Circulation: Cardiovascular Interventions Editors’ Picks

Abstract

HomeCirculation: Cardiovascular InterventionsVol. 6, No. 6Circulation: Cardiovascular Interventions Editors’ Picks Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBCirculation: Cardiovascular Interventions Editors’ PicksMost Important Articles in ST-Elevation–Myocardial Infarction The Editors The Editors Search for more papers by this author Originally published1 Dec 2013https://doi.org/10.1161/CIRCINTERVENTIONS.113.001090Circulation: Cardiovascular Interventions. 2013;6:e69–e79Risk FactorsPrognostic Impact of Hyperglycemia in Nondiabetic and Diabetic Patients With ST-Elevation–Myocardial Infarction: Insights From Contrast-Enhanced Magnetic Resonance ImagingSummary: Previous studies have suggested that hyperglycemia on admission is a risk factor for increased mortality in patients with acute ST-elevation–myocardial infarction (STEMI). However, data regarding the relationship between hyperglycemia and myocardial damage in STEMI are scarce. This largest cardiac magnetic resonance study to date evaluating the relationship of diabetes mellitus status and elevated glucose levels on admission on myocardial damage in STEMI patients reperfused by primary percutaneous coronary intervention has 2 essential findings: (1) STEMI patients with pre-existing diabetes mellitus are at greater risk for major adverse cardiovascular events despite having similar infarct sizes and extent of reperfusion injury than patients without known diabetes mellitus. (2) Elevated glucose levels on admission are associated with greater myocardial damage (larger infarcts, more pronounced reperfusion injury, left ventricular dysfunction) and an increased risk of clinical events at long-term follow-up. However, hyperglycemia was a stronger indicator of myocardial injury in STEMI patients without previously recognized diabetes mellitus than in those with established diabetes mellitus. Thus, the authors’ study confirms and expands previous findings by demonstrating that the amount of myocardial injury does not explain the substantially higher mortality rates in diabetic patients with STEMI. Moreover, the authors could demonstrate that the relationship between hyperglycemia and myocardial damage is different in STEMI patients with and without known diabetes mellitus.Conclusions: The higher mortality rate in diabetic versus nondiabetic STEMI patients is not explained by more pronounced myocardial damage. Hyperglycemia on admission is associated with greater myocardial injury and an increased risk of major adverse cardiovascular events at long-term follow-up. However, hyperglycemia has a stronger relationship to myocardial injury in nondiabetic compared with diabetic patients.1Polyvascular Disease and Long-Term Cardiovascular Outcomes in Older Patients With Non–ST-Segment–Elevation Myocardial InfarctionSummary: Prior studies have shown that patients with non–ST-segment–elevation myocardial infarction and polyvascular disease (prior peripheral arterial disease, cerebrovascular disease, or both in addition to coronary artery disease) have worse in-hospital and intermediate-term (6–12 months) outcomes after their acute myocardial infarction. There seems to be a gradation of risk with the number of affected arterial beds such that patients with atherosclerotic involvement of all 3 arterial beds have worse short-term and intermediate-term outcomes compared with those with dual-bed involvement, whereas those with coronary bed involvement alone have the lowest risk. The present analysis extends findings of prior studies to the long-term setting by demonstrating in a contemporary cohort that older patients with non–ST-segment–elevation myocardial infarction and polyvascular disease have very high rates of mortality (>50% at 3 years) and composite ischemic end points compared with patients without polyvascular disease. The risk of long-term outcomes increases incrementally with increasing number of arterial beds involved. Despite increased long-term risk associated with polyvascular disease, the use of guidelines-based recommended therapies is modest.Conclusions: Among older patients with non–ST-segment–elevation myocardial infarction, those with polyvascular disease have substantially higher long-term risk for recurrent events or death. Future studies targeting greater adherence to secondary prevention strategies and novel therapies are needed to help to reduce long-term cardiovascular events in this vulnerable population.2Frailty Is Independently Associated With Short-Term Outcomes for Elderly Patients With Non–ST-Segment Elevation Myocardial InfarctionSummary: There is sometimes a disconnect between biological and chronological age, and this has been identified as a major obstacle in applying evidence-based treatments. For the large and growing population of elderly patients with cardiovascular disease, it is important to identify clinically relevant measures of biological age and their contribution to risk. Frailty is an emerging concept in medicine denoting increased vulnerability and decreased physiological reserves. Frailty instruments have thus far been validated and used mainly in a geriatric context, in which frailty stratification has been shown to be associated with a patient’s risk of death and need for institutional care. The authors analyzed the manner in which the variable frailty is associated with short-term outcomes for elderly non–ST-segment elevation myocardial infarction patients. Frailty is strongly and independently associated with risk for in-hospital mortality, 1-month mortality, prolonged hospital care, and the primary composite outcome (all-cause death, myocardial reinfarction, revascularization due to ischemia, hospitalization for any cause, major bleeding, stroke/transient ischemic attack, and need for dialysis up to 1 month after inclusion). The combined use of frailty and comorbidity may constitute an ultimate risk prediction concept for cardiovascular patients with complex needs. In clinical decision making, frailty could function as a tool in estimating the patient’s benefit–risk ratio associated with a treatment, including the expected lifetime for individual patients and its relation to the overall yield of a treatment. It could enhance decision making in regard to whether to focus on prognostic or symptomatic treatment.Conclusions: Frailty is strongly and independently associated with in-hospital mortality, 1-month mortality, prolonged hospital care, and the primary composite outcome. The combined use of frailty and comorbidity may constitute an ultimate risk prediction concept in regard to cardiovascular patients with complex needs.3Prognostic Value of Admission Glycosylated Hemoglobin and Glucose in Nondiabetic Patients With ST-Segment–Elevation Myocardial Infarction Treated With Percutaneous Coronary InterventionSummary: Measurement of admission glucose and hemoglobin A1c (HbA1c) in acute myocardial infarction may identify patients with disturbed glucose metabolism and an increased risk for adverse outcome. Although HbA1c and glucose are related, they can differentiate between mechanisms of adverse outcome. Admission glucose is related to increased hemodynamic stress, whereas HbA1c identifies patients with higher long-term cardiovascular risk, possibly by abnormal long-term glucose levels. Early identification of these patient groups enables the initiation of specific intervention strategies and may help us develop strategies to improve prognosis in these high-risk patient groups. This is of particular importance because there is a global increase in the number of patients with cardiovascular disease with underlying insulin resistance, prediabetes, and overt diabetes mellitus. Both glucose and HbA1c should be measured in patients admitted with ST-segment–elevation myocardial infarction.Conclusions: In nondiabetic patients with ST-segment–elevation myocardial infarction, both elevated admission glucose and HbA1c levels were associated with adverse outcome. Both of these parameters reflect different patient populations, and their association with outcome is probably due to different mechanisms. Measurement of both parameters enables identification of these high-risk groups for aggressive secondary risk prevention.4Assessment of Infarct SizePrognostic Value and Determinants of a Hypointense Infarct Core in T2-Weighted Cardiac Magnetic Resonance in Acute Reperfused ST-Elevation–Myocardial InfarctionSummary: CMR can provide a wide range of prognostic information in acute STEMI by detecting infarct size, MO, and myocardial salvage. Additionally, a hypointense core of infarcted myocardium in T2-weighted CMR has been used as a noninvasive marker for IMH. However, the clinical significance of such findings has not yet been established. The present study is the largest study thus far to assess determinants and the prognostic significance of hypointense infarct cores in T2-weighted CMR. A hypointense core within the AAR of reperfused infarcted myocardium in T2-weighted CMR is a frequent finding in reperfused STEMI patients and is closely related to infarct size, impaired LV function, and late MO. Moreover, hypointense infarct cores are a strong indicator of MACE at 6-month clinical follow-up and may serve as a new CMR marker of severe reperfusion injury. However, further validation is necessary to ascertain the relationship conclusively between hypointense infarct cores and IMH, and large, multicenter studies are warranted to further investigate the prognostic significance of hypointense infarct cores.Conclusions: A hypointense infarct core within the area at risk of reperfused infarcted myocardium in T2-weighted CMR is closely related to infarct size, microvascular obstruction, and impaired left ventricular function, with subsequent adverse clinical outcome.5Right Ventricular Injury in ST-Elevation–Myocardial Infarction: Risk Stratification by Visualization of Wall Motion, Edema, and Delayed-Enhancement Cardiac Magnetic ResonanceSummary: Cardiac magnetic resonance (CMR) is a useful tool to evaluate left ventricular myocardial damage after reperfused ST-elevation–myocardial infarction. It provides detailed prognostic information by visualizing edema, infarct size, and microvascular obstruction. Recently, CMR has also been introduced for detection of right ventricular injury (RVI); however, the prognostic significance of such findings has not yet been established. RVI is typically detected by echocardiography and/or ECG, but wall motion impairment of the inferior RV wall is difficult to visualize in echocardiography, and ECG changes of RVI may be transient. This work demonstrates the value of CMR value for not only diagnosis, but also prognosis in demonstrating and quantifying RVI after ST-elevation–myocardial infarction. Similar to the left ventricle, myocardial salvage index can be calculated for the RV.Conclusions: RVI detected by cardiac magnetic resonance is a strong and independent predictor of clinical outcome after acute reperfused STEMI.6Sex Differences in Myocardial Salvage and Clinical Outcome in Patients With Acute Reperfused ST-Elevation–Myocardial Infarction: Advances in Cardiovascular ImagingSummary: Studies have highlighted important sex differences in the pathophysiology, presentation, treatment, and outcome of ischemic heart disease. It has been also speculated that the efficacy (myocardial salvage) of primary percutaneous coronary intervention (PCI) in high-risk patients with ST-elevation–myocardial infarction (STEMI) seems to be sex-dependent. Whether sex disparities in clinical care and death after STEMI are still present in the current PCI era remains a matter of constant debate and has important clinical implications. In this study, the authors analyzed the relationship between sex and outcomes as well as sex and myocardial salvage in an unselected and consecutive population of patients with STEMI exclusively reperfused by primary PCI. Their study is the first using cardiac MRI for assessment of sex-specific reperfusion therapy efficacy. The authors observed no sex-associated differences in myocardial salvage and reperfusion injury. Although women STEMI patients had higher unadjusted in-hospital and 30-day mortality rates than did men, multivariate analysis revealed that these differences were likely because of disparities in baseline risk. Thus, the authors’ data highlight that sex by itself, in the current PCI era, does not independently predict death after STEMI and that once women are referred for cardiac catheterization, revascularization practices, success, and complications are similar to those in men.Conclusions: The efficacy of primary percutaneous coronary intervention (myocardial salvage) in patients with STEMI is not sex dependent. Although women STEMI patients had worse unadjusted in-hospital and 30-day clinical outcomes than did men, multivariate analysis revealed that the observed sex-based differences in early death after STEMI were likely related to differences in baseline risk and clinical characteristics.7Dynamic Changes of Edema and Late Gadolinium Enhancement After Acute Myocardial Infarction and Their Relationship to Functional Recovery and Salvage IndexSummary: Late gadolinium enhancement (LGE) and edema imaging are used to assess acute myocardial injury, area at risk, and salvaged myocardium after reperfusion. LGE is currently considered the gold standard for myocardial infarct visualization both in acute and chronic myocardial infarction and an accurate predictor of recovery of wall motion after revascularization. The present study shows that cardiac magnetic resonance features of acute myocardial infarction are dynamic and change for both LGE and edema. After revascularization, edema is shown to peak within the first week after reperfusion. LGE performed in the first 24 hours does not necessarily indicate irreversible injury; the authors’ results show that 51% of the segments with transmural LGE at 24 hours after reperfusion recovered function at 6 months. A detailed knowledge of the early dynamic changes of both LGE and edema imaging is crucial in assessing final infarct size and myocardium salvage, especially when designing clinical trials using cardiac magnetic resonance.Conclusions: Myocardial edema is maximal and constant over the first week after myocardial infarction, providing a stable window for the retrospective evaluation of area at risk. By contrast, myocardial areas with high signal intensity in LGE images recede over time with corresponding recovery of function, indicating that acutely detected LGE does not necessarily equate with irreversible injury and may severely underestimate salvaged myocardium.8Characterizing Myocardial Edema and Hemorrhage Using Quantitative T2 and T2* Mapping at Multiple Time Intervals Post ST-Segment Elevation Myocardial InfarctionSummary: Cardiovascular magnetic resonance imaging has gained clinical importance in the noninvasive assessment of myocardial injury parameters including myocardial edema, hemorrhage, microvascular obstruction, and infarct size post acute myocardial infarction. The authors prospectively characterized the evolution of these parameters post reperfused acute myocardial infarction at both early and late time points. The authors noted that edema is still present in infracted tissue at 3 weeks, whereas hemorrhage resolves faster. Noninfarcted segments can demonstrate edema in the acute phase as well, perhaps indicative of more severe myocardial injury. The presence of hemorrhage in the acute phase makes edema quantification challenging due to susceptibility effects. In addition, both hemorrhage and microvascular obstruction are associated with worse left ventricular remodeling. Gaining this knowledge about the temporal resolution of myocardial damage and its impact on remodeling processes using quantitative techniques is potentially important in grading severity, evaluating treatment strategies, and improving clinical outcomes.Conclusions: Quantification of myocardial edema and hemorrhage by T2 and T2* mapping is feasible post acute myocardial infarction and demonstrates that hemorrhage resolves faster than edema. Noninfarcted segments can also demonstrate edema in the acute phase possibly due to global hyperemia.9Quality of Care and Systems of CareCare Processes Associated With Quicker Door-In–Door-Out Times for Patients With ST-Elevation–Myocardial Infarction Requiring Transfer: Results From a Statewide Regionalization ProgramSummary: Shortening transfer delays from hospitals without percutaneous coronary intervention (PCI) to hospitals with PCI capability remains a top priority to improve ST-segment elevation–myocardial infarction (STEMI) care and patient outcomes. There are few data identifying factors that contribute to shorter door-in–door-out times among STEMI patients evaluated at non-PCI hospitals.Conclusions: Prehospital, ED, and hospital processes of care were independently associated with shorter door-in–door-out times for STEMI patients requiring transfer. Adoption of several EMS processes was associated with the largest reduction in treatment times. These findings highlight the need for an integrated, system-based approach to improving STEMI care.10Left Ventricular Ejection Fraction Assessment Among Patients With Acute Myocardial Infarction and Its Association With Hospital Quality of Care and Evidence-Based Therapy UseSummary: In patients with acute myocardial infarction, the appropriate medical regimen and subsequent management are dependent, in part, on residual left ventricular function. Therefore, assessment of left ventricular ejection fraction is a class I guideline recommendation for patients after an acute myocardial infarction. This analysis demonstrates overall high rates of left ventricular ejection fraction assessment in recent years; however, significant variability in assessment rate exists between hospitals. Importantly, hospitals with lower rates of left ventricular ejection fraction assessment are associated with lower quality of care for patients with acute myocardial infarction.Conclusions: The assessment of LVEF among patients with AMI has improved significantly over time, yet significant interhospital variability exists. Patients who did not have in-hospital LVEF assessment were less likely to receive evidence-based medications at discharge. These patients represent targets for future quality improvement efforts.11Transfer Times and Outcomes in Patients With ST-Segment–Elevation Myocardial Infarction Undergoing Interhospital Transfer for Primary Percutaneous Coronary Intervention: APEX-AMI InsightsSummary: Randomized trials have found that rapid transfer of patients with STEMI to PPCI-capable centers improves outcomes compared with immediate fibrinolysis. Observational studies have shown that only a fraction of patients undergoing interhospital transfer for PPCI in the United States meet guideline-recommended door-to–balloon times and that delays in portions of the transfer process (eg, DiDo time in transfer hospital) are associated with increased mortality. This study used an integrated measure of interhospital transfer delay, D1D2 time, which incorporates both presenting hospital and transportation delays. Longer D1D2 times were associated with a higher incidence of death, shock, and heart failure at 90 days, although the association was no longer significant after multivariable adjustment. Lack of an independent association of the interhospital transfer delays observed within the Assessment of Pexelizumab in Acute Myocardial Infarction (APEX-AMI) trial may have been, at least in part, owing to the relatively short delays compared with other controlled trials and observational registries.Conclusions: Longer transfer times were associated with higher rate of death, shock, and heart failure among patients undergoing interhospital transfer from primary percutaneous coronary intervention, although this difference did not persist after adjusting for baseline characteristics.12Mortality Implications of Primary Percutaneous Coronary Intervention Treatment Delays: Insights From the Assessment of Pexelizumab in Acute Myocardial Infarction TrialSummary: Primary percutaneous coronary intervention (PCI) reperfusion delays for patients with ST-elevation–myocardial infarction are associated with increased mortality. Prior studies differ on whether patient total ischemic time (symptom onset-to-balloon) or hospital “door-to-balloon” time more strongly predict mortality. Advanced age, female sex, and interhospital transfer are important determinants of primary PCI reperfusion delays. Mortality following ST-elevation–myocardial infarction rises sharply with symptom onset-to-balloon delays exceeding 5 hours and linearly with any door-to-balloon delay.Conclusions: Both symptom onset-to-balloon time and hospital door-to-balloon time are strongly associated with 90-day mortality following STEMI.13Dimensions of Socioeconomic Status and Clinical Outcome After Primary Percutaneous Coronary InterventionSummary: There is a well-known association between low socioeconomic status (SES) and high incidence of and mortality from coronary heart disease. There also seems to be SES-related differences in care among ST-elevation–myocardial infarction patients, but the exact role of SES in relation to post-ST-elevation–myocardial infarction outcomes remains poorly understood.Conclusions: Even in a tax-financed healthcare system, low-SES patients treated with primary percutaneous coronary intervention face a worse prognosis than high-SES patients. The poor outcome seems to be largely explained by differences in baseline patient characteristics. Employment status and income (but not education level) were associated with clinical outcomes.14Transport Time and Care Processes for Patients Transferred With ST-Segment–Elevation Myocardial Infarction: The Reperfusion in Acute Myocardial Infarction in Carolina Emergency Rooms ExperienceSummary: There are multiple components to the interhospital transfer process for ST-segment-elevation myocardial infarction patients that make the process challenging. Achieving timely reperfusion requires an integrated well-developed regional system of ST-segment-elevation myocardial infarction care. Interhospital transfer can be achieved via different modes, namely ground versus air transport. Significant challenges remain in achieving guideline-based reperfusion goals for ST-segment-elevation myocardial infarction patients initially presenting to more distant non-PCI hospitals. Air transfer may not necessarily be associated with faster reperfusion times, perhaps as a result of lengthier door-in door-out times at the transferring hospital.Conclusions: In a well-developed ST-segment–elevation myocardial infarction system, D2D times within 90 to 120 minutes seem most feasible for hospitals within 30-minute transfer drive time. Helicopter transport did not offer D2D time advantages for transferred STEMI patients. This finding appears to be attributable to comparably longer door-in door-out times for air transfers.15One-Year Clinical Outcome of Interventionalist- Versus Patient-Transfer Strategies for Primary Percutaneous Coronary Intervention in Patients With Acute ST-Segment Elevation Myocardial Infarction: Results From the REVERSE-STEMI StudySummary: Primary percutaneous coronary intervention (PPCI) is the preferred treatment option for patients with ST-segment elevation myocardial infarction (STEMI) presenting to PPCI-capable hospitals. Interhospital transfer often is used for patients with STEMI who present to hospitals without PPCI capability. This multicenter, prospective, randomized clinical study compares the 1-year outcomes of patients with STEMI treated by a strategy of interhospital patient transfer versus that of interventionalist transfer to regional hospital PPCI. The interventionalist-transfer strategy resulted in significantly shorter door-to-balloon times and better 1-year clinical outcomes. This novel strategy of interventionalist transfer for PPCI may improve the care of patients with STEMI presenting to a non-PPCI-capable hospital, particularly in regions where patient transfers are prolonged by delays in transport.Conclusions: The interventionalist-transfer strategy for PPCI may be effective in improving the care of patients with STEMI presenting to a non-PPCI-capable hospital, particularly in a congested cosmopolitan region where patient transfers could be prolonged.16Why Does Primary Angioplasty Not Work in Registries? Quantifying the Susceptibility of Real-World Comparative Effectiveness Data to Allocation BiasSummary: There is conflict between randomized, controlled trials demonstrating that primary angioplasty is superior to fibrinolysis in ST-segment elevation myocardial infarction, and observational, registry-based comparative effectiveness research contradicting this. Understanding the basis of this conflict could help determine how future comparisons between therapies should be conducted. The conflict between randomized, controlled trials and observational research may be explained by preferential allocation of higher risk patients by clinicians to primary angioplasty. The authors derived a formula for resistance to allocation bias of observational results, the Number needed to Abolish, and demonstrate that it is small for myocardial infarction. The results of this study suggest that observational comparative efficacy research is especially vulnerable to incorrect conclusions when clinicians (a) can readily identify a high-risk subset, and (b) preferentially allocate them to one therapy rather than the other.Conclusions: In ST-segment elevation myocardial infarction, clinicians’ preference for management of a few high-risk patients can shift mortality substantially. Comparative effectiveness research in any disease is vulnerable to this, especially diseases with an immediately identifiable high-risk subgroup that clinicians prefer to allocate to 1 therapy. For this reason, preliminary indications from registry-based comparative effectiveness research should be definitively tested by randomized, controlled trials.17Impact of Door-to-Activation Time on Door-to-Balloon Time in Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarctions: A Report From the Activate-SF RegistrySummary: Door-to-balloon time in primary percutaneous coronary intervention for ST-elevation–myocardial infarction is strongly related to both short- and long-term mortality. The time from hospital arrival to ST-segment elevation myocardial infarction diagnosis and activation of the catheterization laboratory (door-to-activation time) varies widely at the hospital level and is more strongly correlated with overall door-to-balloon times than other components of the primary percutaneous coronary intervention process.Conclusions: Achieving a door-to-activation time ≤20 minutes was key to achieving a door-to-balloon time ≤90 minutes. Delays in door-to-activation time are not associated with delays in other aspects of the primary percutaneous coronary intervention process.18Guideline Adherence After ST-Segment Elevation Versus Non-ST Segment Elevation Myocardial InfarctionSummary: Despite pathophysiologic differences between ST-segment elevation myocardial infarction and non–ST-segment myocardial infarction, the guidelines for medical treatment are nearly identical. Patients with latter are often afflicted by more numerous medical comorbidity, however, rates of guideline adherence are lower in these patients. The Get With the Guidelines–Coronary Artery Disease program aims to improve compliance with guideline-based therapy in these patients. Rates of guideline adherence are generally high, however, a small difference remains between those having ST segment elevation myocardial infarction and non–ST-segment myocardial infarction.Conclusions: Among hospitals participating in GWTG–CAD, adherence with guideline-based medical therapy was high for patients with both STEMI and NSTEMI. Yet, there is still room for further improvement, particularly in the care of NSTEMI patients.19Development of 2 Registry-Based Risk Models Suitable for Characterizing Hospital Performance on 30-Day All-Cause Mortality Rates Among Patients Undergoing Percutaneous Coronary InterventionSummary: The outcomes of patients undergoing percutaneous coronary intervention vary by the quality of care provided. To date, the United States has not had a national effort to monitor or report percutaneous coronary intervention mortality rates, in part due to the absence of mechanisms for systematically collecting and analyzing the data needed to adjust for differences in case mix across institutions that perform percutaneous coronary intervention. Two models of 30-day percutaneous coronary intervention mortality that leverage the clinical information collected by percutaneous coronary intervention hospitals through the National Cardiovascular Data Registry’s CathPCI Registry. The models produce hospital specific estimates of risk-standardized 30-day mortality rates for patients undergoing percutaneous coronary intervention. These models are consistent with the consensus standards for publicly reported outcomes measures and have been approved by the National Quality Forum for this purpose.Conclusions: These National Quality Forum endorsed registry-based models produce estimates of hospital risk-standardized mortality rates for patients undergoing PCI.20Systems of Care for ST-Segment–Elevation Myocardial Infarction: A Report From the American Heart Association’s Mission: LifelineSummary: Coronary reperfusion can be greatly accelerated by coor