Door-to-balloon time with primary percutaneous coronary intervention for acute myocardial infarction impacts late cardiac mortality in high-risk patients and patients presenting early after the onset of symptoms.

OBJECTIVES: The purpose of this study was to evaluate the impact of door-to-balloon time with primary percutaneous coronary intervention (PCI) on late cardiac mortality. BACKGROUND: The impact of door-to-balloon time on outcomes is controversial, and the impact on late mortality has not been studied. METHODS: Consecutive patients (n = 2,322) treated with primary PCI from 1984 to 2003 were prospectively identified and followed up for a median of 83 months. RESULTS: Prolonged door-to-balloon times (0 to 1.4 h vs. 1.5 to 1.9 h vs. 2.0 to 2.9 h vs. > or =3.0 h) were associated with higher in-hospital mortality (4.9% vs. 6.1% vs. 8.0% vs. 12.2%, p < 0.0001) and late mortality (12.6% vs. 16.4% vs. 20.4% vs. 27.1% at 7 years, p < 0.0001) and were an independent predictor of late mortality by Cox regression (p = 0.0004). Prolonged door-to-balloon times (> or =2 h vs. <2 h) were associated with higher late mortality in high-risk patients (32.5% vs. 21.5%; hazard ratio [HR], 1.53; 95% confidence interval [CI], 1.22 to 1.90; p = 0.0002) but not in low-risk patients (10.8% vs. 9.2%; HR, 1.13; 95% CI, 0.78 to 1.64; p = 0.53) and in patients presenting early (< or =3 h) (24.7% vs. 15.0%; HR, 1.54; 95% CI, 1.24 to 1.90; p = 0.0001) but not late (>3 h) (21.1% vs. 18.5%; HR, 0.95; 95% CI, 0.62 to 1.45; p = 0.80). CONCLUSIONS: Delays in door-to-balloon time impact late survival in high-risk but not low-risk patients and in patients presenting early but not late after the onset of symptoms. These findings have implications for the triage of patients for primary PCI.

Poor long-term patient and graft survival after primary percutaneous coronary intervention for acute myocardial infarction due to saphenous vein graft occlusion.

Primary percutaneous coronary intervention (PCI) for ST segment elevation myocardial infarction (STEMI) due to saphenous vein graft (SVG) occlusion has been associated with poor procedural results and poor short-term outcomes, but long-term graft patency and patient survival have not been evaluated. Consecutive patients (n = 2,240) with STEMI treated with primary PCI from 1984 to 2003 were followed for 6.6 years (median). Follow-up angiography was obtained in 80% of hospital survivors following primary PCI for SVG occlusion at 2.3 years (median). Patients with primary PCI for SVG occlusion (n = 57) vs. native artery occlusion had more prior MI, advanced Killip class, and three-vessel coronary disease and lower acute ejection fraction (EF). Patients with SVG occlusion had lower rates of TIMI 3 flow post-PCI (80.7% vs. 93.6%; P = 0.0001), higher in-hospital mortality (21.1% vs. 8.0%; P = 0.0004), and lower follow-up EF (49.3% vs. 54.7%; P = 0.055). Culprit SVGs were patent in 64% of patients at 1 year and 56% at 5 years. Late survival was strikingly worse in patients with primary PCI for SVG occlusion vs. native vessel occlusion (49% vs. 76% at 10 years), and SVG occlusion was the second strongest predictor of late cardiac mortality by multivariate analysis (HR = 2.11; 95% CI = 1.38-3.23; P = 0.0006). Patients with STEMI due to SVG occlusion treated with primary PCI have poor acute procedural results, frequent late reocclusion, and very high late mortality. The introduction of new adjunctive therapies (distal protection, thrombectomy, and drug-eluting stents) may improve short-term outcomes, but improved long-term outcomes may require new and more durable revascularization strategies.

Relation between electrocardiographic ST-segment resolution and early and late outcomes after primary percutaneous coronary intervention for acute myocardial infarction.

ST-segment resolution (STR) is a surrogate end point in reperfusion trials of acute myocardial infarction, but there are few data regarding the optimum methods of measurement, clinical predictors, and correlation with late cardiac mortality. Consecutive patients (n = 1,005) who had acute myocardial infarction and >/=2 mm ST-segment elevation controlled with primary percutaneous coronary intervention (PCI) constituted our study group. Follow-up was obtained in 97% of patients at a median of 6.2 years. STR measured as maximum ST-segment elevation after PCI provided better discrimination of late cardiac mortality than did STR measured as percent resolution. Complete STR (<1.0 mm ST-segment elevation after PCI) was achieved in only 42% of patients. Anterior infarction, Killip's class 3 to 4, and Thrombolysis In Myocardial Infarction flow grades <2 before PCI and <3 after PCI were strong independent predictors of partial or poor STR. STR (complete [<1.0 mm] vs partial [1.0 to 2.0 mm] vs poor [>2.0 mm]) correlated with in-hospital mortality (4.0% vs 6.7% vs 11.6%, p = 0.005), reinfarction (1.4% vs 3.4% vs 6.1%, p = 0.01), and late cardiac mortality (17% vs 25% vs 44%, p <0.0001). Correlation with late mortality was stronger for nonanterior than for anterior infarction. Poor STR was a strong independent predictor of late mortality (hazard ratio 1.63, 95% confidence interval 1.06 to 2.50, p = 0.028), even after adjusting for Thrombolysis In Myocardial Infarction flow. These data support the use of STR as a simple method to stratify patients by risk after primary PCI for acute myocardial infarction and support the use of STR as a surrogate end point in reperfusion trials of acute myocardial infarction.