Unplanned repeat coronary angiography (CAG) after balloon angioplasty for ST-elevation myocardial infarction (STEMI) was common before the advent of coronary stenting. Limited data are available regarding the role of unplanned repeat CAG in contemporary percutaneous coronary intervention (PCI) for STEMI. Therefore, we analyzed a large, 2-center prospective STEMI registry (January 2011 to June 2020) stratified by the presence or absence of unplanned repeat CAG during index hospitalization. Patients with planned CAG for staged PCI or experimental drug administration were excluded. Among 3,637 patients with STEMI, 130 underwent unplanned repeat CAG (3.6%) during index hospitalization. These patients were more likely to have cardiogenic shock (16% vs 9.8%, p = 0.021), left anterior descending culprit (44% vs 31%, p <0.001), lower left ventricular ejection fraction (45% vs 52%, p <0.001), and higher peak troponin levels (22 vs 8 ng/ml, p <0.001) than those without repeat CAG. At repeat CAG, 80 patients had a patent stent (62%) including 65 requiring no further intervention (50%) and 15 who underwent intervention on a nonculprit lesion (12%). Only 32 patients had stent thrombosis (25%). Repeat CAG was associated with a higher incidence of recurrent MI (19% vs 0%, p <0.001) and major bleeding (12% vs 4.5%, p <0.001), yet similar in-hospital mortality (7% vs 6.4%, p = 0.93) than those without repeat CAG. In conclusion, in the era of contemporary PCI for STEMI, unplanned repeat CAG during index hospitalization was infrequent and more commonly observed in patients with left anterior descending culprit in the presence of significant left ventricular dysfunction or shock and was associated with higher in-hospital recurrent myocardial infarction and major bleeding complications.
Percutaneous transluminal coronary angioplasty was a major advance in the treatment of coronary artery disease (CAD); however, it was often accompanied by unique complications such as coronary artery dissection, abrupt vessel closure, and restenosis. , In the percutaneous transluminal coronary angioplasty era, between 2% and 10% of patients with stable CAD and up to 15% with unstable CAD had abrupt or threatened vessel closure, which necessitated repeat coronary angiography (CAG) during index hospitalization (also known as “relook” CAG). Advances in stent technology remarkably reduced abrupt vessel closure and restenosis rates; however, stent thrombosis (early or late), in-stent restenosis, and bleeding complications remain as challenges. Previous studies reported between 4% and 9% incidence of unplanned repeat revascularization within 1 year of index percutaneous coronary intervention (PCI) in unselected patients with acute myocardial infarction (AMI) ; however, no recent clinical study has focused on the incidence of unplanned repeat CAG during index hospitalization. Therefore, we examined the frequency, etiology, and impact of unplanned repeat CAG during index hospitalization after contemporary PCI for ST-elevation myocardial infarction (STEMI) to address gaps in knowledge.
This analysis of 2-center (Minneapolis Heart Institute at Abbott Northwestern Hospital in Minneapolis, Minnesota, and The Christ Hospital in Cincinnati, Ohio) prospective registry enrolled consecutive patients with STEMI between January 2011 and June 2020. These STEMI centers are part of the Midwest STEMI Consortium. All patients aged >18 years who presented within 24 hours of symptom onset with ST-elevation ≥1 mm in at least 2 contiguous leads or new left bundle branch block were included in the prospective registries in each center. All patients, even those with high-risk clinical features such as advanced age, cardiac arrest, cardiogenic shock, or transferred from distant locations, were included in the registries except for those ineligible for PCI because of advanced dementia or terminal cancer. Baseline characteristics, relevant comorbidities, detailed angiographic features, and clinical outcomes were collected by reviewing electronic medical records. The study protocol and data-sharing agreement between the 2 centers were approved by the institutional review board in each center.
Unplanned repeat CAG during index hospitalization was defined as the first unscheduled CAG after primary PCI but before hospital discharge. We compared the clinical and procedural characteristics and outcomes of patients with or without unplanned repeat CAG during index hospitalization. Outcomes included all-cause mortality, recurrent myocardial infarction (MI), stroke, and bleeding complications in-hospital and at 30-day follow-up. Recurrent MI was defined per the universal definition of myocardial infarction, and bleeding complications were categorized per the thrombolysis in myocardial infraction bleeding classification. ,
Discrete variables are reported as frequency and percentage and compared using the chi-square or Fisher’s exact tests, where appropriate. Continuous variables are reported as mean ± SD if normally distributed or median (interquartile range) if skewed. Analyses of continuous variables were performed using t test or Wilcoxon rank-sum test, depending on the distribution. All analyses were performed using Stata version 15.1 (College Station, Texas).
Between January 2011 and June 2020, a total of 3,832 consecutive patients with STEMI were included in the initial cohort. After excluding 195 patients with planned CAG for staged PCI or investigational drug administration, the final study cohort included 3,637 patients with STEMI, of whom 130 underwent unplanned repeat CAG (3.6%) and 62 required unplanned revascularization (1.7%) during index hospitalization ( Figure 1 ). Among those with repeat CAG, mean age was 64 ± 13 years, and most were men as in the overall cohort. Patients with unplanned repeat CAG were more likely to occur in the presence of cardiogenic shock, left anterior descending (LAD) culprit lesion, lower left ventricular ejection fraction (LVEF), and a higher peak troponin level than those without repeat CAG. Patients with unplanned repeat CAG also had more diseased vessels at primary PCI but periprocedural antiplatelet agents (P2Y12 inhibitors or glycoprotein IIb/IIIa inhibitors) and stent types (bare-metal or drug-eluting) were similar between the 2 groups ( Table 1 ).
| Variables | Unplanned repeat coronary angiography | p-value | |
|---|---|---|---|
| Yes (n = 130) | No (n = 3507) | ||
| Age (years) * | 64 ± 13 | 64 ± 13 | 0.81 |
| Men | 94 (72%) | 2,431 (69%) | 0.53 |
| Coronary artery disease | 49 (38%) | 1114 (32%) | 0.19 |
| Myocardial infarction | 39 (30%) | 794 (23%) | 0.064 |
| Hypertension | 85 (65%) | 2,120 (61%) | 0.32 |
| Dyslipidemia | 83 (64%) | 1,918 (55%) | 0.059 |
| Diabetes mellitus | 36 (28%) | 781 (22%) | 0.17 |
| Stroke | 8 (6.2%) | 196 (5.6%) | 0.95 |
| Smoking | 87 (67%) | 2,143 (62%) | 0.25 |
| Cardiogenic shock | 21 (16%) | 338 (9.8%) | 0.021 |
| Cardiac arrest | 19 (15%) | 390 (11%) | 0.26 |
| Ejection fraction (%) † | 45 (35, 55) | 52 (40, 60) | <0.001 |
| Peak troponin (ng/mL) † | 22 (3, 80) | 8 (1, 36) | <0.001 |
| Baseline creatinine (mg/dL) † | 1.00 (0.83, 1.24) | 0.98 (0.82, 1.20) | 0.35 |
| Peak creatinine (mg/dL) † | 1.09 (0.90, 1.49) | 1.03 (0.86, 1.28) | 0.009 |
| Pharmaco-invasive strategy | 33 (25%) | 763 (22%) | 0.4 |
| Number of diseased vessels † | 2 (1, 3) | 1 (1, 2) | 0.002 |
| Culprit artery | |||
| Left anterior descending | 57 (44%) | 1078 (31%) | <0.001 |
| Left circumflex | 11 (8.5%) | 437 (13%) | |
| Right coronary artery | 46 (36%) | 1222 (36%) | |
| Left main | 0 (0%) | 45 (1.3%) | |
| Multiple | 2 (1.6%) | 58 (1.7%) | |
| Graft | 8 (6.2%) | 84 (2.5%) | |
| Other | 0 (0%) | 2 (0%) | |
| None | 5 (3.9%) | 499 (15%) | |
| Preprocedural TIMI flow | |||
| 0 or 1 | 79 (66%) | 1829 (60%) | 0.22 |
| 2 or 3 | 40 (34%) | 1200 (40%) | |
| Postprocedural TIMI flow | |||
| 0 or 1 | 4 (3%) | 64 (2%) | 0.33 |
| 2 or 3 | 115 (97%) | 2960 (98%) | |
| Number of stents † | 1 (1, 2) | 1 (1, 2) | 0.018 |
| Stent types | |||
| Bare-metal stent | 5 (3.2%) | 69 (2.1%) | 0.38 |
| Drug-eluting stent | 141 (90%) | 3028 (90%) | |
| P2Y12 inhibitors | 126 (97%) | 3248 (93%) | 0.16 |
| Clopidogrel | 55 (43%) | 1674 (49%) | 0.015 |
| Ticagrelor | 66 (52%) | 1483 (43%) | |
| Prasugrel | 1 (0.8%) | 15 (0.4%) | |
| Glycoprotein IIb/IIIa inhibitors | 26 (28%) | 722 (27%) | 0.96 |
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