Primary Angioplasty In Myocardial Infarction Research Articles

A tale of two culprits: a case report

Acute thrombotic closure of more than one coronary artery causing STEMI is an infrequent finding in coronary angiography during primary angioplasty in myocardial infarction (PAMI). We presented a case of 37 years old male with acute inferior wall myocardial infarction (IWMI) with complete heart block (CHB) with left ventricular failure (LVF). Coronary angiography showed thrombotic occlusion in right coronary artery (RCA) and circumflex arteries. Clinical condition improved only after percutaneous transluminal coronary angioplasty (PTCA) of both arteries. Given this unique presentation, the best management is not standardized. Further studies are needed to better predict outcomes and guide future management.

Study of Demographic Profile, Clinical Manifestations, and a Short-term Follow-up of Young Patients Presenting with Myocardial Infarction at a Tertiary Care Hospital

Background: The present study was undertaken to analyze the clinical manifestations, treatment, and outcome of young patients presenting with myocardial infarction (MI) at a tertiary care hospital. Materials and Methods: The present study was a cross-sectional, observational hospital-based study conducted on patients with MI younger than 40 years. Results: Among the 50 patients, there were 49 males and one female. The age group ranged from 25 to 40 years—most of the patients presented with typical chest pain. Dyslipidemia was the most common risk factor 64%, followed by hypertension 42%, smoking 30%, high altitude area (HAA) 18%, positive family history 12%, metabolic syndrome 06%, and chronic kidney disease 02%. Serial creatine kinase-MB was elevated in 33 (66%) patients and normal in 17 (34%) patients. Troponin T/I was positive in 41 (82%) patients and negative in 09 (18%) patients. On echocardiogram, almost all patients had regional wall motion abnormality. The left ventricular ejection fraction <30% (2%), 30%–40% (18%), 41%–50% (32%), and >50% (22%). All 50 patients underwent a coronary angiogram, 19 had small vessel disease (38%), and 30 had recanalized/slow flow noted in coronaries (60%). Most of the patients, 36 (72%), underwent thrombolysis and had evidence of recanalized coronaries on coronary angiography; one patient was taken up for primary angioplasty in MI, 14 patients underwent percutaneous transluminal coronary angioplasty with stenting. Conclusion: The study describes the clinic-demographic profile of MI in young. The role of dyslipidemia, hypertension, smoking, high altitude area, and positive family history may need further elucidation in these patients.

Changing Concepts in Treatment of ST-Segment Elevation Myocardial

ST-Segment Elevation Myocardial (STEMI) is a lifethreatening condition that requires emergent, complex, well-coordinated treatment. Although the primary goal of treatment is simple to describe, reperfusion as quickly as possible- the management process is complicated and is affected by multiple factors including location, patient and practitioners’ characteristics. Indeed, treatment of acute STEMI has progressed considerably over the past 100 years, from the early stages of bed rest and development of thrombolytics and myocardial reperfusion, to today’s current strategy with a variety of mechanical and pharmacologic modalities. But the debate continues regarding optimal antithrombotic/anticoagulant and interventional strategies employed. Given the scientific and technological advantages, treatment strategies can be catered to better suit the patient and their presentation. Fibrinolytic therapy did save the lives compared to placebo, but at best restored Thrombolysis in Myocardial Infarction (TIMI) 3 Flow in 55-70% cases with increased incidence of recurrent ischaemia and infarction and intracranial haemorrhage. From Primary Angioplasty in Myocardial Infarction (PAMI) to 23 RCTs of Thrombolysis in Myocardial Infarction (TIMI) Vs Lysis showed that there is significant reduction in death (7.0% Vs 9.3%), Re-infarction (2.5% Vs 6.8%), haemorrhagic stroke (0.1% Vs 1.0%) and total stroke (1.0%) in Percutaneous Coronary Intervention (PCI) group. STEMI success has plateaued because of suboptimal salvage of myocardium and high rates of non-culprit lesion related events and reperfusion injury. Promising approaches should be further explored like hypothermia, stem cell and super-saturated oxygen therapy and PiCSO to enhance myocardial recovery and reduce infarct size. Bangladesh J Medicine 2023; Vol. 34, No. 2(1) Supplement: 182

Severe Acute Respiratory Syndrome Coronavirus 2 Antibodies in ST-segment Elevation Myocardial Infarction Patients and its Impact on Thrombus in the Coronaries

Objective: Higher thrombus load and poorer outcomes have been reported in coronavirus disease 2019 (COVID-19) patients with ST-segment elevation myocardial infarction (STEMI). The presence of antibodies to the COVID-19 infection has been linked to excess thrombus. This retrospective study compared the thrombus burden and outcomes in STEMI during primary angioplasty in myocardial infarction (PAMI) between the two groups with Sars antibody positive (SAP) and Sars antibody negative (SAN). Materials and Methods: Consecutive STEMI patients undergoing PAMI from November 2020 to July 2021 admitted to this single center were included. All patients were ruled out for an active infection by a negative rapid antigen and subsequently by reverse transcription polymerase chain reaction test. Participants were divided into SAP and SAN groups based on COVID-19 antibody results performed with the Roche kit. The primary aim was to compare thrombus load, coronary risk factors, and demographic characteristics between SAP and SAN patients and the secondary aim was to compare the inhospital and 30-day mortality between the two groups after primary percutaneous coronary intervention (PPCI). Results: The study included 261 consecutive STEMI patients (≥18 years; average age: 60.32 + 11.5 [standard deviation]). COVID antibody test results were available for 177 patients (36 SAP and 141 SAN), and these patients were included in the analysis; 144 were male, and 33 were female. There was no significant difference in baseline demographic characteristics between the two groups. Inflammatory markers, such as C-reactive protein (P = 0.479), troponin-T (P = 0.466), or D-dimer (P = 0.681) levels, and thrombus load status (G0 to G5) were not statistically significantly different (P = 0.344) between the two groups. Two patients in the SAP group and none in the SAN group (P = 0.005) died. The 30-day mortality rate (one patient in each group; P = 0.272) was not statistically significantly different between the two groups. Conclusion: Positive COVID-19 antibody levels in the blood did not produce changes in thrombus load and presentation in STEMI PAMI patients. The inhospital mortality rates and 30-day mortality rates were not affected by the antibody levels to COVID-19 infection.

Safety of early hospital discharge following admission with ST-elevation myocardial infarction treated with percutaneous coronary intervention: a nationwide cohort study.

The Second Primary Angioplasty in Myocardial Infarction (PAMI-II) risk score is recommended by guidelines to identify low-risk patients with ST-elevation myocardial infarction (STEMI) for an early discharge strategy. We aimed to assess the safety of early discharge (≤2 days) for low-risk STEMI patients treated with primary percutaneous coronary intervention (PCI). Using nationwide data from the SWEDEHEART registry, we identified patients with STEMI treated with primary PCI during the period 2009-2017, of whom 8,092 (26.4%) were identified as low risk with the PAMI-II score. Low-risk patients were stratified according to their length of hospital stay (≤2 days vs >2 days). The primary endpoint was major adverse cardiovascular events (MACE, including death, reinfarction treated with PCI, stroke or heart failure hospitalisation) at one year, assessed using a Cox proportional hazards model with propensity score as well as an inverse probability weighting propensity score of average treatment effect to adjust for confounders. A total of 1,449 (17.9%) patients were discharged ≤2 days from admission. After adjustment, the one-year MACE rate was not higher for patients discharged at >2 days from admission than for patients discharged ≤2 days (4.3% vs 3.2%; adjusted HR 1.31, 95% confidence interval [CI]: 0.92-1.87, p=0.14), and no difference was observed regarding any of the individual components of the main outcome. Results were consistent across all subgroups with no difference in MACE between early and late discharge patients. Nationwide observational data suggest that early discharge of low-risk patients with STEMI treated with PCI is not associated with an increase in one-year MACE.

Can we simplify or improve long-term risk stratification for patients with ST-segment elevation myocardial infarction undergoing primary intervention?

Abstract Background Various scores have been developed to predict early to mid-term prognosis after ST-elevation myocardial infarction (STEMI). The aim of this study was to compare the predictive value of 7 popular risks scores for the long-term outcome of STEMI patients undergoing primary intervention, and to find an easy model with similar or superior predictive and discriminative ability. Methods Patients who underwent primary PCI from January 2003 through August 2007 in a single tertiary-center were analysed (n=665) using a dedicated prospective registry. Global Registry for Acute Coronary Events (GRACE), GRACE 6 months, Thrombolysis In Myocardial Infarction (TIMI) STEMI, dynamic TIMI, TIMI risk index, Primary Angioplasty in Myocardial Infarction (PAMI) and Zwolle primary percutaneous coronary intervention (PCI) index were calculated for each patient. We assessed, through the C statistic in receiver-operating characteristic analysis, the predictive accuracy of these scores using all-cause mortality at 5 year as an endpoint. With multivariate regression analysis the variables with highest predictive ability were applied to build a model. Results All-cause mortality at 5 years after primary PCI was 22.1%. The risk scores showed moderate predictive ability, GRACE (0.759, 95% confidence interval (CI) 0.712–0.805), GRACE 6 months (0.802, 95% CI 0.759–0.845), TIMI STEMI (0.744, 95% CI 0.696–0.791), dynamic TIMI (0.774, 95% CI 0.727–0.820), TIMI risk index (0.757, 95% CI 0.710–0.803), PAMI (0.753, 95% CI 0.707–0.800) and Zwolle index (0.749, 95% CI 0.703–0.795). Six independent predictors of 5-year mortality were identified (age >70 years, history of MI, history of stroke, heart tare above 85 beats per min, 3-vessel disease and in-hospital adverse events) and the model built had similar discriminative performance in estimation of probabilities of death (0.804, 95% CI 0.762–0.846, p=0.953 for difference with GRACE score). Conclusions The prediction values of currently recommended risk scores are moderate for long-term perspective (5-year). The simplified risk stratification score for STEMI and primary angioplasty using only six variables demonstrates accuracy similar to the more advanced risk scores. Funding Acknowledgement Type of funding sources: None.

Clinical Profile and Approach to Osteal LAD Lesion During Primary Angioplasty in Myocardial Infarction (PAMI)

Isolated Coronary Artery Stenoses (CAS) involving the ostium of the Left Anterior Descending (LAD) artery is very challenging, especially in a setting of primary Angioplasty in Myocardial Infarction (PAMI). Intimal atherosclerosis in the Left Main Coronary Artery (LMCA) bifurcation is primarily in area of low shear stress which is the lateral wall, close to the LAD and Left Circumflex (LCx). Thus, carina is usually free of disease, which can explain why single-stent strategy can be successful. However, precise stent placement is often difficult due to unwanted stent movement within vessel or its proximity to side branches. A decision must be made at the outset, to decide on the approach to be employed, to treat osteal LAD lesions. Limited data is available on patients undergoing primary PCI of osteal LAD lesions. Here, we present our experience and problems encountered during the management of osteal LAD lesions in the setting of PAMI.

Predictive Power of In-Hospital and Long-Term Mortality of the GRACE, TIMI, Revised CADILLAC and PAMI Score in NSTEMI Patients with Diabetes - Data from TSOC ACS-DM Registry.

Risk score is widely used in non-ST segment elevation myocardial infarction (NSTEMI) patients to predict the in-hospital outcome for immediate coronary angiography decision and care of unit selection. This study compared the performances of the thrombolysis in myocardial infarction (TIMI), Global Registry of Acute Coronary Events (GRACE), Primary Angioplasty in Myocardial Infarction (PAMI), and Revised Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (Revised CADILLAC) risk scores in predicting in-hospital and long-term outcomes in diabetic NSTEMI patients. A total of 750 diabetic NSTEMI patients from 27 hospitals were enrolled between January 2013 and December 2015 in the nationwide registry initiated by the Taiwan Society of Cardiology. Four score systems were calculated with receiver operator characteristic analysis used to compare outcome discrimination performance. No studied risk scores reached acceptable discrimination per area under curve (AUC) in the prediction of in-hospital outcome except for the revised CADILLAC score which reached acceptable discrimination in new-onset cardiogenic shock (AUC = 0.7191) and acute renal failure (AUC = 0.7283). In long-term outcomes, only the revised CADILLAC score reached acceptable discrimination of mortality prediction at 6, 12 and 24 months (AUC = 0.7261 at 6 months, 0.7319 at 12 months, and 0.7256 at 24 months). Subgroup analysis based on the revised CADILLAC score risk class showed a significant difference in adjusted mortality rate between low-risk group/intermediate-risk group and high-risk group. Only the revised CADILLAC score showed acceptable accuracy to predict the long-term mortality outcome among the scores studied.

Timely discharge of low-risk STEMI patients admitted for primary PCI in an Essex cardiothoracic centre.

Data for low-risk ST-elevation myocardial infarction (STEMI) patients in the Essex cardiothoracic centre (CTC) during a three-month period were evaluated and the average duration of admission was calculated to be 67.2 hours. The data were sifted by applying Second Primary Angioplasty in Myocardial Infarction (PAMIII) criteria for low-risk STEMI patients who could be safely discharged after 48 hours. After application of a proforma as a quality improvement intervention tool, data were re-assessed and the average time of admission observed for a similar cohort of patients dropped down to an average of 55.2 hours. Overall, there was a 13% average increase in rate of early discharge for low-risk STEMI patients.

Index of Microcirculatory Resistance at the Time of Primary Percutaneous Coronary Intervention Predicts Early Cardiac Complications: Insights From the OxAMI (Oxford Study in Acute Myocardial Infarction) Cohort.

BackgroundEarly risk stratification after primary percutaneous coronary intervention (PPCI) for ST‐segment–elevation myocardial infarction is currently challenging. Identification of a low‐risk group may improve triage of patients to alternative clinical pathways and support early hospital discharge. Our aim was to assess whether the index of microcirculatory resistance (IMR) at the time of PPCI can identify patients at low risk of early major cardiac complications and to compare its performance against guideline‐recommended risk scores.Methods and Results IMR was measured using a pressure–temperature sensor wire. Cardiac complications were defined as the composite of cardiac death, cardiogenic shock, pulmonary edema, malignant arrhythmias, cardiac rupture, and presence of left ventricular thrombus either before hospital discharge or within 30‐day follow‐up. In total, 261 patients undergoing PPCI who were eligible for coronary physiology assessment were prospectively enrolled. Twenty‐two major cardiac complications were reported. Receiver operating characteristic curve analysis confirmed the utility of IMR in predicting complications and showed significantly better performance than coronary flow reserve, the Primary Angioplasty in Myocardial Infarction II (PAMI‐II), and Zwolle score (P≤0.006). Low microvascular resistance (IMR ≤40) was measured in 159 patients (61%) of the study population and identified all patients who were free of major cardiac complications (sensitivity: 100%; 95% CI, 80.5–100%).Conclusions IMR immediately at the end of PPCI for ST‐segment–elevation myocardial infarction reliably predicts early major cardiac complications and performed significantly better than recommended risk scores. These novel data have implications for early risk stratification after PPCI.

Intra-aortic balloon pump for high-risk percutaneous coronary intervention.

The intra-aortic balloon pump (IABP) was first introduced into clinical practice in 1968.1 Early experimental and clinical trials suggested that intra-aortic balloon counterpulsation could provide circulatory assistance to a failing left ventricle.2,3 Counterpulsation—balloon inflation during diastole and deflation in systole—augments the intrinsic Windkessel effect, whereby potential energy stored in the aortic root during systole is converted to kinetic energy with the elastic recoil of the aortic root. Counterpulsation leads to a decline in afterload, a reduction in cardiac work, and therefore myocardial oxygen requirements of the ventricle. Augmentation of diastolic pressure when the balloon is fully inflated together with reduction in left ventricular (LV) filling pressures contribute to improved coronary perfusion (Figures 1 and 2).4 This proposed improvement in myocardial energetics has been further supported by a significant reduction in systemic lactate.5 These physiological enhancements are thought to be of particular benefit after acute myocardial infarction (AMI), supported by animal studies, which have shown a reduction in infarct size when counterpulsation is used.6,7 Figure 1. Coronary perfusion. Coronary flow is predominantly diastolic and further enhanced by counterpulsation, which augments diastolic blood flow and thus coronary perfusion. In addition, aortic recoil during diastole further improves efficiency of the left ventricle. Figure 2. Systemic arterial pressure waveform on introduction of intra-aortic balloon pump–assisted diastolic augmentation. The intra-aortic balloon pump inflates at the dicrotic notch, leading to peak-augmented diastolic pressure. As the balloon deflates, assisted end diastolic pressure is seen to be lower than unassisted end diastolic pressure and assisted systolic pressure is lower than unassisted systolic pressure. Peak diastolic augmentation should be greater than the unassisted systolic pressure and both assisted pressures should be less than the unassisted pressures. Intra-aortic balloon counterpulsation was initially used as a means of supporting patients undergoing surgical revascularization. Percutaneous delivery …

What is Primary Angioplasty in Myocardial Infarction

What is Primary Angioplasty in Myocardial Infarction

Endovascular Therapy for Stroke

> Those who cannot remember the past are condemned to repeat it.1 > > — George Santayana, 1863 to 1952 In the late 1970s, Gruentzig’s groundbreaking reports on a series of successfully performed coronary angioplasties created the field of endovascular medicine, setting the precedent for the Food and Drug Administration’s 510(k) approval of the procedure in 1981.2 Over the next decade, the number of angioplasties performed in the United States grew exponentially from 1000 procedures in 1980 to >300 000 by 1995.3 Despite robust growth, however, clinical trials failed to demonstrate the benefits of angioplasty over thrombolysis for the treatment of ST-segment–elevation myocardial infarction (STEMI).4–7 The Primary Angioplasty in Myocardial Infarction (PAMI) and ZWOLLE trials in 1993 were the first randomized, controlled studies to demonstrate the efficacy of percutaneous coronary intervention (PCI) over fibrinolytic therapy,8,9 nearly 10 years after reimbursement by the Centers for Medicare & Medicaid (diagnosis-related group 108) was granted.10 Although subsequent studies disputed the merits of PCI,11–13 several meta-analyses provided definitive evidence that PCI was superior for STEMI.14,15 In 1996, the American College of Cardiology/American Heart Association incorporated PCI as a Class I recommendation for STEMI if performed in a “timely fashion…by personnel in high volume center[s].”16 The use of PCI as a facilitated or rescue strategy after fibrinolysis, however, remained controversial, having only recently been shown to be effective.17–19 As history repeats itself, many challenges encountered by cardiology are being revisited by acute stroke trialists. Since the publication of the nonpositive results of the Interventional Management of Stroke (IMS) III, The Mechanical Retrieval and Recanalization of Stroke Clots Using Embolectomy (MR RESCUE), and SYNTHESIS Expansion trials,20–22 endovascular procedures for stroke are being met with skepticism, similar …

Accuracy of Dedicated Risk Scores in Patients Undergoing Primary Percutaneous Coronary Intervention in Daily Clinical Practice

BackgroundComparisons between dedicated risk scores in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (pPCI) in real-world clinical practice are scarce. The aim of this study was to assess the diagnostic performance of the Global Registry of Acute Coronary Events (GRACE), Primary Angioplasty in Myocardial Infarction (PAMI), Thrombolysis in Myocardial Infarction (TIMI), and Zwolle scores in STEMI patients undergoing pPCI in contemporary clinical practice. MethodsThis was a prospective cohort study of consecutive patients with STEMI undergoing pPCI between December 2009 and November 2010 in a high-volume tertiary referral centre. The outcomes assessed were major cardiovascular events (MACEs) and death within 30 days. The diagnostic accuracy of the scores was assessed using receiver operating characteristic curves, and scores were compared using the DeLong method. ResultsDuring the study period, 501 patients were included. Within 30 days, 62 patients (12.4%) presented a MACE and 39 individuals (7.8%) died. All scores were statistically associated with death and MACE within 30 days (P < 0.01). The c-statistic and 95% confidence intervals for 30-day mortality were: GRACE, 0.84 (0.78-0.90); TIMI, 0.81 (0.74-0.87); Zwolle, 0.80 (0.73-0.87); and PAMI, 0.75 (0.68-0.82) (P < 0.01). There was no statistically significant difference regarding the accuracy of the TIMI, GRACE, and Zwolle scores for 30-day mortality, but the GRACE score was superior to the PAMI score (P < 0.01). ConclusionsThe TIMI, GRACE, and Zwolle scores performed equally well as predictors of mortality in patients who underwent pPCI in current practice. These results suggest that these scores are suitable options for risk assessment in a real-world setting.

Association Between Intraprocedural Thrombotic Events and Adverse Outcomes After Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction (a Harmonizing Outcomes With RevasculariZatiON and Stents in Acute Myocardial Infarction [HORIZONS-AMI] Substudy)

The present study sought to determine the extent to which adverse angiographic events encountered during percutaneous coronary intervention for ST-segment elevation myocardial infarction (STEMI) are associated with adverse clinical outcomes. Patients with STEMI represent a cohort at particularly high risk of intraprocedural thrombotic events (IPTEs). The overall frequency and implications of IPTEs occurring in patients with STEMI have not been systematically quantified in previous studies. A total of 3,163 patients undergoing primary percutaneous coronary intervention with stent implantation for STEMI in the Harmonizing Outcomes with RevasculariZatiON and Stents in Acute Myocardial Infarction (HORIZONS-AMI) trial underwent detailed frame-by-frame core laboratory angiographic analysis to assess IPTEs. The clinical outcomes at 30 days were compared between the patients with and without IPTEs. IPTEs, defined as the development of new or increasing thrombus, abrupt vessel closure, no reflow, slow reflow, and distal embolization at any point during the procedure, occurred in 386 patients (12.2%). The independent predictors of IPTE were thrombus at baseline, lesion length, and randomization to bivalirudin; the patients with IPTEs were also more likely to receive bailout glycoprotein IIb/IIIa inhibitors and unplanned thrombectomy. Compared with patients without IPTEs, the patients with IPTEs had higher 30-day rates of composite major adverse cardiovascular events (death, myocardial infarction, ischemic target vessel revascularization, and stroke; 7.8% vs 4.2%, p = 0.002), major bleeding not related to coronary artery bypass grafting (11.8% vs 6.5%, p <0.001), and all-cause death (4.2% vs 1.8%, p = 0.002). On multivariate analysis, IPTEs were independently associated with 30-day major adverse cardiovascular events, major bleeding, and death. In conclusion, the development of IPTEs in patients undergoing primary percutaneous coronary intervention for STEMI was associated with subsequent adverse outcomes, including major adverse cardiovascular events, major bleeding, and death. Additional studies of strategies to decrease the occurrence of IPTEs are warranted.

Comparison of the Prognostic Predictive Value of the TIMI, PAMI, CADILLAC, and GRACE Risk Scores in STEACS Undergoing Primary or Rescue PCI

Introduction and objectivesWe sought to compare the predictive value of the Thrombolysis In Myocardial Infarction (TIMI), Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC), Primary Angioplasty in Myocardial Infarction (PAMI), and Global Registry for Acute Coronary Events (GRACE) scores for the outcome of ST-segment elevation acute coronary syndrome undergoing urgent percutaneous coronary intervention. MethodsWe performed a retrospective analysis of a cohort composed of all consecutive patients with ST-segment elevation acute coronary syndrome treated by urgent percutaneous coronary intervention between 2006 and 2010 (n=1503). TIMI, PAMI, CADILLAC, and GRACE risk scores were calculated for each patient according to different clinical variables. We assessed the predictive accuracy of these scores for death, reinfarction, and target-vessel revascularization at 30 days and 1 year, using the C statistic, which was obtained by means of logistic regression and ROC curves. ResultsThe TIMI, PAMI, CADILLAC and GRACE showed an excellent predictive value for 30-day and 1-year mortality (C statistic range, 0.8-0.9), with superiority of the TIMI, CADILLAC, and GRACE risk models. The performance of these 4 scores was poor for both reinfarction and target-vessel revascularization (C statistic, 0.5-0.6). ConclusionsThe TIMI, PAMI, CADILLAC, and GRACE scores provide excellent information to stratify the risk of mortality in patients treated by percutaneous coronary intervention. The TIMI, CADILLAC, and GRACE models have higher predictive accuracy. The usefulness of these models for reinfarction and target-vessel revascularization prediction is questionable.

Comparación del valor predictivo pronóstico de los scores TIMI, PAMI, CADILLAC y GRACE en el SCACEST sometido a ICP primario o de rescate

Introduction and objectivesWe sought to compare the predictive value of the Thrombolysis In Myocardial Infarction (TIMI), Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC), Primary Angioplasty in Myocardial Infarction (PAMI), and Global Registry for Acute Coronary Events (GRACE) scores for the outcome of ST-segment elevation acute coronary syndrome undergoing urgent percutaneous coronary intervention. MethodsWe performed a retrospective analysis of a cohort composed of all consecutive patients with ST-segment elevation acute coronary syndrome treated by urgent percutaneous coronary intervention between 2006 and 2010 (n=1503). TIMI, PAMI, CADILLAC, and GRACE risk scores were calculated for each patient according to different clinical variables. We assessed the predictive accuracy of these scores for death, reinfarction, and target-vessel revascularization at 30 days and 1 year, using the C statistic, which was obtained by means of logistic regression and ROC curves. ResultsThe TIMI, PAMI, CADILLAC and GRACE showed an excellent predictive value for 30-day and 1-year mortality (C statistic range, 0.8-0.9), with superiority of the TIMI, CADILLAC, and GRACE risk models. The performance of these 4 scores was poor for both reinfarction and target-vessel revascularization (C statistic, 0.5-0.6). ConclusionsThe TIMI, PAMI, CADILLAC, and GRACE scores provide excellent information to stratify the risk of mortality in patients treated by percutaneous coronary intervention. The TIMI, CADILLAC, and GRACE models have higher predictive accuracy. The usefulness of these models for reinfarction and target-vessel revascularization prediction is questionable.

Prediction of 1-Year Clinical Outcomes Using the SYNTAX Score in Patients With Acute ST-Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention: A Substudy of the STRATEGY (Single High-Dose Bolus Tirofiban and Sirolimus-Eluting Stent Versus Abciximab and Bare-Metal Stent in Acute Myocardial Infarction) and MULTISTRATEGY (Multicenter Evaluation of Single High-Dose Bolus Tirofiban Versus Abciximab With Sirolimus-Eluting Stent or Bare-Metal Stent

This study sought to evaluate the impact of SYNTAX score (SXscore), and compare its performance in isolation and combination with the PAMI (The Primary Angioplasty in Myocardial Infarction Study) score, for the prediction of 1-year clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention. Patients with STEMI were excluded from the original SYNTAX score (SXscore) algorithm. Therefore, the utility of using the SXscore in this patient group remains undefined. SXscore was calculated retrospectively in 807 patients with STEMI enrolled in the randomized STRATEGY (Single High-Dose Bolus Tirofiban and Sirolimus-Eluting Stent Versus Abciximab and Bare-Metal Stent in Acute Myocardial Infarction) and MULTISTRATEGY (Multicenter Evaluation of Single High-Dose Bolus Tirofiban Versus Abciximab With Sirolimus-Eluting Stent or Bare-Metal Stent in Acute Myocardial Infarction Study) clinical trials. Clinical outcomes of all-cause death, reinfarction, and clinically driven target vessel revascularization were subsequently stratified according to SXscore tertiles: SXLOW ≤9 (n = 311), 9 < SXMID ≤16 (n = 234), SXHIGH >16 (n = 262). At 1-year follow-up, all clinical outcomes including mortality, mortality/reinfarction, major adverse cardiac events (MACE) (a composite of all-cause death, reinfarction and target vessel revascularization), and definite, definite/probable, and any stent thrombosis were all significantly higher in patients in the highest SXscore tertile. SXscore was identified as an independent predictor of mortality, MACE, and stent thrombosis out to 1-year follow-up. The combination SYNTAX-PAMI score led to a net reclassification improvement of 15.7% and 4.6% for mortality and MACE, respectively. The C-statistics for the SXscore, PAMI score, and the combined SYNTAX-PAMI score were 0.65, 0.81, and 0.73 for 1-year mortality, and 0.68, 0.64, and 0.69 for 1-year MACE, respectively. SXscore does have a role in the risk stratification of patients with STEMI having primary percutaneous coronary intervention; however, this ability can be improved through a combination with clinical variables. (Multicentre 2×2 Factorial Randomised Study Comparing Tirofiban Versus Abciximab and SES Versus BMS in AMI; NCT00229515)

043 Invasive arrhythmic assessment after myocardial infarction; actual results

Programmed ventricular stimulation (PVS) was proposed after myocardial infarction (MI) more than 25 years ago, but the management of MI has changed during this period. The purpose of the study was to look for the results of systematic PVS after MI according to the period of indication and remaining indications. PVS was performed between 1982 and march 2010, from 4 to 8 weeks after acute MI in 797 patients (pts) without syncope or ventricular tachycardia (VT) to stratify the risk of arrhythmias: 301 (group I) were studied between 1982 and 1989, 315 (group II) between 1990 and 1999 and 179 (group III) between 2000 and 2010. PVS used the same protocol (up to 3 extrastimuli in 2 sites of right ventricle). Group III pts were older (61 ± 10 years) than group I (56 ± 11) and group II pts (58 ± 11) (p<0.002). LVEF was lower in group III (36 ± 11%) than in group I (44 ± 15) and II (41 ± 12) (p<0.05). PVS was as frequently negative in group III (58.5%) as in group I (52%) and II (47%). Monomorphic VT < 270 b/min was induced as frequently in group III (27%) as in group I (20%) and II (21.5%). Ventricular fibrillation was induced less frequently in group III (7%) than in group II (12%) and I (13%) (p<0.04). Ventricular flutter (VT > 265 b/min) was induced less frequently in group III (8%), than in group II (18%, p<0.001) and I (15%) (p < 0.03). The only significant difference was the primary angioplasty with recanalization of occluded coronary artery, more systematic since 2000: total revascularization was obtained in 39% of group III and 27% of groups II and I (p<0.05). The interpretation of PVS are now easier to interpret, because the induction of non specific arrhythmias, the ventricular flutter and fibrillation, is rarer than before 2000, although PVS was indicated in patients with lower LVEF. The decrease of the induction of this arrhythmia could be related to the more systematic indication of primary angioplasty in MI since 2000. PVS remains useful in pts with debatable indications of defibrillator to help to take a decision.

Infarctus par occlusion aiguë du tronc commun non protégé : à propos de six cas traités par angioplastie

Aim Acute main left coronary artery occlusion is rarely observed during primary angioplasty in myocardial infarction. This retrospective study reports the results of six patients treated by angioplasty in a hospital without cardiac surgery department. Patients and methods From 2002 to 2009, 746 patients were treated by primary angioplasty for acute coronary syndromes with ST elevation. Among those patients, six (0,7%) had acute non protected main left coronary occlusion. We report clinical, angiographical data and follow-up. Results The population was composed of six patients (five males) with an average age of 64 ± 7 years. Five patients were admitted with cardiogenic shock and four were mechanically ventilated. Distal occlusion of main left coronary artery and dominant right coronary artery were noted in all cases. Sub-occluded lesion of right coronary artery was noted in one case. Successful procedure with bare metal stent was achieved in five cases. Mortality rate was 66% ( n = 4): three patients died in hospital and another 1 or 2 months later of congestive heart failure. Coronary artery bypass grafting was performed at 4 and 12 months later for two patients. They are alive after 12 and 72 months of follow-up. Conclusion We demonstrate the feasibility of percutaneous coronary intervention of acute main left coronary occlusion. Inspite successful procedure, intrahospital mortality rate is still high and prognosis is related to cardiogenic shock.