Time-related impact of distal embolisation on myocardial perfusion and survival among patients undergoing primary angioplasty with glycoprotein IIb-IIIa inhibitors: insights from the EGYPT cooperation.
OBJECTIVE
Considerable interest has been focused in recent years on the role of distal embolisation as a major determinant of impaired reperfusion after primary angioplasty for STEMI. The aim of the current study was to evaluate in a large cohort of STEMI patients undergoing primary angioplasty with glycoprotein (Gp) IIb-IIIa inhibitors, whether the impact of distal embolisation on myocardial perfusion and survival may depend on time-to-treatment.


RESULTS
Our population is represented by 1,182 patients undergoing primary angioplasty for STEMI included in the EGYPT database. Patients were grouped according to time-to-treatment (<3 hours, 3-6 hours, >6 hours). Distal embolisation was defined as an abrupt "cutoff" in the main vessel or one of the coronary branches of the infarct-related artery, distal to the angioplasty site. Myocardial perfusion was evaluated by angiography or ST-segment resolution, whereas infarct size was estimated by using peak creatine kinase (CK) and CK-MB. Follow-up data were collected between 30 days and one year after primary angioplasty. Distal embolisation was observed in 132 patients (11.1%) and tended to occur more frequently in late presenters (p=0.067). Patients with distal embolisation less often had post-procedural Thrombolysis In Myocardial Infarction (TIMI) 3 flow (p<0.001), post-procedural myocardial blush grade (MBG) 2-3 (p<0.001), complete ST-segment resolution (p=0.021) and larger infarct size (p=0.012). Distal embolisation was associated with a significantly higher mortality (9.2% vs. 2.7%, heart rate [HR] [95% CI]=3.41 [1.73-6.71], p<0.0001). The impact of distal embolisation on myocardial perfusion and survival persisted for all time intervals.


CONCLUSIONS
This study showed that among STEMI patients treated with Gp IIb-IIIa inhibitors, the negative impact of distal embolisation on myocardial perfusion and mortality is independent of the time from symptom onset to balloon angioplasty.
Division of Cardiology, "Maggiore della Carità" Hospital, Eastern Piedmont University, Novara, Italy. giuseppe.deluca@maggioreosp.novara.it
Giuseppe
G
De Luca
C Michael
CM
Gibson
Kurt
K
Huber
Dariusz
D
Dudek
Donald
D
Cutlip
Uwe
U
Zeymer
Maryann
M
Gyöngyösi
Francesco
F
Bellandi
Marko
M
Noc
Hans-Richard
HR
Arntz
Mauro
M
Maioli
Gioel Gabrio
GG
Secco
Simona
S
Zorman
H Mesquita
HM
Gabriel
Ayse
A
Emre
Tomasz
T
Rakowski
Arnoud W J
AW
Van't Hof
D000368:Aged; D015906:Angioplasty, Balloon, Coronary / Q000295:instrumentation / Q000379:methods*; D015331:Cohort Studies; D003324:Coronary Artery Disease / Q000150:complications / Q000628:therapy*; D004562:Electrocardiography; D004617:Embolism / Q000150:complications*; D005260:Female; D005500:Follow-Up Studies; D006339:Heart Rate / Q000502:physiology; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000209:etiology / Q000401:mortality* / Q000517:prevention & control*; D009206:Myocardium / Q000473:pathology; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use; D019039:Platelet Glycoprotein GPIIb-IIIa Complex / Q000037:antagonists & inhibitors*; D012189:Retrospective Studies; D015607:Stents; D015996:Survival Rate; D013997:Time Factors; D061665:Time-to-Treatment
D010975:Platelet Aggregation Inhibitors; D019039:Platelet Glycoprotein GPIIb-IIIa Complex