cohort study including consecutive patients with acute ST-segment elevation myocardial infarction undergoing primary PCI with thrombus aspiration from December 2009 to December 2011. Aspiration thrombectomy was performed at the operators discretion and success was defined as effective thrombus aspiration by a dedicated catheter with the achievement of a final TIMI flow > 0. RESULTS: 1,055 primary PCIs were performed and aspiration thrombectomy was used in 37% of cases with a success rate of 70%. Aspiration thrombectomy success was observed in 254 patients whereas failure was observed in 107 patients. Aspiration thrombectomy failure was associated with age, hypertension, diabetes mellitus, dyslipidemia, previous PCI, TIMI risk score, Killip IV, leukocyte count, serum fibrinogen, target vessel reference diameter and preprocedural TIMI 3 flow. Patients with failed thrombus aspiration had a trend towards higher mortality (11.6% vs. 5.9%; P = 0.09). CONCLUSIONS: Aspiration thrombectomy failure during primary PCI was observed in 30% of the cases and was associated with a trend towards higher mortality. The identification of clinical, laboratory and angiographic predictors may help improve these devices and the technique and enable better patient selection.

Predictors of Failed Thrombus Aspiration in Patients Undergoing Primary Percutaneous Coronary Intervention

ABSTRACT Background: Aspiration thrombectomy is recommended as an adjunctive method in patients undergoing primary percutaneous coronary intervention (PCI), however, thrombus aspiration failure is relatively frequent. The objective of this study was to evaluate the rate and identify predictors of failed thrombus aspiration in a contemporaneous series of patients. Methods Prospective cohort study including consecutive patients with acute ST-segment elevation myocardial infarction undergoing primary PCI with thrombus aspiration from December 2009 to December 2011. Aspiration thrombectomy was performed at the operator’s discretion and success was defined as effective thrombus aspiration by a dedicated catheter with the achievement of a final TIMI flow > 0. Results 1,055 primary PCIs were performed and aspiration thrombectomy was used in 37% of cases with a success rate of 70%. Aspiration thrombectomy success was observed in 254 patients whereas failure was observed in 107 patients. Aspiration thrombectomy failure was associated with age, hypertension, diabetes mellitus , dyslipidemia, previous PCI, TIMI risk score, Killip IV, leukocyte count, serum fibrinogen, target vessel reference diameter and preprocedural TIMI 3 flow. Patients with failed thrombus aspiration had a trend towards higher mortality (11.6% vs. 5.9%; P = 0.09). Conclusions Aspiration thrombectomy failure during primary PCI was observed in 30% of the cases and was associated with a trend towards higher mortality. The identification of clinical, laboratory and angiographic predictors may help improve these devices and the technique and enable better patient selection.

Intervenção coronária pelas vias radial ou femoral no infarto agudo do miocárdio com supradesnivelamento do segmento ST: uma visão da prática clínica contemporânea

BACKGROUND: Radial access is a safe approach for percutaneous procedures and reduces local vascular complications. This study compared the hospital outcomes of patients with ST-elevation acute myocardial infarction (STEMI) submitted to primary percutaneous coronary intervention (pPCI) using the radial vs. femoral approaches. METHODS: Prospective cohort study with consecutive patients treated between December 2009 and May 2011. RESULTS: Seven hundred and ninety-four patients were included, 82 (10.3%) treated by radial access and 712 (89.7%) treated by femoral access. Radial access patients were younger (56.2 ± 10,7 years vs. 61,2 ± 11,9 years; P 0.99), stent thrombosis (2.4% vs. 3%; P > 0.99), major bleeding (0 vs. 1.6%; P = 0.61) or minor bleeding (5.3% vs. 7.3%; P = 0.81) rates. CONCLUSIONS: The transradial approach has proven to be safe and effective with similar results to transfemoral approach in patients with STEMI.