The development of door-to-angiography time in the last 14 years for patients with acute ST-elevation myocardial infarction treated with primary coronary intervention: Determinants and outcome. Results from the MITRAplus and OPTAMI registry.

AIM OF THE STUDY: To examine the development of door-to-angiography time (DTA) and to evaluate the impact of door-to-angiography time in patients with ST-elevation myocardial infarction (STEMI) on hospital and one-year mortality. METHODS AND RESULTS: From 1994 to 2008, 5078 patients (pts) and known DTA with acute ST-elevation myocardial infarction were enrolled into the MITRAplus and OPTAMI registry in Germany. Our data showed a reduction of the door-to- angiography time from 80 min to 64 min in the last 14 years (P < 0.001). Over 80% of patients received an angiography less than two hours after admission. The main predictor of a shorter door-to-balloon time was a hypotension with a blood pressure lower than 100 mmHg (OR 1.46, 95%CI: 1.08-1.91). Whereas a history of prior myocardial infarction (OR 0.61, 95%CI: 0.45-0.84), a previous coronary bypass grafting (OR 0.55, 95%CI: 0.33-0.91), age older than 75 years (OR 0.78, 95%CI: 0.62-0.99) and a pre-hospital delay more than three hours (OR 0.78, 95%CI: 0.66-0.93) were independent predictors for a longer of the door-to-balloon time. In the multivariate regression analysis no influence was detected of door-to-angiography time on hospital or one-year mortality. CONCLUSION: The DTA decreased in the last 14 years and is actually very short in Germany. We indentified predictors of a longer door-to-angiography time in clinical practice. Given the overall short in-hospital delay, the observed door-to-angiography time did not have influence on hospital and mid term mortality.

Primary percutaneous coronary intervention and thrombolysis improve survival in patients with ST-elevation myocardial infarction and pre-hospital resuscitation.

BACKGROUND: Patients with ST-elevation myocardial infarction (STEMI) surviving pre-hospital resuscitation represent a selected subgroup of patients with a very high adverse event rate. Only few data on the outcome of primary percutaneous coronary intervention (primary PCI) and thrombolysis in such patients are available. METHODS: We analysed the Maximal Individual Therapy of Acute Myocardial Infarction (MITRA) Plus registry. 1529 survivors of pre-hospital resuscitation with STEMI were included. 593 (38.8%) of those patients did not receive early reperfusion therapy, 793 (51.9%) patients received thrombolysis and 143 (9.4%) patients received primary PCI. Hospital mortality in patients receiving primary PCI or thrombolysis was adjusted for confounding factors with a propensity score analysis. RESULTS: Primary PCI as well as thrombolysis in survivors of pre-hospital resuscitation with STEMI were associated with a significant reduction of hospital mortality (OR: 0.29, 95% CI 0.17-0.50; and 0.74, 95% CI 0.54-0.99, respectively), while primary PCI was superior compared to thrombolysis (OR 0.50, 95% CI 0.30-0.84). CONCLUSION: Reperfusion therapy improves mortality of patients with STEMI surviving pre-hospital resuscitation, while primary PCI seems to be more effective than thrombolysis.

Gender differences in patients with acute ST-elevation myocardial infarction complicated by cardiogenic shock.

INTRODUCTION: The aim of our analysis is to assess gender differences in baseline characteristics, acute therapies, and clinical outcome in patients with acute ST-elevation myocardial infarction (STEMI) complicated by cardiogenic shock. METHODS: The Maximal Individual Therapy of Acute Myocardial Infarction PLUS registry (MITRA PLUS) is a German prospective, multicenter, observational data pool of current treatment of STEMI. RESULTS: STEMI was more often (P < 0.0001) complicated by cardiogenic shock in female patients (12.9%) when compared to male patients (9.3%). This was still true after adjusting for confounding variables (OR 1.19, 95% CI 1.09-1.30). Women with STEMI admitted in a cardiogenic shock were older (P < 0.0001) and had more often concomitant diseases (P < 0.0001). There was no differences in rates of reperfusion therapy (OR 0.92, 95% CI 0.77-1.09). Hospital mortality was 67.7% in female patients, when compared to 57.2% in male patients (P < 0.0001). After adjusting for confounding variables in the multivariate analysis hospital mortality did not differ between men and women (OR 1.16, 95% CI 0.98-1.38). Early reperfusion therapy was associated with a significant reduction of hospital mortality in female patients with STEMI complicated by cardiogenic shock (OR 0.68, 95% CI 0.52-0.90) with primary PCI being more effective than thrombolytic therapy (OR 0.46, 95% CI 0.31-0.68). CONCLUSION: In women, STEMI was more often complicated by cardiogenic shock when compared to men. However, the use of early reperfusion therapy did not differ between the sexes. Primary PCI was associated with the best outcome in female patients with STEMI complicated by cardiogenic shock and is therefore the therapy of choice.

Clinical benefit of early reperfusion therapy in patients with ST-elevation myocardial infarction usually excluded from randomized clinical trials (results from the Maximal Individual Therapy in Acute Myocardial Infarction Plus [MITRA Plus] registry).

Randomized clinical trials (RCTs) usually enroll selected patient populations that may not be representative for patients seen in everyday practice. Therefore, concerns have been raised regarding their external validity. For the present study we evaluated the MITRA Plus registry and included 20,175 patients with ST-elevation myocardial infarction. We defined RCT-ineligible patients as patients fulfilling >or=1 of the following criteria: age >or=75 years, prehospital delay >12 hours, prehospital cardiopulmonary resuscitation, cardiogenic shock, impaired renal function, and previous stroke. Those patients (n = 9,369, 46.4%) were compared to patients eligible for enrollment in RCTs (n = 11,806, 53.6%). Ineligible patients were older (p <0.0001), more often were women (p <0.0001), and more often had concomitant diseases (p <0.0001). Ineligible patients less often received early reperfusion therapy (p <0.0001), aspirin (p <0.0001), clopidogrel (p <0.0001), and statins (p <0.0001). Ineligible patients had a higher hospital mortality (20.1% vs 4.9%; p <0.0001) and a higher rate of nonfatal strokes (1.5% vs 0.4%, p <0.0001) compared to eligible patients. Early reperfusion therapy (thrombolysis and/or percutaneous coronary intervention [PCI]) in ineligible patients was associated with a significant decrease of hospital mortality (odds ratio 0.62, 95% confidence interval 0.49 to 0.79), with primary PCI being more effective than thrombolytic therapy (odds ratio 0.52, 95% confidence interval 0.41 to 0.65). In conclusion, about 50% of patients with ST-elevation myocardial infarction seen in clinical practice are usually excluded from RCTs. Hospital mortality in those patients is very high. Primary PCI improves the prognosis and is therefore the preferred reperfusion strategy in these patients.

Reperfusion therapy for acute ST-elevation and non ST-elevation myocardial infarction: what can be achieved in daily clinical practice in unselected patients at an interventional center?

BACKGROUND: In the year 2000 a new definition of acute myocardial infarction (AMI) was introduced, now differentiating ST segment elevation AMI (STEMI) from non-ST segment elevation AMI (NSTEMI). The characterization of AMI patients according to this definition is still incomplete. METHODS AND RESULTS: 888 consecutive AMI patients at a single interventional center were included: 493 (55.5%) STEMI and 395 (44.5%) NSTEMI patients. Median age of STEMI patients was four years lower compared to NSTEMI patients (62.8 versus 66.6 years, P<0.001). STEMI patients more often presented in cardiogenic shock (11.0% versus 2.0%, P<0.001) and after pre-hospital resuscitation (4.9% versus 0.8%, P<0.001). Catheterization was performed in 98.4% of STEMI and in 95.9% of NSTEMI patients (P<0.001). The circumflex artery was more often the culprit lesion in NSTEMI patients compared to STEMI patients (58.3% versus 48%, P=0.003). They also showed significantly more often a 3 vessel disease (41.4% versus 29.9%, P=0.002). Out of STEMI patients 10.1% were treated with medical therapy only compared to 27.2% of NSTEMI patients (P<0.001). Whereas PCI was performed more often in STEMI patients (84.3% versus 57.8%, P<0.001), CABG was used more often in NSTEMI patients (21.6% versus 9.1%, P<0.001). In-hospital death was 8.7% in STEMI compared to 4.8% in NSTEMI patients (P<0.001). CONCLUSIONS: In clinical practice STEMI and NSTEMI seem to occur with similar frequency. Invasive strategies were applied in a high percentage in both groups, however with different therapeutic consequences. In-hospital mortality was twice as high in STEMI compared to NSTEMI patients.

Angioplasty within 24 h after thrombolysis in patients with acute ST-elevation myocardial infarction: current use, predictors and outcome. Results of the MITRA plus registry.

BACKGROUND: Percutaneous coronary intervention (PCI) early after thrombolysis (early PCI) in patients with ST-elevation myocardial infarction (STEMI) is currently advised by clinical guidelines, but little is known about its use in clinical practice. METHODS: We analysed the MITRA (Maximal Individual Therapy of Acute Myocardial Infarction) plus registry. RESULTS: Out of a total of 34276 patients with STEMI, 10600 (30.9%) were treated with intravenous thrombolysis. Out of these patients, 487 (4.6%) patients received an angioplasty between 61 min and 24 hours after thrombolysis. They were compared to 10113 (95.4%) patients who received PCI either later than 24 hours after thrombolysis or not at all. A continuous increase in the frequency of early PCI between the years 1994 (2%)-2002 (16.7%) was observed. After adjusting for confounding variables independent predictors to use early PCI were the increasing year of inclusion, the facility of the hospital to perform PCI, younger age and male gender. Hospital mortality was 7.2% in patients receiving early PCI, compared to 11.2% in the other group (<0.01). Independent predictors for a higher hospital mortality were shock, age >65 years, female gender, an anterior STEMI and a prehospital delay of >3 hours. However, early PCI was not longer associated with a lower mortality (OR 0.95, 95% CI 0.64-1.14). CONCLUSION: Early PCI after thrombolysis is used infrequently in current clinical practice in Germany. Especially 'low risk' patients were treated with an early PCI, which may contribute to the missing effect on mortality compared to no or late PCI after thrombolysis.

Incidence and clinical impact of right bundle branch block in patients with acute myocardial infarction: ST elevation myocardial infarction versus non-ST elevation myocardial infarction.

BACKGROUND: Both left bundle branch block and right bundle branch block (RBBB) have been associated with increased inhospital and long-term mortality in patients with acute ST elevation myocardial infarction (STEMI). However, the prognostic role of RBBB in acute non-ST elevation myocardial infarction (NSTEMI) is not well known. Therefore, the aim of the study was to evaluate the incidence and clinical impact of RBBB in patients with NSTEMI compared to patients with STEMI. METHODS: From the German prospective multicenter registry "Maximal Individual Therapy of Acute Myocardial Infarction" (MITRA PLUS), 6,403 consecutive patients with NSTEMI and 20,233 patients with STEMI were analyzed. Patients with left bundle branch block were excluded. The median follow-up time for NSTEMI was 378 days and for STEMI 479 days. RESULTS: A total of 455 (7.1%) patients with NSTEMI and 894 (4.4%) patients with STEMI presented with RBBB on admission. In general, RBBB patients were older, more often had comorbidities, and less often received short-term inhospital treatment according to guidelines. In STEMI, RBBB patients had higher peak enzyme levels and lower left ventricular ejection fraction (LV-EF) than patients without BBB. Right bundle branch block in STEMI was associated with an increased inhospital and long-term mortality. In NSTEMI, however, peak enzyme levels and LV-EF were similar in both groups with and without RBBB. Right bundle branch block in NSTEMI was not independently associated with a worse outcome. CONCLUSIONS: Unlike RBBB in STEMI, RBBB in NSTEMI is not an independent predictor of inhospital and long-term mortality.

Prehospital cardiac arrest: a marker for higher mortality in patients with acute myocardial infarction and moderately reduced left ventricular function: results from the MITRA plus registry.

BACKGROUND: According to the current guidelines for acute myocardial infarction, ventricular fibrillation during the acute phase of myocardial infarction is no indication for specific treatment like ICD implantation. Primary objective of our study was to evaluate the prognostic significance of cardiac arrest within the acute phase of myocardial infarction in patients with moderately reduced left ventricular function. METHODS AND RESULTS: From 1994 until 2004, we included 7111 patients with acute STEMI and an LVEF >30% from the MITRA plus registry who were discharged alive from hospital and had a complete follow up. We compared long term prognosis on total mortality in patients with and without prehospital cardiac arrest. 286 out of 7111 patients (4%) with moderately reduced LVEF >30% after STEMI had prehospital cardiac arrest and were discharged alive from hospital. In these patients, total mortality during a mean follow up of 13 months was 13.6% compared to 8.7% in patients without cardiac arrest, although patients with cardiac arrest were younger and had less risk factors. Higher mortality after cardiac arrest was independent from gender, risk factors and medical treatment. Only in patients with preserved LVEF >55% after STEMI, mortality was equal in patients with and without cardiac arrest. CONCLUSION: Prehospital cardiac arrest in the acute phase of STEMI is an independent risk indicator for higher mortality in patients with moderately reduced left ventricular function (LVEF 30-55%). To evaluate the prognostic impact of the implantation of an ICD in these patients, further investigation is needed.

Impact of the body mass index on occurrence and outcome of acute ST-elevation myocardial infarction.

Obesity is a traditional risk factor for the development of cardiovascular disease. However, recent studies have described a better outcome of obese patients in the clinical course of acute coronary syndromes.We investigated the impact of the body mass index (BMI) on occurrence and outcome of acute ST-elevation myocardial infarction (STEMI). Data of 10 534 consecutive patients with STEMI of the German MITRA PLUS registry were analyzed, comparing international classes of the BMI (obesity: BMI >or= 30 kg/m(2), overweight: 25-29.9 kg/m(2), normal weight: 18.5-24.9 kg/m(2)).STEMI occurred at a younger age in obese patients. The obese patients with first STEMI were 3 years younger than the normal weight patients with first STEMI (62.5 vs 65.7 years, p <0.0001).After STEMI has occurred, the obese patients had the lowest hospital (6.0%) and long-term mortality (4.8%) of all compared BMI-groups. In a multivariate analysis, obesity compared to normal weight was associated with a trend of a reduced mortality without significance during the hospital course (OR 0.81, 95% CI 0.60-1.08) and with significance during follow-up (OR 0.56, 95% CI 0.40-0.79).In conclusion, our data show that obesity is a risk factor of a manifestation of STEMI at a younger age compared to normal weight patients. After STEMI has occurred, obesity is associated with a trend of a lower mortality during the following clinical course. Therefore, the focus of prevention should be the reduction of obesity and metabolic syndrome in young people, to avoid the early occurrence of STEMI by primary prevention.

Prognostic impact of acute beta-blocker therapy on top of aspirin and angiotensin-converting enzyme inhibitor therapy in consecutive patients with ST-elevation acute myocardial infarction.

The prognostic effect of beta-blocker treatment on ST-elevation acute myocardial infarction (STEMI) is controversially discussed in the era of reperfusion therapy. From the German multicenter registry Maximal Individual Therapy of Acute Myocardial Infarction PLUS (MITRA PLUS), 17,809 consecutive patients with STEMI treated with a guideline-recommended therapy with aspirin and an angiotensin-converting enzyme inhibitor were investigated; the prognostic effect of additional acute beta-blocker treatment was analyzed. Patients with cardiogenic shock were excluded. Of included patients, 77.6% received additional acute beta-blocker treatment and 22.4% did not. Patients with beta-blocker treatment were younger and more often received reperfusion therapy. Acute beta-blocker treatment was associated with a lower hospital mortality (univariate analysis 4.9% vs 10.8%, p <0.001; multivariate analysis odds ratio [OR] 0.70, 95% confidence interval [CI] 0.61 to 0.81). Acute beta blockade was significantly associated with a lower hospital mortality in patients without (OR 0.66, 95% CI 0.56 to 0.79) and with (OR 0.76, 95% CI 0.60 to 0.98) reperfusion therapy. The greatest benefit of acute beta-blocker treatment, measured by the number needed to treat to save 1 life, was found in patients with anterior MI, a heart rate > or =80 beats/min, no reperfusion therapy, female gender, and age > or =65 years. In conclusion, acute beta-blocker therapy in the clinical practice of treating patients with STEMI, in addition to aspirin and angiotensin-converting enzyme inhibitor therapy, was independently associated with a significant decrease in hospital mortality in patients with and without reperfusion therapy. High-risk patients with STEMI, such as elderly patients and patients without reperfusion therapy, showed a greater benefit of acute beta-blocker therapy than low-risk patients with STEMI.

Too little aspirin for secondary prevention after acute myocardial infarction in patients at high risk for cardiovascular events: Results from the MITRA study.

BACKGROUND: A meta-analysis of randomized trials has shown a significant reduction of mortality rate in patients receiving aspirin for secondary prevention after acute myocardial infarction (AMI). However, a significant number of patients do not receive aspirin after AMI. Little is known about why aspirin is withheld or the long-term outcome of these patients today. METHODS: The Maximal Individual Therapy in Acute Myocardial Infarction (MITRA) registry is a multicenter registry of patients with AMI in Germany. RESULTS: Of 4902 patients, 509 (10%) did not receive aspirin at the time of discharge from the hospital. The mean follow-up period for these patients was 17 months. Relative contraindications to aspirin were significantly associated with the withholding of aspirin (in-hospital bleeding: odds ratio [OR], 3.56; 95% CI, 1.86-6.80; history of peptic ulcer: OR, 2.49; 95% CI, 1.62-3.83). Absolute contraindications to aspirin were rare (2.2%). Other medications of proven benefit were also given less often in these patients (beta-blockers: 49.0% vs 61.9%, P <.001; angiotensin-converting enzyme inhibitors: 65.6% vs 70.2%, P =.06; statins: 12.2% vs 15.1%, P =.10). Patients who were not given aspirin were at high risk for vascular events. They were more likely to have a history of prior AMI (OR, 1.34; 95% CI, 1.02-1.79), were in critical clinical condition at admission more often (cardiogenic shock: OR, 1.98; 95% CI, 1.09-3.56; overt heart failure: OR, 1.6; 95% CI, 1.05-2.3), and received acute revascularization less often (OR, 1.32; 95% CI, 1.05-1.67). The 1-year mortality was 2-times higher in patients who did not receive aspirin than in patients who did receive aspirin (16.5% vs 8.3%, P <.001). A significant association of withheld aspirin at discharge with a higher long-term mortality rate was confirmed with multivariate analysis (OR, 1.62; 95% CI, 1.15-2.29). CONCLUSIONS: Ten percent of patients who sustained an AMI did not receive aspirin at the time of hospital discharge. Most of these patients were at high risk for cardiovascular events. Withheld aspirin was significantly associated with higher mortality rate during follow up.

Different treatments and outcomes of consecutive patients with non-ST-elevation myocardial infarction depending on initial electrocardiographic changes (results of the Acute Coronary Syndromes [ACOS] Registry).

Of 6,302 consecutive patients with acute non-ST-elevation myocardial infarction, 42.8% presented with ST depression, 31.9% showed no significant electrocardiographic changes, and 25.3% presented with T inversion. In comparison with patients with T inversion or no significant electrocardiographic changes, patients with ST depression more often had 3-vessel coronary disease, received less acute therapy despite a strong benefit in a subgroup analysis, and had a worse clinical outcome even after adjustment in a multivariate analysis. Patients with T inversion received a high rate of acute therapy and had a better outcome than did patients without significant electrocardiographic changes and patients with ST depression.

Comparison of clinical benefits of clopidogrel therapy in patients with acute coronary syndromes taking atorvastatin versus other statin therapies.

In clinical practice, we found no significant difference between atorvastatin therapy or other statin therapies in the clinical outcomes of patients with acute coronary syndromes receiving clopidogrel therapy. In patients receiving atorvastatin therapy, clopidogrel therapy was associated with a significant decrease in mortality and stroke during univariate analysis and a moderate trend of reduced mortality and stroke without statistical significance in the multivariate analysis.

Impact of ramipril versus other angiotensin-converting enzyme inhibitors on outcome of unselected patients with ST-elevation acute myocardial infarction.

We examined the impact of treatment with ramipril versus other angiotensin-converting enzyme (ACE) inhibitors on clinical outcome in unselected patients of the prospective multicenter registry Maximal Individual Therapy of Acute Myocardial Infarction PLUS registry (MITRA PLUS). Of 14,608 consecutive patients with ST-elevation acute myocardial infarction, 4.7% received acute therapy with ramipril, 39.0% received other ACE inhibitor therapy, and 56.3% received no ACE inhibitor therapy. In a multivariate analysis, the treatment with ramipril compared with the treatment without ACE inhibitors was associated with a significantly lower hospital mortality and a lower rate of nonfatal major adverse coronary and cerebrovascular events. Compared with other generic ACE inhibitors, ramipril therapy was independently associated with a significantly lower hospital mortality (odds ratio [OR] 0.54, 95% confidence interval [CI] 0.32 to 0.90) and a lower rate of nonfatal major adverse coronary and cerebrovascular events (OR 0.65, 95% CI 0.46 to 0.93), but not with a lower rate of heart failure at discharge (OR 0.79, 95% CI 0.50 to 1.27).