Characteristics and clinical outcome of 458 patients with acute myocardial infarction requiring mechanical ventilation. Results of the BEAT registry of the ALKK-study group.

BACKGROUND: Information about the clinical course of patients with acute myocardial infarction requiring mechanical ventilation is scarce. We sought to evaluate the clinical outcome of a large cohort of such patients in clinical practice. METHODS: The German BEAT registry prospectively enrolled consecutive patients requiring mechanical ventilation who were admitted to an internal intensive care unit (ICU) of 45 participating German hospitals between September 2001 and June 2002. For this analysis, we created a subgroup of patients with acute ST-segment-elevation or non-ST-segment-elevation myocardial infarction. RESULTS: During the 9-month study period, 458 consecutive patients fulfilled our inclusion criteria. The mean age was 68 ± 8 years and 71% were men. 40% of the patients were already intubated in the prehospital phase. The initial reason for intubation was in 48% of the cases ventricular fibrillation/tachycardia or sudden cardiac death, in 39% congestive heart failure and in 13% of the cases non-cardiac. The median time of ventilation was 2 days (1-5) among survivors and 1 day (0-5) among non-survivors. Of the 458 patients, 256 (56%) had already or developed cardiogenic shock, 86 (19%) acute renal failure, 76 (17%) coma or brain damage, 64 (14%) severe infection, 46 (10%) sepsis and 28 (6%) multiorgan distress syndrome; 11% were treated with fibrinolysis, 39% with PCI and 6% with coronary artery bypass grafting. The overall hospital mortality rate was 48%. In patients with cardiogenic shock, mortality was even higher with 69%. CONCLUSIONS: Patients requiring mechanical ventilation during an acute myocardial infarction constitute a high risk group with a mortality of about 50%. Further research is necessary to improve the outcome of these patients.

Randomized comparison of percutaneous transluminal coronary angioplasty and medical therapy in stable survivors of acute myocardial infarction with single vessel disease: a study of the Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte.

BACKGROUND: Percutaneous transluminal coronary angioplasty of the infarct-related artery in stable survivors of acute myocardial infarction is often performed, even in patients without any symptoms or residual ischemia. Despite the lack of randomized studies, it is widely believed that this intervention will improve the clinical outcome of these patients. METHODS AND RESULTS: Three hundred patients with single vessel disease of the infarct vessel and no or minor angina pectoris in the subacute phase (1 to 6 weeks) after an acute myocardial infarction were randomized to angioplasty (n=149) or medical therapy (n=151). Primary end point was the survival free of reinfarction, (re)intervention, coronary artery bypass surgery, or readmission for severe angina pectoris at 1 year. The event-free survival at 1 year was 82% in the medical group and 90% in the angioplasty group (P=0.06). This difference was mainly driven by the difference in the need for (re)interventions (20 versus 8, P=0.03). At long-term follow-up (mean, 56 months), survival was 89% and 96% (P=0.02). Survival free of reinfarction, (re)intervention, or coronary artery bypass surgery was 66% and 80% in the medically and interventionally treated patients, respectively (P=0.05). The use of nitrates was significantly lower in the angioplasty group, both at 1 year (38% versus 67%, P=0.001) and at long-term follow-up (36% versus 55%, P=0.006). CONCLUSIONS: Percutaneous revascularization of the infarct-related coronary artery in stable patients with single vessel disease improves clinical outcome at long-term follow-up and reduces the use of nitrates. The results of our study should be reproduced in a confirmatory study with a larger sample size before percutaneous coronary intervention in this low-risk patient subgroup, after myocardial infarction can be recommended as routine treatment in clinical practice.