ABSTRACT
BACKGROUND: Recently, mild therapeutic hypothermia (MTH) has been integrated into the European resuscitation guidelines to improve outcomes after out-of-hospital cardiac arrest (OHCA). Data on long-term results are limited, especially in patients with acute ST-elevation myocardial infarction (STEMI). HYPOTHESIS: Invasive MTH influences long-term prognosis after OHCA due to STEMI. METHODS: We analyzed 48 patients who underwent emergency coronary angiography for STEMI after witnessed OHCA. In 24 consecutive patients, MTH was performed via intravascular cooling (CoolGard System, 34°C maintained for 24 hours) after initialization by rapid infusion of cold saline. Clinical, procedural, and mortality data were compared to 24 historical controls. Neurological recovery was assessed using the Cerebral Performance Category score (CPC) at 30-day and 1-year follow-up. RESULTS: Median time delay until arrival of emergency medical service was 6 minutes (MTH group) vs 6.5 minutes (controls) (P = 0.16). Initial rhythm was ventricular fibrillation in 75% vs 66.7% (P = 0.75). There were no differences regarding baseline characteristics, angiographic findings, and success of cardiac catheterization procedures. MTH was not associated with a higher frequency of bleeding complications or of pneumonia. Thirty-day mortality was 33.3% in both groups. One-year mortality was 37.5% (MTH group) vs 50% (controls) (P = 0.56). At 1 year, favorable neurological outcome (CPC ≤2) was significantly more frequent in the MTH group (58.3% vs 20.8%, P = 0.017). Multivariate analysis identified MTH as independent predictor of favorable neurological outcome (P < 0.02, odds ratio: 12.73). CONCLUSIONS: MTH via intravascular cooling improves neurological long-term prognosis after OHCA due to STEMI and is safe in clinical practice.
Subject(s)
Hypothermia, Induced , Myocardial Infarction/complications , Out-of-Hospital Cardiac Arrest/therapy , Aged , Coronary Angiography , Female , Humans , Hypothermia, Induced/adverse effects , Hypothermia, Induced/mortality , Logistic Models , Male , Middle Aged , Multivariate Analysis , Myocardial Infarction/diagnosis , Myocardial Infarction/mortality , Myocardial Infarction/therapy , Nervous System/physiopathology , Neurologic Examination , Odds Ratio , Out-of-Hospital Cardiac Arrest/diagnosis , Out-of-Hospital Cardiac Arrest/etiology , Out-of-Hospital Cardiac Arrest/mortality , Out-of-Hospital Cardiac Arrest/physiopathology , Percutaneous Coronary Intervention/instrumentation , Platelet Aggregation Inhibitors/therapeutic use , Recovery of Function , Retrospective Studies , Risk Factors , Stents , Time Factors , Time-to-Treatment , Treatment OutcomeABSTRACT
BACKGROUND: Predictors of long-term outcome after ST-elevation myocardial infarction (STEMI) complicated by out-of-hospital cardiac arrest (OHCA) are incompletely understood, including the influence of successful coronary reperfusion. METHODS: We analysed clinical and procedural data as well as 1-year outcome of 72 consecutive patients who underwent primary coronary intervention (PCI) after witnessed OHCA and STEMI and compared the results with 695 patients with STEMI and PCI, but without OHCA. Neurological recovery after OHCA was assessed using the Cerebral Performance Category (CPC) scale. RESULTS: PCI was successful in 83.3% after OHCA vs. 84.3% in the non-OHCA group (p=0.87). One-year mortality was 34.7% vs. 9.5% (p<0.001). 58.3% of the OHCA-patients showed complete neurological recovery (CPC 1) or moderate neurological disability (CPC 2). Another 6.9% showed severe cerebral disability (CPC 3) or permanent vegetative status (CPC 4). Delay from collapse until start of Advanced Cardiopulmonary Life Support (ACLS) was shorter for survivors with CPC status ≤2 (median 1 min, range 0-11 min) compared to non-survivors or survivors with CPC status >2 (median 8 min, range 0-13 min), p<0.0001. Age-adjusted multivariate analysis identified 'unsuccessful PCI', 'vasopressors on admission' and 'start of ACLS after >6 min' as independent predictors of negative long-term outcome (death or CPC >2). CONCLUSIONS: Mortality is high in patients with STEMI complicated by OHCA - even though PCI was performed with the same success rate as in patients without OHCA. The majority of survivors had favourable neurological outcomes at 1 year, especially if advanced life support had been started within ≤6 min and PCI was successful.
Subject(s)
Myocardial Infarction/mortality , Myocardial Infarction/therapy , Nervous System Diseases/mortality , Out-of-Hospital Cardiac Arrest/mortality , Out-of-Hospital Cardiac Arrest/therapy , Percutaneous Coronary Intervention/mortality , Aged , Female , Humans , Male , Middle Aged , Myocardial Infarction/diagnosis , Nervous System Diseases/diagnosis , Nervous System Diseases/prevention & control , Out-of-Hospital Cardiac Arrest/diagnosis , Retrospective Studies , Survival Rate/trends , Survivors , Time Factors , Treatment OutcomeABSTRACT
BACKGROUND: A higher mortality risk for women with acute ST-elevation myocardial infarction (STEMI) has been a common finding in the past, even after acute percutaneous coronary intervention (PCI). We set out to analyze whether there are gender differences in real-world contemporary treatment and outcomes of STEMI. PATIENTS AND METHODS: A retrospective analysis of all consecutive patients with STEMI and acute coronary angiography with the intention of performing a PCI at our center 6/1999-6/2006 was carried out (n = 566). Data were examined for gender-specific differences regarding patients' characteristics, referral patterns, timing of acute symptoms, angiographic findings, procedural details, and adverse events at 30 days after PCI. RESULTS: Women (n = 161) were on average 8 years older than men (n = 405), had higher co-morbidity, were more often transported to the hospital by ambulance and presented less often to the emergency room on their own (4.2% vs. 12.6% in men, P = 0.02). The pre-hospital delay from symptom onset to admission was significantly longer for women (median 185 vs. 135 min, P < 0.02). There was no gender difference in time from admission to PCI (median 46 min vs. 48 min, P = 0.42). Both genders received PCI with similar frequency (88.8% vs. 92.4%, P = 0.19), with similar success rates (83.2% vs. 85.3%, P = 0.68). Thirty-day overall mortality for women was not significantly higher than for men (8.7% vs. 7.2%, P = 0.6). Re-infarction or stroke within 30 days were rare for both genders without gender-specific differences whereas bleeding necessitating blood replacement was significantly more frequent in women (16.8% vs. 5.9%, P < 0.001). In multivariate analysis, female gender was not independently associated with a higher risk of 30-day mortality (OR 0.964, P = 0.93). CONCLUSIONS: Women underwent PCI therapy for STEMI with the same frequency and the same angiographic success as men. Despite their more advanced age and the higher prevalence of co-morbidities, they did not have a significantly higher 30-day mortality rate than men. Female gender was not an independent risk factor of 30-day mortality. Longer pre-hospital delays before hospital admission in women indicate that awareness of risk from coronary artery disease should be further raised in women.
