Long-Term Cardiac Function and Outcome in Patients Receiving Primary Angioplasty for Acute Myocardial Infarction at a Community Hospital Without On-Site Surgical Back-Up
Background. Short- and long-term comparative follow-up studies of patients receiving primary angioplasty or thrombolytic therapy for acute myocardial infarction show higher 30-day survival, and sustained benefits in mortality, reinfarction and ejection fraction in patients treated with primary angioplasty. Long-term benefits of primary angioplasty on cardiac function performed in community hospitals without surgical back-up have not been fully assessed. Methods. Sixty-one patients who underwent primary angioplasty were compared with patients receiving thrombolytic therapy who were matched for age, gender and location of acute myocardial infarction. Clinical information, reviewed through August 2000, was provided by retrospective analysis of healthcare databases and office and hospital charts. Mortality data were confirmed by the social security death index. Results. Of the original 61 primary angioplasty patients, two died during initial hospitalization. Of the 59 surviving patients, fifty-four (92%) had complete follow-up averaging 57 months. Of the original 61 thrombolytic therapy patients, three died during initial hospitalization. Of the 58 surviving patients, fifty-two (90%) had complete follow-up averaging 46 months. At follow-up, averaging 57 months, ejection fraction was significantly higher in the primary angioplasty group, as compared with the thrombolytic therapy group (51.4% versus 45.8%, respectively; p = 0.038). There was no statistical difference between the two groups regarding reinfarction, revascularization at >= 6 months after the initial presentation or cardiac death. Conclusions. Primary angioplasty performed in a community hospital without surgical back-up results in improved cardiac function when compared to thrombolytic therapy. These results are similar to those reported from large tertiary centers with on-site surgical back-up, and provide an explanation for the improved long-term outcome that is observed in patients with acute myocardial infarction treated with primary angiopla
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The Mayo Clinic Risk Score Predicts In-Hospital Mortality Following Primary Angioplasty
Background. The Mayo Clinic Risk Score (MCRS) is a validated numeric score that predicts outcome following primary percutaneous coronary intervention (PCI). Purpose. We evaluated the ability of MCRS to risk stratify patients undergoing primary angioplasty. Methods. Patients undergoing primary angioplasty within 6 hours of the onset of chest pain in the New York State percutaneous coronary intervention reporting system (n = 3,005) had their MCRS calculated using predictive variables: age, presence of cardiogenic shock, renal failure, class III/IV congestive heart failure, left main coronary disease and multivessel coronary disease. All patients were presumed to have intra-coronary thrombus and undergoing an urgent/emergent procedure. Based on the MCRS, patients were classified into five risk categories: very low risk (MCRS < 5), low risk (6ñ8), moderate (9ñ11), high (12ñ14) and very high risk (15ñ25). Results. The mean age of the study population was 62 years, 70% were male; stents were used in 89% and glycoprotein IIb/IIIa antagonists in 72%. The prevalence of cardiogenic shock, multivessel disease and left main disease was higher in patients with MCRS > 12. Overall in-hospital mortality following primary angioplasty was 4.7%; it was 0% in the ìvery low riskî category, 0.9% in the ìlow riskî category, 3.2% in the ìmoderate riskî category, 10.7% in the ìhigh riskî category, and 25.1% in the ìvery high riskî category (p < 0.0001). The higher-risk MCRS category predicted increased risk even when 317 (10.5%) patients with cardiogenic shock were excluded from the analysis. The overall c-statistic for the prediction of in-hospital mortality by MCRS was 0.85. Conclusion. Increasing MCRS predicts in-hospital mortality following primary angioplasty.
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Primary Angioplasty Without On-site Surgical Back-up: The First Experience with Mobile Catherization Facility
Background and objectives. The aim of the present study is to assess the safety and efficacy of performing primary angioplasty in a center without on-site surgical back-up, and compare the data with the literature. Methods. Seventy-eight consecutive primary angioplasty procedures, performed in our center from January 2001 to February 2003, were followed prospectively. Clinical and demographic characteristics of the patients, procedural success, early and late outcomes of the patients were taken into account. The safety of angioplasty was assessed by the analysis of in-hospital complications (death, urgent need for repeat revascularization, AMI with or without ST-elevation and stroke). The angioplasty procedures were considered effective when the post-procedural residual stenosis did not exceed 50% with the distal Thrombolysis in Myocardial Infarction (TIMI) grade III flow. Results. The device success rate was 92.3%. Angiographic success rate was 88.8%. In hospital mortality rate was 4.1 %. These patients were admitted with cardiogenic shock; 1 died during the procedure and the other 2 died during hospital follow-up. One patient died suddenly and another developed acute MI during the 6-month follow-up period. No patients developed stroke or were referred for urgent surgery. Four patients (5.5%) underwent repeat angioplasty during follow-up. Conclusions. Primary angioplasty can be safely performed in centers without on-site surgery. The efficacy and safety requirements of angioplasty, performed in a center without on-site surgical back-up using a mobile catheterization facility were similar to the data obtained from the literature.
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Primary Angioplasty of Unprotected Left Main Coronary Artery for Acute Anterolateral Myocardial Infarction
Background. Mortality of acute unprotected left main coronary artery (LMCA) occlusion is very high. The objectives of this analysis were to determine the effect of primary angioplasty and the impact of cardiogenic shock on unprotected LMCA occlusion-induced acute anterolateral myocardial infarction (AAMI). Methods. Of 1,736 consecutive patients with acute myocardial infarction (AMI), 38 (2.2%) had LMCA occlusion-induced AAMI with Thrombolysis in Myocardial Infarction (TIMI) flow <= 2. All were given primary angioplasty. Results. Of these 38 patients, 17 (45%) were discharged, and 21 (55%) died in-hospital. Cardiogenic shock was overt in 28 patients; 47.1% of the survival group and 95.2% of the mortality group (p = 0.0008). On arrival, the survival-group had higher pH (7.40 ± 0.10 vs. 7.30 ± 0.14; p = 0.013) and base excess (-4.5 ± 3.9 vs. -10.4 ± 6.0 mEq/L; p = 0.0013). In the survival-group reperfusion was successful in 100% of patients, as opposed to 57.1% in the mortality-group (p = 0.0020), and the incident of stenting was not different between the two groups (64.7% vs. 71.4%, p = 0.66). Shock-patients had lower successful angioplasty rate (67.9% vs. 100%, p = 0.040), higher in-hospital mortality (71.4% vs. 10.0%, p = 0.0008), and higher 1-year mortality rates (p = 0.0064), than stable patients. All shock-patients with failed angioplasty died, but the mortality rate was 57.9% (p = 0.021) when angioplasty was successful. Conclusions. Patients presenting with AAMI, LMCA occlusion, and cardiogenic shock have poor survival regardless of primary angioplasty in conjunction with coronary stents. Nevertheless, primary angioplasty is a feasible and effective procedure, and it may save lives in this clinical setting.
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Impact of Glycemic Control on Occurrence of No-Reflow and 30-Day Outcomes in Diabetic Patients Undergoing Primary Angioplasty for Myocardial Infarction
Diabetes mellitus is associated with endothelial dysfunction and platelet activation that may contribute to the occurrence of no-reflow. We postulate that optimal glycemic control is associated with the lower risk of no-reflow and better outcomes. Diabetic patients who underwent primary angioplasty for myocardial infarction from January 2001 to June 2004 were analyzed. No-reflow was defined as TIMI flow < 3 in the absence of mechanical obstruction. Patients were divided into 2 glycemic control groups according to the HbA1c value: optimal (? 7%), and suboptimal (> 7%). A total of 183 diabetic patients (93% noninsulin-requiring) were included for analysis. The median HbA1c of the optimal (n = 37) and suboptimal (n = 146) glycemic control groups were 6.5% and 8.5%, respectively. Compared to the suboptimal glycemic control group, the optimal glycemic control group was older, likely to have hypertension, previously suffered a stroke, have renal failure and a higher baseline creatinine. No-reflow occurred in 16% of the optimal and 18% of the suboptimal glycemic control groups. Multivariate analysis showed that optimal glycemic control was not associated with a lesser occurrence of no-reflow (OR 1.27, 95% CI 0.19?8.29, p = 0.807). The optimal glycemic control group had 30-day survival (90% versus 93%, p = 0.698) and 30-day event-free survival (84% versus 86%, p = 0.695) rates similar to the suboptimal glycemic control group. Among diabetic patients undergoing primary angioplasty, optimal glycemic control was not associated with a lesser occurrence of no-reflow or better 30-day outcomes.
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Reducing Myocardial Free Wall Rupture Following Acute ST-Segment Elevation Myocardial Infarction: A Case for Primary Angioplasty
Reducing Myocardial Free Wall Rupture Following Acute ST-Segment Elevation Myocardial Infarction: A Case for Primary Angioplasty Commentary: Reducing Myocardial Free Wall Rupture Following Acute ST-Segment Elevation Myocardial Infarction: A Case for Primary Angioplasty - Nicolas W. Shammas, MS, MD, FACC, FSCAI Myocardial free wall rupture (FWR) continues to be a dreadful complication of acute ST-segment elevation myocardial infarction (STEMI) ...
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Safety and Feasibility of the Radial Approach for Primary Angioplasty in Acute Myocardial Infarction During Pregnancy
Acute myocardial infarction during pregnancy, though rare, is nevertheless associated with a high mortality rate ranging from 37?50%. Primary angioplasty is the treatment of choice for acute myocardial infarction during pregnancy. There are reports of high vascular bleeding complications when using the transfemoral approach as well as increased morbidity, longer hospital stay and higher hospital cost. We present a case of successful primary angioplasty in acute myocardial infarction during pregnancy via the transradial approach without complications. The patient had an uncomplicated recovery with normal left ventricular function.
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Distal Protection during Primary Angioplasty: A Feasibility and Safety Study Utilizing a Novel Filter Technology
ABSTRACT: Background. The degree of myocardial reperfusion after primary percutaneous coronary intervention (PCI) may be reduced by distal embolization. We tested the safety, feasibility and efficacy of a novel filter device, the Spider? Distal Embolic Protection System, as an adjunct to primary PCI. Methods and Results. Twenty consecutive patients undergoing primary PCI with the Spider Embolic Protection Device were included in the analysis. Successful Spider device positioning was obtained in all cases, with predilatation of the lesions in 1 of these cases (5%). There were no procedural complications attributable to the use of a filter. Histological analysis of the content of 5 filters showed multiple embolic debris in all cases, from 8 to 48 particles per filter, from 101?1,299 mm in diameter and from 212?1,487 mm2 in area. The use of the Spider filter was associated with a profound ST-segment resolution (STR: 85.6 ± 16.5%) and the occurrence of complete (50%) STR of 90%. Conclusions. The Spider Embolic Protection Device as an adjunctive therapy during primary PCI is feasible and safe, preventing distal embolization and improving myocardial reperfusion. Currently, an international, multicenter, randomized clinical trial is prospectively testing this challenging hypothesis.
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Comparison of In-hospital Outcomes Following Early or Delayed Angioplasty for Acute Myocardial Infarction
Background. Studies of primary angioplasty for treatment of acute myocardial infarction (AMI) have not appeared to demonstrate a reduction in efficacy as a function of time to treatment. We sought to compare the outcomes of patients treated in New York State with primary angioplasty within 6 hours of symptom onset to those treated between 6 and 23 hours after the onset of AMI. Methods. We used data from the 1995 Coronary Angioplasty Reporting System of the New York State Department of Health to compare the in-hospital outcomes of patients treated with early (within 6 hours) or delayed angioplasty (6?23 hours) for AMI. Results. Early angioplasty (within 6 hours after onset of chest pain) was attempted in 957 patients (71.3%), while 385 patients (28.7%) had a delayed procedure (6?23 hours after the onset of chest pain). Patients who underwent delayed angioplasty were older (mean age, 62.6 years versus 60.4 years in the early group; p < 0.01) and more often female (36% vs. 28% in the early treatment group; p < 0.001). Patients treated early more frequently demonstrated hemodynamic instability (13.6% versus 9.1% in the late treatment group; p = 0.02), malignant ventricular arrhythmia (8.5% versus 2.9% in the late treatment group; p < 0.001) and cardiogenic shock (6.6% versus 1.8% in the late treatment group; p < 0.001). Overall in-hospital mortality was 63/1,342 (4.7%) with no difference based on early or delayed angioplasty (5.2% versus 3.4%, respectively; p = NS). The composite of the major adverse cardiac events including in-hospital death, reinfarction and emergency bypass surgery did not differ significantly between the early and delayed groups (7.7% versus 5.5%, respectively; p = NS). In multivariable models, delayed angioplasty was not an independent predictor of either in-hospital mortality or major adverse cardiac events. Conclusion. Delayed reperfusion does not influence in-hospital clinical outcomes following PTCA for acute myocardial infarction.
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The Impact of GP IIb/IIIa Inhibitors During Primary Percutaneous Coronary Intervention in Acute Myocardial Infarction Patients
The use of glycoprotein (GP) IIb/IIIa inhibitors during percutaneous coronary interventions (PCI) in the acute phase of myocardial infarction (AMI) is still a matter of debate. The aim of the present study was to compare the outcomes of patients with acute ST-segment elevation myocardial infarction who underwent primary PCI and were concomitantly treated with GP IIb/IIIa inhibitors with those who were not treated with these drugs. Between January 1996 and November 2003, a total of 418 consecutive patients underwent PCI in the setting of ST-segment elevation AMI. At the operator?s discretion, 287 patients were concomitantly treated with GP IIb/IIIa inhibitors and 115 patients were not. Angiographic success and final TIMI 3 flow in the infarct-related artery was achieved more frequently in patients treated with GP IIb/IIIa inhibitors (90% vs. 77%; p = 0.001). The in-hospital composite endpoint of death, reinfarction and bleeding complications was significantly better in patients treated with GP IIb/IIIa inhibitors (4% vs. 12 %; p = 0.005). Furthermore, the adjusted 12-month survival rate was significantly better in these patients (RR: 2.99, CI: 1.29?6.9; p = 0.01). Therefore, adjunctive therapy with GP IIbIIIa inhibitors during primary PCI is associated with improved short-term outcomes and one-year survival without an increased risk of bleeding.
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 Electrophysiologic Perspective on the BIPOLAR RF EPICARDIAL ABLATION Procedure for Atrial Fibrillation
Complimentary Accredited Breakfast Symposium
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Location: The St. Regis San Francisco
125 3rd Street
San Francisco, CA 94103
3rd and Mission Streets
Gallery Ballroom, 2nd floor
This activity is supported by an educational grant from AtriCure, Inc.
This program is not part of the Heart Rhythm 2008 Official Scientific Sessions as planned by the Heart Rhythm Society Scientific Sessions Committee. This event is neither sponsored nor endorsed by the Heart Rhythm Society.
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 Newest Perspectives on Drug-Eluting Stents
Complimentary CME Accredited Dinner Meetings Click Here for More Info.
Miami, FL - Date: Friday, April 4, 2008 6:00pm EST -8:00 pm EST
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This activity is supported by an educational grant from Abbott Vascular.
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 CLINICAL EXPERIENCE WITH A NEW HYBRID CORONARY WIRE
On Demand Web Archive
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This activity is supported by an educational grant from Terumo Medical Corporation.
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 Pharmacoinvasive Management of Acute Coronary Syndrome: Incorporating the 2007 ACC/AHA Guidelines
Complimentary Accredited CME Program
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 Varicose Veins: Causes, Symptoms, Diagnosis and Treatment of Chronic Venous Insufficiency
A Complimentary Accredited ON-DEMAND Webcast
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 Create a Successful Vena Cava Filter Practice
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This activity is supported by an educational grant from Cook Incorporated and has been designed for Interventional Cardiologists, Vascular Surgeons, Fellows and Interventional Cardiovascular Nurses and Technologists.
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 Achieving Optimal Outcomes in Carotid Stenting: Lessons Learned from Recent Clinical Trials
Complimentary Accredited ON DEMAND Webcast
Topics
1. EVA-3S & Space-Bumps in the road
2. CAPTURE 3500-Lesion morphology & Predictors for Stroke
3. CAPTURE II vs. EXACT 1500-Does open or Closed Cell Stent design really matter?
This activity has been developed for Interventional Cardiologists, Vascular Surgeons, Interventional Radiologists, Neurologists, Interventional Nurses and Technologists with an interest in the diagnosis and treatment of peripheral artery disease. |
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 Anticoagulation Techniques for Peripheral Vascular Interventions
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This activity has been developed for Interventional Cardiologists, Vascular Surgeons, Interventional Radiologists, Podiatric Physicians, Endovascular Allied Professionals, Endocrinologists, Wound Care Specialists, Directors of the Wound Care Clinic, and Primary Care Physicians, Pharmacists, Nurses and Technologists.
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 New Treatment Strategies for the Endovascular Approach to Critical Limb Ischemia: ADVANCEMENTS IN LIMB SALVAGE MEDICINE
Complimentary Accredited ON DEMAND Webcast
This activity has been developed for Interventional Cardiologists, Vascular Surgeons, Interventional Radiologists, Podiatric Physicians, Endovascular Allied Professionals, Endocrinologists, Wound Care Specialists, Directors of the Wound Care Clinic, and Primary Care Physicians, Pharmacists, Nurses and Technologists.
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 Reducing the Incidence of CIN during Cardiac Catheterization and PCI
Complimentary Accredited ON DEMAND
Educational Web Archive
This activity has been developed for nurses and technologists. |
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March 2007 Supplement
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Archived Webcast
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Release Date: December 8, 2006