Publications (103) View all
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Article: Relationship Between ST-Segment Recovery and Clinical Outcomes After Primary Percutaneous Coronary Intervention: The HORIZONS-AMI ECG Substudy Report.
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ABSTRACT: BACKGROUND: IN PATIENTS WITH ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION UNDERGOING THROMBOLYTIC THERAPY, THE DEGREE OF ST-SEGMENT RESOLUTION (STR) CORRELATES WITH LONG-TERM CARDIOVASCULAR MORTALITY. THE LONG-TERM PREDICTIVE VALUE OF STR AFTER PRIMARY PERCUTANEOUS CORONARY INTERVENTION (PCI) IS LESS WELL UNDERSTOOD. WE SOUGHT TO DETERMINE THE LONG-TERM PROGNOSTIC VALUE OF STR AFTER PRIMARY PCI IN ST-SEGMENTELEVATION MYOCARDIAL INFARCTION.METHODS AND RESULTS: IN A FORMAL SUBSTUDY FROM THE HARMONIZING OUTCOMES WITH REVASCULARIZATION AND STENTS IN ACUTE MYOCARDIAL INFARCTION (HORIZONS-AMI) TRIAL, 2484 PATIENTS WITH ST-SEGMENTELEVATION MYOCARDIAL INFARCTION UNDERGOING PRIMARY PCI WITH INTERPRETABLE BASELINE AND 60-MINUTE POST-PCI ELECTROCARDIOGRAMS HAD AT LEAST 1 MM OF BASELINE ST-SEGMENT ELEVATION IN 2 CONTIGUOUS LEADS. PATIENTS WERE CATEGORIZED BY THE DEGREE OF STR AT 60 MINUTES: (1) COMPLETE (70%); (2) PARTIAL (30%70%); AND (3) ABSENT (30%). ABSENT, INCOMPLETE, AND COMPLETE STR WERE ACHIEVED IN 514 (20.7%), 712 (28.7%), AND 1258 (50.5%) PATIENTS, RESPECTIVELY. STR 30% WAS ASSOCIATED WITH A GREATER LIKELIHOOD OF HYPERTENSION, DIABETES MELLITUS, LONGER SYMPTOM ONSET TO BALLOON TIME, LOWER LEFT VENTRICULAR EJECTION FRACTION, AND FINAL THROMBOLYSIS IN MYOCARDIAL INFARCTION FLOW 3. AT 3 YEARS, PATIENTS WITH STR30% EXPERIENCED A HIGHER RATE OF MAJOR ADVERSE CARDIOVASCULAR EVENTS (DEATH, REINFARCTION, ISCHEMIA-DRIVEN TARGET VESSEL REVASCULARIZATION OR STROKE; 29.9% VERSUS 20.1% VERSUS 19.6%; P0.0001), ISCHEMIA-DRIVEN TARGET VESSEL REVASCULARIZATION (20.4% VERSUS 14.0% VERSUS 11.7%; P0.001), AND MORTALITY (8.4% VERSUS 5.0% VERSUS 5.6%; P=0.03) THAN THOSE WITH PARTIAL AND COMPLETE STR, RESPECTIVELY. BY MULTIVARIABLE ANALYSIS, STR30% WAS AN INDEPENDENT PREDICTOR OF 3-YEAR MAJOR ADVERSE CARDIOVASCULAR EVENTS (HAZARD RATIO, 1.58; 95% CONFIDENCE INTERVAL, 1.242.00; P=0.0002) AND 3-YEAR ISCHEMIA-DRIVEN TARGET VESSEL REVASCULARIZATION (HAZARD RATIO, 1.87; 95% CONFIDENCE INTERVAL, 1.412.48; P0.0001).CONCLUSIONS: IN THIS LARGE INTERNATIONAL STUDY, ABSENT STR 60 MINUTES AFTER PRIMARY PCI WAS PRESENT IN 1 IN 5 PATIENTS WITH ST-SEGMENTELEVATION MYOCARDIAL INFARCTION AND WAS A SIGNIFICANT INDEPENDENT PREDICTOR OF MAJOR ADVERSE CARDIOVASCULAR EVENTS AND TARGET VESSEL REVASCULARIZATION AT 3 YEARS.CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00433966.Circulation Cardiovascular Interventions 05/2013; · 6.06 Impact Factor -
Article: Comparison of Outcomes of Patients With ST-Segment Elevation Myocardial Infarction With Versus Without Previous Coronary Artery Bypass Grafting (from the Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction [HORIZONS-AMI] Trial).
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ABSTRACT: The present substudy from the Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction (HORIZONS-AMI) trial assessed the outcomes and their relation to different antithrombotic regimens in patients with previous coronary artery bypass grafting (CABG) treated with primary percutaneous coronary intervention. Of 3,599 patients with information regarding a history of CABG, 105 (2.9%) had previously undergone CABG. Of these 105 patients, 46 were randomized to heparin plus a glycoprotein IIb/IIIa inhibitor and 59 to bivalirudin. The patients with versus without previous CABG were less frequently triaged to primary percutaneous coronary intervention (83.8% vs 93.2%, p = 0.0002) and had a longer door-to-balloon time (median 1.9 vs 1.6 hours, p = 0.047), lower rates of final Thrombolysis In Myocardial Infarction flow grade 2 to 3 in the intervened vessel (92.6% vs 97.8%, p = 0.007), and less frequent rates of complete or partial ST-segment resolution (66.3% vs 77.6%, p = 0.019). At 3 years, previous CABG was associated with a significantly greater incidence of major adverse cardiovascular events (36.4% vs 21.4%, p <0.001) owing to greater rates of mortality (11.2% vs 6.7%, p = 0.08), reinfarction (11.6% vs 7.1%, p = 0.09), stroke (5.1% vs 1.8%, p = 0.013), and ischemic target vessel revascularization (23.6% vs 12.9%, p = 0.005). The outcomes did not differ significantly as a function of the antithrombotic regimen. On multivariate analysis, previous CABG was an independent predictor of 3-year ischemic stroke (hazard ratio 3.57, 95% confidence interval 1.09 to 11.66). Intervention on the saphenous vein graft versus the native vessel predicted 3-year major adverse cardiovascular events (hazard ratio 2.69, 95% confidence interval 1.17 to 6.19). In the HORIZONS-AMI trial, previous CABG was associated with a delay to mechanical reperfusion and lower rates of percutaneous coronary intervention and patency of the infarct related vessel along with worse clinical outcomes.The American journal of cardiology 02/2013; · 3.58 Impact Factor -
Article: Long-term Prognosis of Patients Presenting With ST-Segment Elevation Myocardial Infarction With No Significant Coronary Artery Disease (from The HORIZONS-AMI Trial).
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ABSTRACT: The clinical features and prognosis of patients with ST-segment elevation myocardial infarction (STEMI) and no significant coronary artery disease (CAD) have not been well studied. We examined the outcomes of patients with STEMI in the Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction (HORIZONS-AMI) trial according to the presence or absence of significant CAD. "No-CAD" was defined by the absence of any lesion with a diameter stenosis of ≥30% on quantitative coronary angiography of the baseline coronary angiogram. Of 3,602 patients, 127 (3.5%) had no-CAD. Of these, 86 (67.7%) had angiographically normal coronary arteries, and 41 (32.3%) had mild disease (diameter stenosis <30%). Eight patients had previously been treated with coronary artery bypass grafting. Compared to patients with CAD, patients with no-CAD were younger, had a lower body mass index, were more frequently black, had a lower prevalence of smoking and previous angina, and had a greater left ventricular ejection fraction. Cardiac enzymes were elevated in fewer patients with no-CAD than in those with CAD (63.2% vs 98.7%, p <0.001). At 3 years of follow-up, the patients with no-CAD versus CAD had lower rates of major adverse cardiovascular events (7.7% vs 22.2%, p = 0.002), net adverse clinical events (major adverse cardiovascular events or major bleeding not related to coronary artery bypass grafting, 12.5% vs 26.9%, p = 0.005), and postprocedure coronary revascularization (0% vs 19.5%, p <0.001). The differences in the rates of death or reinfarction, stroke, and major bleeding were not statistically significant. In conclusion, 3.5% of patients with STEMI had no significant CAD. The 3-year prognosis for these patients was favorable compared to that of patients with STEMI and with obstructive CAD.The American journal of cardiology 12/2012; · 3.58 Impact Factor -
Article: Coronary reperfusion and clinical outcomes after thrombus aspiration during primary percutaneous coronary intervention: Findings from the HORIZONS-AMI trial.
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ABSTRACT: OBJECTIVES: To assess the quality of coronary reperfusion and long-term clinical outcomes of patients enrolled in the HORIZONS-AMI trial according to the use of thrombus aspiration (TA). BACKGROUND: The impact of manual TA on microvascular perfusion and clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (pPCI) is unsettled. METHODS: In this retrospective, non-randomized, sub-group analysis, the authors evaluated Thrombolysis in Myocardial Infarction (TIMI) flow, tissue myocardial perfusion grade (TMPG), ST-segment resolution (STR), net adverse clinical events (NACE), and major adverse cardiac events (MACE) in patients undergoing pPCI with or without manual TA. RESULTS: A total of 318 patients had pPCI with upfront TA, and 2917 patients had pPCI without TA. Patients who had TA were more likely to have TIMI 0/1 flow at baseline (75.1% vs. 63.7%, p<0.0001). There was no difference in the rates of final TIMI 3 flow (90.2% vs. 92.3%, p=0.19) or dynamic TMPG 2-3 (77.4% vs. 76.4%, p=0.68). STR ≥70% was similar in both groups at 60 minutes but higher in the TA group at discharge (71.8% vs. 64.6%, p=0.02). After multivariable adjustment, TA did not predict MACE at 30 days (HR 0.96 [0.51-1.80], p=0.90), one year (HR 1.03 [0.68-1.55], p=0.89), or 3 years (HR 1.13 [0.86-1.48], p=0.39). Stent thrombosis did not differ at 1 year or 3 years. CONCLUSIONS: In STEMI patients undergoing pPCI, the use of manual TA was associated with improved STR at discharge, but not with any difference in final TIMI flow, TMPG, or MACE. © 2012 Wiley Periodicals, Inc.Catheterization and Cardiovascular Interventions 10/2012; · 2.29 Impact Factor -
Article: Outcomes of Patients With Prior Coronary Artery Bypass Grafting and Acute Coronary Syndromes: Analysis From the ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy) Trial.
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ABSTRACT: This study sought to assess the contemporary outcomes of patients with prior coronary artery bypass graft (CABG) who present with moderate and high-risk acute coronary syndromes (ACS) and are treated with an early invasive strategy and contemporary antithrombin regimens. The prognosis of patients with ACS and prior CABG in relation to triage strategy and contemporary antithrombotic regimens is unknown. In the ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy) trial, 2,475 of 13,764 patients (18.0%) with ACS managed with an early invasive strategy had previously undergone CABG. Their outcomes were examined according to treatment and randomized antithrombin regimen. Prior CABG was associated with older age, more frequent comorbidities, higher Thrombolysis In Myocardial Infarction risk score, and lower left ventricular ejection fraction. Patients with versus without prior CABG were less likely to undergo (repeat) CABG and were more likely to be managed medically. At 1 year, patients with versus without prior CABG had higher rates of major adverse cardiac events (MACE) (22.5% vs. 15.2%, p < 0.0001) due to greater mortality (5.4% vs. 3.9%, p < 0.0001), myocardial infarction (10.0% vs. 6.8%, p < 0.0001), and unplanned revascularization (13.1% vs. 8.2%, p < 0.0001). History of CABG was an independent predictor of MACE. The 1-year MACE rates were not significantly different after randomization to bivalirudin versus heparin plus a glycoprotein IIb/IIIa inhibitor (odds ratio: 1.24, 95% confidence interval: 0.90 to 1.70). Despite the progress in the treatment of coronary artery disease, patients with prior CABG and ACS have a poor prognosis, substantially worse than for those without prior CABG. Whereas bivalirudin monotherapy was an acceptable treatment for these patients, it did not improve their prognoses.09/2012; 5(9):919-26. · 1.07 Impact Factor
