Elective coronary stent implantation in cardiogenic shock complicating acute myocardial infarction: in-hospital and six-month clinical and angiographic results

Percutaneous coronary intervention in cardiogenic shock complicating acute ST-elevation myocardial infarction-a single centre experience

BACKGROUND

Mortality in acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) approaches 70 - 80%, regardless of the type of pharmacological treatment. Early revascularisation improves survival in AMI with CS. Our aim is to assess the predictors of mid-term outcome after percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI) and CS.

METHODS

Forty-one patients who underwent primary or rescue PCI for CS were analysed comparing their baseline, angiographic, PCI data, 30-day and 1-year survival.

RESULTS

There were no significant differences between survivors and non-survivors in baseline characters, except for more number of transfer admissions (P= 0.0005), and cardiopulmonary resuscitations (P= 0.015) in the later group. The mean time between myocardial infarction (MI) onset to shock and MI onset to revascularisation were 12.8 ± 12.9 hours and 17.0 ± 16.8 hours, respectively. Patients with better pre-procedure thrombolysis in myocardial infarction (TIMI) flow in the infarct-related artery (IRA) had better survival (P= 0.0005). Successful PCI was achieved in 48.8% of patients. The 30-day mortality was 56.1% and all were prior to hospital discharge. Patients with successful PCI had better short-term survival in comparison with patients with failed PCI (80% vs 9.6%). Eighteen patients who survived at 30 days were followed up for 12-72 months (mean 28.5 ± 5.4 months). Fifteen patients survived at 1 year after PCI and all were in good functional status.

CONCLUSION

Mortality remains high even with PCI. Achieving IRA patency with TIMI 3 flow is the main determinant of survival. Survival and functional status are good in patients who are discharged from hospital.

Unequal access to interventional cardiac care in Nova Scotia in patients with acute myocardial infarction complicated by cardiogenic shock

BACKGROUND

The optimal treatment of cardiogenic shock (CS) complicating acute myocardial infarction (AMI) remains controversial and continues to be associated with a high mortality rate. The present study evaluated the outcomes of all patients having AMI complicated by CS in a single Canadian province.

METHODS

All consecutive patients diagnosed with AMI and CS from October 1997 to December 2002 in Nova Scotia were included in the present study. The Improving Cardiac Outcomes in Nova Scotia (ICONS) registry was used as the principal source of data. The outcome of interest was in-hospital mortality.

RESULTS

During the study period, a total of 11,300 patients with AMI were identified, with 707 complicated by CS, for an incidence of AMI+CS of 6.3%. The overall mortality rate for patients with AMI+CS was 60.1%. Multivariate regression analysis identified age older than 65 years (OR 2.0; 95% CI 1.4 to 2.9) and renal insufficiency (OR 2.1; 95% CI 1.4 to 3.2) as independent predictors of mortality, while access to invasive cardiac care (defined as admission or transfer to the only cardiac catheterization-capable centre in Halifax, Nova Scotia) was found to be an independent predictor of survival (OR 0.4; 95% CI 0.3 to 0.5). Access to invasive cardiac care was limited to 414 (59%) patients, 250 (35%) of whom actually underwent cardiac catheterization.

CONCLUSIONS

Admissions to a tertiary care centre that can provide invasive care was independently associated with improved survival, and older age and renal insufficiency were associated with death among patients with AMI and CS.

Impact of stents and abciximab on survival from cardiogenic shock treated with percutaneous coronary intervention

This retrospective observational review compares patient characteristics and in-hospital and long-term outcomes of cohorts of patients undergoing percutaneous coronary intervention (PCI) for cardiogenic shock complicating acute myocardial infarction (MI) prior to the use of stents (as well as glycoprotein IIb/IIIa inhibitor and dual-antiplatelet therapy) with PCI in the stent era. Cardiogenic shock remains the leading cause of hospital mortality from acute MI. This is a report of consecutive patients with cardiogenic shock complicating acute MI, without mechanical complication, referred for emergency catheterization to a single operator at two consecutive Veterans Affairs medical centers over a 15-year period (1988 to August 2003). PCI was attempted in all 93 cases: 44 consecutive patients in the present era and 49 consecutive patients in the stent era. Patients with comparable extent of coronary disease, more ST elevation myocardial infarction, multiple areas of infarction, and greater comorbidity underwent PCI in the stent era. Nevertheless, PCI in the stent era was associated with higher rates of acute success and improved in-hospital survival. Kaplan-Meier curves and log-rank testing showed highly significant improvement in overall survival (P < 0.0001). Logistic regression of in-hospital survival demonstrated that stent use (colinear with glycoprotein IIb/IIIa use and dual-antiplatelet therapy) was significantly associated with survival in a model adjusting for extent of coronary disease and comorbidities (P = 0.007). Stents and abciximab have been associated with improved acute angiographic and procedural success of PCI for cardiogenic shock, leading to improved survival.

Impact of invasive strategy for the management of patients with cardiogenic shock after acute myocardial infarction

OBJECTIVE

This study evaluates the influence of early revascularization (with percutaneous transluminal coronary angioplasty (PTCA) and coronary surgery) on short- and long-term survival in patients with cardiogenic shock complicating acute myocardial infarction (AMI).

METHODS AND RESULTS

In-hospital and 6-month survival were retrospectively determined on day 193 (65-270, median +/- 25th and 75th percentiles) in 87 patients who either underwent early invasive reperfusion (group A, n=60) or those who were treated conservatively (group B, n=27). In-hospital mortality was 37% in group A and 56% in group B (P=0.192). Six-month mortality was statistically lower in group A than in group B (30 patients (50%) compared with 25 patients (93%), P=0.005). Being a woman and older age were found to be factors increasing mortality. Lower mortality in the long term was strongly associated with revascularization (odds ratio=0.08, 95% confidence interval=1.54-109). PTCA was found to be an independent predictor of long-term survival (odds ratio= 0.22, 95% confidence interval=0.049-1.00, P=0.050), by multiple logistic regression.

CONCLUSIONS

In conclusion, this study suggests that early revascularization improves long-term survival of patients with cardiogenic shock complicating AMI, even after adjustment for baseline differences between patients who underwent early revascularization and those who did not.

Aspirin alone antiplatelet regimen after intracoronary placement of the Carbostent: the ANTARES study

The effect of stent coatings in preventing early thrombotic occlusion remains to be proved. The purpose of this study was to evaluate the safety and efficacy of the Carbostent, a new coronary stent with a nonthrombogenic coating (Carbofilm), in 110 consecutive patients (73.6% men, mean age 61 +/- 9 years) who met prespecified clinical and angiographic inclusion criteria and were treated with aspirin monotherapy after stenting. Stable angina (75.5%), unstable angina (18.2%), and silent ischemia (6.3%) were clinical indications for coronary revascularization. Patients received 10,000 U of heparin and no IIb/IIIa inhibitors or postprocedural heparin. Complex lesion characteristics (B2, C) were present in 39 out of 129 (30.2%) lesions. Mean lesion length was 15.6 +/- 7.4 mm, and 32% of the lesions were >15 mm (range 16-52 mm). Small coronary vessels (<3.0 mm) were treated in 28% of the cases. A total of 165 Carbostent were used in 129 coronary lesions of the 110 patients. Single-vessel stenting was performed in 97 (88%) patients and multivessel stent placement in 13 (12%) patients. The mean length of the stented segment was 21 +/- 13 mm (range 9-95 mm). Procedural and clinical success was achieved in all patients. At 1-month follow-up, there were no stent thrombosis or other major adverse cardiac events. We observed 2 (1.8%) non-Q-wave myocardial infarctions and 2 (1.8%) vascular complications. This study indicates that the Carbostent may prevent stent thrombosis in selected patients treated with aspirin only. A randomized study comparing aspirin alone versus combined ticlopidine and aspirin after Carbostent implantation will be needed to confirm these results.