Complicating ST-segment Elevation Myocardial Infarction Research Articles

TCT-805 Temporal Trends and Outcomes of Percutaneous Ventricular Septal Rupture Closure in ST-elevation Myocardial Infarction in the United States

Data regarding the utilization and outcomes of percutaneous closure of ventricular septal rupture (VSR) complicating ST-segment elevation myocardial infarction (STEMI) in the United States are lacking. We queried the National Inpatient Sample 2006-2014 to identify STEMI hospitalizations in adult

Temporal Trends in Mechanical Complications of Acute Myocardial Infarction in the Elderly

BackgroundReperfusion therapy led to an important decline in mortality after ST-segment elevation myocardial infarction (STEMI). Because the rate of cardiogenic shock has not changed dramatically, the authors speculated that a reduction in the incidence or fatality rate of mechanical complications (MCs), the second cause of death in these patients, could explain this decrease. ObjectivesThis study sought to assess time trends in the incidence, management, and fatality rates of MC, and its influence on short-term mortality in old patients with STEMI. MethodsTrends in the incidence and outcomes of MC between 1988 and 2008 were analyzed by Mantel-Haenszel linear association test in 1,393 consecutive patients ≥75 years of age with first STEMI. ResultsOverall in-hospital mortality decreased from 34.3% to 13.4% (relative risk reduction, 61%; p < 0.001). Although the absolute mortality due to MC decreased from 9.6% to 3.3% (p < 0.001), the proportion of deaths due to MC among all deaths did not change (28.1% to 24.5%; p = 0.53). The incidence of MC decreased from 11.1% to 4.3% (relative risk reduction 61%) with no change in their hospital fatality rate over time (from 87.1% to 82.4%; p = 0.66). The proportion of patients undergoing surgical repair decreased from 45.2% to 17.6% (p = 0.04), with no differences in post-operative survival (from 28.6% to 33.3%; p = 0.74). ConclusionsAlthough the incidence of MC has decreased substantially since the initiation of reperfusion therapy in elderly STEMI patients, this reduction was proportional to other causes of death and was not accompanied by an improvement in fatality rates, with or without surgery. MCs are less frequent but remain catastrophic complications of STEMI in these patients.

Incidence and Prognosis of Pericarditis After ST-Elevation Myocardial Infarction (from the Acute Coronary Syndrome Israeli Survey 2000 to 2013 Registry Database)

There are scarce contemporary data regarding the incidence and prognosis of early postmyocardial infarction pericarditis (PMIP). Thus, we retrospectively analyzed 6,282 patients with ST-segment elevation myocardial infarction (STEMI) enrolled with known PMIP status in the Acute Coronary Syndrome Israeli Survey 2000 to 2013 registry. The primary outcome was the composite of all-cause mortality, nonfatal myocardial infarction, cerebrovascular event, stent thrombosis, or revascularization. The secondary outcomes were mortality and length of stay during the acute hospitalization. Overall, 76 patients with STEMI had PMIP (1.2%). PMIP incidence gradually decreased from 170 per 10,000 in 2000 to 110 per 10,000 in 2013, respectively (35% reduction, p for trend = 0.035). Patients with PMIP were younger (median 58.0 vs 61.0; p = 0.045), had less hypertension, higher cardiac biomarkers, and more frequently reduced left ventricular ejection fraction (87.0% vs 67.0%; p = 0.001). Patients with PMIP had longer time to reperfusion (225 minutes vs 183 minutes; p = 0.016) and length of stay (7.0 vs 5.0 days; p < 0.001). The composite end point occurred similarly in patients with and without PMIP (10.5% vs 13.2%, respectively). There was no significant difference in 30-day, 1-year, and 5-year survival. In conclusion, PMIP is a relatively rare complication of STEMI in the coronary reperfusion era, portends worse short-term but not long-term outcomes, and is associated with bigger infarct size.

Culprit Vessel-Only Versus Multivessel Percutaneous Coronary Intervention in Patients With Cardiogenic Shock Complicating ST-Segment-Elevation Myocardial Infarction: A Collaborative Meta-Analysis.

The optimal revascularization strategy in patients with multivessel disease presenting with cardiogenic shock complicating ST-segment-elevation myocardial infarction remains unknown. Databases were searched from 1999 to October 2016. Studies comparing immediate/single-stage multivessel percutaneous coronary intervention (MV-PCI) versus culprit vessel-only PCI (CO-PCI) in patients with multivessel disease, ST-segment-elevation myocardial infarction, and cardiogenic shock were included. Primary end point was short-term (in-hospital or 30 days) mortality. Secondary end points included long-term mortality, cardiovascular death, reinfarction, and repeat revascularization. Safety end points were in-hospital stroke, renal failure, and major bleeding. The meta-analysis included 11 nonrandomized studies and 5850 patients (1157 MV-PCI and 4693 CO-PCI). There was no significant difference in short-term mortality with MV-PCI versus CO-PCI (odds ratio [OR], 1.08; 95% confidence interval [CI], 0.81-1.43; P=0.61). Similarly, there were no significant differences in long-term mortality (OR, 0.84; 95% CI, 0.54-1.30; P=0.43), cardiovascular death (OR, 0.72; 95% CI, 0.42-1.23; P=0.23), reinfarction (OR, 1.65; 95% CI, 0.84-3.26; P=0.15), or repeat revascularization (OR, 1.13; 95% CI, 0.76-1.69; P=0.54) between the 2 groups. There was a nonsignificant trend toward higher in-hospital stroke (OR, 1.64; 95% CI, 0.98-2.72; P=0.06) and renal failure (OR, 1.30; 95% CI, 0.98-1.72; P=0.06), with no difference in major bleeding (OR, 1.47; 95% CI, 0.39-5.63; P=0.57) with MV-PCI when compared with CO-PCI. This meta-analysis of nonrandomized studies suggests that in patients with cardiogenic shock complicating ST-segment-elevation myocardial infarction, there may be no significant benefit with single-stage MV-PCI compared with CO-PCI. Given the limitations of observational data, randomized trials are needed to determine the role of MV-PCI in this setting.

100Risk factors for complex ventricular arrhythmias complicating ST-segment elevation myocardial infarction - Data from a 10-year prospective study

100Risk factors for complex ventricular arrhythmias complicating ST-segment elevation myocardial infarction - Data from a 10-year prospective study

Incidence, Predictors, and Outcomes of High-Grade Atrioventricular Block in Patients With ST-Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention (from the HORIZONS-AMI Trial)

High-grade atrioventricular block (HAVB) is historically considered a marker of worse outcomes in patients with ST-segment elevation myocardial infarction (STEMI). However, the predictors and prognostic impact of HAVB in the primary percutaneous coronary intervention (PCI) era remain poorly understood. We sought to describe the characteristics and predictors of HAVB in patients undergoing primary PCI in STEMI and to assess the prognostic significance of HAVB in the contemporary reperfusion era. The present analysis includes 3,115 patients presenting with STEMI from the Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction trial who underwent primary PCI. Outcomes were examined according to the presence of HAVB on a presenting electrocardiogram, as interpreted by an independent electrocardiography core laboratory. HAVB (second-degree Mobitz II or third-degree atrioventricular block) was present at baseline in 46 patients (1.5%). Independent predictors of HAVB included increased age, diabetes mellitus, right coronary artery occlusion, sum of ST-segment deviation, and baseline Thrombolysis In Myocardial Infarction flow 0/1. Thrombolysis In Myocardial Infarction flow 3 was restored in 83.7% and 91.5% of patients with versus without baseline HAVB respectively (p= 0.06). Mortality rate was significantly higher in patients with versus without HAVB at 30-day, 1-, and 3-year follow-ups (unadjusted hazard ratio [HR] 3.83, 95% CI 1.40 to 10.48; unadjusted HR 4.37, 95% CI 2.09 to 9.38 and unadjusted HR 2.78, 95% CI 1.31 to 5.91, respectively). After covariate adjustment, mortality rate was significantly higher in patients with HAVB at 1year (adjusted HR 2.45, 95% CI 1.09 to 5.50, p= 0.03) but not at 30days (adjusted HR 1.70, 95% CI 0.58 to 5.01, p= 0.33) or 3years (adjusted HR 0.71 to 3.41, p= 0.27). In conclusion, HAVB is a rare complication of STEMI but remains associated with increased mortality, even after primary PCI.

635 - Prognosis of acute right ventricular failure as the primary cause of cardiogenic shock complicating ST-segment elevation myocardial infarction

635 - Prognosis of acute right ventricular failure as the primary cause of cardiogenic shock complicating ST-segment elevation myocardial infarction

072 - Incidence, timing, predictors and impact of acute heart failure complicating ST-segment elevation myocardial infarction in patients treated by primary percutaneous coronary intervention

072 - Incidence, timing, predictors and impact of acute heart failure complicating ST-segment elevation myocardial infarction in patients treated by primary percutaneous coronary intervention

TCT-130 Complete Myocardial Revascularisation is not Associated with a Better Prognosis in Cardiogenic Shock Complicating ST-Elevation Myocardial Infarction. Insight from the multicenter prospective ORBI registry.

Guidelines recommend a complete myocardial revascularisation in Cardiogenic shock (CS) complicating ST-segment elevation myocardial infarction (STEMI). However, the impact on the prognosis of residuals stenosis of the coronary arteries is still unclear. We aimed to determine if a complete myocardial

Incidence, timing, predictors and impact of acute heart failure complicating ST-segment elevation myocardial infarction in patients treated by primary percutaneous coronary intervention

BackgroundAcute heart failure (AHF) complicating ST-segment elevation myocardial infarction (STEMI) is recognized as an ominous complication. Previous studies mostly reported outcomes of heterogeneous, non-contemporary population. Moreover, few studies assessed the prognosis of AHF according to its timing. This study evaluated incidence, predictors and impact of AHF according to its timing in a homogeneous STEMI patients population treated by primary percutaneous coronary intervention (pPCI). MethodsData from 6282 patients included in a prospective multicenter registry were analyzed. Patients with AHF (Killip class>I) were compared to patients without AHF and patients with admission AHF were compared to patients who developed in-hospital AHF. In-hospital mortality was the primary endpoint of the study. Propensity-score matching and multivariable regression were used to adjust for confounders. ResultsA total of 1328 patients (21.1%) presented AHF: 739 on admission and 589 during hospitalization. AHF was associated with a markedly increased in-hospital mortality rate (19.9% vs. 0.8%, p<0.001). There was a gradual excess risk with each Killip class and admission AHF patients displayed the highest crude mortality rate (24.1%). By multivariable analysis, AHF was the strongest independent predictor of in-hospital mortality (HR=3.852 (2.303–6.442), p<0.001) without evidence of any difference according to its timing (HR=0.947 (0.638–1.372), p=0.767). These results were consistent after extensive adjustment on baseline characteristics in the matched cohorts. Among other predictors, pPCI beyond guidelines-recommended delays and stent thrombosis were independently associated with AHF. ConclusionAHF regardless of its timing remains a common and dreadful complication of STEMI in the contemporary era.

Differential Clinical Implications of High-Degree Atrioventricular Block Complicating ST-Segment Elevation Myocardial Infarction according to the Location of Infarction in the Era of Primary Percutaneous Coronary Intervention.

Background and ObjectivesThe clinical implication of high-degree (second- and third-degree) atrioventricular block (HAVB) complicating ST-segment elevation myocardial infarction (STEMI) is ripe for investigation in this era of primary percutaneous coronary intervention (PCI). We sought to address the incidence, predictors and prognosis of HAVB according to the location of infarct in STEMI patients treated with primary PCI.Subjects and MethodsA total of 16536 STEMI patients (anterior infarction: n=9354, inferior infarction: n=7692) treated with primary PCI were enrolled from a multicenter registry. We compared in-hospital mortality between patients with HAVB and those without HAVB with anterior or inferior infarction, separately. Multivariate analyses were performed to unearth predictors of HAVB and to identify whether HAVB is independently associated with in-hospital mortality.ResultsSTEMI patients with HAVB showed higher in-hospital mortality than those without HAVB in both anterior (hazard ratio [HR]=9.821, 95% confidence interval [CI]: 4.946-19.503, p<0.001) and inferior infarction (HR=2.819, 95% CI: 2.076-3.827, p<0.001). In multivariate analyses, HAVB was associated with increased in-hospital mortality in anterior myocardial infarction (HR=19.264, 95% CI: 5.804-63.936, p<0.001). However, HAVB in inferior infarction was not an independent predictor of increased in-hospital mortality (HR=1.014, 95% CI: 0.547-1.985, p=0.901).ConclusionIn this era of primary PCI, the prognostic impact of HAVB is different according to the location of infarction. Because of recent improvements in reperfusion strategy, the negative prognostic impact of HAVB in inferior STEMI is no longer prominent.

0019: High-degree atrioventricular block complicating ST-segment elevation myocardial infarction in the contemporary era: data from the ORBI prospective French regional registry

High-degree atrioventricular block (HAVB) is a common complication of ST-segment elevation myocardial infarction (STEMI). HAVB in STEMI is historically considered as a marker of worse outcome but overall data about HAVB in the contemporary era of mechanical reperfusion and potent antiplatelet therapies are scarce. We aimed at analyzing incidence, clinical correlates and impact on inhospital outcomes of HAVB in a large prospective registry (ORBI) of modern management of STEMI with a special focus on potential differences between patients with HAVB on admission and those who developed HAVB during hospitalization. All patients enrolled in ORBI between June 2006 and December 2013 were included in the present analysis and were divided into 3 groups: patients without HAVB at any time, patients with HAVB on admission and those who developed HAVB during hospitalization. 6662 patients (age: 62.0 [52.0-74.0]; male: 76.3%) were included in the present analysis. HAVB was documented in 3.5% of patients, present on admission in 63.7% of patients and occurring during hospitalization in 36.3%. Patients with HAVB on admission or occurring during the first 24h of hospitalization had higher in-hospital mortality rates (18.1% and 28.6% respectively) than patients without (4.5%) or with HAVB occurring beyond the first 24h of hospitalization (8.0%). However by multivariable analysis, HAVB was not independently associated with in-hospital mortality. Patients with HAVB had a higher mortality rate than patients without. However HAVB is not an independent predictor of in-hospital mortality. Abstract 0019 – Figure: Multivariable analysis

Complete Heart Block Complicating ST-Segment Elevation Myocardial Infarction: Temporal Trends and Association With In-Hospital Outcomes

ObjectivesThe purpose of this study was to determine the association of complete heart block (CHB) with outcomes and to examine temporal trends in the incidence and outcomes of CHB complicating ST-segment elevation myocardial infarction (STEMI). BackgroundThere are limited data available on the incidence and outcomes of CHB in STEMI patients who undergo contemporary management. MethodsWe used the 2003 to 2012 National Inpatient Sample databases to identify all patients age ≥18 years hospitalized with STEMI. Patients with a concomitant diagnosis of CHB were then identified. Multivariable logistic regression was used to analyze the association of CHB with outcomes and to examine the temporal trends in incidence and outcomes of CHB complicating STEMI. ResultsOf 2,273,853 patients with STEMI, 49,882 (2.2%) had CHB. The incidence of CHB increased from 2.1% in 2003 to 2.3% in 2012 (adjusted odds ratio [OR] per year: 1.02; 95% confidence interval [CI]: 1.02 to 1.03). STEMI patients with CHB had higher in-hospital mortality than those without CHB (20.4% vs. 8.7%; adjusted OR: 2.47; 95% CI: 2.41 to 2.53). The higher mortality associated with CHB was independent of the location of STEMI; however, the magnitude of this association was greatest in patients with anterior STEMI. In patients with CHB complicating STEMI, although permanent pacemaker implantation rates declined (adjusted OR per year: 0.96; 95% CI: 0.95 to 0.97), in-hospital mortality remained unchanged during the study period (adjusted OR per year: 1.00; 95% CI: 0.99 to 1.01). ConclusionsThe incidence of CHB complicating STEMI has increased slightly over the last decade, although the absolute incidence remains quite low. CHB remains associated with higher in-hospital mortality in STEMI patients even in the current era of prompt reperfusion therapy. In patients with CHB complicating STEMI, there was no change in risk-adjusted in-hospital mortality during the study period.

Combined biomarker analysis for risk of acute kidney injury in patients with ST-segment elevation myocardial infarction.

BackgroundAcute kidney injury (AKI) complicating ST-segment elevation myocardial infarction (STEMI) increases subsequent morbidity and mortality. We combined the biomarkers of heart failure (HF; B-type natriuretic peptide [BNP] and soluble ST2 [sST2]) and renal injury (NGAL [neutrophil gelatinase-associated lipocalin] and cystatin C) in predicting the development of AKI in patients with STEMI undergoing primary percutaneous coronary intervention (PCI).Methods and ResultsFrom March 2010 to September 2013, 189 STEMI patients were sequentially enrolled and serum samples were collected at presentation for BNP, sST2, NGAL and cystatin C analysis. 37 patients (19.6%) developed AKI of varying severity within 48 hours of presentation. Univariate analysis showed age, Killip class ≥2, hypertension, white blood cell counts, hemoglobin, estimated glomerular filtration rate, blood urea nitrogen, creatinine, and all the four biomarkers were predictive of AKI. Serum levels of the biomarkers were correlated with risk of AKI and the Acute Kidney Injury Network (AKIN) stage and all significantly discriminated AKI (area under the receiver operating characteristic [ROC] curve: BNP: 0.86, sST2: 0.74, NGAL: 0.75, cystatin C: 0.73; all P < 0.05). Elevation of ≥2 of the biomarkers higher than the cutoff values derived from the ROC analysis improved AKI risk stratification, regardless of the creatine level (creatinine < 1.24 mg/dL: odds ratio [OR] 11.25, 95% confidence interval [CI] 1.63-77.92, P = 0.014; creatinine ≥ 1.24: OR 15.0, 95% CI 1.23-183.6, P = 0.034).ConclusionsIn this study of STEMI patients undergoing primary PCI, the biomarkers of heart failure (BNP and sST2) and renal injury (NGAL and cystatin C) at presentation were predictive of AKI. High serum levels of the biomarkers were associated with an elevated risk and more advanced stage of AKI. Regardless of the creatinine level, elevation of ≥2 of the biomarkers higher than the cutoff values indicated a further rise in AKI risk. Combined biomarker approach may assist in risk stratification of AKI in patients with STEMI.

Effect of Coronary Thrombectomy in Cardiogenic Shock Complicating ST-Segment Elevation Myocardial Infarction

Optimal coronary reflow is the critical key issue to ameliorate clinical outcomes in patients with cardiogenic shock complicating ST-segment elevation myocardial infarction (Shock-STEMI). We investigated our hypothesis that pre-percutaneous coronary intervention (PCI) procedural coronary thrombectomy may provide clinical advantages to attempt optimal coronary reflow in patients with Shock-STEMI. Of 7,650 patients with acute myocardial infarction registered in the Tokyo CCU Network Scientific Council from January 2009 to December 2011, a total of 180 consecutive patients (144 men, 68 ± 13years) with Shock-STEMI who showed pre-PCI procedural Thrombolysis in Myocardial Infarction flow grade 0 (absent initial coronary flow) were recruited. Achievements of post-PCI procedural Thrombolysis in Myocardial Infarction flow grade 3 (optimal coronary reflow) and also in-hospital mortality were evaluated in those in accordance with and without coronary thrombectomy. Coronary thrombectomy was performed in 128 patients with Shock-STEMI (71% of all). Overall in-hospital mortality was 41% and that in anterior Shock-STEMI with a necessity of mechanical circulatory support increased by 59% (i.e., profound shock). Coronary thrombectomy did not affect any improvements in the achievement of optimal coronary reflow (65% vs 58%, p= 0.368) and in-hospital mortality (42% vs 37%, p= 0.484) in these patients. Even when focused on 76 patients with profound shock, neither an achievement of optimal coronary reflow (56% vs 47%, p= 0.518) nor in-hospital mortality (58% vs 65%, p= 0.601) were different between with and without coronary thrombectomy. Multivariate logistic analysis did not demonstrate any association of coronary thrombectomy (p= 0.798), left main Shock-STEMI (p= 0.258), and use of mechanical circulatory support (p= 0.119) except a concentration of hemoglobin (for each 1g/dl increase, odds ratio 1.247, 95% confidence interval 1.035 to 1.531, p= 0.019) with optimal coronary reflow. In conclusion, pre-PCI procedural coronary thrombectomy may have serious limitations on attempting optimal coronary reflow that indicates a necessity of promising strategies for this critical illness.

Risk factors for Type 1 cardio-renal syndrome after ST-segment elevation myocardial infarction

To explore the risk factors for Type 1 cardio-renal syndrome (CRS1) after ST-segment elevation myocardial infarction (STEMI). A total of 378 patients with STEMI were divided into two groups: a CRS1 group (n=98) and a non-CRS1 group (n=280). Clinical characteristics in the 2 groups were compared, and independent risk factors for CRS1 after STEMI were analyzed, and the effect of emergency percutaneous coronary intervention (PCI) on CRS1 in patients after STEMI were assessed. In the 378 STEMI patients, CRS1 was found in 98 patients (25.9%). Between the 2 groups, there was significant difference in 12 parameters, including age, history of diabetes, admission mean arterial pressure, admission systolic blood pressure, admission heart rate, Killip classification, left ventricular ejection fraction, baseline serum creatinine, baseline evaluated glomerular filtration rate (eGFR), emergency PCI, β-blockers and angiotensin converting enzyme inhibitor/angiotensin, receptor antagonist (ACEI/ARB) application (all P<0.05). Multivariate logistic regression showed that age, history of diabetes, admission systolic blood pressure, Killip classification, reduced left ventricular ejection fraction, reduced eGFR, emergency PCI nonundergo and ACEI/ARB non-use were independent risk factors for CRS1 after STEMI. In the 256 patients undergoing emergency PCI, 50 patients (19.5%) had CRS1. The door-ball time and the amount of contrast agent in the CRS1 group were significantly higher than those in the non- CRS1 group (both P<0.05), but there was no significant difference in the blood flow in the "culprit vessel" after the PCI (P>0.05). CRS1 is a common complication of STEMI, which is associated with many factors. Immediate revascularization can reduce the incidence of CRS1 in patients with ST-segment elevation myocardial infarction.

Percutaneous Coronary Intervention for Nonculprit Vessels in Cardiogenic Shock Complicating ST-Segment Elevation Acute Myocardial Infarction*

We investigated the clinical impact of multivessel percutaneous coronary intervention in ST-segment elevation myocardial infarction complicated by cardiogenic shock with multivessel disease. A prospective, multicenter, observational study. Cardiac ICU of a university hospital. Between November 2005 and September 2010, 338 patients were selected. Inclusion criteria were as follows: 1) ST-segment elevation myocardial infarction with cardiogenic shock and 2) multivessel disease with successful primary percutaneous coronary intervention for the infarct-related artery. Patients were divided into multivessel percutaneous coronary intervention and culprit-only percutaneous coronary intervention. None. Primary outcome was all-cause mortality. Median follow-up duration was 224 days (interquartile range, 46-383 d). Multivessel percutaneous coronary intervention was performed during the primary percutaneous coronary intervention in 60 patients (17.8%). In-hospital mortality was similar in both groups (multivessel percutaneous coronary intervention vs culprit-only percutaneous coronary intervention, 31.7% vs 24.5%; p = 0.247). All-cause mortality during follow-up was not significantly different between the two groups after adjusting for patient, angiographic, and procedural characteristics as well as propensity scores for receiving multivessel percutaneous coronary intervention (35.0% vs 30.6%; adjusted hazard ratio, 1.06; 95% CI, 0.61-1.86; p = 0.831). There were no significant differences between the groups in rates of major adverse cardiac events (41.7% vs 37.1%; adjusted hazard ratio, 1.03; 95% CI, 0.62-1.71; p = 0.908) and any revascularization (6.7% vs 4.7%; adjusted hazard ratio, 1.88; 95% CI, 0.51-6.89; p = 0.344). Multivessel percutaneous coronary intervention could not reduce the prevalence of mortality in patients with cardiogenic shock complicating ST-segment elevation myocardial infarction and multivessel disease during primary percutaneous coronary intervention.

Impact of thrombus aspiration during primary percutaneous coronary intervention in cardiogenic shock complicating ST-segment elevation myocardial infarction

To assess the impact on in-hospital and long-term survival of thrombus aspiration (TA) during primary percutaneous coronary intervention (PPCI) for ST-segment elevation myocardial infarction (STEMI) complicated by cardiogenic shock (CS). From September 2001 to May 2010 we collected data from 155 patients affected with STEMI complicated by CS undergoing PPCI (12.4% of all PPCI) including 70 patients (45.2%) in TA group and 85 patients (54.8%) in conventional PCI group. Patients in TA group were more likely to have right ventricular infarction (24.3% vs 5.9%, p=0.002), higher mean left ventricular ejection fraction (40% ± 9% vs 35% ± 7%, p<0.0001) and lower left main coronary artery occlusion (2.8% vs 21.2%, p=0.002). TA was associated with a lower rate of in-hospital and long-term mortality (31.4% vs 48.2%, p=0.05 and 42.8% vs 64.7%, p=0.01 respectively) at a mean follow-up time of 6.1 ± 2.1 years. At multivariate analysis the only independent predictor of in-hospital and long-term survival was the procedural success (HR 0.18 95% CI 0.025-0.31, p=0.03 and HR 0.46 95% CI 0.09-0.74, p=0.034 respectively). In this retrospective study TA, performed during PPCI for STEMI complicated by CS, was not an independent predictor of in-hospital and long-term survival.

Clinical evidence of exaggerated inflammation in patients with a cardiogenic shock complicating ST-segment elevation myocardial infarction

We characterized the degree of systemic and coronary inflammation and the impact of those on clinical state in patients with a cardiogenic shock complicating first anterior ST-segment elevation myocardial infarction (STEMI). Methods: We recruited 14 consecutive patients with cardiogenic shock (10 men, 69 ± 12 years) and 18 well-matched baseline characteristics without shock (17 men, 64 ± 9 years) undergoing percutaneous coronary intervention (PCI) for an early phase of a first anterior STEMI in whom plasma level of cardiac enzyme was less elevated. We measured systemic and coronary levels of C-reactive protein, interleukin-6, and angiotensin II, and evaluated the relation of those to myocardial tissue-level reperfusion using both angiographic myocardial blush grade from 0 to 3, with the highest grade indicating normal myocardial perfusion, and a resolution of the sum of ST-segment elevation in 12-lead electrocardiogram. Results: In-hospital mortality was 57% in patients with cardiogenic shock and 6% without shock (p = 0.005). Coronary levels of C-reactive protein (9.2 ± 6.9 vs. 1.7 ± 2.1 mg/L, p = 0.001), interleukin-6 (379 ± 137 vs. 24 ± 20 pg/mL, p = 0.003), and angiotensin II (19 ± 10 vs. 10 ± 6 pg/mL, p = 0.010) were extremely higher in patients with shock than without shock. Interleukin-6 and angiotensin II, but not C-reactive protein, revealed higher in coronary levels than in systemic levels. The presence of both myocardial blush grade el reperfusion (p = 0.012). Conclusions: The exaggerated systemic and coronary inflammation, presumably associated with myocardial mal-reperfusion, was presented in patients with a cardiogenic shock complicating first anterior STEMI.

Reduction in Mortality as a Result of Direct Transport From the Field to a Receiving Center for Primary Percutaneous Coronary Intervention

This study sought to determine whether mortality complicating ST-segment elevation myocardial infarction (STEMI) was impacted by the design of transport systems. It is recommended that regions develop systems to facilitate rapid transfer of STEMI patients to centers equipped to perform primary percutaneous coronary intervention (PCI), yet the impact on mortality from the design of such systems remains unknown. Within the framework of a citywide system where all STEMI patients are referred for primary PCI, we compared patients referred directly from the field to a PCI center to patients transported beforehand from the field to a non-PCI-capable hospital. The primary outcome was all-cause mortality at 180 days. A total of 1,389 consecutive patients with STEMI were assessed by the emergency medical services (EMS) and referred for primary PCI: 822 (59.2%) were referred directly from the field to a PCI center, and 567 (40.8%) were transported to a non-PCI-capable hospital first. Death at 180 days occurred in 5.0% of patients transferred directly from the field, and in 11.5% of patients transported from the field to a non-PCI-capable hospital (p < 0.0001. After adjusting for baseline characteristics in a multivariable logistic regression model, mortality remained lower among patients referred directly from the field to the PCI center (odds ratio: 0.52, 95% confidence interval: 0.31 to 0.88, p = 0.01). Similar results were obtained by using propensity score methods for adjustment. A STEMI system allowing EMS to transport patients directly to a primary PCI center was associated with a significant reduction in mortality. Our results support the concept of STEMI systems that include pre-hospital referral by EMS.