Search

Background— In nondiabetic patients with ST-segment–elevation myocardial infarction, acute hyperglycemia is associated with adverse outcome. Whether this association is due merely to hyperglycemia as an acute stress response or whether longer-term glycometabolic derangements are also involved is uncertain. It was our aim to determine the association between both acute and chronic hyperglycemia (hemoglobin A 1c [HbA 1c ]) and outcome in nondiabetic patients with ST-segment–elevation myocardial infarction. Methods and Results— This observational study included consecutive patients (n=4176) without known diabetes mellitus admitted with ST-segment–elevation myocardial infarction. All patients were treated with primary percutaneous intervention. Both glucose and HbA 1c were measured on admission. Main outcome measure was total long-term mortality; secondary outcome measures were 1-year mortality and enzymatic infarct size. One-year mortality was 4.7%, and mortality after total follow-up (3.3±1.5 years) was 10%. Both elevated HbA 1c levels ( P P 1c remained associated with long-term mortality ( P P =0.09). Elevated glucose, but not elevated HbA 1c , was associated with larger infarct size. After multivariate analysis, HbA 1c (hazard ratio, 1.2 per interquartile range; P Conclusions— In nondiabetic patients with ST-segment–elevation myocardial infarction, both elevated admission glucose and HbA 1c levels were associated with adverse outcome. Both of these parameters reflect different patient populations, and their association with outcome is probably due to different mechanisms. Measurement of both parameters enables identification of these high-risk groups for aggressive secondary risk prevention.

Background— Although the relationship between mortality and time delay to treatment has been demonstrated in patients with acute ST-segment elevation myocardial infarction (STEMI) treated by thrombolysis, the impact of time delay on prognosis in patients undergoing primary angioplasty has yet to be clarified. The aim of this report was to address the relationship between time to treatment and mortality as a continuous function and to estimate the risk of mortality for each 30-minute delay. Methods and Results— The study population consisted of 1791 patients with STEMI treated by primary angioplasty. The relationship between ischemic time and 1-year mortality was assessed as a continuous function and plotted with a quadratic regression model. The Cox proportional hazards regression model was used to calculate relative risks (for each 30 minutes of delay), adjusted for baseline characteristics related to ischemic time. Variables related to time to treatment were age >70 years ( P P =0.004), presence of diabetes mellitus ( P =0.002), and previous revascularization ( P =0.035). Patients with successful reperfusion had a significantly shorter ischemic time ( P =0.006). A total of 103 patients (5.8%) had died at 1-year follow-up. After adjustment for age, gender, diabetes, and previous revascularization, each 30 minutes of delay was associated with a relative risk for 1-year mortality of 1.075 (95% CI 1.008 to 1.15; P =0.041). Conclusions— These results suggest that every minute of delay in primary angioplasty for STEMI affects 1-year mortality, even after adjustment for baseline characteristics. Therefore, all efforts should be made to shorten the total ischemic time, not only for thrombolytic therapy but also for primary angioplasty.

Background. Evidence regarding the optimal treatment of non-culprit lesions detected during primary PCI is lacking. A conservative approach is advocated by the current guidelines. However, a more aggressive approach may prevent recurrent cardiac events and improve left ventricular function. Methods . Of 120 patients with at least 1 non-culprit lesion, 80 were randomized to early follow-up coronary angiography including Fractional Flow Reserve (FFR)-guided PCI (invasive group), and 40 to medical treatment followed by ischemia detection at a later stage (conservative group). Primary endpoint was left ventricular ejection fraction at 6 months. Results. The number of non-culprit lesions per patient was identical in both groups (1.25 ± 0.44 vs 1.25 ± 0.44, p=1.00). In the invasive group, follow-up angiography was performed 13 ± 13 days after primary PCI. Only 60 % of the non-culprit lesions that were considered significant during primary PCI had a FFR < 0.75 at follow up indicating hemodynamic significance. Subsequent PCI of at least 1 non-culprit lesion guided by FFR was performed in 50% of patients, PCI without preceding FFR was performed in 15% and CABG was done in 5%. After 236 ± 152 days of follow up, PCI of non-culprit lesions was more frequently needed in the conservative group (18% vs 4%, p=0.015) but the incidence of recurrent myocardial infarction was higher in the invasive group (10% vs 0%, p=0.051), half of which were non-culprit lesion related (5% vs 0%, p=0.150). Death and total major adverse cardiac events were not different between groups. Conclusion: The hemodynamic significance of non-culprit lesions detected during primary PCI is frequently overestimated (40%). Early PCI of non-culprit lesions guided by FFR prevents later PCI procedures but does not result in a reduction of total major cardiac events compared to a more conservative strategy. Data on the primary endpoint at 6 months (EF) will be presented.

Background— The aim of this study was to create a practical score for risk stratification in patients with ST-segment elevation myocardial infarction (STEMI) treated with primary angioplasty and to assess the feasibility of early discharge in low-risk patients. Methods and Results— A prognostic score was built according to 30-day mortality rates in 1791 patients undergoing primary angioplasty for STEMI. For the identified low-risk patients without any contraindication to early discharge, we estimated and compared the costs of conventional care (prolonged 24-hour hospitalization) with the costs of shifting the care from inpatient to outpatient setting (early discharge) between 48 and 72 hours. Independent predictors of 30-day mortality included in the score were age, anterior infarction, Killip class, ischemic time, postprocedural Thrombolysis In Myocardial Infarction (TIMI) flow, and multivessel disease. This score was able to identify a large cohort (73.4%) of low-risk (score ≤3) patients, with a good discriminatory capacity ( c statistic=0.907). The mortality rate was 0.1% at 2 days and 0.2% between 2 and 10 days in patients with a score ≤3. The incremental cost-effectiveness ratio for late discharge in low-risk patients was estimated at 1949.33. Therefore, this policy would save 1 life per 1097 low-risk patients, at additional costs of 194 933.33, in comparison with an early discharge policy. Conclusions— This score is a practical and useful index for risk stratification after primary angioplasty for STEMI, with a significant impact on clinical decision-making and the related costs. It reliably identifies a large group of patients at very low risk, who may safely be discharged early after primary angioplasty.