Impact of routine stenting on clinical outcome in diabetic patients undergoing primary angioplasty for ST-segment elevation myocardial infarction.
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Biomedical subjects
Menko-Jan de Boer
Publications and source records attributed to Menko-Jan de Boer.
Ventricular fibrillation in acute myocardial infarction before and during primary PCI.
BACKGROUND: There are scarce and sometimes contradictory data about ventricular fibrillation (VF) during the acute phase of MI. In-hospital VF most often occurs with inferior MI, when treated with fibrinolytics. Out-of-hospital VF seems to be associated with anterior MI. We studied characteristics of patients with VF during reperfusion therapy by primary angioplasty (PCI) versus patients with VF before PCI. METHODS: From January 1995 until December 2001, we treated 2826 patients for acute MI and reviewed clinical records of all patients who developed VF and classified the patients according to the first episode of VF: either before or during the angioplasty procedure. RESULTS: VF developed in 219 (8%) patients. Patients with VF during reperfusion therapy (n=74, 3%) were older (p=0.03), more frequently female (0.04), less often had heart failure (p=0.04), when compared with patient with VF before PCI (n=145, 5%). Patients with VF during PCI experienced more often preinfarction angina (p=0.009) and suffered more often from inferior MI (p=0.001), when compared with patients with VF before PCI. CONCLUSIONS: Patients with early VF before reperfusion have different characteristics when compared with patients with VF during reperfusion. Infarct location is a major determinant of timing of VF, when both groups are compared (p<0.001).
Angioplasty, Balloon, Coronary↗
Impact of beta-blocker therapy at discharge on long-term mortality after primary angioplasty for ST-segment elevation myocardial infarction.
This study analyzed the effect of beta-blocker therapy at discharge on 1-year mortality rate in a large, unselected cohort of patients who had ST-segment elevation myocardial infarction that was treated by primary angioplasty. Our population is represented by 1,513 patients. At 1-year follow-up, beta blockers at discharge were associated with a significant decrease in mortality rate (2.9% vs 8.5%, RR 0.33, 95% confidence interval [CI] 0.18 to 0.59, p <0.0001), particularly in patients who had anterior wall infarction (3.9% vs 13.4%, RR 0.28, 95% CI 0.14 to 0.54, p <0.0001), whereas nonsignificant benefits were observed in patients who had nonanterior wall infarction (2.0% vs 3.3%, RR 0.6, 95% CI 0.17 to 2.07, p = NS). Benefits in terms of mortality rate that were conferred by beta blockers were confirmed at multivariate analysis that was restricted to patients who had anterior wall infarction (RR 0.43, 95% CI 0.21 to 0.86, p = 0.022).
Adrenergic beta-Antagonists↗
Absence of seasonal variation in myocardial perfusion, enzymatic infarct size, and mortality in patients with ST-segment elevation myocardial infarction treated with primary angioplasty.
The present study investigated any seasonal variation in myocardial perfusion, enzymatic infarct size, and 1-year mortality in 1,548 patients who underwent primary angioplasty for ST-segment elevation myocardial infarction. No seasonal variation was observed in patients' demographic and clinical characteristics. No difference was observed in the prevalence of heart failure at presentation and in myocardial perfusion, enzymatic infarct size, and 1-year mortality.
Angioplasty, Balloon, Coronary↗
The impact of glucose-insulin-potassium infusion in acute myocardial infarction on infarct size and left ventricular ejection fraction [ISRCTN56720616].
BACKGROUND: Favorable clinical outcomes have been observed with glucose-insulin-potassium infusion (GIK) in acute myocardial infarction (MI). The mechanisms of this beneficial effect have not been delineated clearly. GIK has metabolic, anti-inflammatory and profibrinolytic effects and it may preserve the ischemic myocardium. We sought to assess the effect of GIK infusion on infarct size and left ventricular function, as part of a randomized controlled trial. METHODS: Patients (n = 940) treated for acute MI by primary percutaneous coronary intervention (PCI) were randomized to GIK infusion or no infusion. Endpoints were the creatinine kinase MB-fraction (CK-MB) and left ventricular ejection fraction (LVEF). CK-MB levels were determined 0, 2, 4, 6, 24, 48, 72 and 96 hours after admission and the LVEF was measured before discharge. RESULTS: There were no differences between the two groups in the time course or magnitude of CK-MB release: the peak CK-MB level was 249 +/- 228 U/L in the GIK group and 240 +/- 200 U/L in the control group (NS). The mean LVEF was 43.7 +/- 11.0 % in the GIK group and 42.4 +/- 11.7% in the control group (P = 0.12). A LVEF < or = 30% was observed in 18% in the controls and in 12% of the GIK group (P = 0.01). CONCLUSION: Treatment with GIK has no effect on myocardial function as determined by LVEF and by the pattern or magnitude of enzyme release. However, left ventricular function was preserved in GIK treated patients.
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Relation of interhospital delay and mortality in patients with ST-segment elevation myocardial infarction transferred for primary coronary angioplasty.
The aim of the present study was to evaluate the impact of interhospital delay on mortality in 616 patients with ST-segment elevation myocardial infarction transferred for primary angioplasty to our hospital. Longer interhospital delay was associated with impaired perfusion, larger infarct size, and higher 1-year mortality (adjusted RR 1.5, 95% confidence interval 1.07 to 2.12; p = 0.019). These results suggest that in patients with ST-segment elevation myocardial infarction transferred for primary angioplasty, all efforts should be made to reduce time to treatment.
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Comparison of myocardial perfusion after successful primary percutaneous coronary intervention in patients with ST-elevation myocardial infarction with versus without diabetes mellitus.
Patients with diabetes mellitus (DM) have an adverse prognosis after ST-segment elevation myocardial infarction (STEMI). Whether DM was associated with impaired myocardial reperfusion after successful primary percutaneous coronary intervention for STEMI was investigated. Myocardial reperfusion was assessed by ST-segment resolution and myocardial blush grade (MBG). A total of 386 patients were studied, of whom 64 (17%) had DM. These patients more frequently had reduced MBG (20% vs 10%, p = 0.02) and incomplete ST-segment resolution (55% vs 35%, p = 0.02) compared with patients without DM. After multivariate analysis, DM was still associated with impaired ST resolution (odds ratio 2.1, p = 0.03) and reduced MBG (odds ratio 2.2, p = 0.03).
Angioplasty, Balloon, Coronary↗
Hyperglycemia is an important predictor of impaired coronary flow before reperfusion therapy in ST-segment elevation myocardial infarction.
OBJECTIVES: This study was designed to investigate whether elevated glucose is associated with impaired Thrombolysis In Myocardial Infarction (TIMI) flow before primary percutaneous coronary intervention (PCI). BACKGROUND: Reperfusion before primary PCI in patients with ST-segment elevation myocardial infarction (STEMI) is associated with an improved outcome. Hyperglycemia in patients with STEMI is associated with an adverse prognosis. Hyperglycemia may induce a pro-thrombotic state and therefore be of influence on TIMI flow before PCI. METHODS: A total of 460 consecutive patients with STEMI treated with primary PCI were included in this analysis. Hyperglycemia was defined as a glucose > or =7.8 mmol/l (140 mg/dl). RESULTS: Hyperglycemia was observed in 70% and TIMI flow grade 3 before primary PCI in 17% of the patients. Patients with hyperglycemia less often had TIMI flow grade 3 before primary PCI (12% vs. 28%, p < 0.001). After adjustment for differences in baseline variables, hyperglycemia was a strong predictor of absence of reperfusion before primary PCI (odds ratio 2.6, 95% confidence interval 1.5 to 4.5). CONCLUSIONS: Hyperglycemia in patients with STEMI is an important predictor of impaired epicardial flow before reperfusion therapy has been initiated. Investigation of methods improving coronary flow before primary PCI in these patients is warranted.
Angioplasty, Balloon, Coronary↗
Ageing, impaired myocardial perfusion, and mortality in patients with ST-segment elevation myocardial infarction treated by primary angioplasty.
AIMS: It is still unknown whether impaired myocardial perfusion helps to explain the higher mortality observed with ageing in patients with ST-segment elevation myocardial infarction (STEMI) treated with primary angioplasty. METHODS AND RESULTS: In 1548 consecutive patients with STEMI treated with primary angioplasty, myocardial perfusion was evaluated by myocardial blush grade (MBG) and ST-segment resolution. All clinical and follow-up data were prospectively collected. Advanced age was associated with a significantly higher clinical and angiographic risk profile. We found a linear relationship between increasing age, decreased myocardial perfusion, and higher 1-year mortality. After adjustment for baseline potential confounding variables, increased age was still significantly associated with impaired myocardial blush (MBG 0-1) (P=0.028), and ST-segment resolution (<50%) (P=0.007). At multivariable analysis both age (P<0.0001) and poor myocardial perfusion (P<0.0001) were independent predictors of 1-year mortality. CONCLUSION: This study shows that impaired reperfusion is an additional determinant of the poor outcome observed with advanced age in patients with STEMI undergoing mechanical revascularization.
Adult↗
Impact of ST-segment depression resolution on mortality after successful mechanical reperfusion in patients with ST-segment elevation acute myocardial infarction.
The aim of the present study was to evaluate the additional prognostic effect of ST-depression resolution in 610 patients who had ST-elevation myocardial infarction and underwent successful primary angioplasty (postprocedural Thrombolysis In Myocardial Infarction 3 flow and complete resolution of ST-segment elevation). Incomplete resolution of ST-segment depression (<70%) was observed in 50 patients (8.2%). These patients were older, had a higher Killip's class at presentation, had larger infarcts, and had an increased 1-year mortality (10% vs 2%, p = 0.0004). At multivariate analysis, incomplete resolution of ST-segment depression was an independent predictor of 1-year mortality (p = 0.028).
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Glucose-insulin-potassium and reperfusion in acute myocardial infarction: rationale and design of the Glucose-Insulin-Potassium Study-2 (GIPS-2).
BACKGROUND: The combination of reperfusion therapy and high-dose glucose-insulin-potassium (GIK) infusion seems beneficial in acute myocardial infarction (MI). Current evidence, however, is not considered conclusive. STUDY DESIGN: The Glucose-Insulin-Potassium Study-2 (GIPS-2) will investigate whether GIK, in adjunction to reperfusion therapy, is beneficial in MI patients without signs of heart failure at admission. A total of at least 1044 patients with an acute MI treated with either thrombolysis or primary percutaneous coronary intervention will be randomized to an infusion of high-dose GIK or no infusion. The primary end point of the study is 30-day mortality. Secondary end points are mortality at 1 year, recurrence of MI, repeat intervention, and infarct size. IMPLICATIONS: If high-dose GIK significantly reduces mortality at 30 days in all patients, the adjunction of this treatment to reperfusion therapy may become part of standard regimen for patients with acute MI without heart failure.
Algorithms↗
Unsuccessful reperfusion in patients with ST-segment elevation myocardial infarction treated by primary angioplasty.
BACKGROUND: Several studies have shown that patency of the epicardial vessel does not guarantee optimal myocardial perfusion in patients undergoing primary angioplasty for ST-segment elevation myocardial infarction (STEMI). The aim of the current study was to identify clinical and angiographic correlates of unsuccessful reperfusion by the use of myocardial blush grade in a large consecutive cohort of STEMI patients. METHODS: Our population is represented by a total of 1,548 consecutive patients with STEMI treated by primary angioplasty at our institution. All clinical and angiographic data were prospectively collected. Successful reperfusion was defined as postprocedural thrombolysis in myocardial infarction (TIMI) 3 flow with myocardial blush grades 2 to 3. RESULTS: Poor myocardial reperfusion was observed in 358 patients (23.1%) and was associated with a significantly larger infarct size (1838 [350-3387] vs 1187 [607-2257], P < .0001) and lower ejection fraction (41 [31-48.2] vs 65 [36.5-52.5] P < .0001). At multivariate analysis, preprocedural TIMI flow 0 to 1, anterior infarction, ischemic time, postprocedural residual stenosis, advanced Killip class at presentation, and age were identified as independent predictors of poor myocardial reperfusion. At 1-year follow-up, a total of 92 patients (5.9%) had died. At multivariate analysis, including clinical and angiographic variables, unsuccessful reperfusion was an independent predictor of 1-year mortality (relative risk 3.11, 95% CI 1.99-4.87, P < .0001). CONCLUSIONS: The prevalence of poor myocardial reperfusion is relatively high in patients undergoing primary angioplasty for STEMI, with a significant impact on 1-year mortality. Preprocedural TIMI flow, anterior infarction, ischemic time, Killip class at presentation, and age were independently associated with unsuccessful reperfusion. Future research should be focused on these high-risk patients, and treatment strategies should be developed to improve myocardial perfusion and clinical outcome.
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Preprocedural Thrombolysis in Myocardial Infarction (TIMI) flow significantly affects the extent of ST-segment resolution and myocardial blush in patients with acute anterior myocardial infarction treated by primary angioplasty.
BACKGROUND: Although the benefits of primary angioplasty for ST-segment elevation myocardial infarction (STEMI) have been demonstrated, the prognostic role of early recanalization in these patients has yet to be investigated. The aim of the study was to evaluate the impact of preprocedural Thrombolysis in Myocardial Infarction (TIMI) flow on the extent of myocardial reperfusion in patients with anterior STEMI treated with primary angioplasty. METHODS: Our population consisted of 754 consecutive patients with anterior STEMI treated by primary angioplasty from April 1997 to October 2001. All angiographic, clinical, and follow-up data were prospectively collected. RESULTS: Preprocedural TIMI flow was related to postprocedural TIMI 3 flow (P < .0001), ST-segment resolution (P = .009), myocardial blush grade (P < .0001), enzymatic infarct size (P < .0001), and predischarge ejection fraction (P < .0001), even in the analysis restricted to patients with postprocedural TIMI 3 flow. These data explain the observed significant impact of preprocedural TIMI flow on 1-year mortality. CONCLUSIONS: This study shows that in patients with anterior STEMI, poor preprocedural TIMI flow is associated with impaired perfusion, larger infarct size, and 1-year mortality. This study suggests that all efforts should be made to obtain optimal restoration of antegrade flow as early as possible before angioplasty. Further studies are needed to investigate the impact of early adjunctive pharmacological therapy on preprocedural TIMI flow and mortality in these high-risk patients.
Angioplasty↗
Prognostic significance of residual cumulative ST-segment deviation after mechanical reperfusion in patients with ST-segment elevation myocardial infarction.
BACKGROUND: The analysis of ST-segment resolution is a well established and easy method to assess myocardial perfusion after reperfusion therapy for ST-segment elevation myocardial infarction (STEMI). The aim of the current study was to identify an easy and practical instrument for patients' prognostic stratification after angioplasty for STEMI by the use of only postprocedural ST-segment analysis. METHODS: Our population is represented by a total of 1286 patients treated with primary angioplasty for STEMI. Residual ST-segment elevation and deviation were analyzed at 3 hours after revascularization. One-year follow-up data were collected prospectively in all patients. RESULTS: Patients with impaired ST-segment normalization were older, with larger prevalence of diabetes, anterior infarction, hypertension, signs of heart failure at presentation, lower rate of postprocedural thrombolysis in myocardial infarction 3 flow, myocardial blush grades 2 to 3, and successful reperfusion. A linear relationship was found between both residual cumulative ST-segment elevation and deviation with 1-year mortality. At multivariate analysis, postprocedural residual cumulative ST deviation (RR 1.31, 95% CI 1.06-1.63, P = .014), but not residual cumulative ST elevation (RR 0.95, 95% CI 0.55-1.67, P = .87), was an independent predictor of 1-year mortality. Furthermore, we found that residual cumulative ST-segment deviation provides better prognostic information (area receiver operating characteristic [ROC] = 0.733) than ST-segment elevation resolution (area ROC = 0.636) or ST-segment deviation resolution (area ROC = 0.660) in terms of 1-year mortality. These data were confirmed for both anterior and nonanterior infarct location. CONCLUSION: This study showed that postprocedural residual cumulative ST-segment deviation is an independent prognostic parameter in patients treated with primary angioplasty, providing even better prognostic information than ST-segment resolution.
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Circadian variation in myocardial perfusion and mortality in patients with ST-segment elevation myocardial infarction treated by primary angioplasty.
BACKGROUND: Little is known about whether the physiological factors that determine the circadian variation in ST-segment elevation myocardial infarction (STEMI) onset and thrombolysis efficacy may affect myocardial perfusion and long-term outcome of patients with STEMI treated with primary angioplasty. METHODS: Our study population consisted of 1548 consecutive patients with STEMI treated by primary angioplasty between April 1997 and October 2001. All clinical, angiographic, and follow-up data were collected. RESULTS: Most of the patients (65.2%) were treated at daytime (between 8 AM and 8 PM). Patients treated between 1 PM and midnight had a lower prevalence of anterior infarction and longer door-to-balloon time, whereas the shortest ischemic time and the largest use of stent were observed in patients treated between midnight and 4 AM Patients treated between 4 and 8 AM showed the worst outcome in terms of myocardial perfusion, enzymatic infarct size, and 1-year outcome, whereas patients treated between 8 AM and 4 PM had the best myocardial perfusion and lowest 1-year mortality rate. After correction for baseline confounding factors, the time of treatment (between 4 and 8 AM) was still significantly associated with 1-year mortality (relative risk 1.92, 95% CI 1.13-3.26, P = .016). CONCLUSIONS: This is the first study showing a significant relationship between the time of treatment, myocardial perfusion, and long-term mortality in patients with STEMI undergoing mechanical reperfusion.
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ST-segment elevation resolution and outcome in patients treated with primary angioplasty and glucose-insulin-potassium infusion.
BACKGROUND: To evaluate the impact of adjunctive high-dose glucose-insulin-potassium (GIK) on ST-segment elevation resolution in patients with ST-segment elevation myocardial infarction (MI). METHODS: As part of a randomized controlled trial of GIK versus no GIK in patients treated with primary percutaneous coronary intervention (PCI) for ST-elevation MI in a tertiary referral center, we analyzed ST-segment elevation resolution. Paired electrocardiographic recordings (baseline and 3 hours after primary PCI) were available in 612 (65%) of 940 patients. RESULTS: We analyzed paired electrocardiograms of 310 patients randomized to GIK and 302 control patients. Baseline characteristics of the groups were comparable. Combined complete (>70%) and partial (30%-70%) resolution was more commonly observed in the GIK group (87%) when compared with the control group (78%), odds ratio 1.92 (95% CI 1.23-3.02, P = .004); 1-year mortality was lower in patients with combined complete and partial resolution compared with patients without resolution (3.8% vs 10.3%, P = .011). There was no difference in 1-year mortality between GIK and control patients (5.5% vs 4.3%, P = .58). CONCLUSIONS: In patients with ST-elevation MI treated with primary PCI, addition of GIK is associated with improved ST-segment elevation resolution. ST-segment elevation resolution is related to improved 1-year survival. No benefit of GIK on 1-year outcome was observed. Future trials should investigate whether GIK-induced improvement of ST-segment elevation resolution results in more favorable clinical outcome.
Angioplasty↗
Impact of adjunctive tirofiban administration on myocardial perfusion and mortality in patients undergoing primary angioplasty for ST-segment elevation myocardial infarction.
Several studies have shown that suboptimal myocardial perfusion may be observed despite optimal epicardial recanalisation in patients undergoing primary angioplasty for ST-segment elevation myocardial infarction (STEMI), resulting in unfavourable outcome. The aim of the current study was to evaluate the benefits in myocardial perfusion and mortality from adjunctive tirofiban administration in patients undergoing primary angioplasty for (STEMI). Atotal of 1,969 patients with STEMI treated by primary angioplasty represent the population of the current study. All clinical, angiographic and follow-up data were prospectively collected. Tirofiban was administrated in 481 patients (24.4%) (all before angioplasty). Tirofiban was associated with less distal embolisation (11.7% vs 16.1%, p = 0.048), better postprocedural MBG 3 (50.9% vs 39.7%, adjusted p < 0.0001) and a significant reduction in 1-year mortality (3% vs 6.4%, adjusted p = 0.045). The benefits in mortality were confirmed in all subgroups identified according to the quartiles of the propensity score. This study shows that, when compared to control group, adjunctive tirofiban before primary angioplasty for STEMI is associated with better myocardial perfusion and a reduction in 1-year mortality.
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The Zwolle global experience on primary percutaneous coronary intervention.
Timely restoration of antegrade blood flow in the infarct-related artery of patients with ST-segment elevation myocardial infarction (STEMI) results in myocardial salvage and improved survival. We describe the Zwolle approach with regard to prehospital phase, the first 15 min in hospital, initial pharmacological therapy, angiography, angioplasty, risk stratification, rehabilitation and secondary prevention. Confirmation of the diagnosis by 12-lead electrocardiography by either general practitioners or ambulance paramedics allows substantial reduction in the time-delay to first balloon inflation, as the hospital and the catheterization laboratory can be prepared in advance, and the emergency room and the coronary care unit with their unavoidable delays can be skipped on the way to acute angiography. In our setting all patients with STEMI are treated at the time of diagnosis (before or during transportation) with heparin (5000 IU) and aspirin (500 mg) intravenously, with additional oral bolus (300 mg) of clopidogrel and additional 5000 IU heparin at the time of angiography. Our attitude is that an optimal balloon angioplasty result should never be jeopardized just for somewhat lower rate of target vessel revascularization during the first year after the acute event. In particular, attention should be paid to side branches, which may be of more clinical relevance in this setting than with elective angioplasty. Additional mechanical devices, such as distal protection devices and/or thrombosuction, should be mostly used when relevant thrombotic material is visible, with concomitant higher risk of distal embolization, particularly in high-risk patients. Finally, the use of the Zwolle risk score may help to identify low-risk patients who could be safely discharged within 36-48 hours after primary angioplasty, with a significant reduction in the costs of hospitalization.
Angioplasty, Balloon, Coronary↗