Percutaneous Coronary Intervention For Acute Myocardial Infarction Research Articles

The effect of microvascular obstruction and intramyocardial hemorrhage on contractile recovery in reperfused myocardial infarction: insights from cardiovascular magnetic resonance.

BackgroundFollowing acute myocardial infarction (AMI), microvascular obstruction (MO) and intramyocardial hemorrhage (IMH) adversely affect left ventricular remodeling and prognosis independently of infarct size. Whether this is due to infarct zone remodeling, changes in remote myocardium or other factors is unknown. We investigated the role of MO and IMH in recovery of contractility in infarct and remote myocardium.MethodsThirty-nine patients underwent cardiovascular magnetic resonance (CMR) with T2-weighted and T2* imaging, late gadolinium enhancement (LGE) and myocardial tagging at 2, 7, 30 and 90 days following primary percutaneous coronary intervention for AMI. Circumferential strain in infarct and remote zones was stratified by presence of MO and IMH.ResultsOverall, infarct zone strain recovered with time (p < 0.001). In the presence of MO with IMH and without IMH, epicardial strain recovered (p = 0.03, p < 0.01 respectively), but mid-myocardial or endocardial strain did not (mid-myocardium: p = 0.05, p = 0.12; endocardium: p = 0.27, p = 0.05, respectively). By day 90, infarcts with MO had more attenuated strain in all myocardial layers compared to infarcts without MO (p < 0.01); those with IMH were attenuated further (p < 0.01). Remote myocardial strain was similar across groups at all time-points (p > 0.2). Infarct transmural extent did not correlate with strain (p > 0.05 at each time point). In multivariable logistic regression, MO and IMH were the only significant independent predictors of attenuated 90-day infarct zone strain (p = 0.004, p = 0.011, respectively).ConclusionsStrain improves within the infarct zone overall following reperfusion with or without MO or IMH. Mid-myocardial and endocardial infarct contractility is diminished in the presence of MO, and further in the presence of IMH. MO and IMH are greater independent predictors of infarct zone contractile recovery than infarct volume or transmural extent.

Incidence and Outcomes of No-Reflow Phenomenon During Percutaneous Coronary Intervention Among Patients With Acute Myocardial Infarction

Previous studies describing the no-reflow phenomenon in patients with acute myocardial infarction (AMI) undergoing percutaneous coronary intervention (PCI) were largely confined to single-center studies or small registries. To better characterize the incidence, predictors, and outcomes of the no-reflow phenomenon in a large contemporary population, we analyzed patients with AMI who were undergoing PCI of native coronary artery stenoses in the CathPCI Registry from January 1, 2004 through September 5, 2008 (n= 291,380). The angiographic no-reflow phenomenon was site reported using a standardized definition. No-reflow developed in 2.3% of the patients with AMI (n= 6,553) during PCI. Older age, ST-segment elevation AMI, prolonged interval from symptom onset to admission, and cardiogenic shock were clinical variables independently associated with the development of no-reflow (p <0.001). The angiographic factors independently associated with no-reflow included longer lesion length, higher risk class C lesions, bifurcation lesions, and impaired preprocedure Thrombolysis In Myocardial Infarction flow (p <0.001). No-reflow was associated with greater in-hospital mortality (12.6% vs 3.8%, adjusted odds ratio 2.20, 95% confidence interval 1.97 to 2.47, p <0.001) and unsuccessful lesion outcome (29.7% vs 6.6%, adjusted odds ratio 4.70, 95% confidence interval 4.28 to 5.17, p <0.001) compared to patients without no-reflow. In conclusion, the development of no-reflow, although relatively uncommon during PCI for AMI, is associated with adverse clinical outcomes. Upfront strategies to reduce the incidence of no-reflow could be considered for high-risk patients to improve outcomes.

Association of Public Reporting for Percutaneous Coronary Intervention With Utilization and Outcomes Among Medicare Beneficiaries With Acute Myocardial Infarction

Public reporting of patient outcomes is an important tool to improve quality of care, but some observers worry that such efforts will lead clinicians to avoid high-risk patients. To determine whether public reporting for percutaneous coronary intervention (PCI) is associated with lower rates of PCI for patients with acute myocardial infarction (MI) or with higher mortality rates in this population. Retrospective observational study conducted using data from fee-for-service Medicare patients (49,660 from reporting states and 48,142 from nonreporting states) admitted with acute MI to US acute care hospitals between 2002 and 2010. Logistic regression was used to compare PCI and mortality rates between reporting states (New York, Massachusetts, and Pennsylvania) and regional nonreporting states (Maine, Vermont, New Hampshire, Connecticut, Rhode Island, Maryland, and Delaware). Changes in PCI rates over time in Massachusetts compared with nonreporting states were also examined. Risk-adjusted PCI and mortality rates. In 2010, patients with acute MI were less likely to receive PCI in public reporting states than in nonreporting states (unadjusted rates, 37.7% vs 42.7%, respectively; risk-adjusted odds ratio [OR], 0.82 [95% CI, 0.71-0.93]; P = .003). Differences were greatest among the 6708 patients with ST-segment elevation MI (61.8% vs 68.0%; OR, 0.73 [95% CI, 0.59-0.89]; P = .002) and the 2194 patients with cardiogenic shock or cardiac arrest (41.5% vs 46.7%; OR, 0.79 [95% CI, 0.64-0.98]; P = .03). There were no differences in overall mortality among patients with acute MI in reporting vs nonreporting states. In Massachusetts, odds of PCI for acute MI were comparable with odds in nonreporting states prior to public reporting (40.6% vs 41.8%; OR, 1.00 [95% CI, 0.71-1.41]). However, after implementation of public reporting, odds of undergoing PCI in Massachusetts decreased compared with nonreporting states (41.1% vs 45.6%; OR, 0.81 [95% CI, 0.47-1.38]; P = .03 for difference in differences). Differences were most pronounced for the 6081 patients with cardiogenic shock or cardiac arrest (prereporting: 44.2% vs 36.6%; OR, 1.40 [95% CI, 0.85-2.32]; postreporting: 43.9% vs 44.8%; OR, 0.92 [95% CI, 0.38-2.22]; P = .03 for difference in differences). Among Medicare beneficiaries with acute MI, the use of PCI was lower for patients treated in 3 states with public reporting of PCI outcomes compared with patients treated in 7 regional control states without public reporting. However, there was no difference in overall acute MI mortality between states with and without public reporting.

Early statin treatment prior to primary PCI for acute myocardial infarction: REPERATOR, a randomized placebo‐controlled pilot trial

The aim of this pilot study was to determine whether early atorvastatin treatment will reduce left ventricle (LV) remodeling, infarct size, and improve microvascular perfusion. In animal studies, early statin therapy reduces reperfusion injury after a percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI). Forty-two consecutive patients (82% male, mean age 61.2 ± 9.8) who underwent a primary PCI for a first ST-elevated AMI were randomized for pretreatment with atorvastatin 80 mg (n = 20) or placebo (n = 22) and continued with the same dosage daily for 1 week. All patients received atorvastatin 80 mg once daily 7 days after primary PCI. The LV function and infarct size were measured by magnetic resonance imaging within 1 day, at 1 week, and 3 months follow up. The primary endpoint was the end-systolic volume index (ESVI) at 3 months. Secondary endpoints were global LV function measurements, myocardial infarct size, biochemical cardiac markers, TIMI flow, and ST-T elevation resolution. ESVI 3 months after AMI was 25.1 mL/m(2) in the atorvastatin arm and 25.0 mL/m(2) in the placebo arm (P = 0.74). The differences in change from baseline to 3 months follow up in global LV function and myocardial infarct size did not differ between both treatment arms. Furthermore, biochemical markers, TIMI flow, and ST-T elevation resolution did not differ between atorvastatin and placebo arm. In this pilot study, pretreatment with atorvastatin in an acute myocardial infarction does not result in an improved cardiac function, microvascular perfusion, or decreased myocardial infarct size.

Birth month and longevity – monthly birth distribution in acute coronary events provoked by atherothrombosis in patients treated with percutaneous coronary intervention (PCI)

Human homeostasis is time related. Environmental physical factors also play a role. Recent studies published by the National Academy of Sciences (USA) describe human longevity links with the month of birth. The aim of this study was to check monthly birth distribution in patients undergoing percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) related to atherothrombosis - one of the main causes of morbidity and mortality in the industrial world. A total of 4732 (3594 men) subjects were included in the study. Patients treated with PCI for AMI in the years 2000 to March 2010 were studied. The population registry specific to 1950 excluded 1024 patients, i.e., those registered as born on January 1 and they were replaced with patients with an average of births from January 2 to 31. A total of 3675 patients were finally studied (2839 men, 836 women). The average monthly birth number was 306±60.38. Significant monthly differences in birth number (q2=21.077, p<0.03) were observed. A higher birth rate in the first four months of the year was revealed, with the exception of February. The number of births in these months exceeded the following two four-month data (q2=20.57, p<0.024). March births exceeded the monthly average by more than two standard deviations (SD) - 462, with an analogical increase for both genders. In May-December births were below average. Patients with AMI treated with PCI show differences in the month of birth with the majority being born in the first four months of the year and of those most were born in March. Possible implications on pathogenetic clues of atherothrombosis can be assumed.

Comparison of Outcomes of Unprotected Left Main Versus Multivessel Coronary Artery Interventions

Left main coronary artery (LMCA) percutaneous coronary intervention (PCI) has emerged as an appealing alternative to bypass surgery for significant LMCA disease, especially in high-risk candidates. PCI for unprotected LMCA stenosis is currently designated a class IIb indication. Direct comparisons between unprotected LMCA PCI and multivessel PCI are lacking. We aimed to determine the incremental risk associated with unprotected LMCA PCI compared to multivessel PCI. We queried the Cleveland Clinic PCI database to identify patients who underwent unprotected LMCA PCI from 2003 through 2009 and compared these to patients undergoing multivessel PCI in the same period. Patients undergoing PCI for acute myocardial infarction were excluded. Mortality was derived using the Social Security Death Index. Short-term (≤30-day) mortality rates in the LMCA PCI group (n = 468, 1.9%) were similar to the death rate in the multivessel PCI group (n = 1,973, 1.3%, p = 0.3). There was no significant difference in adjusted mortality between the 2 study groups. Stratifying LMCA PCI by the number of concomitant vessel territories treated, there was no significant difference in mortality in any LMCA PCI category (LMCA only, LMCA + 1-vessel PCI, LMCA + multivessel PCI) compared to multivessel PCI. In conclusion, there was comparable short-term and long-term mortality in the LMCA PCI and multivessel PCI groups. LMCA stenting did not appear to incur incremental risk compared to multivessel PCI.

Prognostic effects on percutaneous coronary intervention of different time windows in patients with acute myocardial infarction

To compare the prognostic effects of different time windows on initiating PCI (percutaneous coronary intervention) in AMI (acute myocardial infarction) patients. Ninety-five AMI patients undergoing PCI were enrolled continuously from January 2007 to September 2008. According to the timing of direct PCI, the patients were divided into 3 groups: after AMI, < 6 h (Group A, n = 45), 6 - 12 h (Group B, n = 45) and 12 - 24 h (Group C, n = 35). Comparisons were made among these 3 groups in terms of the post-PCI incidence of heart failure and mortality. The left ventricular ejection fraction (LVEF) and left ventricular end-diastolic inside diameter (LVEDV) were measured by echocardiogram at Month 6. During the hospitalization and follow-up, Group A had a lower incidence of heart failure and mortality than Groups B and C. And Group B had a lower rate than Group C. The difference was significant (P < 0.05). Compared with LVEF(%) (52.25 ± 4.27) in Group B and LVEF (%) (47.75 ± 6.86) in Group C, LVEF(%) (57.51 ± 6.9) in Group A were significantly improved on ECG at Month 6 months. LVEDV (mm) (45.89 ± 4.23) in Group A were significantly lower than LVEDV (mm) (49.0 ± 3.1) in Group B and LVEDV (mm) (52.46 ± 4.9) in Group C. The differences were both statistically significant (P < 0.05). An early time windows of initiating PCI in AMI patients can significantly improve the left ventricular functions and reduce the incidence of heart failure, left ventricular remodeling and the mortality rate. All these measures could improve left ventricular functions and prognosis.

Circulating CD34+ progenitor cells and growth factors in patients treated with PCI for acute myocardial infarction or stable angina pectoris

Objective. To differentiate the effect of myocardial infarction from the effect of percutaneous coronary intervention (PCI) on the circulatory profiles of CD34+ cells and growth factors in patients with ST-elevation myocardial infarction (STEMI). Methods. Twenty patients with STEMI and 10 with angina pectoris (AP) were included. All were treated with PCI. Blood was drawn before PCI in the AP group, and after 3 and 12 hours, and 1, 3, 5, 7 and 14 days after PCI in both groups. In STEMI patients, correlation analyses between TIMI myocardial perfusion grade (TMP-grade) and circulating CD34+cells were also assessed. Results. Circulating CD34+ cells increased from day 1 to days 5 and 7 after PCI only in STEMI patients (p < 0.05). Between-group analyses revealed a borderline significant difference in change in SDF-1α concentrations from 3 h to 14 days after PCI (p = 0.05), and SDF-1α was significantly higher in STEMI patients 14 days after PCI (p < 0.05). In both groups, peak HGF concentrations were observed 3 h after PCI, whereas IGF-1 increased in AP patients only, 3 h after PCI (p < 0.005). TIMI perfusion grade was negatively correlated to the circulating number of CD34+ cells 5 days after PCI (r =−0.69, p < 0.005). Conclusion. After PCI, STEMI patients have significantly higher numbers of circulating CD34+ progenitor cells compared to patients with AP. STEMI results in a significant increase in SDF-1α after 14 days, and the increase at this time may indicate a favorable environment for progenitor cell therapy.

Biolimus-eluting biodegradable polymer-coated stent versus bare metal stent in acute ST-elevation and non-ST elevation myocardial infarction: Justification for biodegradable polymer-coated stent in acute coronary syndrome (JANICE) registry

We evaluated the efficacy and safety of a biolimus- eluting biodegradable polymer-coated stent (BES) in patients with ST-segment elevation and non ST-segment elevation acute myocardial infarction (AMI). This was an observational study involving a single centre patient registry. We compared the rates of cardiac death, myocardial infarction, target vessel revascularization (TVR) and composite end point of cardiac death and myocardial infarction at 24 months in 106 patients who received BES versus 94 patients who received an otherwise similar bare metal stent (BMS) during percutaneous coronary intervention for AMI. There was no significant difference in the rate of cardiac death (0.9% versus 7.4%; P = 0.09), myocardial infarction (4.7% versus 3.2%; P = 0.69), stent thrombosis (0.9% versus 3.2%; P = 0.30) or cardiac death and myocardial infarction (5.7% versus 10.6%; P = 0.30) between the two groups. The rate of TVR was significantly higher in the BMS group (1.9% versus 8.5%; P = 0.04), with patients receiving BMS being four times more likely to require TVR. The use of BES in selected patients with AMI appears to be safe and is associated with significantly reduced rate of TVR, when compared with an otherwise similar BMS.

Coronary Artery Bypass Grafting After Recent or Remote Percutaneous Coronary Intervention in the Commonwealth of Massachusetts

In this study, we sought to characterize the outcomes after isolated coronary artery bypass grafting (CABG) in patients with a history of remote (≥14 days), and recent (<14 days), percutaneous coronary intervention (PCI). Patients with PCI within 5 years of CABG were identified among 12 591 primary isolated CABG reported in the mandatory Massachusetts Adult Cardiac Surgery Database. Patients were excluded if they were out-of-state (n=1043, 8%), had undergone primary PCI for acute myocardial infarction (n=401, 3%), had a PCI-CABG interval >5 years or unknown (n=136 and n=673, 1% and 5%). Patients with a history of remote and recent PCI were analyzed separately. Each CABG patient with PCI was matched to 3 patients without PCI using a propensity score. Outcomes were analyzed using generalized estimating equations and stratified proportional hazards models, with a mean follow-up of 4.1±1.2 years. There were 1117 CABG patients (9%) with prior PCI (n(remote)=823; n(recent)=294). In matched CABG patients with remote prior PCI, no differences were found in 30-day mortality (1.1% versus 1.5%; P=0.432), hospital morbidity (41% versus 40%; P=0.385) and overall survival (hazard ratio, [95% confidence interval] for death for prior PCI, 0.93 [0.74 to 1.18]; P=0.555). In matched CABG patients with recent prior PCI, hospital morbidity was higher (59% versus 45%; P<0.001), but no differences were found in 30-day mortality (3.5% versus 3.1%; P=0.754) and overall survival (HR, 1.18 [0.83 to 1.69]; P=0.353). In patients undergoing CABG, remote prior PCI (≥14 days) was not associated with adverse outcomes at 30 days or during long-term follow-up.

Long-term survival and functional outcome of unselected patients undergoing percutaneous coronary intervention for acute myocardial infarction.

Percutaneous coronary intervention (PCI) is the most effective reperfusion modality in patients with acute myocardial infarction (MI). Data concerning long-term survival and functional outcome are sparse. One thousand consecutive patients treated by emergency PCI were systematically ana-lysed in a single-centre registry. Multivariate predictors of in-hospital mortality, post-discharge mortality and late functional capacity were identified. Follow-up was completed for 978 patients. The median clinical follow-up length was 3.2 years. In-hospital and post-discharge mortality were 7.6% and 7.3%, respectively. Annualised post-discharge mortality remained stable over time at 2% per year. Independent predictors of in-hospital death were cardiogenic shock, TIMI flow <3 after PCI, left ventricular ejection fraction <40%, age and time to patent artery >6 h. Independent predictors of post-discharge mortality were TIMI flow after PCI <3, prior MI, elevated glucose levels at admission, and increasing age. In contrast, cardiogenic shock, time to patent artery and left ventricular ejection fraction <40% were not independently associated with post-hospital death. At late follow-up, 47% of patients had normal functional capacity and 49.1% were in New York Heart Association functional class II. Predictors of impaired functional capacity at follow-up were age, gender, smoking habits and multivessel coronary disease. Post-discharge mortality after PCI for acute MI was 2% per year. Significant differences exist between predictors of in-hospital and post-discharge mortality. The functional capacity of surviving patients was remarkably good, even when presented in cardiogenic shock.

Long-term survival and functional outcome of unselected patients undergoing percutaneous coronary intervention for acute myocardial infarction.

Percutaneous coronary intervention (PCI) is the most effective reperfusion modality in patients with acute myocardial infarction (MI). Data concerning long-term survival and functional outcome are sparse. One thousand consecutive patients treated by emergency PCI were systematically ana-lysed in a single-centre registry. Multivariate predictors of in-hospital mortality, post-discharge mortality and late functional capacity were identified. Follow-up was completed for 978 patients. The median clinical follow-up length was 3.2 years. In-hospital and post-discharge mortality were 7.6% and 7.3%, respectively. Annualised post-discharge mortality remained stable over time at 2% per year. Independent predictors of in-hospital death were cardiogenic shock, TIMI flow <3 after PCI, left ventricular ejection fraction <40%, age and time to patent artery >6 h. Independent predictors of post-discharge mortality were TIMI flow after PCI <3, prior MI, elevated glucose levels at admission, and increasing age. In contrast, cardiogenic shock, time to patent artery and left ventricular ejection fraction <40% were not independently associated with post-hospital death. At late follow-up, 47% of patients had normal functional capacity and 49.1% were in New York Heart Association functional class II. Predictors of impaired functional capacity at follow-up were age, gender, smoking habits and multivessel coronary disease. Post-discharge mortality after PCI for acute MI was 2% per year. Significant differences exist between predictors of in-hospital and post-discharge mortality. The functional capacity of surviving patients was remarkably good, even when presented in cardiogenic shock.

Microvascular obstruction after percutaneous coronary intervention

Successful revascularization of the epicardial coronary artery can be achieved in over 90% of percutaneous coronary intervention (PCI) procedures. However, postprocedural microvascular obstruction, despite the presence of normal epicardial flow, remains an important limitation which substantially reduces the beneficial effects of PCI. In this review article, a number of different methods available to diagnose microvascular obstruction after PCI are outlined. We also discussed the various pharmacological and mechanical strategies to reduce the occurrence of microvascular obstruction. In this regard, pretreatment with antiplatelet therapy remains crucial. In urgent PCI for acute myocardial infarction, available data suggest that manual thrombus aspiration device is beneficial in reducing the occurrence of procedure-related microvascular obstruction and possibly improve long-term clinical outcomes.

The risk of definitive stent thrombosis is increased after “off-label” stent implantation irrespective of drug-eluting stent or bare-metal stent use

A limitation of drug-eluting stent (DES) use to FDA-approved indications has been suggested to reduce the risk of stent thrombosis. This study evaluated predictors of stent thrombosis in clinical practice after the use of drug-eluting as well as bare-metal stents (BMS), including adherence to the FDA indications for DES. Between July 2002 and October 2006 percutaneous coronary intervention (PCI) was performed on 5,945 patients using BMS (68%) or DES (32%). Patients had 1-year follow-up for definitive stent thrombosis (ARC criteria). 76 patients (1.27%) developed definitive stent thrombosis. Clinical, procedural, and angiographic parameters were related to those of 786 patients without stent thrombosis to define predictors of stent thrombosis. Off-label or on-label implantation of stents according to the FDA-approved indications for DES was included as parameter in the analysis. In 434 patients, stent implantation was performed within FDA-approved indications and in 428 patients outside of FDA-approved indications for DES. Predictors of stent thrombosis were PCI in acute myocardial infarction (OR = 4.51, P < 0.001), treatment of bifurcation lesions (OR = 4.43, P < 0.001), stent length per mm (OR = 1.07, P < 0.001), implantation of multiple stents (OR = 3.67, P < 0.001), and stent implantation outside of FDA indications (OR = 6.13, P < 0.001). The risk was increased for DES as well as BMS. In a multivariate analysis, PCI in acute myocardial infarction (OR = 2.56, P = 0.014), LV-EF < 30% (OR = 3.60, P < 0.001), treatment of bifurcation lesion (OR = 3.65, P = 0.004), stent length in mm (OR = 1.04, P = 0.015), and implantation of multiple stents (OR = 2.64, P = 0.002) remained predictors of stent thrombosis. Off-label stent implantation was no independent additional predictor as it is a combined parameter of the above-mentioned predictors. Implantation of coronary stents outside of the FDA-approved indications for DES is associated with an increased risk of stent thrombosis using DES and BMS.

Impact of intravascular ultrasound guidance in patients with acute myocardial infarction undergoing percutaneous coronary intervention

The aim of this study was to examine the utility of routine intravascular ultrasound (IVUS) guidance in patients with acute myocardial infarction (MI) undergoing percutaneous coronary intervention (PCI) with stent implantation. Stent thrombosis (ST) is a serious complication of PCI with stent implantation for patients presenting with acute MI. Mechanical factors such as incomplete stent expansion and smaller stent diameters are known to correlate with ST and restenosis. IVUS guidance for stent deployment is reported to reduce these events in stable patients. We analyzed a cohort of 905 consecutive patients who underwent primary PCI for acute MI and were discharged alive. The clinical outcomes of 382 patients who underwent IVUS-guided PCI were compared to those of 523 patients who did not. Patients who presented with cardiogenic shock and rescue PCI were excluded. The primary composite endpoint of death, MI, and target lesion revascularization at 1-year follow-up was systematically indexed and a propensity score was performed with regard to the use of IVUS-guided PCI. Patients undergoing IVUS-guided PCI were older, more diabetic and hypertensive, but presented with less history of previous MI. The severity of coronary artery disease was balanced between both groups. The number of treated lesions and stents used was higher in the IVUS-guided group, with a longer procedural duration. The overall rates of the composite primary outcome were similar (14.5% vs. 14.3%, P = 0.94) as were the rates of definite and probable stent thrombosis at 1 year (2.1% vs. 2.1%, P = 0.99) in the IVUS-guided and no-IVUS groups, respectively. After multivariate and propensity score adjustment, IVUS guidance was not an independent predictor for the primary endpoint. This study does not support the routine use of IVUS guidance for stent deployment in patients who present with acute MI and undergo primary PCI.

Prognostic Value of Kidney Function in Patients With ST-Elevation and Non–ST-Elevation Acute Myocardial Infarction Treated With Percutaneous Coronary Intervention

Patients with decreased kidney function and acute ST-elevation myocardial infarction (STEMI) and non-STEMI are less likely to receive reperfusion therapy and aggressive medical treatment. This undertreatment may contribute to the poor outcome of these patients. The prognostic value of kidney function in patients with STEMI and NSTEMI treated predominantly with percutaneous coronary intervention (PCI) and aggressive medical treatment is less known. Prospective cohort study. 2 academic centers in Germany; 4,701 consecutive patients with acute myocardial infarction (AMI) from 1998 to 2006. Estimated creatinine clearance (eCCr) at admission. The primary end point was all-cause mortality during the first year after PCI for AMI (STEMI and NSTEMI) with a prespecified landmark at 30 days (landmark analysis). Secondary end points were nonfatal myocardial infarction, stroke, and major bleeding. Patients were divided into quartiles according to eCCr less than 56, 56 to 76, 77 to 100, and greater than 100 mL/min. Patients had an increased risk of death with decreased eCCr both within 30 days (7.7%, 3.1%, 1.4%, and 0.7% for the 4 quartiles; P < 0.001) and after 30 days (12.1%, 4.8%, 1.9%, and 1.2%; P < 0.001). The association of eCCr with mortality was similar in patients younger and older than 70 years. Major bleeding within 30 days and incidence of stroke also were more frequent with reduced eCCr. However, recurrent myocardial infarction was not associated with eCCr. After adjustment for additional baseline characteristics, kidney function based on eCCr at admission remained a strong independent predictor of mortality at 1 year after AMI (hazard ratio, 1.21 per 10-mL/min decrease; 95% confidence interval, 1.13 to 1.30). Single assessment of eCCr. In patients with AMI treated with primary PCI for STEMI and early PCI for NSTEMI, eCCr at admission remains a powerful independent predictor of short- and long-term mortality.

Combined Impact of Age and Estimated Glomerular Filtration Rate on In-Hospital Mortality After Percutaneous Coronary Intervention for Acute Myocardial Infarction (from the American College of Cardiology National Cardiovascular Data Registry)

Age and chronic kidney disease are major risk factors for poor cardiovascular outcome; however, renal function is often estimated on the basis of serum creatinine levels, and advanced renal impairment may be hidden behind near normal creatinine levels. We assessed the impact of estimated glomerular filtration rate (GFR) on in-hospital mortality in young (<65 years old), old (65 to 84 years old), and very old (> or = 85 years old) patients undergoing percutaneous coronary intervention (PCI) for acute myocardial infarction. The adjusted risk of death was calculated in 169,826 patients from the American College of Cardiology National Cardiovascular Data Registry undergoing primary PCI for acute myocardial infarction. Younger patients had fewer co-morbidities, higher estimated GFR, less frequent multivessel disease, and lower unadjusted mortality rates than older patients (p <0.0001 for all comparisons). However, the adjusted risk of in-hospital mortality for patients with severe renal insufficiency (estimated GFR <30 ml/min/1.73 m(2)) compared with those with normal renal function (estimated GFR > or = 60 ml/min/1.73 m(2)) was higher in young patients (adjusted odds ratio = 7.58, 95% confidence interval 6.18 to 9.29) than old (adjusted odds ratio = 4.75, 95% confidence interval 4.14 to 5.45) and very old patients (adjusted odds ratio = 3.50, confidence interval 2.50 to 4.89). In conclusion, severe renal insufficiency is associated with a greater risk of in-hospital mortality in young than old and very old patients after primary PCI. Risk stratification for patients with acute myocardial infarction should incorporate an assessment of renal function with estimated GFR values rather than absolute serum creatinine levels as done in the currently utilized risk scoring algorithms.

Bivalirudin With Provisional Glycoprotein IIb/IIIa Inhibitors in Patients Undergoing Primary Angioplasty in the Setting of Cardiogenic Shock

In patients undergoing percutaneous coronary intervention (PCI), clinical trials have demonstrated that the use of bivalirudin with provisional glycoprotein IIb/IIIa inhibitors is not inferior to heparin with systematic glycoprotein IIb/IIIa inhibitors on major adverse cardiac events and is associated with lower rates of bleeding in various clinical settings. Patients with cardiogenic shock (CS), however, have been excluded from all pivotal trials. A retrospective analysis of 86 consecutive patients undergoing PCI for acute myocardial infarction complicated by CS in our center from April 2003 to September 2007 was performed. In-hospital death, major adverse cardiac events, and bleeding rates were compared in 37 patients who received bivalirudin with or without glycoprotein IIb/IIIa inhibitors and 49 patients who were treated with heparin and glycoprotein IIb/IIIa inhibitors as anticoagulation management. Baseline demographic, clinical, and biological characteristics were similar in the 2 groups. The in-hospital death rate was significantly lower in the bivalirudin group (5.4 vs 32.7%, p = 0.002). There were no differences in the rate of major hematoma between the bivalirudin group and the heparin group (3 vs 2.6%, p = 0.46). In conclusion, bivalirudin with provisional use of glycoprotein IIb/IIIa inhibitors appears to be a safe and effective anticoagualtion strategy in patients undergoing primary PCI for acute myocardial infarction complicated by CS.

Thrombectomy during PCI for acute myocardial infarction

Macro and microembolization during percutaneous coronary intervention (PCI) in ST elevation acute myocardial infarction (STEAMI) is frequent and may result in obstruction of the microvascular network with subsequent reduction in efficacy of reperfusion. Numerous mechanistic studies have shown that the presence and size of the culprit thrombus is the most powerful predictor of incidence of embolization and slow flow/no reflow. Techniques that have been used to reduce the incidence of these events include thrombectomy devices and embolic protection devices. Although numerous prospective randomized clinical trials have been performed to evaluate the role of thrombectomy devices in patients with STEAMI, the results of these trials are conflicting and they speak to both sides of the controversy. The Achilles heal of the majority of these trials is the premise that thrombectomy devices should be routinely used in all patients presenting with STEAMI even irrespective of the presence and size of the thrombus. Such a hypothesis is naively optimistic and it ignores the basic knowledge available to us regarding the relationship between thrombus burden and embolization. Nonetheless, clinicians are faced every day with the reality of making difficult decisions on how to best treat patients presenting with STEAMI and large thrombus burden. The current available "evidence-based medicine" cannot and should not be generalized to these patients because only a minority of these patients was included in these randomized clinical trials. In these patients, thrombectomy devices should be strongly considered as an integral part of the armamentarium available to reduce thrombus burden prior to definitive treatment. Whether a future clinical trial will provide a definitive answer in terms of clinical outcome difference is doubtful because such a trial will need to include large number of selected patients with STEAMI who both have large amount of myocardium at jeopardy and large thrombus burden, a difficult and possibly undoable study.

Bivalirudin during Primary PCI in Acute Myocardial Infarction

Treatment with the direct thrombin inhibitor bivalirudin, as compared with heparin plus glycoprotein IIb/IIIa inhibitors, results in similar suppression of ischemia while reducing hemorrhagic complications in patients with stable angina and non-ST-segment elevation acute coronary syndromes who are undergoing percutaneous coronary intervention (PCI). The safety and efficacy of bivalirudin in high-risk patients are unknown. We randomly assigned 3602 patients with ST-segment elevation myocardial infarction who presented within 12 hours after the onset of symptoms and who were undergoing primary PCI to treatment with heparin plus a glycoprotein IIb/IIIa inhibitor or to treatment with bivalirudin alone. The two primary end points of the study were major bleeding and combined adverse clinical events, defined as the combination of major bleeding or major adverse cardiovascular events, including death, reinfarction, target-vessel revascularization for ischemia, and stroke (hereinafter referred to as net adverse clinical events) within 30 days. Anticoagulation with bivalirudin alone, as compared with heparin plus glycoprotein IIb/IIIa inhibitors, resulted in a reduced 30-day rate of net adverse clinical events (9.2% vs. 12.1%; relative risk, 0.76; 95% confidence interval [CI] 0.63 to 0.92; P=0.005), owing to a lower rate of major bleeding (4.9% vs. 8.3%; relative risk, 0.60; 95% CI, 0.46 to 0.77; P<0.001). There was an increased risk of acute stent thrombosis within 24 hours in the bivalirudin group, but no significant increase was present by 30 days. Treatment with bivalirudin alone, as compared with heparin plus glycoprotein IIb/IIIa inhibitors, resulted in significantly lower 30-day rates of death from cardiac causes (1.8% vs. 2.9%; relative risk, 0.62; 95% CI, 0.40 to 0.95; P=0.03) and death from all causes (2.1% vs. 3.1%; relative risk, 0.66; 95% CI, 0.44 to 1.00; P=0.047). In patients with ST-segment elevation myocardial infarction who are undergoing primary PCI, anticoagulation with bivalirudin alone, as compared with heparin plus glycoprotein IIb/IIIa inhibitors, results in significantly reduced 30-day rates of major bleeding and net adverse clinical events. (ClinicalTrials.gov number, NCT00433966 [ClinicalTrials.gov].).