Relationship Between Infarct Size and Outcomes Following Primary PCI

Stone, Gregg W.; Selker, Harry P.; Thiele, Holger; Patel, Manesh R.; Udelson, James E.; Ohman, E. Magnus; Maehara, Akiko; Eitel, Ingo; Granger, Christopher B.; Jenkins, Paul; Nichols, Melissa; Ben‐Yehuda, Ori

doi:10.1016/j.jacc.2016.01.069

Cited by 538 publications

(352 citation statements)

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“…Of note, a 5.1% absolute reduction in IS in the "Stent Versus Thrombolysis for Occluded Coronary Arteries in Patients With Acute Myocardial Infarction" trial is generally accepted as a clinically meaningful result for cardioprotection trials 19 . Moreover, IS of >29.8% was shown to be significantly correlated with increased mortality or heart failure hospitalisation within one year 20 . In our study, 16% of the patients in the hypothermia group had an IS >29.8% compared to 41% of patients in the control group (p=0.16).…”

Section: Cool Ami Eu Pilot Trialmentioning

confidence: 90%

COOL AMI EU pilot trial: a multicentre, prospective, randomised controlled trial to assess cooling as an adjunctive therapy to percutaneous intervention in patients with acute myocardial infarction

Noč¹,

Erlinge²,

Nešković³

et al. 2017

EuroIntervention

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Aims: We aimed to investigate the rapid induction of therapeutic hypothermia using the ZOLL Proteus Intravascular Temperature Management System in patients with anterior ST-elevation myocardial infarction (STEMI) without cardiac arrest. Methods and results:A total of 50 patients were randomised; 22 patients (88%; 95% confidence interval [CI]: 69-97%) in the hypothermia group and 23 patients (92%; 95% CI: 74-99) in the control group completed cardiac magnetic resonance imaging at four to six days and 30-day follow-up. Intravascular temperature at coronary guidewire crossing after 20.5 minutes of endovascular cooling decreased to 33.6°C (range 31.9-35.5°C). There was a 17-minute (95% CI: 4.6-29.8 min) cooling-related delay to reperfusion. In "per protocol" analysis, median infarct size/left ventricular mass was 16.7% in the hypothermia group versus 23.8% in the control group (absolute reduction 7.1%, relative reduction 30%; p=0.31) and median left ventricular ejection fraction (LVEF) was 42% in the hypothermia group and 40% in the control group (absolute reduction 2.4%, relative reduction 6%; p=0.36). Except for self-terminating paroxysmal atrial fibrillation (32% versus 8%; p=0.074), there was no excess of adverse events in the hypothermia group.Conclusions: We rapidly and safely cooled patients with anterior STEMI to 33.6°C at the time of coronary guidewire crossing. This is ≥1.1°C lower than in previous cooling studies. Except for self-terminating atrial fibrillation, there was no excess of adverse events and no clinically important cooling-related delay to reperfusion. A statistically non-significant numerical 7.1% absolute and 30% relative reduction in infarct size warrants a pivotal trial powered for efficacy. ClinicalTrials.

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Section: Cool Ami Eu Pilot Trialmentioning

confidence: 90%

COOL AMI EU pilot trial: a multicentre, prospective, randomised controlled trial to assess cooling as an adjunctive therapy to percutaneous intervention in patients with acute myocardial infarction

Noč¹,

Erlinge²,

Nešković³

et al. 2017

EuroIntervention

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“…Patients were excluded from the CMR substudy if they had contraindications for CMR, such as claustrophobia, severely reduced kidney function, metal implants, arrhythmia, previous infarction in the current infarct‐related artery, or were clinically unstable. The clinical endpoint of all‐cause mortality and hospitalization for heart failure was chosen a priori 25. All‐cause mortality and hospitalization for heart failure were identified from the National Danish Heart Registry and validated using hospital records; all events were validated by an independent events committee.…”

Section: Methodsmentioning

confidence: 99%

Left Ventricular Hypertrophy Is Associated With Increased Infarct Size and Decreased Myocardial Salvage in Patients With ST‐Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

Nepper‐Christensen

Lønborg

Ahtarovski

et al. 2017

JAHA

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BackgroundApproximately one third of patients with ST‐segment elevation myocardial infarction (STEMI) have left ventricular hypertrophy (LVH), which is associated with impaired outcome. However, the causal association between LVH and outcome in STEMI is unknown. We evaluated the association between LVH and: myocardial infarct size, area at risk, myocardial salvage, microvascular obstruction, left ventricular (LV) function (all determined by cardiac magnetic resonance [CMR]), and all‐cause mortality and readmission for heart failure in STEMI patients treated with primary percutaneous coronary intervention.Methods and ResultsIn this substudy of the DANAMI‐3 trial, 764 patients underwent CMR. LVH was defined by CMR and considered present if LV mass exceeded 77 (men) and 67 g/m2 (women). One hundred seventy‐eight patients (24%) had LVH. LVH was associated with a larger final infarct size (15% [interquartile range {IQR}, 10–21] vs 9% [IQR, 3–17]; P<0.001) and smaller final myocardial salvage index (0.6 [IQR, 0.5–0.7] vs 0.7 [IQR, 0.5–0.9]; P<0.001). The LVH group had a higher incidence of microvascular obstruction (66% vs 45%; P<0.001) and lower final LV ejection fraction (LVEF; 53% [IQR, 47–60] vs 61% [IQR, 55–65]; P<0.001). In a Cox regression analysis, LVH was associated with a higher risk of all‐cause mortality and readmission for heart failure (hazard ratio 2.59 [95% CI, 1.38–4.90], P=0.003). The results remained statistically significant in multivariable models.ConclusionsLVH is independently associated with larger infarct size, less myocardial salvage, higher incidence of microvascular obstruction, lower LVEF, and a higher risk of all‐cause mortality and incidence of heart failure in STEMI patients treated with primary percutaneous coronary intervention.Clinical Trial RegistrationURL: http://www.clinicaltrials.gov. Unique identifier: NCT01435408.

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“…The study only studied the in-hospital results and the long-term outcomes are not known. The infarct size as measured by peak creatinekinase MB levels, was significantly higher in pharmacoinvasive group, and we already know that the peak infarct size is related to worse long-term outcomes from several large trials in the past (2). However, this difference may not be clinically significant as the composite of mortality, reinfarction, or stroke was similar between the two groups.…”

mentioning

confidence: 90%

The relationship between total ischemic time and mortality in patients with STEMI: every second counts

Khalid

Jneid

Denktaş

2017

Cardiovasc. Diagn. Ther.

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We read with great interest the recently published article in the October 2016 issue of JACC Cardiovasc Interv by Rashid et al. (1). Briefly, it was a retrospective, single center study that analyzed ST-elevation myocardial infarction (STEMI) patients with symptom onset <12 hours. Patients with primary percutaneous intervention (PCI) were compared with those who received fibrinolytic therapy prior to arrival at the hospital due to non-availability of primary PCI. The authors concluded that the pharmaco-invasive strategy was associated with similar rates of the composite endpoint of mortality, reinfarction, or stroke as compared with a primary PCI strategy. There was propensity for increased bleeding in the pharmaco-invasive group, with a significant fraction (approximately 1 in every 21 patients) having major bleeding, including intracranial bleeding.Non-inferiority of pharmaco-invasive strategy compared to primary PCI strategy in this study emphasizes the importance of total ischemic time. These are patients who received fibrinolytic therapy within few minutes of presentation at the initial hospital (with no primary PCI capability) which could have led to dissolution of the thrombus and re-canalization of the culprit artery, and hence reduction of the total ischemic time. The similar outcomes between the groups despite a big difference in the door-to-balloon times are most likely due to the shortening of the total ischemic time by the administration of fibrinolysis. However, we must not ignore the limitations of the study. There was a disparity between the control group vs. test group, i.e., 236 pharmaco-invasive strategy patients vs. 980 primary PCI patients (approximately 4:1 ratio), which may have influenced the statistical model. As the patients were not randomized, unknown confounders may have affected the results owing to the retrospective nature of the study. For example, the median time from symptom onset to arrival at the first hospital was significantly shorter in the pharmacoinvasive group, which may have favored these patients. The study only studied the in-hospital results and the long-term outcomes are not known. The infarct size as measured by peak creatinekinase MB levels, was significantly higher in pharmacoinvasive group, and we already know that the peak infarct size is related to worse long-term outcomes from several large trials in the past (2). However, this difference may not be clinically significant as the composite of mortality, reinfarction, or stroke was similar between the two groups. Nevertheless, the long-term outcomes are unknown in these patients. Also, the infarct zone at risk was not defined so that the selection bias for patients who were destined to have larger infarcts was not eliminated. To better define the zone at risk an MRI study like the one done by Eitel et al. would have been very useful (3). Furthermore, the pharmacologic regimen used for the groups were different. The pharmaco-invasive group patients received a lower dose of clopidogrel and an infusion of heparin...

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Relationship Between Infarct Size and Outcomes Following Primary PCI

Cited by 538 publications

References 33 publications

COOL AMI EU pilot trial: a multicentre, prospective, randomised controlled trial to assess cooling as an adjunctive therapy to percutaneous intervention in patients with acute myocardial infarction

COOL AMI EU pilot trial: a multicentre, prospective, randomised controlled trial to assess cooling as an adjunctive therapy to percutaneous intervention in patients with acute myocardial infarction

Left Ventricular Hypertrophy Is Associated With Increased Infarct Size and Decreased Myocardial Salvage in Patients With ST‐Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

The relationship between total ischemic time and mortality in patients with STEMI: every second counts

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