title: Impact of pre-procedural cardiopulmonary instability in patients with acute myocardial infarction undergoing primary percutaneous coronary intervention (from the Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction Trial).
abstract: Rapid reperfusion with primary percutaneous coronary intervention improves survival in patients with ST-segment elevation myocardial infarction. Preprocedural cardiopulmonary instability and adverse events (IAE) may delay reperfusion time and worsen prognosis. The aim of this study was to evaluate the relation between preprocedural cardiopulmonary IAE, door-to-balloon time (DBT), and outcomes in the Harmonizing Outcomes With Revascularization and Stents in AMI (HORIZONS-AMI) trial. Preprocedural cardiopulmonary IAE included sustained ventricular or supraventricular tachycardia or fibrillation requiring cardioversion or defibrillation, heart block or bradycardia requiring pacemaker implantation, severe hypotension requiring vasopressors or intra-aortic balloon counterpulsation, respiratory failure requiring mechanical ventilation, and cardiopulmonary resuscitation. Three-year outcomes of patients with and without IAE according to DBT were compared. Among 3,602 patients, 159 (4.4%) had ≥1 IAE. DBT did not differ significantly in patients with and without IAE; however, patients with IAE were less likely to have Thrombolysis In Myocardial Infarction (TIMI) grade 3 flow after percutaneous coronary intervention. Mortality at 3 years was significantly higher in patients with versus those without IAE (17.0% vs 6.3%, p<0.0001), and IAE was an independent predictor of mortality, whereas DBT was not. However, a significant interaction was present such that 3-year mortality was reduced in patients with DBT<99 minutes (the median) versus ≥99 minutes to a greater extent in patients with IAE (9.9% vs 20.7%, hazard ratio 0.43, 95% confidence interval 0.16 to 1.16) compared with those without IAE (5.0% vs 7.2%, hazard ratio 0.69, 95% confidence interval 0.50 to 0.95) (p for interaction=0.004). In conclusion, IAE before PCI is an independent predictor of death and identifies a high-risk group in whom faster reperfusion may be particularly important to improve survival.
authors.affiliation: Department of Medicine, New York Methodist Hospital, Brooklyn, New York; Cardiovascular Research Foundation, New York, New York. Electronic address: sjb9005@nyp.org.
authors.forename: Sorin J
authors.initials: SJ
authors.lastname: Brener
authors.affiliation: Department of Medicine, LeBauer Cardiovascular Research Foundation, Greensboro, North Carolina.
authors.forename: Bruce R
authors.initials: BR
authors.lastname: Brodie
authors.affiliation: Cardiovascular Research Foundation, New York, New York.
authors.forename: Alejandra
authors.initials: A
authors.lastname: Guerchicoff
authors.affiliation: Department of Medicine, Amper Kliniken, Dachau, Germany.
authors.forename: Bernhard
authors.initials: B
authors.lastname: Witzenbichler
authors.affiliation: Department of Medicine, Ospedale Papa Giovanni XXIII, Bergamo, Italy.
authors.forename: Giulio
authors.initials: G
authors.lastname: Guagliumi
authors.affiliation: Cardiovascular Research Foundation, New York, New York.
authors.forename: Ke
authors.initials: K
authors.lastname: Xu
authors.affiliation: Cardiovascular Research Foundation, New York, New York; Department of Medicine, Mount Sinai Medical Center, New York, New York.
authors.forename: Roxana
authors.initials: R
authors.lastname: Mehran
authors.affiliation: Cardiovascular Research Foundation, New York, New York; Department of Medicine, Columbia University Medical Center, New York, New York.
authors.forename: Gregg W
authors.initials: GW
authors.lastname: Stone
mesh_terms: D000368:Aged; D004562:Electrocardiography; D005060:Europe / Q000453:epidemiology; D005260:Female; D006327:Heart Block / Q000209:etiology* / Q000628:therapy; D006801:Humans; D007022:Hypotension / Q000209:etiology* / Q000628:therapy; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000150:complications* / Q000401:mortality / Q000601:surgery; D015425:Myocardial Reperfusion / Q000379:methods*; D062645:Percutaneous Coronary Intervention; D057234:Preoperative Period; D011379:Prognosis; D015607:Stents; D015996:Survival Rate / Q000639:trends; D017180:Tachycardia, Ventricular / Q000209:etiology* / Q000628:therapy; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology