Frequency, clinical and angiographic characteristics, and outcomes of high-risk non-ST-segment elevation acute coronary syndromes patients with left circumflex culprit lesions.

BACKGROUND: The relationship between culprit vessel, infarct size, and outcomes in non-ST-segment elevation acute coronary syndromes (NSTE ACS) is unclear. In some reports, the left circumflex artery (LCX) was more often the culprit at angiography than the right coronary artery (RCA) or left anterior descending artery (LAD), and infarcts were larger with LCX culprits. METHODS: We determined culprit vessel frequency and initial patency (TIMI flow grade), median fold elevation of peak troponin above the upper limit of normal, and outcomes (30-day death or myocardial infarction [MI] and 1-year mortality) by culprit vessel in high-risk NSTE ACS patients in the EARLY ACS trial. RESULTS: Of 9406 patients, 2066 (22.0%) had angiographic core laboratory data. We evaluated 1774 patients for whom the culprit artery was not the left main, a bypass graft, or branch vessel. The culprit was the LCX in 560 (31.6%), LAD in 653 (36.8%), and RCA in 561 (31.6%) patients. There were fewer women (24.1%) and more prior MI (25.5%) among patients with a culprit LCX compared with those with a culprit LAD or RCA. Patients with LCX (21.2%) and RCA (27.5%) culprits more often had an occluded artery (TIMI 0/1) than did those with LAD (11.3%). Peak troponin elevation was significantly higher for LCX than RCA or LAD culprits. LCX culprit vessels were not associated with worse 30-day or 1-year outcomes in adjusted models. CONCLUSIONS: Among patients with NSTE ACS, the frequencies of LCX, LAD, and RCA culprits were similar. Although LCX lesions were associated with higher peak troponin levels, there was no difference in short- or intermediate-term outcomes by culprit artery.

Impact of Aging on Radial Spasm During Coronary Catheterization.

AIMS: To assess the impact of aging on the incidence and severity of radial spasm during coronary catheterization. BACKGROUND: One of the main predictors for transradial approach failure during coronary catheterization is the occurrence of radial spasm. Although it has been suggested that radial spasm might be more common in old patients, the role of confounding factors in older populations and the intuitive thinking that younger patients are more prone to spasm render this debate still active. METHODS: This was a transversal study, which prospectively included consecutive patients referred to our center for elective coronary catheterization during a 6-month period. RESULTS: A total of 190 patients were included. The mean age was 67.9 ± 3.6 years and 130 (68%) were males. Overall, 32 (16.8%) presented with radial spasm. Patients with radial spasm were younger (64.8 ± 12.1 years vs 69.6 ± 12.6 years; P=.04). In the quartile analysis, the largest difference was observed between patients ≤61 years and those >80 years, who presented with a rate of spasm of 25.6% and 9.1%, respectively (P=.04). Multivariable analysis showed that the age of patients was inversely related to the occurrence of radial spasm, decreasing 3% with every additional year (odds ratio [OR], 0.97; 95% confidence interval [CI], 0.94-0.99), and the number of catheters, increasing around 50% with every additional used catheter (OR, 1.54; 95% CI, 1.07-2.23). CONCLUSION: The main finding of the present paper is the inverse association between aging and radial spasm. The present study suggests the need to intensify preventive measures in young patients in order to reduce the incidence of radial spasm.

Right versus left transradial approach for coronary catheterization in octogenarian patients.

OBJECTIVES: The aim of the study was to evaluate if the left radial approach (LRA) confers any additional advantage compared to the right radial approach (RRA) in octogenarian patients who undergo a coronary diagnostic procedure. BACKGROUND: Octogenarians, an increasing segment of patients in our society, present a higher risk of access-site complications related to invasive coronary catheterization. Transradial approach has been shown to be an effective alternative to reduce vascular complications. Although some studies have suggested that elderly people might benefit from a LRA, the advantages of using the left or right radial access remain not clear. METHODS: One hundred octogenarian patients undergoing a transradial coronary angiogram with normal Allen test and without previous history of coronary artery by-pass grafting were randomized to either LRA (n = 50) or RRA (n = 50). The primary end-points of the study were procedural and fluoroscopy times. RESULTS: Mean age was 82.6 years (80-88) and 59% were males. Procedural and fluoroscopy times were similar among study groups. Crossover was required in two patients (4%) with RRA and five patients (10%) with LRA (P = 0.24). Subclavian tortuosity was more frequent in the right side (32% vs. 6% in the left side; P = 0.002) but this difference did not translate into longer procedural or fluoroscopy times or higher cross-over, procedural difficulty or wire manipulation. CONCLUSIONS: In our series of octogenarian patients, the LRA was a valid alternative for diagnostic procedures but its usage was not associated with a significant reduction in procedural and fluoroscopy times compared to the RRA.

Ischaemic postconditioning revisited: lack of effects on infarct size following primary percutaneous coronary intervention.

AIMS: To assess the short- and long-term effects of postconditioning (p-cond) on infarct size, extent of myocardial salvage, and left ventricular ejection fraction (LVEF) in a series of patients presenting with evolving ST-elevation myocardial infarction (STEMI). Previous studies have shown that p-cond during primary percutaneous coronary intervention (PCI) confers protection against ischaemia-reperfusion injury and thus might reduce myocardial infarct size. METHODS AND RESULTS: Seventy-nine patients undergoing PCI for a first STEMI with TIMI grade flow 0-1 and no collaterals were randomized to p-cond (n= 39) or controls (n= 40). Postconditioning was performed by applying four consecutive cycles of 1 min balloon inflation, each followed by 1 min deflation. Infarct size, myocardial salvage, and LVEF were assessed by cardiac-MRI 1 week and 6 months after MI. Postconditioning was associated with lower myocardial salvage (4.1 ± 7.2 vs. 9.1 ± 5.8% in controls; P= 0.004) and lower myocardial salvage index (18.9 ± 27.4 vs. 30.9 ± 20.5% in controls; P= 0.038). No significant differences in infarct size and LVEF were found between the groups at 1 week and 6 months after MI. CONCLUSION: This randomized study suggests that p-cond during primary PCI does not reduce infarct size or improve myocardial function recovery at both short- and long-term follow-up and might have a potential harmful effect.

Endothelin-1 levels predict endothelial progenitor cell mobilization after acute myocardial infarction.

INTRODUCTION: Endothelin-1 (ET-1), circulating endothelial cells (CEC) and endothelial progenitor cells (EPC) are well-known modulators of endothelial function with important cardiac effects after an acute myocardial infarction. However, the relationship between them has never been assessed. The objective of the present study was to establish the relationship between ET-1, CEC, and EPC concentrations after ST-elevation myocardial infarction (STEMI). METHODS: Endothelin-1, CEC, and EPC levels were measured in 61 patients presenting with a first STEMI. Samples were withdrawn acutely 6-24h and 1week after admission. Assessments included reperfusion outcomes (angiography), left ventricular ejection fraction (echocardiography), and 30-day mortality. RESULTS: Mean age was 60.6±12.6years and 45 (74%) were males. Higher ET-1 plasma levels were associated with lower EPC count after 1week (7.45±2.53pg/ml if EPCs in the first quartile vs 5.72±1.49pg/ml if EPCs in the fourth quartile; P=0.04). In contrast with CEC and EPC count, higher ET-1 concentrations on admission were associated with Killip≥2 (9.92±2.01pg/ml vs 7.32±2.13pg/ml; P<0.001), post-reperfusion thrombolysis in myocardial infarction (TIMI) <3 (8.65±2.86pg/ml vs 5.87±1.93pg/ml; P=0.002), myocardial blush grade (MBG) <3 (7.46±2.48pg/ml vs 5.99±2.01pg/ml; P=0.004) and higher 30-day mortality (10.29±2.02pg/ml vs 6.57±2.20pg/ml; P=0.005). CONCLUSIONS: In STEMI patients, high ET-1 levels on admission predict a lower EPC mobilization after 1week. Endothelin-1 provides better clinical, angiographic and echocardiographic information for prognosis than do CEC and EPC concentrations.

Utilidad de la determinación de endotelina-1 en el infarto agudo de miocardio / Usefulness of endothelin-1 assessment in acute myocardial infarction

Introducción y objetivos. Los valores elevados de endotelina-1 (ET-1) se han relacionado con un mal pronóstico tras un infarto agudo de miocardio con elevación del ST (IAMCEST). La vasoconstricción de la microcirculación coronaria parece ser el mecanismo causal. El objetivo de este estudio es analizar los efectos de la ET-1 sobre la microcirculación coronaria, el tamaño del infarto, la fracción de eyección del ventrículo izquierdo (FEVI) y el miocardio rescatado tras un IAMCEST. Métodos. Se determinaron los valores de ET-1 de 127 pacientes (6-24h) tras un IAMCEST. En 97 pacientes se realizó una resonancia magnética para evaluar la obstrucción microvascular (OM), el tamaño del infarto y la FEVI. El índice de miocardio rescatado (IMR) se definió como el porcentaje de área en riesgo angiográfica sin necrosis en la resonancia. Resultados. La edad media de la población fue de 60,9±11,8 años (77% varones). Los pacientes con valores de ET-1 por encima de la mediana presentaron un mayor porcentaje de OM (77,7% si ET-1>6,8 pg/ml frente a 16,6% si ET-1 ≤ 6,8 pg/ml; p<0,001) y menor IMR (13,8%±26% si ET-1>6,8 pg/ml frente a 37,4%±26% si ET-1 ≤ 6,8 pg/ml; p=0,02). Los valores de ET-1 no se asociaron de manera significativa con el tamaño del infarto (p=0,11) ni con la FEVI (p=0,16). En el análisis multivariable, los valores de ET-1 fueron predictores de OM (odds ratio [OR]=2,78; intervalo de confianza [IC] del 95%, 1,16-6,66; p=0,021) e IMR ≤ percentil 25 (OR=1,69; IC del 95%, 1,01-2,81; p=0,04). Conclusiones. Los valores elevados de ET-1 tras un IAMCEST se asocian a un mayor porcentaje de OM y un menor IMR (AU)

Introduction and objectives: High endothelin-1 (ET-1) levels have been linked to poor clinical outcomes after ST-segment elevation myocardial infarction (STEMI). Vasoconstriction of the coronary microcirculation seems to be the underlying mechanism. The aim of the study was to assess the effect of ET-1 on microvascular integrity, infarct size, left ventricular ejection fraction (LVEF) and myocardial salvage in evolving myocardial infarction (MI). Methods: We measured ET-1 levels acutely (6-24 h) in 127 patients presenting with their first STEMI. Contrast-enhanced cardiac magnetic resonance (ce-CMR) was performed in 94 patients within 1 week to assess microvascular obstruction (MO), infarct size and LVEF. A myocardial salvage index (MSI) was defined as the percentage of at-risk angiographic area without necrosis on the ce-CMR. Results: Mean age was 60.9 >= 11.8 years and 98 (77%) were males. Median ET-1 level within the first 24 h was 6.8 pg/mL (25th –75th percentile range: 5.4–8.5 pg/mL). Patients with ET-1 concentrations over the median presented higher percentage of MO (77.7% for ET-1 > 6.8 pg/mL vs. 16.6% for ET-1 6.8 pg/mL, P < .001) and lower MSI values (13.8 <= 26% for ET-1 > 6.8 pg/mL vs. 37.4 (26%) for ET-1 <= 6.8 pg/mL, P = .02). ET-1 levels did not show a significant association with infarct size (P = .11) and LVEF (P = .16). Multivariate analysis found ET-1 to be a significant predictor of MO (OR = 2.78; CI 95% 1.16-6.66; P = .021) and MSI <= Percentile 25 (OR = 1.69, CI 95% 1.01-2.81; P = .04). Conclusions: High ET-1 levels after myocardial infarction are associated with the presence of microvascular obstruction and lower myocardial salvage index (AU)

Usefulness of endothelin-1 assessment in acute myocardial infarction.

INTRODUCTION AND OBJECTIVES: High endothelin-1 (ET-1) levels have been linked to poor clinical outcomes after ST-segment elevation myocardial infarction (STEMI). Vasoconstriction of the coronary microcirculation seems to be the underlying mechanism. The aim of the study was to assess the effect of ET-1 on microvascular integrity, infarct size, left ventricular ejection fraction (LVEF) and myocardial salvage in evolving myocardial infarction (MI). METHODS: We measured ET-1 levels acutely (6-24h) in 127 patients presenting with their first STEMI. Contrast-enhanced cardiac magnetic resonance (ce-CMR) was performed in 94 patients within 1 week to assess microvascular obstruction (MO), infarct size and LVEF. A myocardial salvage index (MSI) was defined as the percentage of at-risk angiographic area without necrosis on the ce-CMR. RESULTS: Mean age was 60.9 ± 11.8 years and 98 (77%) were males. Median ET-1 level within the first 24h was 6.8 pg/mL (25(th) -75(th) percentile range: 5.4-8.5 pg/mL). Patients with ET-1 concentrations over the median presented higher percentage of MO (77.7% for ET-1>6.8 pg/mL vs. 16.6% for ET-1 ≤ 6.8 pg/mL, P<.001) and lower MSI values (13.8 ± 26% for ET-1>6.8 pg/mL vs. 37.4 (26%) for ET-1 ≤ 6.8 pg/mL, P=.02). ET-1 levels did not show a significant association with infarct size (P=.11) and LVEF (P=.16). Multivariate analysis found ET-1 to be a significant predictor of MO (OR=2.78; CI 95% 1.16-6.66; P=.021) and MSI ≤ Percentile 25 (OR=1.69, CI 95% 1.01-2.81; P=.04). CONCLUSIONS: High ET-1 levels after myocardial infarction are associated with the presence of microvascular obstruction and lower myocardial salvage index.

Primary angioplasty vs. fibrinolysis in very old patients with acute myocardial infarction: TRIANA (TRatamiento del Infarto Agudo de miocardio eN Ancianos) randomized trial and pooled analysis with previous studies.

AIMS: To compare primary percutaneous coronary intervention (pPCI) and fibrinolysis in very old patients with ST-segment elevation myocardial infarction (STEMI), in whom head-to-head comparisons between both strategies are scarce. METHODS AND RESULTS: Patients ≥75 years old with STEMI <6 h were randomized to pPCI or fibrinolysis. The primary endpoint was a composite of all-cause mortality, re-infarction, or disabling stroke at 30 days. The trial was prematurely stopped due to slow recruitment after enrolling 266 patients (134 allocated to pPCI and 132 to fibrinolysis). Both groups were well balanced in baseline characteristics. Mean age was 81 years. The primary endpoint was reached in 25 patients in the pPCI group (18.9%) and 34 (25.4%) in the fibrinolysis arm [odds ratio (OR), 0.69; 95% confidence interval (CI) 0.38-1.23; P = 0.21]. Similarly, non-significant reductions were found in death (13.6 vs. 17.2%, P = 0.43), re-infarction (5.3 vs. 8.2%, P = 0.35), or disabling stroke (0.8 vs. 3.0%, P = 0.18). Recurrent ischaemia was less common in pPCI-treated patients (0.8 vs. 9.7%, P< 0.001). No differences were found in major bleeds. A pooled analysis with the two previous reperfusion trials performed in older patients showed an advantage of pPCI over fibrinolysis in reducing death, re-infarction, or stroke at 30 days (OR, 0.64; 95% CI 0.45-0.91). CONCLUSION: Primary PCI seems to be the best reperfusion therapy for STEMI even for the oldest patients. Early contemporary fibrinolytic therapy may be a safe alternative to pPCI in the elderly when this is not available.

Angiographic and magnetic resonance imaging evaluation of in-hospital delay in primary percutaneous intervention delivery on myocardial salvage.

Shortening symptom-to-reperfusion time improves prognosis in patients with ST-segment elevation myocardial infarction. Accordingly, current guidelines target a door-to-balloon time <90 minutes, irrespective of symptom-to-door time; nevertheless, the relation between door-to-balloon and symptom-to-door time and its potential impact on myocardial salvage remains largely unknown. We investigated the influence of door-to-balloon guideline fulfillment on myocardial salvage in patients presenting with different symptom-to-door times. Contrast-enhanced magnetic resonance study was performed acutely to measure infarct size in 172 patients admitted for primary percutaneous coronary intervention of their first ST-segment elevation myocardial infarction to 2 tertiary hospitals. The Bari score was adapted to quantify the angiographic area at risk, and the myocardial salvage index (MSI) was computed as percent area at risk that spared necrosis. Increased symptom-to-balloon time was associated with a significant decrease in MSI only within the first 5 hours (p <0.001). Accomplishment of a target door-to-balloon <90 minutes was associated with a significant increase in MSI only in patients presenting within the first hour of symptom onset (48.5 ± 30.9 vs 29.6 ± 22.3%, p <0.05). Achieving a door-to-balloon time <60 minutes further increased MSI in patients presenting within the second hour of symptoms (43.5 ± 8.6 vs 26.3 ± 20.5%, p <0.01). In conclusion, myocardial salvage progressively decreases up to 5 hours after symptom onset. However, the benefit of the recommended door-to-balloon time appears to be confined to patients presenting within 1 hour of symptom onset.

Enoxaparin in primary and facilitated percutaneous coronary intervention A formal prospective nonrandomized substudy of the FINESSE trial (Facilitated INtervention with Enhanced Reperfusion Speed to Stop Events).

OBJECTIVES: The aim of this study was to assess the risk-benefit of enoxaparin (Sanofi-Aventis, Paris, France) in primary percutaneous coronary intervention (PCI). BACKGROUND: Randomized studies have demonstrated the superiority of enoxaparin over unfractionated heparin (UFH) in acute ST-segment elevation myocardial infarction (STEMI) treated with fibrinolytics. METHODS: In the FINESSE (Facilitated INtervention with Enhanced Reperfusion Speed to Stop Events) trial--a double-blind, placebo-controlled study-2,452 patients with STEMI were randomized to primary PCI or facilitated PCI with abciximab alone or with half-dose reteplase. In this prospective FINESSE substudy, centers pre-specified use of either enoxaparin (0.5 mg/kg intravenous [IV], 0.3 mg/kg subcutaneous [SC]) or UFH (40 U/kg IV, 3,000 U maximum) with PCI. A logistic-regression model and a propensity multivariate model, both adjusted for baseline variables, were used to evaluate primary safety and secondary efficacy end points for enoxaparin versus UFH. RESULTS: Enoxaparin was administered to 759 patients and UFH to 1,693 patients. Nonintracranial Thrombolysis In Myocardial Infarction (TIMI) major/minor bleeding was not significantly different, but lower nonintracranial TIMI major bleeding was found with enoxaparin (2.6% vs. UFH 4.4%, logistic-regression adjusted odds ratio [OR]: 0.55; 95% confidence interval [CI]: 0.31 to 0.99, p = 0.045), whereas intracranial hemorrhage was similar (0.27% vs. 0.24%, adjusted OR: 1.03; 95% CI: 0.11 to 9.68, p = 0.980). Lower death, myocardial infarction, urgent revascularization, or refractory ischemia through 30 days was also associated with enoxaparin (5.3%) versus UFH (8.0%, adjusted OR: 0.47, 95% CI: 0.31 to 0.72, p = 0.0005) as was all-cause mortality through 90 days (3.8% vs. 5.6%, respectively, adjusted OR: 0.59, 95% CI: 0.35 to 0.99, p = 0.046). End points evaluating the net clinical benefit also significantly favored enoxaparin over UFH. CONCLUSIONS: Enoxaparin seems to be associated with a lower risk of cardiovascular outcomes compared with UFH in patients with STEMI undergoing primary PCI. Confirmation of these findings in a randomized study is warranted. (A Study of Abciximab and Reteplase When Administered Prior to Catheterization After a Myocardial Infarction [Finesse]; NCT00046228).

Reperfusion therapy for ST elevation acute myocardial infarction in Europe: description of the current situation in 30 countries.

AIMS: Patient access to reperfusion therapy and the use of primary percutaneous coronary intervention (p-PCI) or thrombolysis (TL) varies considerably between European countries. The aim of this study was to obtain a realistic contemporary picture of how patients with ST elevation myocardial infarction (STEMI) are treated in different European countries. METHODS AND RESULTS: The chairpersons of the national working groups/societies of interventional cardiology in European countries and selected experts known to be involved in the national registries joined the writing group upon invitation. Data were collected about the country and any existing national STEMI or PCI registries, about STEMI epidemiology, and treatment in each given country and about PCI and p-PCI centres and procedures in each country. Results from the national and/or regional registries in 30 countries were included in this analysis. The annual incidence of hospital admission for any acute myocardial infarction (AMI) varied between 90-312/100 thousand/year, the incidence of STEMI alone ranging from 44 to 142. Primary PCI was the dominant reperfusion strategy in 16 countries and TL in 8 countries. The use of a p-PCI strategy varied between 5 and 92% (of all STEMI patients) and the use of TL between 0 and 55%. Any reperfusion treatment (p-PCI or TL) was used in 37-93% of STEMI patients. Significantly less reperfusion therapy was used in those countries where TL was the dominant strategy. The number of p-PCI procedures per million per year varied among countries between 20 and 970. The mean population served by a single p-PCI centre varied between 0.3 and 7.4 million inhabitants. In those countries offering p-PCI services to the majority of their STEMI patients, this population varied between 0.3 and 1.1 million per centre. In-hospital mortality of all consecutive STEMI patients varied between 4.2 and 13.5%, for patients treated by TL between 3.5 and 14% and for patients treated by p-PCI between 2.7 and 8%. The time reported from symptom onset to the first medical contact (FMC) varied between 60 and 210 min, FMC-needle time for TL between 30 and 110 min, and FMC-balloon time for p-PCI between 60 and 177 min. CONCLUSION: Most North, West, and Central European countries used p-PCI for the majority of their STEMI patients. The lack of organized p-PCI networks was associated with fewer patients overall receiving some form of reperfusion therapy.

1-year survival in a randomized trial of facilitated reperfusion: results from the FINESSE (Facilitated Intervention with Enhanced Reperfusion Speed to Stop Events) trial.

OBJECTIVES: The aim of this report was to evaluate 12-month outcomes of facilitated percutaneous coronary intervention (PCI) in the FINESSE (Facilitated Intervention with Enhanced Reperfusion Speed to Stop Events) trial. BACKGROUND: Treatment delays remain common for patients with primary PCI leading to studies evaluating possible benefit of "facilitated" PCI. In the FINESSE trial, no reduction in the 90-day primary ischemic end point and an increase in bleeding were observed with both facilitated approaches, although modest favorable trends were seen for some patient subgroups. METHODS: A total of 2,452 patients with ST-segment elevation myocardial infarction (MI) and anticipated 1 to 4 h delay until catheterization were randomized to reduced-dose reteplase + abciximab, abciximab alone, or placebo, followed by expedited primary PCI. Placebo-treated patients received abciximab in the cath lab. One-year mortality was a pre-specified secondary end point. RESULTS: One-year mortalities in the 3 groups noted in the preceding text were 6.3%, 7.4%, and 7.0%, respectively (p = NS), representing 1.1%, 1.9%, and 2.5% increments since the 90-day outcome (p = 0.053 for combination treatment vs. primary PCI). A favorable trend with combination treatment was seen for patients with anterior MI (p = 0.09), but no other specified groups benefited or tended to benefit. Independent baseline correlates of 1-year mortality were systolic blood pressure <100 mm Hg, prior MI, age, Killip class >1, anterior MI, body mass index < or =25 kg/m(2), heart rate >100 beats/min, and no statin use. CONCLUSIONS: These results suggest that widespread utilization of the facilitated approaches tested cannot be justified, but that high-risk patient groups such as patients with anterior MI may deserve further study. (The FINESSE trial; NCT00046228).

Benefit of facilitated percutaneous coronary intervention in high-risk ST-segment elevation myocardial infarction patients presenting to nonpercutaneous coronary intervention hospitals.

OBJECTIVES: We hypothesized that patients most likely to benefit would be those at high risk with a shorter duration of acute ischemia and who required transfer for percutaneous coronary intervention (PCI). BACKGROUND: The FINESSE (Facilitated Intervention with Enhanced Reperfusion Speed to Stop Events) study failed to demonstrate an improvement in the 90-day composite clinical end point of early treatment with abciximab plus half-dose reteplase (combination-facilitated PCI) or abciximab alone. METHODS: We performed a retrospective analysis of 2,452 patients in this double-blind, placebo-controlled study. Patients were stratified by Thrombolysis In Myocardial Infarction (TIMI) risk score for ST-segment elevation myocardial infarction (STEMI), presentation to a spoke (no PCI available) or hub site, and symptom-to-randomization time. Outcomes included the primary composite end point of death, ventricular fibrillation after 48 h, cardiogenic shock, and congestive heart failure through day 90 as well as 1-year mortality. RESULTS: Mortality for all patients at 1 year was directly related to TIMI risk score (23 of 1,223 = 1.9% in patients with score <3 and 145 of 1,229 = 11.8% with score > or =3, p < 0.001). Patients with TIMI risk score > or =3 and presentation to a spoke site with a symptom-to-randomization time < or =4 h had significantly better 1-year survival if treated with combination-facilitated PCI (hazard ratio [HR]: 0.351, p = 0.01) as well as 90-day composite outcome (HR: 0.45, p = 0.009). A trend for improved survival was also observed in patients with TIMI score > or =3 and spoke site alone (HR: 0.549, p = 0.06). CONCLUSIONS: Facilitation of PCI with a combination of abciximab and half-dose reteplase improved survival at 1 year in high-risk patients presenting to a spoke hospital with symptom-to-randomization time < or =4 h. Further prospective study of facilitated PCI in this subgroup of patients is warranted.

Early risk stratification of patients with cardiogenic shock complicating acute myocardial infarction who undergo percutaneous coronary intervention.

The mortality rate of patients with cardiogenic shock complicating acute myocardial infarction remains exceedingly high despite early mechanical revascularization. Early risk stratification is of great importance to identify patients who could benefit from ventricular assist devices and urgent heart transplantation (UHT). All consecutive patients with cardiogenic shock complicating acute myocardial infarction admitted from June 2001 to December 2007 were prospectively included. Clinical, hemodynamic, and echocardiographic variables were registered on admission and patients were followed for a median of 297 days. A total of 74 patients were included. One-year mortality was 55% and 7 patients (9%) underwent UHT. One-year mortality or need for UHT for patients with postprocedural Thrombolysis In Myocardial Infarction (TIMI) grade 3, 2, and 0 or 1 flows were 38%, 92%, and 90%, respectively (p <0.001). After adjustment by multivariate analysis, the most important predictors of mortality or need for UHT were age >75 years (hazard ratio [HR] 3.56, 95% confidence interval [CI] 1.07 to 11.80), left main coronary artery occlusion (HR 3.75, 95% CI 1.09 to 12.84), left ventricular ejection fraction <25% (HR 2.70, 95% CI 1.17 to 6.22), and postprocedural TIMI grade <3 flow (HR 3.37, 95% CI 1.48 to 7.72). A simple risk score constructed with these 4 variables effectively predicted 1-year survival without the need for UHT (83% for score 0, 19% for score 1, and 6% for score 2, p <0.001). In conclusion, age >75 years, left main coronary artery occlusion, left ventricular ejection fraction <25%, and postprocedural TIMI grade <3 flow were significantly associated with worse prognosis. A simple risk score rapidly available in the catheterization laboratory can efficiently estimate prognosis.

Comparison of six-month outcomes for primary percutaneous revascularization for acute myocardial infarction with drug-eluting versus bare metal stents (from the APEX-AMI study).

We evaluated the use and outcomes of drug-eluting stents (DESs) and bare metal stents (BMSs) in a large primary percutaneous coronary intervention (PCI) acute ST-elevation myocardial infarction (MI) trial. Recently concerns have been raised with "off-label" use of DESs for short- and long-term clinical outcomes. Limited randomized data exist evaluating DESs versus BMSs in ST-elevation MI. Patients (n=5,745) in the Assessment of Pexelizumab in Acute Myocardial Infarction (APEX-AMI) trial were categorized by stent type used. Baseline variables and clinical outcomes were collected at 90 days and 6 months. Outcomes by stent type were adjusted for using conventional multivariable predictors of 90-day mortality (age, anterior location, total ST-segment deviation, and Killip class), time to PCI, and Thrombolysis In Myocardial Infarction grade flow. Stents were deployed (at the investigator's discretion) in 5,124 patients (89.2%) with acute MI, with DES use in 2,221 (43.3%) and BMS use in 2,903 (56.7%). Patients receiving DESs were younger (median 59 vs 63 years of age, p<0.001), had left anterior descending coronary artery PCI (57.9% vs 48.1%, p<0.001), and often were treated in the United States (58.2%). DES-treated patients had a lower adjusted mortality at 90 days (hazard ratio 0.73, 95% confidence interval [CI] 0.54 to 0.99, p=0.046) and trended toward lower mortality (hazard ratio 0.77, 95% CI 0.58 to 1.03, p=0.084) and recurrent MI (hazard ratio 0.81, 95% CI 0.59 to 1.11, p=0.186) at 6 months compared with BMSs. In conclusion, in this observational analysis of stent use from a large primary percutaneous intervention for acute MI trial, DESs appear as safe as BMSs with similar 6-month clinical outcomes with regard to death and recurrent MI.

New insights in the management of cardiogenic shock complicating myocardial infarction: role of urgent heart transplantation.

OBJECTIVE: This study assessed the role of heart transplantation (HTx) in the management of patients with acute myocardial infarction (MI) complicated by refractory cardiogenic shock despite percutaneous coronary intervention (PCI). The primary end-point of the study was mortality at the 1-year follow-up. METHODS: Between January 2001 and December 2005, 74 consecutive patients with acute MI complicated with cardiogenic shock were retrospectively analyzed. Thirty-nine patients did not have a contraindication for HTx and qualified for the study (age < 65 years, no comorbidities). RESULTS: Urgent HTx was performed in 10 patients. The remaining 29 patients served as controls. The HTx vs no HTx groups were well balanced in age (50 vs 53 years), proportion of multivessel disease (30% vs 10%), cardiac index (2.2 vs 2.4 liters/min/m(2)), and left ventricular ejection fraction (23% vs 25%). Mortality rates were significantly lower in the HTx group, both in the hospital (10% vs 45%, p < 0.03) and at 1 year (10% vs 52%, p < 0.03). Survival at 1 year among patients alive at hospital discharge was 100% in the HTx group vs 94% in the no HTx group. CONCLUSIONS: Urgent HTx dramatically improves survival of acute MI patients presenting with refractory cardiogenic shock despite early PCI. Therefore, this approach--wherever feasible--needs to be considered in the management of this particular subset of patients.

Facilitated PCI in patients with ST-elevation myocardial infarction.

BACKGROUND: We hypothesized that percutaneous coronary intervention (PCI) preceded by early treatment with abciximab plus half-dose reteplase (combination-facilitated PCI) or with abciximab alone (abciximab-facilitated PCI) would improve outcomes in patients with acute ST-segment elevation myocardial infarction, as compared with abciximab administered immediately before the procedure (primary PCI). METHODS: In this international, double-blind, placebo-controlled study, we randomly assigned patients with ST-segment elevation myocardial infarction who presented 6 hours or less after the onset of symptoms to receive combination-facilitated PCI, abciximab-facilitated PCI, or primary PCI. All patients received unfractionated heparin or enoxaparin before PCI and a 12-hour infusion of abciximab after PCI. The primary end point was the composite of death from all causes, ventricular fibrillation occurring more than 48 hours after randomization, cardiogenic shock, and congestive heart failure during the first 90 days after randomization. RESULTS: A total of 2452 patients were randomly assigned to a treatment group. Significantly more patients had early ST-segment resolution with combination-facilitated PCI (43.9%) than with abciximab-facilitated PCI (33.1%) or primary PCI (31.0%; P=0.01 and P=0.003, respectively). The primary end point occurred in 9.8%, 10.5%, and 10.7% of the patients in the combination-facilitated PCI group, abciximab-facilitated PCI group, and primary-PCI group, respectively (P=0.55); 90-day mortality rates were 5.2%, 5.5%, and 4.5%, respectively (P=0.49). CONCLUSIONS: Neither facilitation of PCI with reteplase plus abciximab nor facilitation with abciximab alone significantly improved the clinical outcomes, as compared with abciximab given at the time of PCI, in patients with ST-segment elevation myocardial infarction. (ClinicalTrials.gov number, NCT00046228 [ClinicalTrials.gov].)