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Acute myocardial infarction: facilitation and transport strategies
TUESDAY 9/16/03 9:00 –11:00
AM
and 2:00 – 4:00
Acute Myocardial Infarction: Facilitation and Transport Strategies Tuesday, September 16, 2003 9:00-11:00 AM 2:00-4:00 PM Exhibit Hall B on the Lower Level (Abstract nos. 355–360)
TCT-355 Abciximab Treatment Initiated Before Transport of Patients With Acute Myocardial Infarction for Primary Angioplasty Improves Outcome. S.L. Beeres, P.V. Oemrawsingh, D.E. Atsma, J.W. Jukema, E.E. van der Wall, M.J. Schalij. Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands.
P O S T E R A B S T R A C T S
Background: Clinical outcome of patients with acute myocardial infarction (AMI) improves when treated by primary angioplasty with stent placement and adjunctive abciximab. In this study, we compared the outcome of patients pretreated with abciximab initiated either before transport to a tertiary care center or immediately before primary percutaneous coronary intervention (PCI). Methods:The 6-month clinical outcome of all patients with AMI who were referred for primary PCI (n ⫽ 447) from May 1, 1999 to March 1, 2002 was evaluated. All patients received an abciximab bolus of 0.25 mg/kg intravenously, followed by infusion of 0.125 g/kg per minute intravenously for 12 hours. Results: During the study period, 308 patients were transported without abciximab (late group; 61 ⫾ 9 years; 75.6% male) and in 139 patients abciximab was started in the referring hospital before ambulance transport (early group; 61 ⫾ 9 years; 70.5% male). Transport time was comparable in both groups (45 ⫾ 15 minutes; range, 15 to 60 minutes). Known coronary artery disease was more frequent in the early group (n ⫽ 49; 36.3%) compared with the late group (n ⫽ 74; 26.7%; p ⫽ 0.05), but other baseline data were similar. Major bleeding complications occurred in 6.7% (n ⫽ 9) of patients in the early group and 5.9% (n ⫽ 16) of patients in late group (NS). In both groups, the revascularization rate was similar (n ⫽ 17, 14.8%; vs n ⫽ 49, 19,4%; NS). Acute coronary syndromes were more frequent in the late group compared with the early group (n ⫽ 50, 19.9%; vs n ⫽ 13, 11.3%; p ⫽ 0.043). There was no difference in mortality between both groups (n ⫽ 29, 10.1%; vs n ⫽ 11, 8.9%; NS). Major adverse cardiac events occurred in 27.4% (n ⫽ 34) of patients in the early group vs 37.5% (n ⫽ 102) of patients in the late group (p ⫽ 0.05). Conclusion: Abciximab initiated before transport to a tertiary center for primary angioplasty improves 6-month clinical outcome in patients with extensive AMI. Angiographic details and subgroup analysis will be presented at the meeting.
152L
The American Journal of Cardiology姞
PM
(Exhibit Hall B on the Lower Level)
TCT-356 The 4-Year Clinical and Angiographic Follow-Up in Patients With Acute Myocardial Infarction Treated With Immediate Thrombolysis Versus Primary Angioplasty Versus Combined Strategy: Single-Center Randomized Trial, Subgroup of PRAGUE Study. L. Groch, I. Horˇncˇek, O. Hlinomaz, L. Nechvt´al, M. Rezek, J. Seme´nka, J. Sitar, M. Tejc. First InternalCardioangiological Department, Masaryk University, St. Anna Hospital, Brno, Czech Republic. Background: The multicenter randomized PRAGUE study showed feasibility and safety of transferring patients with acute myocardial infarction (AMI) to a tertiary center for primary angioplasty. Compared with the thrombolytic strategy (streptokinase 1.5 million units), transfer for primary angioplasty was associated with fewer patients with reinfarction and with the combined endpoint of death/reinfarction/stroke at 3 days. The combined strategy of thrombolysis plus primary percutaneous transluminal coronary angioplasty (PTCA) was not associated with a better outcome than thrombolytic therapy alone. Methods: The aim of our study was to compare the results of longterm (50 months) follow-up of 148 patients, who presented with AMI in our center and participated in 1997 and 1998 in the PRAGUE study. Results: The number of survivors in 3 treatment regimens (group A, thrombolysis in general hospital; group B, thrombolysis plus immediate transfer to PTCA center; group C, primary PTCA after transferring to PTCA center) and event-free (death, reinfarction, target vessel revascularization, coronary artery bypass graft) survivors after 50 months of follow-up evaluation are shown (Table). The infarction-related artery was patent at a rate of 65% in group A, 78% in group B, and 91% in group C, respectively, (p ⫽ 0.05 between A-C). TABLE 1. group
% of survivals
p
% of event free survivals
p
A B C
66 82 74
A-B 0.05 B-C NS C-A NS
43 67 64
A-B 0.04 B-C NS C-A NS
Conclusion: We conclude that primary angioplasty is a superior strategy for treatment of AMI in comparison with thrombolysis alone. Facilitated PTCA (pretreatment with streptokinase) was the best option for AMI patients in our group, even in long-term follow-up.
TCT-357 Is Rapid Transfer of ST-Elevation Myocardial Infarction Patients for Primary Angioplasty Feasible in the United States? D.M. Larson1, S.W. Sharkey2, B.T. Unger2, M.R. Mooney2, J.D. Madison2, T.H. Henry2. 1Ridgeview Medical Center, Waconia, Minnesota, USA; 2Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA. Background: Recent trials report improved outcomes for ST Elevation Myocardial Infarction (STEMI) patients transferred for direct percutaneous coronary intervention (PCI) versus fibrinolysis at community hospitals without PCI capability. Although the door-to-balloon times ⬍120 minutes is associated with lower mortality, this has been difficult to achieve in the United States. We have established an ongoing pilot study demonstrating an integrated, efficient protocol for transferring STEMI patients from community hospitals for PCI. Methods: Abbott Northwestern (ANW) hospital is a tertiary heart center in Minnesota with referral relationships with 30 to 35 community hospitals. A pilot project with 5 rural/community hospitals 20 to 60
SEPTEMBER 15–17, 2003
TCT ABSTRACTS/Poster
TUESDAY 9/16/03 9:00 –11:00
AM
and 2:00 – 4:00
miles (mean, 41) from ANW was initiated to determine the safety and feasibility of transferring patients for PCI with goal door-to-balloon times ⬍90 minutes. The “Level 1 Heart Attack” protocol for STEMI or new left branch bundle block includes immediate activation of transport services, mobilization of the catheterization laboratory team and administration of adjunctive treatment after an established protocol. Key clinical and laboratory data are faxed directly to the catheterization laboratory from the community hospital. Results: From January to May 2003, 26 STEMI patients were transferred for direct PCI from 5 Community hospitals (17 from initial pilot site) by ambulance (21) or helicopter (5). There were no deaths during transport and 1 patient was successfully defibrillated during transfer. The in-door– out-door time (median) in the community hospitals was 32 minutes, transport time was 32 minutes, and door-toballoon times at ANW was 31 minutes. The median door-to-balloon times from the community emergency department was 98 minutes. In-hospital mortality was 4% (89-year-old patient, with left main coronary artery disease, in cardiogenic shock). Conclusion: Rapid transfer of STEMI patients from community hospitals located up to 60 miles away from PCI centers in the United States is safe and feasible when an integrated coordinated system of acute cardiac care is in place. This requires a team approach with cooperation between cardiologists, emergency and primary care physicians, nurses, paramedics and other ancillary technicians, as well as various healthcare organizations. Results from this ongoing pilot study with 3 to 5 additional hospitals and an anticipated 10 to 15 STEMI patients per month will be presented.
TCT-358 Benefit of Prehospital Administration of Abciximab in Mobile Intensive Care Units in Patients With Acute Myocardial Infarction Treated by Primary Angioplasty. M. Fajraoui, M. Angioi, T. Chouied, F. Moulin, S. Sadoune-Urion, L. Mock, J. Frey, R. Piquemal, S. Albizzati, G. Ethevenot, E. Aliot. Centre Hospitalier Universite´ de Nancy, Vandoeuvre, France. Background: Recent data from the Abciximab Before Direct Angioplasty and Stenting in Acute Myocardial Infarction Regarding Acute and Long-Term Follow-Up (ADMIRAL) study suggest that the benefit of abciximab (abx) in patients who undergo primary angioplasty for acute myocardial infarction (AMI) is mainly because of early prehospital administration of abx. We assess the early benefit of prehospital abx administration compared with catheterization laboratory abx administration in the setting of primary angioplasty. Methods: We used a monocentric registry, including 228 consecutive patients (male 81%, age 60 ⫾ 14 years) with AMI (⬍12 hours), who underwent facilitated primary angioplasty with abx, which was administrated in mobile intensive care unit in 68 patients (30%, group 1) and in the catheterization laboratory in 158 patients (70%, group 2). Results: Baseline characteristics of the 2 groups were similar. Pain to admission to catheterization laboratory time was slightly shorter, although not statistically different, in group 1 (222 ⫾ 136 minutes vs 198 ⫾ 109 minutes). Stent use was similar in group 1 and 2 (97 vs 90%, p ⫽ 0.11), but direct stenting was more frequent in group 1 (47 vs 20%, p ⬍0.0001). Preprocedural thrombolysis in myocardial infarction (TIMI) flow grade 2 or 3 were more often observed in group 1 (41 vs 26%, p ⬍0.026). Postprocedural TIMI-3 flow grade was achieved in 93% in group 1 and 85% in group 2 (p ⫽ 0.13). Postprocedural corrected TIMI frame count was, however, significantly better in group 1 (22 ⫾ 11, vs 28 ⫾ 13; p ⬍0.006). Left ventricular ejection fraction (LVEF) was significantly higher in group 1 patients (51 ⫾ 10% vs 46 ⫾ 11%, p ⬍0.001). Although not reaching the statistical level of significance (4.4 vs 11.4%, p ⬍0.09), there was a clear reduction of in-hospital major adverse cardiac events (death, recurrent MI, repeat percutaneous transluminal coronary angioplasty of the culprit lesion) in group 1 with no increase in major TIMI
The American Journal of Cardiology姞
PM
(Exhibit Hall B on the Lower Level)
bleeding events (1.5% vs 1.3%, p ⫽ NS). Using a stepwise multivariate analysis, belonging to group 1 was an independent predictor of postprocedural corrected TIMI frame count (p ⬍0.0001) and of improved left ventricular ejection fraction (p ⬍0.01). Conclusion: Compared with catheterization laboratory administration, prehospital administration of abx to facilitate primary angioplasty in patients with AMI is safe and improves coronary epicardial blood flow and left ventricular ejection fraction, which are 2 major determinants of prognosis.
TCT-359 Prospective Identification of Predictors of Failed Thrombolysis in ST-Segment Elevation Myocardial Infarction to Expedite Primary Percutaneous Coronary Intervention. I. Sadiq1, G. Saperia1, G. Agnelli2, G. Steg3, G. Montalescot3, E. Gurfinkel4, P. Kuznetsova5, J.M. Gore5. 1Saint Vincent Hospital, Worcester, Massachusetts, USA; 2Istituto de Medicina Interna e Medicina Vascolare, Perugia, Italy; 3Hopital Pitie-Salpetriere, Paris, France; 4 Buenos Aires University, Buenos Aires, Argentina; 5University of Massachusetts Medical School, Worcester, Massachusetts, USA. Background: Thrombolytic therapy (TT) failure, encountered in 15% to 50% of ST-elevation myocardial infarction (STEMI) patients, leads to significant delay in provision of rescue percutaneous coronary intervention (PCI). We propose to identify significant predictors of failed TT in a global registry population to facilitate primary consideration of alternative reperfusion strategies. Methods: Patients with STEMI treated with TT in the Global Registry of Acute Coronary Events (GRACE) were divided into 2 groups: failed thrombolysis and successful thrombolysis. Only patients presenting to hospitals with a cardiac catheterization laboratory were included. Patients were assigned to failed thrombolysis group if they required rescue PCI, developed subsequent cardiogenic shock or died within 24 hours of hospital admission. The remaining patients were assigned to the successful thrombolysis group. Using multivariate logistic regression significant predictors of failed thrombolysis were identified. Results: Of 26,267 patients enrolled in GRACE, 8,260 had STEMI and 2,292 met the study inclusion criteria. In all, 600 patients were determined to have failed thrombolysis and 1,692 had successful thrombolysis. Most (⬎74%) patients were male, and ⬎50% presented during the daytime (6 AM to 6 PM) with no differences between the 2 groups in time of presentation (day vs night). Patients with a prior history of angina, coronary artery disease, PCI, and those receiving long-term -blockers and thienopyridines were more likely to fail thrombolytic therapy. Patients with positive initial creatine kinase and Q-wave results on index electrocardiography were also more likely to fail thrombolysis. However, the most significant multivariate predictors of failed thrombolysis included prior angina, prior PCI, and anterior STEMI. Conclusion: In hospitals equipped with catheterization laboratory facilities, patients presenting with STEMI who have a history of prior coronary artery disease, revascularization, or who present with anterior STEMI should be stratified so strong consideration can be given to primary PCI over thrombolytic therapy as the primary reperfusion strategy. Variables
OR
95% CI
History of PCI Anterior ST elevation MI History of angina
1.463 1.536 1.643
(1.006; 2.128) (1.266; 1.863) (1.334; 2.024)
Factors predicting thrombolytic failure. CI ⫽ confidence interval; MI ⫽ myocardial infaction; OR ⫽ odds ratio; PCI ⫽ percutaneous coronary intervention
SEPTEMBER 15–17, 2003
TCT ABSTRACTS/Poster
153L
P O S T E R A B S T R A C T S
TUESDAY 9/16/03 9:00 –11:00
AM
and 2:00 – 4:00
TCT-360 Collaboration Between Peripheral Hospitals and a Central Hospital Equipped With Hemodynamic Facilities for Treatment of Acute Myocardial Infarction: Preliminary Results. M. Romano, C. Lettieri, F. Buffoli, N. Baccaglioni, M.A. Cattabiani, L. Tomasi, R. Zanini. Division of Cardiology, C. Poma Hospital, Mantova, Italy. Background: Percutaneous coronary intervention (PCI) is a consolidated therapeutic strategy in cases of acute myocardial infarction (AMI), but optimal results depend on the timing of the intervention. Methods: Our Cardiology Department has had an active AMI treatment protocol since May 1, 2001, which has been extended to peripheral hospitals lacking hemodynamic facilities. The treated patients have: (1) absolute contraindications against or have failed to respond to thrombolytic therapy (rescue PCI); (2) AMI with hemodynamic impairment; (3) anterior or inferior AMI with right ventricular involvement. All patients undergoing primary PCI are premedicated by means of an abciximab bolus plus infusion. In the case of an expected transportation time of ⬎60 minutes, the protocol recommends pretreatment with a combination of 50 mg recombinant tissue plasminogen activator plus ReoPro plus 40 U/kg of intravenous heparin (facilitated
PM
(Exhibit Hall B on the Lower Level)
PCI). Between May 1, 2001, and December 31, 2002, 150 AMI patients (age 63 ⫾ 15 years; 75% males) underwent primary PCI (33% from peripheral hospitals): 81% were pretreated with ReoPro alone for direct PCI, 13% were pretreated with the combination therapy for facilitated PCI, and 6% were pretreated with rescue PCI. Results: The coronary angiography results showed that 20% of patients in the group treated with ReoPro alone had a thrombolysis in myocardial infarction (TIMI) flow grade of 1 to 2, and 2% had a TIMI flow grade of 3; the remaining 78% had a TIMI flow grade of 0. In the facilitated PCI group, 60% had a TIMI flow of 3, 20% a TIMI flow of 1 to 2, and 20% a TIMI flow of 0. At the end of the procedure, 98% of patients had a TIMI flow grade of 3. Patients with major bleeding (2%) were treated with emotrasfusion (no case of brain bleeding). The average time of “door-to-balloon” for the all patients was 129 minutes (87 minutes for the patients coming from peripheral hospitals). The periprocedural and in-hospital mortality rates were 0% and 6%, respectively. Conclusion: Our data demonstrate: the optimal results of primary PCI in AMI patients; the early clinical reperfusion and more complete angiographic revascularization of facilitated PCI; the usefulness of early and safe transportation to a tertiary intensive care unit of patients experiencing on going AMI.
P O S T E R A B S T R A C T S
154L
The American Journal of Cardiology姞
SEPTEMBER 15–17, 2003
TCT ABSTRACTS/Poster
AM
and 2:00 – 4:00
Acute Myocardial Infarction: Facilitation and Transport Strategies Tuesday, September 16, 2003 9:00-11:00 AM 2:00-4:00 PM Exhibit Hall B on the Lower Level (Abstract nos. 355–360)
TCT-355 Abciximab Treatment Initiated Before Transport of Patients With Acute Myocardial Infarction for Primary Angioplasty Improves Outcome. S.L. Beeres, P.V. Oemrawsingh, D.E. Atsma, J.W. Jukema, E.E. van der Wall, M.J. Schalij. Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands.
P O S T E R A B S T R A C T S
Background: Clinical outcome of patients with acute myocardial infarction (AMI) improves when treated by primary angioplasty with stent placement and adjunctive abciximab. In this study, we compared the outcome of patients pretreated with abciximab initiated either before transport to a tertiary care center or immediately before primary percutaneous coronary intervention (PCI). Methods:The 6-month clinical outcome of all patients with AMI who were referred for primary PCI (n ⫽ 447) from May 1, 1999 to March 1, 2002 was evaluated. All patients received an abciximab bolus of 0.25 mg/kg intravenously, followed by infusion of 0.125 g/kg per minute intravenously for 12 hours. Results: During the study period, 308 patients were transported without abciximab (late group; 61 ⫾ 9 years; 75.6% male) and in 139 patients abciximab was started in the referring hospital before ambulance transport (early group; 61 ⫾ 9 years; 70.5% male). Transport time was comparable in both groups (45 ⫾ 15 minutes; range, 15 to 60 minutes). Known coronary artery disease was more frequent in the early group (n ⫽ 49; 36.3%) compared with the late group (n ⫽ 74; 26.7%; p ⫽ 0.05), but other baseline data were similar. Major bleeding complications occurred in 6.7% (n ⫽ 9) of patients in the early group and 5.9% (n ⫽ 16) of patients in late group (NS). In both groups, the revascularization rate was similar (n ⫽ 17, 14.8%; vs n ⫽ 49, 19,4%; NS). Acute coronary syndromes were more frequent in the late group compared with the early group (n ⫽ 50, 19.9%; vs n ⫽ 13, 11.3%; p ⫽ 0.043). There was no difference in mortality between both groups (n ⫽ 29, 10.1%; vs n ⫽ 11, 8.9%; NS). Major adverse cardiac events occurred in 27.4% (n ⫽ 34) of patients in the early group vs 37.5% (n ⫽ 102) of patients in the late group (p ⫽ 0.05). Conclusion: Abciximab initiated before transport to a tertiary center for primary angioplasty improves 6-month clinical outcome in patients with extensive AMI. Angiographic details and subgroup analysis will be presented at the meeting.
152L
The American Journal of Cardiology姞
PM
(Exhibit Hall B on the Lower Level)
TCT-356 The 4-Year Clinical and Angiographic Follow-Up in Patients With Acute Myocardial Infarction Treated With Immediate Thrombolysis Versus Primary Angioplasty Versus Combined Strategy: Single-Center Randomized Trial, Subgroup of PRAGUE Study. L. Groch, I. Horˇncˇek, O. Hlinomaz, L. Nechvt´al, M. Rezek, J. Seme´nka, J. Sitar, M. Tejc. First InternalCardioangiological Department, Masaryk University, St. Anna Hospital, Brno, Czech Republic. Background: The multicenter randomized PRAGUE study showed feasibility and safety of transferring patients with acute myocardial infarction (AMI) to a tertiary center for primary angioplasty. Compared with the thrombolytic strategy (streptokinase 1.5 million units), transfer for primary angioplasty was associated with fewer patients with reinfarction and with the combined endpoint of death/reinfarction/stroke at 3 days. The combined strategy of thrombolysis plus primary percutaneous transluminal coronary angioplasty (PTCA) was not associated with a better outcome than thrombolytic therapy alone. Methods: The aim of our study was to compare the results of longterm (50 months) follow-up of 148 patients, who presented with AMI in our center and participated in 1997 and 1998 in the PRAGUE study. Results: The number of survivors in 3 treatment regimens (group A, thrombolysis in general hospital; group B, thrombolysis plus immediate transfer to PTCA center; group C, primary PTCA after transferring to PTCA center) and event-free (death, reinfarction, target vessel revascularization, coronary artery bypass graft) survivors after 50 months of follow-up evaluation are shown (Table). The infarction-related artery was patent at a rate of 65% in group A, 78% in group B, and 91% in group C, respectively, (p ⫽ 0.05 between A-C). TABLE 1. group
% of survivals
p
% of event free survivals
p
A B C
66 82 74
A-B 0.05 B-C NS C-A NS
43 67 64
A-B 0.04 B-C NS C-A NS
Conclusion: We conclude that primary angioplasty is a superior strategy for treatment of AMI in comparison with thrombolysis alone. Facilitated PTCA (pretreatment with streptokinase) was the best option for AMI patients in our group, even in long-term follow-up.
TCT-357 Is Rapid Transfer of ST-Elevation Myocardial Infarction Patients for Primary Angioplasty Feasible in the United States? D.M. Larson1, S.W. Sharkey2, B.T. Unger2, M.R. Mooney2, J.D. Madison2, T.H. Henry2. 1Ridgeview Medical Center, Waconia, Minnesota, USA; 2Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA. Background: Recent trials report improved outcomes for ST Elevation Myocardial Infarction (STEMI) patients transferred for direct percutaneous coronary intervention (PCI) versus fibrinolysis at community hospitals without PCI capability. Although the door-to-balloon times ⬍120 minutes is associated with lower mortality, this has been difficult to achieve in the United States. We have established an ongoing pilot study demonstrating an integrated, efficient protocol for transferring STEMI patients from community hospitals for PCI. Methods: Abbott Northwestern (ANW) hospital is a tertiary heart center in Minnesota with referral relationships with 30 to 35 community hospitals. A pilot project with 5 rural/community hospitals 20 to 60
SEPTEMBER 15–17, 2003
TCT ABSTRACTS/Poster
TUESDAY 9/16/03 9:00 –11:00
AM
and 2:00 – 4:00
miles (mean, 41) from ANW was initiated to determine the safety and feasibility of transferring patients for PCI with goal door-to-balloon times ⬍90 minutes. The “Level 1 Heart Attack” protocol for STEMI or new left branch bundle block includes immediate activation of transport services, mobilization of the catheterization laboratory team and administration of adjunctive treatment after an established protocol. Key clinical and laboratory data are faxed directly to the catheterization laboratory from the community hospital. Results: From January to May 2003, 26 STEMI patients were transferred for direct PCI from 5 Community hospitals (17 from initial pilot site) by ambulance (21) or helicopter (5). There were no deaths during transport and 1 patient was successfully defibrillated during transfer. The in-door– out-door time (median) in the community hospitals was 32 minutes, transport time was 32 minutes, and door-toballoon times at ANW was 31 minutes. The median door-to-balloon times from the community emergency department was 98 minutes. In-hospital mortality was 4% (89-year-old patient, with left main coronary artery disease, in cardiogenic shock). Conclusion: Rapid transfer of STEMI patients from community hospitals located up to 60 miles away from PCI centers in the United States is safe and feasible when an integrated coordinated system of acute cardiac care is in place. This requires a team approach with cooperation between cardiologists, emergency and primary care physicians, nurses, paramedics and other ancillary technicians, as well as various healthcare organizations. Results from this ongoing pilot study with 3 to 5 additional hospitals and an anticipated 10 to 15 STEMI patients per month will be presented.
TCT-358 Benefit of Prehospital Administration of Abciximab in Mobile Intensive Care Units in Patients With Acute Myocardial Infarction Treated by Primary Angioplasty. M. Fajraoui, M. Angioi, T. Chouied, F. Moulin, S. Sadoune-Urion, L. Mock, J. Frey, R. Piquemal, S. Albizzati, G. Ethevenot, E. Aliot. Centre Hospitalier Universite´ de Nancy, Vandoeuvre, France. Background: Recent data from the Abciximab Before Direct Angioplasty and Stenting in Acute Myocardial Infarction Regarding Acute and Long-Term Follow-Up (ADMIRAL) study suggest that the benefit of abciximab (abx) in patients who undergo primary angioplasty for acute myocardial infarction (AMI) is mainly because of early prehospital administration of abx. We assess the early benefit of prehospital abx administration compared with catheterization laboratory abx administration in the setting of primary angioplasty. Methods: We used a monocentric registry, including 228 consecutive patients (male 81%, age 60 ⫾ 14 years) with AMI (⬍12 hours), who underwent facilitated primary angioplasty with abx, which was administrated in mobile intensive care unit in 68 patients (30%, group 1) and in the catheterization laboratory in 158 patients (70%, group 2). Results: Baseline characteristics of the 2 groups were similar. Pain to admission to catheterization laboratory time was slightly shorter, although not statistically different, in group 1 (222 ⫾ 136 minutes vs 198 ⫾ 109 minutes). Stent use was similar in group 1 and 2 (97 vs 90%, p ⫽ 0.11), but direct stenting was more frequent in group 1 (47 vs 20%, p ⬍0.0001). Preprocedural thrombolysis in myocardial infarction (TIMI) flow grade 2 or 3 were more often observed in group 1 (41 vs 26%, p ⬍0.026). Postprocedural TIMI-3 flow grade was achieved in 93% in group 1 and 85% in group 2 (p ⫽ 0.13). Postprocedural corrected TIMI frame count was, however, significantly better in group 1 (22 ⫾ 11, vs 28 ⫾ 13; p ⬍0.006). Left ventricular ejection fraction (LVEF) was significantly higher in group 1 patients (51 ⫾ 10% vs 46 ⫾ 11%, p ⬍0.001). Although not reaching the statistical level of significance (4.4 vs 11.4%, p ⬍0.09), there was a clear reduction of in-hospital major adverse cardiac events (death, recurrent MI, repeat percutaneous transluminal coronary angioplasty of the culprit lesion) in group 1 with no increase in major TIMI
The American Journal of Cardiology姞
PM
(Exhibit Hall B on the Lower Level)
bleeding events (1.5% vs 1.3%, p ⫽ NS). Using a stepwise multivariate analysis, belonging to group 1 was an independent predictor of postprocedural corrected TIMI frame count (p ⬍0.0001) and of improved left ventricular ejection fraction (p ⬍0.01). Conclusion: Compared with catheterization laboratory administration, prehospital administration of abx to facilitate primary angioplasty in patients with AMI is safe and improves coronary epicardial blood flow and left ventricular ejection fraction, which are 2 major determinants of prognosis.
TCT-359 Prospective Identification of Predictors of Failed Thrombolysis in ST-Segment Elevation Myocardial Infarction to Expedite Primary Percutaneous Coronary Intervention. I. Sadiq1, G. Saperia1, G. Agnelli2, G. Steg3, G. Montalescot3, E. Gurfinkel4, P. Kuznetsova5, J.M. Gore5. 1Saint Vincent Hospital, Worcester, Massachusetts, USA; 2Istituto de Medicina Interna e Medicina Vascolare, Perugia, Italy; 3Hopital Pitie-Salpetriere, Paris, France; 4 Buenos Aires University, Buenos Aires, Argentina; 5University of Massachusetts Medical School, Worcester, Massachusetts, USA. Background: Thrombolytic therapy (TT) failure, encountered in 15% to 50% of ST-elevation myocardial infarction (STEMI) patients, leads to significant delay in provision of rescue percutaneous coronary intervention (PCI). We propose to identify significant predictors of failed TT in a global registry population to facilitate primary consideration of alternative reperfusion strategies. Methods: Patients with STEMI treated with TT in the Global Registry of Acute Coronary Events (GRACE) were divided into 2 groups: failed thrombolysis and successful thrombolysis. Only patients presenting to hospitals with a cardiac catheterization laboratory were included. Patients were assigned to failed thrombolysis group if they required rescue PCI, developed subsequent cardiogenic shock or died within 24 hours of hospital admission. The remaining patients were assigned to the successful thrombolysis group. Using multivariate logistic regression significant predictors of failed thrombolysis were identified. Results: Of 26,267 patients enrolled in GRACE, 8,260 had STEMI and 2,292 met the study inclusion criteria. In all, 600 patients were determined to have failed thrombolysis and 1,692 had successful thrombolysis. Most (⬎74%) patients were male, and ⬎50% presented during the daytime (6 AM to 6 PM) with no differences between the 2 groups in time of presentation (day vs night). Patients with a prior history of angina, coronary artery disease, PCI, and those receiving long-term -blockers and thienopyridines were more likely to fail thrombolytic therapy. Patients with positive initial creatine kinase and Q-wave results on index electrocardiography were also more likely to fail thrombolysis. However, the most significant multivariate predictors of failed thrombolysis included prior angina, prior PCI, and anterior STEMI. Conclusion: In hospitals equipped with catheterization laboratory facilities, patients presenting with STEMI who have a history of prior coronary artery disease, revascularization, or who present with anterior STEMI should be stratified so strong consideration can be given to primary PCI over thrombolytic therapy as the primary reperfusion strategy. Variables
OR
95% CI
History of PCI Anterior ST elevation MI History of angina
1.463 1.536 1.643
(1.006; 2.128) (1.266; 1.863) (1.334; 2.024)
Factors predicting thrombolytic failure. CI ⫽ confidence interval; MI ⫽ myocardial infaction; OR ⫽ odds ratio; PCI ⫽ percutaneous coronary intervention
SEPTEMBER 15–17, 2003
TCT ABSTRACTS/Poster
153L
P O S T E R A B S T R A C T S
TUESDAY 9/16/03 9:00 –11:00
AM
and 2:00 – 4:00
TCT-360 Collaboration Between Peripheral Hospitals and a Central Hospital Equipped With Hemodynamic Facilities for Treatment of Acute Myocardial Infarction: Preliminary Results. M. Romano, C. Lettieri, F. Buffoli, N. Baccaglioni, M.A. Cattabiani, L. Tomasi, R. Zanini. Division of Cardiology, C. Poma Hospital, Mantova, Italy. Background: Percutaneous coronary intervention (PCI) is a consolidated therapeutic strategy in cases of acute myocardial infarction (AMI), but optimal results depend on the timing of the intervention. Methods: Our Cardiology Department has had an active AMI treatment protocol since May 1, 2001, which has been extended to peripheral hospitals lacking hemodynamic facilities. The treated patients have: (1) absolute contraindications against or have failed to respond to thrombolytic therapy (rescue PCI); (2) AMI with hemodynamic impairment; (3) anterior or inferior AMI with right ventricular involvement. All patients undergoing primary PCI are premedicated by means of an abciximab bolus plus infusion. In the case of an expected transportation time of ⬎60 minutes, the protocol recommends pretreatment with a combination of 50 mg recombinant tissue plasminogen activator plus ReoPro plus 40 U/kg of intravenous heparin (facilitated
PM
(Exhibit Hall B on the Lower Level)
PCI). Between May 1, 2001, and December 31, 2002, 150 AMI patients (age 63 ⫾ 15 years; 75% males) underwent primary PCI (33% from peripheral hospitals): 81% were pretreated with ReoPro alone for direct PCI, 13% were pretreated with the combination therapy for facilitated PCI, and 6% were pretreated with rescue PCI. Results: The coronary angiography results showed that 20% of patients in the group treated with ReoPro alone had a thrombolysis in myocardial infarction (TIMI) flow grade of 1 to 2, and 2% had a TIMI flow grade of 3; the remaining 78% had a TIMI flow grade of 0. In the facilitated PCI group, 60% had a TIMI flow of 3, 20% a TIMI flow of 1 to 2, and 20% a TIMI flow of 0. At the end of the procedure, 98% of patients had a TIMI flow grade of 3. Patients with major bleeding (2%) were treated with emotrasfusion (no case of brain bleeding). The average time of “door-to-balloon” for the all patients was 129 minutes (87 minutes for the patients coming from peripheral hospitals). The periprocedural and in-hospital mortality rates were 0% and 6%, respectively. Conclusion: Our data demonstrate: the optimal results of primary PCI in AMI patients; the early clinical reperfusion and more complete angiographic revascularization of facilitated PCI; the usefulness of early and safe transportation to a tertiary intensive care unit of patients experiencing on going AMI.
P O S T E R A B S T R A C T S
154L
The American Journal of Cardiology姞
SEPTEMBER 15–17, 2003
TCT ABSTRACTS/Poster