|Year : 2016 | Volume
| Issue : 1 | Page : 67-72
Prediction of short-term mortality after primary percutaneous coronary intervention for acute ST-elevation myocardial infarction
Abdalla M Kamal, Mahmoud A Soliman, El Sayed A El Sebaay Ali Habba
Department of Cardiology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
|Date of Submission||14-Sep-2014|
|Date of Acceptance||23-Jan-2015|
|Date of Web Publication||18-Mar-2016|
El Sayed A El Sebaay Ali Habba
MBBCh, Department of Cardiology, Nasr City Hospital For Insurance in Cairo, El Manshia El Gededa-El Santa-El Gharbia Governorate, Cairo
Source of Support: None, Conflict of Interest: None
The aim of this work was to predict short-term mortality after a primary percutaneous coronary intervention (PCI) for patients with ST-elevation myocardial infarction (STEMI) in terms of demographic, clinical, echocardiographic, and coronary angiographic data.
Accurate risk stratification after primary PCI is important as mortality in STEMI patients represents a considerable number of all causes of mortality.
Patients and methods
This registry included 50 patients who presented to the emergency department at Nasr City Health Insurance Hospital in Cairo during the period from September 2012 to June 2013 and were diagnosed with STEMI. Every patient underwent demographic, clinical, echocardiographic, and angiographic assessments for risk factors leading to mortality in hospital and after 6 months of follow-up.
Eight variables were identified in our registry as predictors of short-term mortality after primary PCI including age (P = 0.005), increased serum creatinine (P = 0.010), KILLIP class (P < 0.001), left ventricular ejection fraction less than 40% (P = 0.021), multivessel disease (P = 0.018), type of culprit vessel (P < 0.001), postprocedural TIMI flow (P < 0.001), and postprocedural myocardial blush (P < 0.001).
In acute myocardial infarction patients treated with primary PCI, eight risk factors were identified. These factors predict short-term mortality accurately.
Keywords: Acute ST-elevation myocardial infarction, predictors of mortality, primary percutaneous coronary intervention
|How to cite this article:|
Kamal AM, Soliman MA, El Sebaay Ali Habba EA. Prediction of short-term mortality after primary percutaneous coronary intervention for acute ST-elevation myocardial infarction. Menoufia Med J 2016;29:67-72
|How to cite this URL:|
Kamal AM, Soliman MA, El Sebaay Ali Habba EA. Prediction of short-term mortality after primary percutaneous coronary intervention for acute ST-elevation myocardial infarction. Menoufia Med J [serial online] 2016 [cited 2019 Sep 21];29:67-72. Available from: http://www.mmj.eg.net/text.asp?2016/29/1/67/178987
| Introduction|| |
ST-segment elevation myocardial infarction (STEMI) constitutes around 40% of all acute myocardial infarctions (AMI) and continues to be a major public health problem, both in developed and in developing countries .
Reperfusion therapy is the cornerstone of the treatment of patients with acute STEMI . Mechanical reperfusion has gained increasing acceptance as a reperfusion strategy for AMI as data from numerous randomized trials have shown more superior outcomes compared with thrombolytic therapy .
Primary percutaneous coronary intervention (PCI) is now classified as a class I indication in STEMI in the guidelines of the European Society of Cardiology .
Primary PCI for AMI should be performed with a door-to-balloon time of less than 90 min. Although normal epicardial flow can be restored in more than 85% of cases, prognosis is heavily dependent on restoration of adequate perfusion at the level of microcirculation .
Prediction of mortality after primary PCI is important; thus, many factors were identified depending on demographic, clinical, echocardiographic, and angiographic information. These factors accurately predict mortality at the time of intervention .
| Patients and methods|| |
This registry is prospective and enrolled patients who presented to the Emergency department at Nasr City Health Insurance Hospital in Cairo during the period from September 2012 to June 2013 with typical ischemic chest pain and were diagnosed with an acute STEMI according to the American College of cardiology and American Heart Association guidelines with a time window of up to 12 h .
We excluded from the registry patients who received fibrinolytic therapy, those with contraindication(s) to antiplatelet and/or anticoagulants, those presenting more than 12 h after the onset of chest pain, and those who presented with pulmonary edema and cardiogenic shock.
All patients were subjected to a thorough assessment of history, with a focus on demographic data, analysis of chest pain, including timing variables (pain-to-door time), risk factors of coronary artery diseases, drug history, and history of preinfarction angina. Physical examination was performed including vital signs and evidence of heart failure (S3 gallop, pulmonary rales, elevated JVP) and mitral regurgitation.
Twelve-lead surface ECG: new ST elevation at the J point in at least two contiguous leads of at least 2 mm (0.2 mV) in men or at least 1.5 mm (0.15 mV) in women in leads V2-V3 and/or of at least 1 mm (0.1 mV) in other contiguous chest leads or the limb leads .
When diagnosis was established, patients were administered aspirin 300 mg in the emergency room , a 600 mg loading dose of clopidogrel,  and unfractionated heparin at a dose of 60 μg/kg; reboluses could be administered according to requirements . The glycoprotein GPIIb/IIIa receptor (Eptifibatide) was administered in our registry at a bolus dose of 180 mcg/kg, followed by a maintenance dose of 2 mic/kg/minute according to requirements .
The steps of the procedure were as follows: informed written consent was obtained from all patients. Sedation may have been required in some patients. Sterilization and local infiltration of anesthesia of the right groin, right femoral artery puncture using Seldinger's technique, and selective left and right coronary angiographies (RCA) in multiple views starting with the non-infarct-related artery were performed, and percutaneous transluminal coronary angioplasty (PTCA) was optionally performed using a suitable balloon. A thrombus aspiration catheter was used in cases with heavy thrombus burden or absence of flow after the passage of the guiding wire .
A stent suitable in diameter and length was inserted according to the angiographic findings in each patient, except in patients who had undergone PTCA only and patients who arrested before the procedure; in our hospital, only the bare metal stent (BMS) was available and used.
After PCI, coronary flow in the infarct related vessel was assessed by thrombolysis in myocardial infarction (TIMI) flow grade, and myocardial blush grade (MBG) was also assessed.
Patients were then admitted to the coronary care unit for at least 48 h, where an ECG was performed immediately and 90 min after the procedure to monitor ST-segment elevation resolution with chest pain resolution after PCI. The sheath was removed after normalization of the clotting time.
Every patient was subjected to a predischarge echocardiography during the patient's hospital stay, with a focus on left ventricular ejection fraction, left ventricular end-systolic as well as end-diastolic dimensions and volumes, segmental wall motion abnormalities, and mechanical complications; significant LV systolic dysfunction was defined as EF less than 40% .
Patients were discharged after gradual titration of their medication; cardiac rehabilitation was advised and a follow-up visit after 6 months was carried out involving clinical assessment, 12-lead ECG, and transthoracic echocardiography.
Statistical presentation and analysis of the present registry was carried out using the mean ± SD, t-test, and the ν2 -test using SPSS, version 17 (SPSS Inc., Chicago, Illinois, USA) . A P-value of less than 0.05 was considered significant.
| Results|| |
This registry included 50 patients who underwent primary PCI at Nasr City Health Insurance Hospital in Cairo at catheterization laboratories in the period from September 2012 to June 2013. Forty patients were eventually followed up for 6 months after the procedure (four patients were difficult to contact and the other six died).
The mean age of the current registry population was 57.52 ± 10.22 years, ranging from 19 to 84 years (P = 0.005), and included 40 men and 10 women (P = 0.075). Smoking was the most prevalent risk factor affecting 58% (P = 0.194), followed by diabetes mellitus (DM), 48% (P = 0.056), hypertension, 42% (P = 0.194), and dyslipidemia, 24% (P = 0.060). Previous ischemia was reported in five patients; two patients had previous PCI (P = 0.085). No CABG was reported in our registry.
Forty-four patients presented with KILLIP class I and six patients presented with KILLIP class II (P < 0.001); the mean pain-to-door time was 4.00 ± 1.565 h (P = 0.784), whereas the mean door-to-balloon time was 99.8 ± 32.8 min (P = 0.437) [Table 1],[Table 2],[Table 3],[Table 4] and [Table 5] and [Figure 1],[Figure 2],[Figure 3] and [Figure 4].
|Figure 3: Relation between the number of vessels diseased and mortality at 6 months.|
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|Figure 4: Relation between postprocedural thrombolysis in myocardial infarction flow and mortality at 6 months.|
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|Table 3: Relation between the number of vessels diseased and mortality at 6 months|
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|Table 4: Postprocedural thrombolysis in myocardial infarction flow and mortality at 6 months|
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|Table 5: Univariate analysis between age, pain-to-door time, door-to-balloon time, ejection fraction%, and mortality at 6 months|
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Anterior infarction was found in 58% of the registry population. The most revascularized vessel was LAD, 56% (P < 0.001). Forty-four percent of patients presented with single epicardial coronary vessel disease and 56% presented with multivessel coronary artery disease (P = 0.018).
Direct stenting was performed in 62% of the procedures (P = 0.843), whereas predilatation was performed in 20% of the procedures (P = 0.744). All the implanted stents were BMS.
Only PTCA was performed in 14% of patients (P = 0.669), a thrombus aspiration device was used in 22% of patients (P = 0.729), and GPIIb/IIIa inhibitors were administered in 16% of patients (P = 0.585).
Seventy-two percent of patients presented with total occlusion with TIMI flow 0; postprocedural TIMI flow 3 was achieved in 70% of patients (P < 0.001) and postprocedural MBG III was achieved in 66% of patients (P < 0.001).
In-hospital mortality was reported in 4.0% of the cases, whereas mortality at the 6-month follow-up was reported in 12% of the followed up sample.
| Discussion|| |
Coronary artery disease is one of the most important causes of death worldwide. However, PCI represents one of the cornerstone management modalities for patients with coronary artery disease. To date, data are lacking on the long-term outcomes in Egypt .
Three realistic goals for other countries were defined on the basis of these experiences: primary PCI should be used for more than 70% of all STEMI patients, primary PCI rates should reach more than 600/million inhabitants per year, and existing PCI centers should treat all their STEMI patients by primary PCI, that is should offer a 24/7service .
The primary PCI setup at Naser City Health Insurance Hospital fulfilled the following criteria: Hospital Volume more than 2500 angiographic and interventional procedures.
In the current registry, we found that the mean age of our registry population was younger than the National Registry of Myocardial infarction (NRMI) (57.52 vs. 76.9 years). Most of our registry patients were men (80%); in the NRMI, only 50.3% of the patients were men .
We also found that smoking was the most prevalent risk factor, which was present in 58% of registry populations, followed by DM (48%) and hypertension (HTN) (42%). In the EHS on PCI registry, 60% of the population were smokers and DM was found in 25% of the population. This might be explained by poor dietary habits and the sedentary life style of Egyptians, which may increase the overall prevalence of DM and hypertension.
Dyslipidemia was found in only 24% of our registry population, whereas in the EHS on PCI, it was found in 63% of patients. This may be because dyslipidemia was underdiagnosed (no routine laboratory test was performed).
In our registry, the mean pain-to-door time (symptom onset-to-ER time) was 240 min. This might be because of lower patient awareness of the importance of seeking medical advice promptly if chest pain occurs. In our registry, the mean door-to-balloon time was 99.8 min.
The NRMI investigators more recently reported, however, that the median first-door-to-balloon time in the USA has been decreasing steadily (to 143 min in 2005), which has been associated with decreasing mortality .
In our registry population, we found that the LAD was the most revascularized target vessel as it represented 58% of the revascularized vessels, RCA in 22%, LCX in 18%, and LM in 2%. In the EHS on PCI, we found that LAD was revascularized in 49%, LCX in 10%, RCA in 38%, and LM in 3%.
In terms of the diameters and lengths of stents utilized in our registry, we found that the mean stent diameter and length in our registry was 3.085 ± 0.28 and 17.751 ± 5.3 mm, respectively.
All stents used in our registry were BMS. In contrast, the EHS on the PCI registry showed that 47% of the stents utilized were DES, and this might be explained by the difference in cost, which is the main reason why DES utilization is favored in Europe .
Direct stenting was performed in 62% of the population in our registry. This strategy may help to reduce the cost of coronary interventions by reducing the overall procedure and fluoroscopy times and the amount of contrast medium used. It may also result in a significant reduction in microvascular injury, as suggested by improved ST-segment resolution after reperfusion; TRENDS and DIRECTOR are two trials that showed the superiority of direct stent deployment over stenting with predilatation .
PTCA alone was performed in 14% of the population in our registry; these patients were having difficult coronary anatomy and would be sent for CABG.
Patients with multivessel disease constituted 56% of all the patients in the registry. Single-vessel stenting was performed in 82% of all patients. In the HORIZONS-AMI at 1 year, patients who underwent single PCI had a mortality rate of 9.2% compared with 2.3% in patients who underwent staged PCI as multivessel PCI may be associated with a higher risk of mortality and stent thrombosis .
GPIIb/IIIa antagonists were administered in 16% of the patients. The latest updated guidelines advocate starting GPIIb/IIIa inhibitors only at the time of primary PCI, not before, and even then only in 'selected' patients as a class IIa recommendation .
Thrombus aspiration devices were use in 22% of the population in our registry in cases with heavy burden thrombus . Postprocedural TIMI III flow was achieved in 70% of the patients and MBG III was achieved in 66% of patients. This might be because of the delay in presentation leading to greater thrombus formation or because of higher rates of balloon dilatation leading to distal thrombus fragmentation and microvascular compromise.
The overall in-hospital mortality was reported in two cases (4%) in our registry population compared with 5.81% in the New York State Primary Angioplasty Registry; we found that the 6-month mortality was 12% in the patients who were followed up. However, patients with pulmonary edema and cardiogenic shock were not included in the registry; a 3-year mortality of only 12.6% was found in the New York State Primary Angioplasty Registry . Our figure is apparently high, probably because of many factors including delayed presentation, more risk factors, difference in equipment used, experience of the PCI providers, uses of BMS, and medication noncompliance issues.
Eight variables were identified in our registry that accurately predicted mortality: older age, patients with higher KILLIP class, increased serum creatinine, lower ejection fraction (<40%), multivessel disease, type of culprit vessel (Lt main and LAD), lower TIMI flow, and MBG after the procedure. These results are in agreement with those in the CADILLAC trial, in which seven variables were identified (age, lower glomerular filtration, anemia, KILLIP class, ejection fraction less than 40%, multivessel disease, postprocedural TIMI flow) .
As Egypt pays attention to a cardiovascular epidemic, acute STEMI will continue to occur, leading to a loss in productivity. The mean age of the population in our registry was younger than 57 years, an age group that comprises the workforce of any nation. Thus, developing countries such as Egypt need widespread, expensive primary PCI services.
| Conclusion|| |
In AMI patients treated with primary PCI, eight risk factors were identified. These factors accurately predict short-term mortality. Identification of these factors is important to decrease mortality; these factors were older age, increased serum creatinine, lower ejection fraction (<40%), type of culprit vessels, multivessel disease, low TIMI flow, and low myocardial blush, and precautions to improve TIMI flow should be adopted, such as the use of thrombectomy devices especially in heavy burden thrombus. Also, the use of GPIIb/IIIa inhibitors can improve coronary flow. The need for drug-eluting stents can decrease the incidence of instent restenosis, rehospitalization, and finally mortality.
| Acknowledgements|| |
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]