title: Incidence, Predictors, and Outcomes of High-Grade Atrioventricular Block in Patients With ST-Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention (from the HORIZONS-AMI Trial).
abstract: High-grade atrioventricular block (HAVB) is historically considered a marker of worse outcomes in patients with ST-segment elevation myocardial infarction (STEMI). However, the predictors and prognostic impact of HAVB in the primary percutaneous coronary intervention (PCI) era remain poorly understood. We sought to describe the characteristics and predictors of HAVB in patients undergoing primary PCI in STEMI and to assess the prognostic significance of HAVB in the contemporary reperfusion era. The present analysis includes 3,115 patients presenting with STEMI from the Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction trial who underwent primary PCI. Outcomes were examined according to the presence of HAVB on a presenting electrocardiogram, as interpreted by an independent electrocardiography core laboratory. HAVB (second-degree Mobitz II or third-degree atrioventricular block) was present at baseline in 46 patients (1.5%). Independent predictors of HAVB included increased age, diabetes mellitus, right coronary artery occlusion, sum of ST-segment deviation, and baseline Thrombolysis In Myocardial Infarction flow 0/1. Thrombolysis In Myocardial Infarction flow 3 was restored in 83.7% and 91.5% of patients with versus without baseline HAVB respectively (p = 0.06). Mortality rate was significantly higher in patients with versus without HAVB at 30-day, 1-, and 3-year follow-ups (unadjusted hazard ratio [HR] 3.83, 95% CI 1.40 to 10.48; unadjusted HR 4.37, 95% CI 2.09 to 9.38 and unadjusted HR 2.78, 95% CI 1.31 to 5.91, respectively). After covariate adjustment, mortality rate was significantly higher in patients with HAVB at 1 year (adjusted HR 2.45, 95% CI 1.09 to 5.50, p = 0.03) but not at 30 days (adjusted HR 1.70, 95% CI 0.58 to 5.01, p = 0.33) or 3 years (adjusted HR 0.71 to 3.41, p = 0.27). In conclusion, HAVB is a rare complication of STEMI but remains associated with increased mortality, even after primary PCI.
authors.affiliation: Cardiovascular Research Foundation, Clinical Trials Center, New York, New York; Department of Cardiology, NewYork-Presbyterian Hospital, Columbia University Medical Center, New York, New York. Electronic address: ikosmidou@crf.org.
authors.forename: Ioanna
authors.initials: I
authors.lastname: Kosmidou
authors.affiliation: Cardiovascular Research Foundation, Clinical Trials Center, New York, New York.
authors.forename: Björn
authors.initials: B
authors.lastname: Redfors
authors.affiliation: Cardiovascular Research Foundation, Clinical Trials Center, New York, New York.
authors.forename: Rushad
authors.initials: R
authors.lastname: Dordi
authors.affiliation: Cardiovascular Research Foundation, Clinical Trials Center, New York, New York; Department of Cardiology, NewYork-Presbyterian Hospital, Columbia University Medical Center, New York, New York.
authors.forename: José M
authors.initials: JM
authors.lastname: Dizon
authors.affiliation: Cardiovascular Research Foundation, Clinical Trials Center, New York, New York.
authors.forename: Thomas
authors.initials: T
authors.lastname: McAndrew
authors.affiliation: Cardiovascular Research Foundation, Clinical Trials Center, New York, New York; Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York.
authors.forename: Roxana
authors.initials: R
authors.lastname: Mehran
authors.affiliation: Cardiovascular Research Foundation, Clinical Trials Center, New York, New York; Department of Cardiology, NewYork-Presbyterian Hospital, Columbia University Medical Center, New York, New York.
authors.forename: Ori
authors.initials: O
authors.lastname: Ben-Yehuda
authors.affiliation: Cardiovascular Research Foundation, Clinical Trials Center, New York, New York.
authors.forename: Gary S
authors.initials: GS
authors.lastname: Mintz
authors.affiliation: Cardiovascular Research Foundation, Clinical Trials Center, New York, New York; Department of Cardiology, NewYork-Presbyterian Hospital, Columbia University Medical Center, New York, New York.
authors.forename: Gregg W
authors.initials: GW
authors.lastname: Stone
mesh_terms: D000367:Age Factors; D000368:Aged; D054537:Atrioventricular Block / Q000453:epidemiology*; D002304:Cardiac Pacing, Artificial / Q000706:statistics & numerical data; D001026:Coronary Artery Bypass / Q000706:statistics & numerical data; D054059:Coronary Occlusion / Q000453:epidemiology; D003920:Diabetes Mellitus / Q000453:epidemiology; D004562:Electrocardiography; D005260:Female; D006801:Humans; D006949:Hyperlipidemias / Q000453:epidemiology; D015994:Incidence; D008297:Male; D008875:Middle Aged; D010138:Pacemaker, Artificial; D062645:Percutaneous Coronary Intervention; D011379:Prognosis; D016016:Proportional Hazards Models; D012307:Risk Factors; D000072657:ST Elevation Myocardial Infarction / Q000453:epidemiology* / Q000401:mortality / Q000601:surgery; D012720:Severity of Illness Index; D016896:Treatment Outcome