Summary
Background
Although primary angioplasty achieves thrombolysis in myocardial infarction (TIMI) 3 flow in most patients with ST-elevation myocardial infarction, epicardial recanalization does not guarantee optimal perfusion in a large proportion of patients. The influence of multivessel disease on myocardial reperfusion and survival after primary angioplasty has not been extensively investigated.
Aim
To evaluate the impact of multivessel disease on myocardial perfusion and survival in a large cohort of patients with ST-elevation myocardial infarction treated with angioplasty and glycoprotein (GP) IIb/IIIa inhibitors.
Methods
This analysis is based on 1494 patients undergoing primary angioplasty included in the EGYPT database. Myocardial perfusion was evaluated by angiography or ST-segment resolution, whereas infarct size was estimated by using peak creatine kinase-MB (CK-MB). Follow-up data were collected between 30 days and 1 year after primary angioplasty.
Results
Multivessel disease was observed in 870 patients (58.2%). The extent of coronary artery disease was associated with age, diabetes, hypertension, previous myocardial infarction, previous revascularization, abciximab treatment and longer ischaemic time, and was independently associated with impaired angiographic myocardial perfusion (adjusted odds ratio 1.18, 95% confidence interval [CI] 1.01–1.40, P = 0.049). At 208 ± 160 days, the extent of coronary artery disease was independently associated with higher mortality (adjusted hazard ratio 1.54, 95% CI 1.06–2.24, P = 0.022).
Conclusions
Among patients with ST-elevation myocardial infarction undergoing primary angioplasty with GP IIb/IIIa inhibitor treatment, the extent of coronary artery disease was independently associated with impaired myocardial perfusion and survival.
Résumé
Justification
Bien que l’angioplastie primaire aboutisse à un flux TIMI 3 chez la majorité des patients ayant un infarctus du myocarde avec sus-décalage du segment ST (STEMI), la recanalisation épicardique ne garantit pas une reperfusion optimale dans une proportion significative de patients. L’influence de la présence de lésions coronaires pluritronculaires sur la reperfusion myocardique ainsi que la survie au décours d’une angioplastie primaire n’a pas été évaluée de façon détaillée.
Objectifs
Évaluer l’impact de lésions coronaires pluritronculaires sur la perfusion myocardique et la survie au sein d’une cohorte de patients ayant un STEMI traité par angioplastie primaire et sous anti-GPIIb-IIIa.
Méthode
Cette analyse a inclus 1494 patients bénéficiant d’une angioplastie primaire, inclus dans la base EGYPT. La perfusion myocardique a été évaluée angiographiquement ou sur la résolution du sus-décalage du segment ST et la taille de l’infarctus a été évaluée sur le pic de CPK-MB. Les données de suivi ont été collectées à j30 et à un an après l’angioplastie primaire.
Résultats
Les lésions coronaires pluritronculaires ont été observées chez 870 patients (58,2 %). L’étendue de la maladie coronaire était associée à l’âge, au diabète, à l’hypertension artérielle, à un antécédent d’infarctus du myocarde, à un antécédent de revascularisation coronaire, à un traitement par abciximab, et à une durée prolongée de l’ischémie et était associée de façon indépendante à une altération de la perfusion myocardique évaluée en angiographie ( odds ratio ajusté 1,18, IC 95 % 1,01–1,4, p = 0,049). À j208 ± 160, l’étendue de la maladie coronaire est associée de façon indépendante à une surmortalité ( hazard ratio ajusté 1,54, IC 95 % 1,06–2,24, p = 0,022).
Conclusion
Parmi les patents ayant un STEMI traité par angioplastie primaire, sous anti-GP IIb-IIIA, l’étendue de la maladie coronaire est attestée de façon indépendante à une altération de la perfusion myocardique et à la survie.
Background
In patients presenting with acute myocardial infarction primary angioplasty improves survival compared with thrombolysis, due mainly to a large percentage of restoration of TIMI 3 flow , with further improvement in clinical outcomes observed with the use of new antithrombotic therapies and devices . However, epicardial recanalization does not guarantee optimal myocardial perfusion, which remains suboptimal in a relatively large proportion of patients . In addition, concomitant atherosclerosis in coronary vessels other than the infarct-related artery (IRA) is observed in a notable proportion of patients undergoing primary percutaneous coronary intervention (PCI), ranging from 40% to 50% . The prognostic impact of multivessel coronary artery disease (CAD) has not been extensively investigated . Thus, the aim of the current study was to investigate the impact of multivessel disease on procedural success, myocardial reperfusion, infarct size and mortality in patients with ST-elevation myocardial infarction (STEMI) enrolled in Early Glycoprotein IIb/IIIa Inhibitors in Primary Angioplasty (EGYPT) database.
Methods
Our initial population comprises patients with STEMI treated by primary angioplasty and included in the EGYPT database. Detailed data on the EGYPT cooperation have been published ; characteristics of the studies included are reported in Table 1 . All patients were admitted within 12 h of symptom onset, received aspirin (500 mg intravenously) and heparin (10,000 IU intravenously) as well as glycoprotein (GP) IIb/IIIa inhibitors before the procedure (in the cardiac care unit or ambulance [early] or in the cath lab [late]), and were on double oral antiplatelet therapy (aspirin and clopidogrel) for 4 weeks or more, after stent implantation. Thereafter, aspirin (or clopidogrel, in patients with side-effects from aspirin) was continued as monotherapy.
| Variable | I VD ( n = 624) | II VD ( n = 510) | III VD ( n = 360) | P value (trend) |
|---|---|---|---|---|
| Clinical | ||||
| Age (years) | 58.2 ± 12.1 | 61.6 ± 11.4 | 64.8 ± 11.9 | < 0.001 |
| Female gender (%) | 23.2 | 22.0 | 23.1 | 0.88 |
| Hypertension (%) | 38.5 | 45.9 | 46.9 | 0.005 |
| Diabetes (%) | 13.5 | 18.6 | 22.8 | < 0.001 |
| Smoking (%) | 56.3 | 53.5 | 43.3 | < 0.001 |
| Hypercholesterolemia (%) | 36.2 | 36.9 | 38.1 | 0 57 |
| Previous myocardial infarction (%) | 3 | 10.0 | 17.2 | < 0.001 |
| Anterior myocardial infarction (%) | 50.6 | 42.0 | 38.2 | < 0.001 |
| Previous revascularization (%) | 4 | 7.8 | 14.7 | < 0.001 |
| Killip class > 1 | 9.6 | 14.4 | 12.7 | 0.12 |
| Time-to-treatment (min) | 221 ± 130 | 250 ± 169 | 272 ± 274 | < 0.001 |
| Angiographic | ||||
| Preprocedural TIMI 3 flow | 19.8 | 17.4 | 16 | 0.12 |
| Coronary stenting (%) | 85.9 | 86.6 | 79.3 | 0.02 |
| Abciximab (%) | 40.1 | 32.7 | 26.4 | < 0.001 |
| Early GP IIb/IIIa inhibitors (%) | 51.3 | 50.0 | 50.6 | 0.78 |
| Postprocedural TIMI 3 flow (%) | 86.9 | 87.8 | 96.2 | < 0.001 |
| Postprocedural myocardial blush grade 3 (%) | 52.2 | 46.2 | 42 | 0.005 |
| Distal embolization (%) | 10.4 | 11.2 | 12.6 | 0.36 |
| Complete ST resolution | 56.4 | 57.9 | 58.1 | 0.6 |
Data from angiograms and electrocardiograms were provided by each principal investigator (not analysed by a central core laboratory). Analysis of angiograms was based on standard definitions . Angiographic myocardial perfusion was evaluated by myocardial blush grade or myocardial perfusion grade . Optimal myocardial reperfusion was considered as myocardial blush grade 3 or myocardial perfusion grade 3. Distal embolization was defined as an abrupt ‘cut-off’ in the main vessel or one of the coronary branches of the infarct-related artery (IRA), distal to the angioplasty site . Even though ST-segment analysis was performed according to the prespecified criteria of each trial, data were provided according to uniform thresholds (< 30% no resolution; 30–70% partial resolution; > 70% complete resolution). Infarct size was estimated using peak creatine kinase (CK) and CK-MB.
Clinical outcome was assessed between 30 days and 1 year after primary angioplasty by telephone interview or at medical visit. The primary study outcome was mortality at follow-up; the secondary study outcome was myocardial perfusion as evaluated by myocardial blush grade and ST-segment resolution.
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