Inverse relation between diastolic blood pressure and long-term outcomes in patients undergoing pharmacoinvasive therapy for myocardial infarction: the J-shaped relation in the contemporary era of revascularisation.
OBJECTIVE
In the thrombolytic era, it was reported that in the presence of significant coronary stenosis, lowering diastolic blood pressure (DBP) below a critical threshold would result in a paradoxical increase in the occurrence of myocardial infarction (MI). We sought to re-evaluate this J-shaped relation in the era of pharmacoinvasive therapy.


METHODS
A total of 182 patients who underwent early (<1 week, mean 2.3 days) coronary angioplasty after thrombolysis were analysed.


RESULTS
Thrombolytic agents (streptokinase in 60%, tissue plasminogen activator in 40%) were administered in an average door-to-needle time of 66 min (<=30 min in 43 [24%] patients). A thrombolysis in myocardial infarction (TIMI) 3 flow was achieved in 56% of patients after thrombolysis, and it was enhanced to 92% after angioplasty. During an average follow-up period of 26 +/-13 months, the adverse event (death, re-MI, target vessel revascularisation or stroke) rate was 21%. Older age, low systolic blood pressure and DBP, fast heart rate, high creatine kinase, hypercholesterolaemia, thrombus-laden lesion, baseline TIMI 0-2 flow were associated with higher occurrence of adverse events. After adjusting for the differing clinical and procedural factors, low DBP (odds ratio 1.10, 95% confidence interval 1.01-1.20, P = 0.041), fast heart rate (odds ratio 1.08, 95% confidence interval 1.02-1.14, P = 0.008) and anterior MI (odds ratio 18.98, 95% confidence interval 2.13-169.19, P = 0.008) were all independent predictors of long-term adverse rate occurrence.


CONCLUSIONS
A low DBP is an independent predictor of long-term adverse event rates in patients undergoing routine early coronary angioplasty after thrombolysis. This suggests that excessive lowering of DBP may not be desirable before complete revascularisation.
Lee
Chi Hang
CH
Cardiac Department, National University Hospital, The Heart Institute, Singapore. leerch@hotmail.com
Foo
David
D
Wong
Hwee Bee
HB
Hong
Eric C T
EC
Seow
Swee Chong
SC
Ng
Kheng Siang
KS
Lim
Yean Teng
YT
Tan
Huay Cheem
HC
D015906:Angioplasty, Balloon, Coronary / Q000009:adverse effects; D001794:Blood Pressure / Q000187:drug effects*; D017023:Coronary Angiography; D003326:Coronary Circulation / Q000187:drug effects; D003971:Diastole; D005260:Female; D005343:Fibrinolytic Agents / Q000494:pharmacology / Q000627:therapeutic use*; D005500:Follow-Up Studies; D006339:Heart Rate / Q000187:drug effects; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000188:drug therapy* / Q000401:mortality / Q000503:physiopathology / Q000601:surgery; D009204:Myocardial Revascularization / Q000009:adverse effects; D016017:Odds Ratio; D011237:Predictive Value of Tests; D012372:ROC Curve; D012008:Recurrence; D012107:Research Design; D012307:Risk Factors; D012680:Sensitivity and Specificity; D013300:Streptokinase / Q000627:therapeutic use; D020521:Stroke / Q000209:etiology; D015912:Thrombolytic Therapy; D013997:Time Factors; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use; D016896:Treatment Outcome
D005343:Fibrinolytic Agents; D013300:Streptokinase; D010959:Tissue Plasminogen Activator