Long-term survival of elderly patients undergoing percutaneous coronary intervention for myocardial infarction complicated by cardiogenic shock.

BACKGROUND: The long-term benefit of early percutaneous coronary intervention (PCI) for cardiogenic shock (CS) in elderly patients remains unclear. We sought to assess the long-term survival of elderly patients (age ≥ 75 years) with myocardial infarction (MI) complicated by CS undergoing PCI. METHODS: We analyzed baseline characteristics, early outcomes, and long-term survival in 421 consecutive patients presenting with MI and CS who underwent PCI from the Melbourne Interventional Group registry from 2004 to 2011. Mean follow-up of patients who survived to hospital discharge was 3.0 ± 1.8 years. RESULTS: Of the 421 consecutive patients, 122 patients were elderly (≥ 75 years) and 299 patients were younger (< 75 years). The elderly cohort had significantly more females, peripheral and cerebrovascular disease, renal impairment, heart failure (HF) and prior MI (all p < 0.05). Procedural success was lower in the elderly (83% vs. 92%, p < 0.01). Long-term mortality was significantly higher in the elderly (p < 0.01), driven by high in-hospital mortality (48% vs. 36%, p < 0.05). However, in a landmark analysis of hospital survivors in the elderly group, long-term mortality rates stabilized, approximating younger patients with CS (p = 0.22). Unsuccessful procedure, renal impairment, HF and diabetes mellitus were independent predictors of long-term mortality. However, age ≥ 75 was not a significant predictor (HR 1.2; 95% CI 0.9-1.7; p = 0.2). CONCLUSIONS: Elderly patients with MI and CS have lower procedural success and higher in-hospital mortality compared to younger patients. However, comparable long-term survival can be achieved, especially in patients who survive to hospital discharge with the selective use of early revascularization.

Radiation exposure with the radial approach for diagnostic coronary angiography in a centre previously performing purely the femoral approach.

INTRODUCTION: Use of the radial approach for coronary angiography and percutaneous coronary intervention (PCI) is known to improve many patient outcome measures. However, there is some concern that it may be associated with increased patient radiation exposure. This study explores radiation exposure with the radial approach compared with the femoral approach in a centre previously performing purely femoral approach. PATIENTS AND METHODS: Data was collected retrospectively for all patients undergoing diagnostic coronary angiography over a six month period. PCIs and procedures with inherent technical difficulty or use of additional techniques (graft studies, optical coherence tomography, fractional flow reserve) were excluded. Dose area product (DAP) and fluoroscopy time (FT) were analysed for all remaining procedures (n=389), comparing radial (n=109) and femoral (n=280) approaches. RESULTS: The overall mean FT for transradial cases (7.45 mins) was significantly higher than for transfemoral cases (4.59 mins; p<0.001). The overall mean DAP for transradial cases (95.64 G Gycm(2)) was significantly higher than for transfemoral cases (70.25 Gycm(2), p<0.05)). Neither the FT nor the DAP decreased over the six month period. CONCLUSION: The radial approach was associated with significantly higher DAP and FT compared to the femoral approach during an initial introductory phase which was likely insufficient to develop radial proficiency. The results of this study are consistent with previous studies and may influence choice of access for non-emergent diagnostic coronary angiography before radial proficiency has been established, particularly for patients more susceptible to radiation risks.

Survival in patients with myocardial infarction complicated by out-of-hospital cardiac arrest undergoing emergency percutaneous coronary intervention.

OBJECTIVES: We sought to evaluate the clinical outcomes of patients with myocardial infarction (MI) complicated by out-of-hospital cardiac arrest (OHCA) undergoing percutaneous coronary intervention (PCI). BACKGROUND: Controversy remains regarding the benefit of early PCI in patients with MI complicated by OHCA. METHODS: We analyzed the outcomes of 88 consecutive patients presenting with MI complicated by OHCA compared to 5101 patients with MI without OHCA who underwent PCI from the Melbourne Interventional Group registry between 2004 and 2009. RESULTS: Patients with OHCA had a higher proportion of ST-elevation MI presentations (90.9% vs. 50%, p<0.01) and were more likely to be to be in cardiogenic shock (38.6% vs. 4.6%, p<0.01). Procedural success was similar in the two groups (95.5% OHCA vs. 96.5% non-OHCA MI cohort, p=0.65). In-hospital, 30-day, and 1-year survival in the OHCA cohort versus the non-OHCA MI cohort were 62.5% vs. 97.2% (p<0.01), 61.4% vs. 96.5% (p<0.01), and 60.2% vs. 94.2% (p<0.01), respectively. Within the OHCA cohort, presentation with cardiogenic shock (OR 7.2, 95% CI: 2.7-18.8; p<0.01) was strongly associated with in-hospital mortality. Importantly, 1-year survival of patients discharged alive from hospital was similar between the two groups (96% vs. 97% p=0.8). CONCLUSION: Patients with MI complicated by OHCA remain a high-risk group associated with high mortality. However, high procedural success rates similar to non-OHCA patients can be attained. Survival rates better than previously reported were observed with an emergent PCI approach, with 1-year survival comparable to a non-OHCA cohort if patients survive to hospital discharge.

Family history does not predict angiographic localization or severity of coronary artery disease.

BACKGROUND: Family history of MI is an established risk factor for coronary artery disease and subclinical atherosclerosis. Maternal MI and maternal stroke are more common in females than males presenting with acute coronary syndromes (ACS), suggesting sex-specific heritability, but the effects of family history on location and extent of coronary artery disease are unknown. METHODS: In a prospective, population-based study (Oxford Vascular Study) of all patients with ACS, family history data for stroke and MI were analysed by sex of proband and affected first degree relatives (FDRs), and coronary angiograms were reviewed, where available. RESULTS: Of 835 probands with one or more ACS, 623 (420 males) had incident events and complete family history data. 351 patients with incident events (56.3%; 266 males) underwent coronary angiography. Neither angiographic disease localization nor severity were associated with sex-of-parent/sex-of-offspring in men or women. CONCLUSIONS: Sex-specific family history data do not predict angiographic localization of coronary disease in patients presenting with ACS. Maternal stroke and maternal MI probably affect ACS in females by a mechanism unrelated to atherosclerosis or coronary anatomy. However, family history data may still be useful in risk prediction and prognosis of ACS.

Early diagnosis of perioperative myocardial infarction after coronary bypass grafting: a study using biomarkers and cardiac magnetic resonance imaging.

BACKGROUND: Myocardial injury related to coronary artery bypass grafting (CABG) is poorly characterized, and understanding the characteristic release of biomarkers associated with revascularization injury might provide novel therapeutic opportunities. This study characterized early changes in biomarkers after revascularization injury during on-pump CABG. METHODS: This prospective study comprised 28 patients undergoing on-pump CABG and late gadolinium enhancement (LGE) cardiac magnetic resonance imaging (CMRI) who underwent measurements of cardiac troponin I (cTnI), creatine kinase-MB, and inflammatory markers (C-reactive protein, serum amyloid A, myeloperoxidase, interleukin 6, tumor necrosis factor-α, matrix metalloproteinase 9a, monocyte chemotactic protein-1, plasminogen activator inhibitor-1a) at baseline, at 1, 6, 12, and 24 hours, and at 1 week (inflammatory markers only) post-CABG. Biomarker results at 1 hour were studied for a relationship to new myocardial infarction as defined by CMRI-LGE, and the diagnostic utility of combining positive biomarkers was assessed. RESULTS: All patients had an uneventful recovery, but 9 showed a new myocardial infarction demonstrated by new areas of hyperenhancement on CMR. Peak cTnI at 24 hours (ρ = 0.66, p < 0.001) and CK-MB (ρ = 0.66, p < 0.001) correlated with the amount of new LGE. At 1 hour, 3 biomarkers--cTnI, interleukin 6, and tumor necrosis factor-α--were significantly elevated in patients with vs those without new LGE. Receiver operating curve analysis showed cTnI was the most accurate at detecting new LGE at 1 hour: a cutoff of cTnI exceeding 5 µg/L at 1 hour had 67% sensitivity and 79% specificity for detecting new LGE. CONCLUSIONS: Unexpected CABG-related myocardial injury occurs in a significant proportion of patients. A cTnI test at 1 hour after CABG could potentially differentiate patients with significant revascularization injury.

Systemic levels of endothelin correlate with systemic inflammation and not with myocardial injury or left ventricular ejection fraction in patients undergoing percutaneous coronary intervention and on-pump coronary artery bypass grafting.

Endothelin (ET-1) is a potent vasoconstrictor. We compared patterns of ET-1 in percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) and correlated it with markers of inflammation. Patients with multivessel disease were enrolled in a prospective randomized study of PCI vs. on-pump CABG. Procedural myocardial injury was assessed biochemically (CK-MB) and with new late gadolinium enhancement (LGE) on magnetic resonance imaging (MRI) one week postprocedure. ET-1 was measured at baseline, 1 h, 6 h, 12 h, 24 h and one week postprocedure. Log ET-1 values were compared between PCI and CABG and between patients without significant myocardial injury. Measurement of ET-1 values was performed in 36 PCI and 31 CABG patients. Baseline ET-1 values were similar between PCI and CABG patients (0.91 ± 0.36 vs. 1.0 ± 49 pg/ml, P = 0.38). Peak values were reached at 1 h in PCI and at 24 h in CABG patients and patients undergoing CABG had significantly higher log ET-1 values at 6 h, 12 h and 24 h. ET-1 did not correlate with biochemical or morphological markers of myocardial injury or change of left ventricular ejection fraction (LV-EF) but good linear correlation between max logET-1 and max logCRP was found (r = 0.44, P = 0.0002). ET-1 rise is more pronounced in on-pump CABG and ET-1 production could be driven by periprocedural inflammatory reaction.

Familial history of stroke is associated with acute coronary syndromes in women.

BACKGROUND: Stroke in female first-degree relatives (FDRs) is a powerful risk factor for ischemic stroke in women, but its association with acute coronary syndromes (ACS) is unknown. Family history (FH) of stroke is omitted from existing myocardial infarction risk prediction tools, which perform less well in women than in men. Our objective was to study the sex-of-parent and sex-of-proband interactions for FH of stroke in ACS patients. METHODS AND RESULTS: In a prospective, population-based study (Oxford Vascular Study) of all patients with ACS or stroke/transient ischemic attack, FH data for stroke and myocardial infarction were analyzed by sex of proband and FDRs, and coronary angiograms were reviewed, where available; 942 of 1058 ACS probands and 1015 of 1152 stroke/transient ischemic attack probands had complete FH data; 24.1% of ACS probands and 24.3% of stroke/transient ischemic attack probands had history of stroke in ≥1 FDR. Maternal stroke was more common than paternal stroke in female ACS probands (odds ration [OR], 2.53; 1.39 to 4.61) but not in male probands (OR, 0.92; 0.64 to 1.32) (difference-P=0.004). Overall, female ACS probands were more likely to have female than male FDRs with stroke (OR, 2.09; 1.29 to 3.37), whereas the opposite trend was seen in male ACS probands (OR, 0.69; 0.50 to 0.97) (difference-P=0.0002). However, there was no association between parental history of stroke and disease localization or presence of multivessel disease on coronary angiography. CONCLUSIONS: FH of stroke is as common in ACS patients as in stroke/transient ischemic attack patients and sex-of-parent/sex-of-proband interactions are similar. Stroke in female FDRs may help to identify women at increased risk of ACS as well as ischemic stroke.

With the "universal definition," measurement of creatine kinase-myocardial band rather than troponin allows more accurate diagnosis of periprocedural necrosis and infarction after coronary intervention.

OBJECTIVES: We aimed to assess the differential implications of creatine kinase-myocardial band (CK-MB) and troponin measurement with the universal definition of periprocedural injury after percutaneous coronary intervention. BACKGROUND: Differentiation between definitions of periprocedural necrosis and periprocedural infarction has practical, sociological, and research implications. Troponin is the recommended biomarker, but there has been debate about the recommended diagnostic thresholds. METHODS: Thirty-two patients undergoing multivessel percutaneous coronary intervention and late gadolinium enhancement (LGE) cardiac magnetic resonance (CMR) imaging in a prospective study had cardiac troponin I, CK-MB, and inflammatory markers (C-reactive protein, serum amyloid A, myeloperoxidase, tumor necrosis factor alpha) measured at baseline, 1 h, 6 h, 12 h, and 24 h after the procedure. Three "periprocedural injury" groups were defined with the universal definition: G1: no injury (biomarker <99th percentile); G2: periprocedural necrosis (1 to 3 × 99th percentile); G3: myocardial infarction (MI) type 4a (>3 × 99th percentile). Differences in inflammatory profiles were analyzed. RESULTS: With CK-MB there were 17, 10, and 5 patients in groups 1, 2, and 3, respectively. Patients with CK-MB-defined MI type 4a closely approximated patients with new CMR-LGE injury. Groups defined with CK-MB showed progressively increasing percentage change in C-reactive protein and serum amyloid A, reflecting increasing inflammatory response (p < 0.05). Using cardiac troponin I resulted in 26 patients defined as MI type 4a, but only a small minority had evidence of abnormality on CMR-LGE, and only 3 patients were defined as necrosis. No differences in inflammatory response were evident when groups were defined with troponin. CONCLUSIONS: Measuring CK-MB is more clinically relevant for diagnosing MI type 4a, when applying the universal definition. Current troponin thresholds are oversensitive with the arbitrary limit of 3 × 99th percentile failing to discriminate between periprocedural necrosis and MI type 4a. (Myocardial Injury following Coronary Artery bypass Surgery versus Angioplasty: a randomised controlled trial using biochemical markers and cardiovascular magnetic resonance imaging; ISRCTN25699844).

Myocardial injury following coronary artery surgery versus angioplasty (MICASA): a randomised trial using biochemical markers and cardiac magnetic resonance imaging.

AIMS: To compare the frequency and extent of Troponin I and late gadolinium enhancement (LGE) cardiac magnetic resonance (CMR) defined injury following PCI compared with CABG in patients with multivessel and/or left main coronary artery disease (CAD), and interpret these finding in light of the new ESC/ACCF/AHA/WHF Task Force definitions for necrosis and infarction. METHODS AND RESULTS: Prospective, registered, single centre randomised controlled trial. Eighty patients with 3 vessel CAD (≥ 50% stenoses), or 2 vessel CAD including a type C lesion in the LAD, and/or left main disease were enrolled. Mean SYNTAX and EuroSCOREs were similar for both groups. Forty patients underwent PCI with drug eluting stents and 39 underwent CABG (one died prior to CABG). In the PCI group 6/38 (15.8%) patients had LGE, compared with 9/32 (28.1%) CABG patients (p = 0.25). Using the new Task Force definitions, necrosis occurred in 30/40 (75%) PCI patients and 35/35 (100%) CABG patients (p = 0.001), whilst infarction occurred in 30/40 (75%) PCI patients and 9/32 (28.1%) CABG patients (p = 0.0001). CONCLUSIONS: Periprocedural necrosis according to the Task Force definition was significantly lower in the PCI group, and universal in the CABG group. The incidence and extent of CMR defined infarction following PCI did not differ compared with CABG. This demonstrates that PCI can achieve revascularisation in complex patients without increased procedural myocardial damage.

Survival of elderly patients undergoing percutaneous coronary intervention for acute myocardial infarction complicated by cardiogenic shock.

OBJECTIVES: We sought to assess clinical outcomes of elderly patients (age >or=75 years) undergoing percutaneous coronary intervention (PCI) for acute myocardial infarction (MI) complicated by cardiogenic shock (CS) in a contemporary multicenter PCI registry. BACKGROUND: Although benefits of early PCI have been shown in younger groups, few studies have reported on clinical outcomes in elderly shock patients using current PCI techniques. METHODS: We analyzed baseline characteristics and procedural and clinical outcomes in 143 consecutive patients presenting with MI and CS who underwent PCI from the Melbourne Interventional Group registry between 2004 and 2007. RESULTS: Of the 143 patients, 31.5% (n = 45) were elderly and 68.5% were younger (age <75 years). Elderly patients were more likely to be female (46.7% vs. 22.4%, p < 0.01) and have hypertension (77.8% vs. 46.4%, p < 0.01), previous MI (31.1% vs. 15.5%, p = 0.03), renal failure (24.4% vs. 11.3%, p < 0.05) and multivessel coronary artery disease (93.1% vs. 68.3%, p < 0.01). Stent (86.7% vs. 94.8%, p = 0.09), glycoprotein IIb/IIIa inhibitor (68.9% vs. 65.3%, p = 0.67), and intra-aortic balloon pump (57.8% vs. 58.2%, p = 0.97) use were similar in both groups. In-hospital, 30-day, and 1-year mortality in the elderly group versus the younger group were 42.2% vs. 33.7% (p = 0.32), 43.2% vs. 36.1% (p = 0.42), and 52.6% vs. 46.8% (p = 0.56), respectively. CONCLUSIONS: In this study, the 1-year survival of elderly patients with acute MI complicated by CS undergoing PCI was comparable to younger patients. These data suggest that in elderly patients presenting with CS, benefit is possible with selective use of early revascularization and merits further investigation.