RESUMO
BACKGROUND: Recent trials suggest that complete revascularization in patients with acute ST-segment-elevation myocardial infarction and multivessel disease is associated with better outcomes than infarct-related artery (IRA)-only revascularization. There are different methods to select non-IRA lesions for revascularization procedures. We assessed the clinical outcomes of complete angiographically guided revascularization versus stress echocardiography-guided revascularization in patients with ST-segment-elevation myocardial infarction. METHODS: We performed a randomized clinical trial in patients with multivessel disease who underwent a successful percutaneous coronary intervention of the IRA to test differences in prognosis (composite end point included cardiovascular mortality, nonfatal reinfarction, coronary revascularization, and readmission for heart failure after 12 months of follow-up) between complete angiographically guided revascularization (n=154) or stress echocardiography-guided revascularization (n=152) of the non-IRA lesions in an elective procedure before hospital discharge. RESULTS: The trial was prematurely stopped after the inclusion of 77% of the planned study population. As many as 152 (99%) patients in the complete revascularization group and 44 (29%) patients in the selective revascularization group required a percutaneous coronary intervention procedure of a non-IRA lesion before discharge. The primary end point occurred in 21 (14%) patients of the stress echocardiography-guided revascularization group and 22 (14%) patients of the complete angiographically guided revascularization group (hazard ratio, 0.95; 95% CI, 0.52-1.72; P=0.85). CONCLUSIONS: In patients with ST-segment-elevation myocardial infarction and multivessel disease, stress echocardiography-guided revascularization may not be significantly different to complete angiographically guided revascularization, thereby reducing the need for elective revascularization before hospital discharge. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01179126.
Assuntos
Angiografia Coronária , Doença da Artéria Coronariana/terapia , Vasos Coronários/diagnóstico por imagem , Ecocardiografia sob Estresse , Intervenção Coronária Percutânea , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Idoso , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/mortalidade , Doença da Artéria Coronariana/fisiopatologia , Vasos Coronários/fisiopatologia , Término Precoce de Ensaios Clínicos , Teste de Esforço , Feminino , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/fisiopatologia , Insuficiência Cardíaca/terapia , Humanos , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/mortalidade , Valor Preditivo dos Testes , Recidiva , Fatores de Risco , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico por imagem , Infarto do Miocárdio com Supradesnível do Segmento ST/mortalidade , Infarto do Miocárdio com Supradesnível do Segmento ST/fisiopatologia , Espanha , Fatores de Tempo , Resultado do TratamentoRESUMO
Introducción y objetivos. Analizar los resultados y cambios asistenciales del programa de angioplastia primaria del Complejo Hospitalario Universitario A Coruña tras iniciar el Programa Gallego de Atención al Infarto de Miocardio (PROGALIAM). Métodos. Registro observacional de 1.434 pacientes remitidos para angioplastia primaria entre 2003 y 2007. Los resultados de la era PROGALIAM (de mayo de 2005 a diciembre de 2007; n = 963) se compararon con los de la etapa previa (de enero de 2003 a abril de 2005; n = 388). Resultados. Tras iniciar el PROGALIAM, aumentó el número de casos de angioplastia primaria (etapa previa, 14,4 casos/mes; PROGALIAM, 32,3 casos/mes), la media de edad (etapa previa, 61,3 ± 11,9 años; PROGALIAM, 64,2 ± 11,7 años; p < 0,001) y la proporción de pacientes procedentes de hospitales periféricos y pacientes tratados fuera del horario laboral. La mediana de retraso primer contacto-balón se incrementó en el conjunto del programa (etapa previa, 106 min; etapa PROGALIAM, 113 min; p = 0,02), pero se redujo entre los pacientes procedentes de centros secundarios (etapa previa, 171 min; etapa PROGALIAM, 146 min; p < 0,001). La proporción de casos con retraso primer contacto-balón < 120 min permaneció invariable entre los pacientes del centro intervencionista (etapa previa, 69%; etapa PROGALIAM, 71%; p = 0,56) y se incrementó entre los pacientes de centros periféricos, si bien en este subgrupo continuó siendo baja (etapa previa, 17%; etapa PROGALIAM, 30%; p = 0,04). La mortalidad a 30 días (etapa previa, 5,2%; etapa PROGALIAM, 6,2%; p = 0,85) y a 1 año (etapa previa, 9,5%; etapa PROGALIAM, 10,2%; p = 0,96) fue similar en ambas etapas. Conclusiones. El PROGALIAM ha permitido incrementar la proporción de pacientes tratados con angioplastia primaria manteniendo los resultados de esta terapia (AU)
Introduction and objectives. To analyze changes in healthcare delivery and results for primary angioplasty at Centro Hospitalario Universitario A Coruña following implementation of the PROGALIAM protocol. Methods. Observational registry of 1434 patients referred for primary angioplasty between 2003 and 2007. Results under PROGALIAM (May 2005 - December 2007; n=963) were compared with those from the preceding period (January 2003 - April 2005; n=388). Results. After implementing PROGALIAM, there were increases in the number of primary angioplasty procedures (preceding period, 14.4 cases/month; PROGALIAM, 32.2 cases/month), mean patient age (preceding period, 61.3 (11.9) years; PROGALIAM, 64.2 (11.7) years; P<.001), and the percentage of patients referred from peripheral hospitals and treated after normal working hours. Overall median first medical contact-to-balloon time increased (previous period, 106min; PROGALIAM, 113min; P=.02), but decreased significantly among patients referred from noninterventional centers (previous period, 171min; PROGALIAM, 146min; P<.001). Percentage of cases with an first medical contact-to-balloon time <120min remained unchanged among interventional-center patients (preceding period, 69%; PROGALIAM, 71%; P=.56) and increased among patients at noninterventional centers, although it remained low in this subgroup (preceding period, 17%; PROGALIAM, 30%; P=.04). Thirty-day mortality (preceding period, 5.2%; PROGALIAM, 6.2%; P=.85) and 1-year mortality (preceding period, 9.5%; PROGALIAM, 10.2%; P=.96) remained unchanged. Conclusions. Implementation of PROGALIAM allowed us to increase the percentage of patients receiving primary angioplasty without jeopardizing the clinical results of this treatment (AU)
Assuntos
Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Angioplastia/métodos , Angioplastia/tendências , Angioplastia , Infarto do Miocárdio/complicações , Infarto do Miocárdio/diagnóstico , Aspirina/uso terapêutico , Angiografia/métodos , Angiografia , Infarto do Miocárdio/fisiopatologia , Infarto do Miocárdio , /normas , Medicina de Emergência/métodos , Análise de Variância , Prognóstico , Análise Multivariada , Modelos LogísticosRESUMO
INTRODUCTION AND OBJECTIVES: To analyze changes in healthcare delivery and results for primary angioplasty at Centro Hospitalario Universitario A Coruña following implementation of the PROGALIAM protocol. METHODS: Observational registry of 1434 patients referred for primary angioplasty between 2003 and 2007. Results under PROGALIAM (May 2005 - December 2007; n=963) were compared with those from the preceding period (January 2003 - April 2005; n=388). RESULTS: After implementing PROGALIAM, there were increases in the number of primary angioplasty procedures (preceding period, 14.4 cases/month; PROGALIAM, 32.2 cases/month), mean patient age (preceding period, 61.3 (11.9) years; PROGALIAM, 64.2 (11.7) years; P<.001), and the percentage of patients referred from peripheral hospitals and treated after normal working hours. Overall median first medical contact-to-balloon time increased (previous period, 106 min; PROGALIAM, 113 min; P=.02), but decreased significantly among patients referred from noninterventional centers (previous period, 171 min; PROGALIAM, 146 min; P<.001). Percentage of cases with an first medical contact-to-balloon time <120 min remained unchanged among interventional-center patients (preceding period, 69%; PROGALIAM, 71%; P=.56) and increased among patients at noninterventional centers, although it remained low in this subgroup (preceding period, 17%; PROGALIAM, 30%; P=.04). Thirty-day mortality (preceding period, 5.2%; PROGALIAM, 6.2%; P=.85) and 1-year mortality (preceding period, 9.5%; PROGALIAM, 10.2%; P=.96) remained unchanged. CONCLUSIONS: Implementation of PROGALIAM allowed us to increase the percentage of patients receiving primary angioplasty without jeopardizing the clinical results of this treatment.