Clinical Outcomes after Percutaneous Coronary Intervention for Cardiogenic Shock Secondary to Total Occlusive Unprotected Left Main Coronary Artery Lesion-Related Acute Myocardial Infarction.

BACKGROUND: Acute myocardial infarction (AMI) with occlusion of an unprotected left main coronary artery (ULMCA) is a rare condition with a high mortality. The literature on clinical outcomes after percutaneous coronary intervention (PCI) for cardiogenic shock secondary to ULMCA-related AMI is scarce. METHODS: In this retrospective analysis, all consecutive patients undergoing PCI for cardiogenic shock secondary to total occlusive ULMCA-related AMI were included between January 1998 and January 2017. The primary endpoint was 30-day mortality. The secondary endpoints were long-term mortality and 30-day and long-term major adverse cardiovascular and cerebrovascular events. The differences in clinical and procedural variables were assessed. A multivariable model was created to search for independent predictors of survival. RESULTS: Forty-nine patients were included, and the mean age was 62 ± 11 years. The majority of patients suffered cardiac arrest prior or during PCI (51%). Thirty-day mortality was 78%, of which 55% died within 24 h. The median follow-up of patients who survived 30 days (n = 11) was 9.9 years (interquartile range 4.7-13.6), and long-term mortality was 84%. Long-term all-cause mortality was independently associated with cardiac arrest prior or during PCI (hazard ratio [HR] 2.02, 95% confidence interval 1.02-4.01, p = 0.043). Patients who survived to the 30-day follow-up with severe left ventricular dysfunction had a significantly higher risk of mortality compared to patients with moderate to mild dysfunction (p = 0.007). CONCLUSIONS: Cardiogenic shock secondary to total occlusive ULMCA-related AMI carries a very high 30-day all-cause mortality. Thirty-day survivors with a severe left ventricular dysfunction have a poor long-term prognosis.

Clinical outcomes after bare-metal stenting in diabetic patients with lesions carrying a low risk of restenosis.

OBJECTIVE: To evaluate the clinical results of diabetic patients undergoing percutaneous coronary intervention (PCI) for coronary artery lesions carrying a low risk of restenosis treated with a bare-metal stent (BMS). BACKGROUND: There is a discrepancy between current international guidelines on the use of BMS in diabetics with low risk of restenosis coronary artery lesions. METHODS AND RESULTS: Registry data from diabetic patients who underwent non-urgent PCI in a high-volume tertiary referral hospital in the Netherlands was used. The main outcomes were target lesion revascularization (TLR) and the composite of cardiac death, myocardial infarction, and target vessel revascularization at 1-year of follow-up. A total of 1,951 patients were included, of which 1,596 non-diabetics (non-DM), 231 non-insulin requiring diabetics (NIRDM), and 124 insulin requiring diabetics (IRDM).TLR rates in non-DM versus NIRDM were similar (6.3% vs. 5.6%; P = 0.68), whereas TLR in IRDM was higher (6.3% vs. 11.3%; P = 0.03). The composite of cardiovascular clinical outcomes was not significantly different in non-DM versus NIRDM (9.5% vs. 13.4%; P = 0.07), though in IRDM the incidence was higher (9.5% vs. 17.7%; P < 0.01). CONCLUSION: No differences were observed in TLR or composite clinical endpoint at 1-year between non-DM and NIRDM after BMS placement in coronary artery lesions carrying a low risk of restenosis. The presence of IRDM was associated with higher TLR rates when treated with BMS. These results imply that BMS placement may be considered in patients with NIRDM but further work is required to define treatment strategies and, more importantly, improve the outcomes in diabetics.

Gender difference in the prognostic value of estimated glomerular filtration rate at admission in ST-segment elevation myocardial infarction: a prospective cohort study.

OBJECTIVE: To evaluate gender differences in the prognostic value of renal function for mortality in ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PPCI). DESIGN: Prospective single-center cohort. SETTING: Single tertiary referral center in Amsterdam, The Netherlands. Patients consecutive STEMI patients undergoing PPCI (1412 men and 558 women). MAIN OUTCOME MEASURE: The authors calculated adjusted HRs for 3-year all-cause mortality according to the presence of a reduced renal function (estimated glomerular filtration rate <60 ml/min) using Cox proportional hazards models. In order to investigate a possible gender difference in the prognostic value of a reduced renal function, a comparison was made between the HRs of male and female patients and an interaction term was added to the model and tested for significance. Adjustments were made for age, body mass index, history of diabetes or hypertension, systolic blood pressure and heart rate, anterior myocardial infarction and time to treatment. RESULTS: In male patients, a reduced renal function was associated with increased 3-year mortality (adjusted HR 6.31, 95% CI 3.74 to 10.63, p<0.001). A reduced renal function was associated with a twofold increase in the mortality hazard in female patients (adjusted HR 2.22, 95% CI 1.25 to 3.94, p=0.006). CONCLUSIONS: In this large single-centre registry of STEMI patients undergoing PPCI, renal dysfunction as assessed by estimated glomerular filtration rate had prognostic significance for mortality in both male and female patients.