Coronary Artery Disease
Impact of Pre-Procedural Cardiopulmonary Instability in Patients With Acute Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention (from the Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction Trial)

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Highlights

Preprocedural cardiopulmonary IAE before primary PCI for STEMI were defined in the HORIZONS-AMI trial as sustained ventricular or supraventricular tachycardia or fibrillation requiring cardioversion or defibrillation, heart block or bradycardia requiring pacemaker implantation, severe hypotension requiring vasopressors or intra-aortic balloon counterpulsation, respiratory failure requiring mechanical ventilation, and cardiopulmonary resuscitation. IAE before PCI is an independent predictor of death and identifies a high-risk group in whom faster reperfusion may be particularly important to improve survival.

Rapid reperfusion with primary percutaneous coronary intervention improves survival in patients with ST-segment elevation myocardial infarction. Preprocedural cardiopulmonary instability and adverse events (IAE) may delay reperfusion time and worsen prognosis. The aim of this study was to evaluate the relation between preprocedural cardiopulmonary IAE, door-to-balloon time (DBT), and outcomes in the Harmonizing Outcomes With Revascularization and Stents in AMI (HORIZONS-AMI) trial. Preprocedural cardiopulmonary IAE included sustained ventricular or supraventricular tachycardia or fibrillation requiring cardioversion or defibrillation, heart block or bradycardia requiring pacemaker implantation, severe hypotension requiring vasopressors or intra-aortic balloon counterpulsation, respiratory failure requiring mechanical ventilation, and cardiopulmonary resuscitation. Three-year outcomes of patients with and without IAE according to DBT were compared. Among 3,602 patients, 159 (4.4%) had ≥1 IAE. DBT did not differ significantly in patients with and without IAE; however, patients with IAE were less likely to have Thrombolysis In Myocardial Infarction (TIMI) grade 3 flow after percutaneous coronary intervention. Mortality at 3 years was significantly higher in patients with versus those without IAE (17.0% vs 6.3%, p <0.0001), and IAE was an independent predictor of mortality, whereas DBT was not. However, a significant interaction was present such that 3-year mortality was reduced in patients with DBT <99 minutes (the median) versus ≥99 minutes to a greater extent in patients with IAE (9.9% vs 20.7%, hazard ratio 0.43, 95% confidence interval 0.16 to 1.16) compared with those without IAE (5.0% vs 7.2%, hazard ratio 0.69, 95% confidence interval 0.50 to 0.95) (p for interaction = 0.004). In conclusion, IAE before PCI is an independent predictor of death and identifies a high-risk group in whom faster reperfusion may be particularly important to improve survival.

Section snippets

Methods

The HORIZONS-AMI trial design and results have been reported in detail.9, 10 In brief, 3,602 patients with STEMIs <12 hours in duration were randomized in an open-label fashion to bivalirudin or to heparin plus a glycoprotein IIb/IIIa inhibitor during primary PCI. A second randomization was performed in 3,006 patients eligible for stenting to a paclitaxel-eluting stent or an identical bare-metal stent. Clinical follow-up was performed at 30 days, 6 months, 1 year, and then yearly through 3

Results

Of 3,602 patients enrolled in the study, 159 patients (4.4%) had ≥1 preprocedural IAE (total of 216 IAE), including hypotension requiring intravenous vasopressors (n = 40 [25.2% of all IAE]), hypotension requiring intra-aortic balloon counterpulsation (n = 12 [7.5%]), sustained ventricular tachycardia or fibrillation requiring defibrillation or cardioversion (n = 78 [49.1%]), atrial fibrillation or supraventricular tachycardia requiring cardioversion (n = 6 [3.8%]), heart block or bradycardia

Discussion

The principal findings of the present study are as follows: (1) In patients with STEMIs who undergo primary PCI and are enrolled in the randomized HORIZONS-AMI trial, preprocedural evidence of cardiopulmonary instability manifesting as important arrhythmias, hemodynamic impairment, or respiratory insufficiency was present in approximately 5% of the study population; (2) when present, IAE identified a group of patients with substantially higher rates of early and late death and MACEs; (3)

Disclosures

Drs. Mehran and Stone served as consultants for The Medicine Company and Abbott Vascular. The other authors have no conflicts to report.

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