Myocardial revascularization failure among patients requiring cardiac catheterization and secondary revascularization in contemporary clinical practice: Results of the REVASEC multicenter registry.

BACKGROUND: Myocardial revascularization failure (MRF) and Secondary revascularization (SR) are contemporary interventional cardiology challenges. AIM: To investigate the characteristics, management, and prognosis of patients with myocardial revascularization failure (MRF) and need for secondary revascularization (SR) in contemporary practice. METHODS: The REVASEC study is a prospective registry (NCT03349385), which recruited patients with prior revascularization referred for coronary angiography at 19 centers. The primary endpoint is a patient-oriented composite (POCE) at 1 year, including death, myocardial infarction, or repeat revascularization. RESULTS: A total of 869 patients previously revascularized by percutaneous intervention (83%) or surgery (17%) were recruited. MRF was found in 83.7% (41.1% stent/graft failure, 32.1% progression of coronary disease, and 10.5% residual disease). SR was performed in 70.1%, preferably by percutaneous intervention (95%). The POCE rate at 1 year was 14% in the overall cohort, with 6.4% all-cause death. In the multivariate analysis, lower POCE rates were found in the groups without MRF (9.4%) and with disease progression (11%) compared with graft/stent failure (17%) and residual disease (18%), hazard ratio 0.67 (95% confidence interval: 0.45-0.99), p = 0.043. At 1 year, the SR group had less chronic persistent angina (19% vs. 34%, p < 0.001), but a higher rate of repeat revascularization (9% vs. 2.9%, p < 0.001). CONCLUSION: MRF was found in 84% of patients with prior revascularization referred for coronary angiography. Stent/graft failure and residual coronary disease were associated with a worse prognosis. SR provided better symptom control at the expense of a higher rate of new revascularization.

Design and Rationale for a Real-World Prospective, Multicenter Registry of Myocardial Revascularization Failure and Secondary Revascularization: The REVASEC Study.

AIM: To investigate key aspects of the problem of myocardial revascularization failure (MRF) and repeat or secondary myocardial revascularization (SR) in contemporary practice. METHODS: The registry of secondary revascularization (REVASEC) is an investigator-initiated, multicenter, prospective registry enhanced with data monitoring and independent event adjudication (ClinicalTrials.govNCT03349385). It includes patients with prior revascularization referred to coronary angiography for suspected MRF with broad inclusion criteria. The main objectives are to describe the characteristics of patients with prior revascularization referred for repeat angiography, to describe and the rate and mechanisms of MRF (stent or graft failure, coronary artery disease progression or residual coronary artery disease); to evaluate the management including medical treatment and SR of these patients; and to assess the prognosis according to the outlined causative mechanisms. The registry has one year follow up for the primary endpoint (Patient-oriented composite endpoint including all-cause death, any myocardial infarction or any new unplanned revascularization according to subsets of MRF), but extended follow-up will be carried out up to 5 years. CONCLUSION: The REVASEC Registry will provide updated data on the characteristics, patterns of treatment, and 1-year outcomes of patients with MRF and SR in contemporary clinical practice.

Distortion of the QRS in elderly patients with myocardial infarction.

BACKGROUND: Distortion of the terminal portion of the QRS in the initial electrocardiogram (ECG) is a strong predictor of adverse outcome in myocardial infarction. Our purpose is to assess the relationship of distortion of QRS and other ECG characteristics with older age. METHODS AND RESULTS: We analysed 634 consecutive patients (age 62.6 +/- 13.7, 77% male) admitted in the first 12 hours of ST-elevation myocardial infarction. Two groups of age were defined: < 75 years-old and >or= 75 years-old. Additionally, we defined two ECG groups according to the presence of ST segment elevation with distortion of the terminal portion of the QRS in two or more adjacent leads (QRS+) or the absence of this pattern (QRS-). Older people had more often QRS+ (30% vs. 20%, p = 0.023). The older group with QRS+ had an in-hospital mortality of 18%, vs. 7% with QRS- (p = 0.04), and an incidence of major adverse events of 40% vs. 14% (p = 0.002). In the multivariate analysis, age >or= 75 years was an independent predictor of distortion of the QRS (odds ratio 2.1, 1.2-4.9, p = 0.016). CONCLUSIONS: The distortion of the terminal portion of the QRS in myocardial infarction is more frequent in elderly people, and is significantly related to adverse prognosis. This ECG finding can be helpful to promptly stratify the risk in elderly patients.

Distortion of the terminal portion of the QRS is associated with poor collateral flow before and poor myocardial perfusion after percutaneous revascularization for myocardial infarction.

AIMS: The distortion of the terminal portion of the QRS has been related to adverse outcome in patients with ST-segment elevation myocardial infarction. METHODS: We studied the relationship of this electrocardiographic pattern with the angiographic findings in patients treated with percutaneous revascularization for ST-segment elevation myocardial infarction. We included 349 patients, 318 treated with primary angioplasty and 31 with rescue angioplasty after failed thrombolysis. RESULTS: Eighty-five patients were found with distortion of the terminal portion of the QRS complex (group 1) and 264 without it (group 2). Collateral flow was absent in 30 patients (35%) from group 1, versus 52 patients (20%) from group 2 [odds ratio (OR) 1.806, 1.097-2.974, P 0.019]. No-reflow occurred in 12 (14%) patients in group 1 versus 17 (6.4%) in group 2 (OR 2.388, 1.091-5.230, P 0.016). Myocardial perfusion was graded 2-3 in 28 patients (58%) of group 1 versus 98 (76%) in group 2 (OR 0.443, 0.220-0.893, P 0.021). CONCLUSION: Patients with ST-segment elevation myocardial infraction showing distortion of the terminal portion of the QRS have worse collateral flow, and present more often no-reflow or poor myocardial perfusion after percutaneous revascularization. These data contribute to explain the worse clinical outcome of these patients.

Distortion of the terminal portion of the QRS is predictor of shock after primary percutaneous coronary intervention for acute myocardial infarction.

BACKGROUND: Although invasive management of ST segment elevation myocardial infarction has improved the clinical outcome, cardiogenic shock (CS) remains an important issue. Our purpose was to asses the utility of the initial electrocardiogram in detecting patients who are at increased risk of CS after percutaneous coronary intervention for acute myocardial infarction. METHODS: We evaluated 508 consecutive patients admitted in our Coronary Unit and treated by primary angioplasty within 12 h of an ST segment elevation myocardial infarction. Patients with cardiogenic shock at admission were excluded. Two groups were defined according to the presence of distortion of the terminal portion of the QRS in two or more adjacent leads (group 1) or the absence of this pattern (group 2). RESULTS: There were 99 patients (20%) in group 1 and 409 (80%) in group 2. CS developed in 38 patients, 18 in group 1 (18%) and 20 in group 2 (5%), p<0.001. Seventeen patients died in hospital, 6 in group 1 (6%) and 11 in group 2 (3%), p 0.094. Multivariate analysis including clinical, electrocardiographic and angiographic variables showed distortion of the QRS as an independent predictor of cardiogenic shock (odds ratio 3.17, 95% confidence interval 1.44 to 6.96, p 0.004), together with Killip class at admission and TIMI 3 flow after revascularization. CONCLUSIONS: Distortion of the terminal portion of the QRS complex is a strong predictor of cardiogenic shock in STEMI patients. Close hemodynamic monitoring should be warranted in patients showing this electrocardiographic pattern.

[In-hospital prognostic value of glomerular filtration rate in patients with acute coronary syndrome and a normal creatinine level]. / Valor pronóstico intrahospitalario del filtrado glomerular en pacientes con síndrome coronario agudo y creatinina normal.

INTRODUCTION AND OBJECTIVES: Kidney failure is more prevalent in patients with ischemic heart disease than in the general population. A high serum creatinine level is known to be a predictor of an adverse outcome in acute coronary syndrome. The aim of this study was to investigate the clinical significance of the glomerular filtration rate in patients with acute coronary syndrome and a normal baseline creatinine level. METHODS: The study included 583 consecutive patients admitted to a coronary care unit with acute coronary syndrome (with or without ST-segment elevation) whose baseline serum creatinine level was less than 1.3 mg/dL. The creatinine clearance rate at admission was calculated using the Cockcroft-Gault equation, and the presence of cardiovascular risk factors, coronary anatomy (from angiography), type of revascularization, maximum cardiac enzyme levels, left ventricular ejection fraction and, ultimately, in-hospital mortality were recorded. RESULTS: Around 50.8% of patients presented with ST-segment elevation acute coronary syndrome. The median serum creatinine level on admission was 0.98 mg/dL (0.9-1.1 mg/dL) and the median creatinine clearance rate was 81.29 mL/min (61.2-98.4 mL/min). The in-hospital mortality rate was 2.7%. Glomerular filtration rate, previous coronary disease, Killip class on admission, and the need for intraaortic balloon counterpulsation were found to be independent predictors of mortality. CONCLUSIONS: In patients with acute coronary syndrome and a normal creatinine level on admission, estimation of the glomerular filtration rate provided important information on short-term prognosis. This parameter should be included in the risk assessment of patients with normal serum creatinine levels.

Valor pronóstico intrahospitalario del filtrado glomerular en pacientes con síndrome coronario agudo y creatinina normal / In-hospital prognostic value of glomerular filtration rate in patients with acute coronary syndrome and a normal creatinine level

Introducción y objetivos. La insuficiencia renal es más prevalente en los pacientes con cardiopatía isquémica que en la población general. La presencia de creatinina sérica elevada es un conocido factor de mal pronóstico en el síndrome coronario agudo. En este estudio se evalúa la relevancia clínica del filtrado glomerular renal en los pacientes con síndrome coronario agudo y un valor de creatinina basal normal. Métodos. Se incluyó a 583 pacientes consecutivos que ingresaron en la unidad coronaria con síndrome coronario agudo (con y sin elevación del segmento ST) y creatinina basal < 1,3 mg/dl. Se estimó el filtrado glomerular renal en el momento del ingreso mediante la fórmula de Cockcroft-Gault y se revisó la presencia de factores de riesgo cardiovascular, la anatomía coronaria (coronariografía), el tipo de revascularización, los niveles máximos de las enzimas cardiacas, la fracción de eyección y, finalmente, la mortalidad hospitalaria. Resultados. El 50,8% de los pacientes presentaba síndrome coronario agudo con elevación del segmento ST. La mediana de la creatinina sérica en el momento del ingreso fue de 0,98 mg/dl (0,9-1,1 mg/dl) y del aclaramiento de creatinina de 81,29 ml/min (61,2-98,4 mg/dl). La mortalidad intrahospitalaria fue del 2,7%. Se encontraron como factores predictores independientes de mortalidad el filtrado glomerular renal, los antecedentes de cardiopatía isquémica, la clase Killip en el momento del ingreso y la necesidad de balón de contrapulsación. Conclusiones. En pacientes con un síndrome coronario agudo y creatinina normal en el momento del ingreso, el cálculo del filtrado glomerular renal aporta una información relevante para el pronóstico en la fase aguda. Este parámetro debería añadirse en la valoración del riesgo de los pacientes con cifras normales de creatinina basal (AU)

Introduction and objectives. Kidney failure is more prevalent in patients with ischemic heart disease than in the general population. A high serum creatinine level is known to be a predictor of an adverse outcome in acute coronary syndrome. The aim of this study was to investigate the clinical significance of the glomerular filtration rate in patients with acute coronary syndrome and a normal baseline creatinine level. Methods. The study included 583 consecutive patients admitted to a coronary care unit with acute coronary syndrome (with or without ST-segment elevation) whose baseline serum creatinine level was less than 1.3 mg/dL. The creatinine clearance rate at admission was calculated using the Cockcroft-Gault equation, and the presence of cardiovascular risk factors, coronary anatomy (from angiography), type of revascularization, maximum cardiac enzyme levels, left ventricular ejection fraction and, ultimately, in-hospital mortality were recorded. Results. Around 50.8% of patients presented with ST-segment elevation acute coronary syndrome. The median serum creatinine level on admission was 0.98 mg/dL (0.9-1.1 mg/dL) and the median creatinine clearance rate was 81.29 mL/min (61.2-98.4 mL/min). The in-hospital mortality rate was 2.7%. Glomerular filtration rate, previous coronary disease, Killip class on admission, and the need for intraaortic balloon counterpulsation were found to be independent predictors of mortality. Conclusions. In patients with acute coronary syndrome and a normal creatinine level on admission, estimation of the glomerular filtration rate provided important information on short-term prognosis. This parameter should be included in the risk assessment of patients with normal serum creatinine levels (AU)