Revascularisation of Left Main Coronary Artery-Related AMI
Objectives We evaluated 30-day and 1-year clinical outcomes after percutaneous or surgical coronary revascularisation in patients with unprotected left main coronary artery (ULMCA)-related acute myocardial infarction (AMI).
Design Single-centre registry.
Patients Between January 1998 and December 2008, 84 patients with ULMCA-related AMI underwent revascularisation treatment in our institution (55 underwent percutaneous coronary intervention (PCI), 29 underwent coronary artery bypass graft surgery (CABG)).
Methods One-year clinical follow-up was obtained for all patients. Univariable and multivariable analyses were performed to find predictors for 30-day mortality and treatment allocation.
Results In the PCI-group, all-cause mortality was 64% at 30 days and 69% at 1 year. In the CABG-group, this was 24% at 30 days and 1 year. Independent predictors of 30-day mortality were cardiogenic shock (HR 2.83), thrombolysis in MI (TIMI) 0/1 flow (HR 2.27) and diabetes mellitus (HR 2.65). Treatment allocation to PCI was primarily determined by TIMI 0/1 flow on baseline angiogram (OR 150). In patients with TIMI 2/3 flow on initial angiogram, treatment allocation was determined by presentation with cardiogenic shock (OR 5.61), year of inclusion (OR 1.72), and distal/bifurcation disease (OR 0.11).
Conclusions Thirty-day mortality was high in patients presenting with an ULMCA-related AMI, both in the PCI as in the CABG-treatment group. Presentation with cardiogenic shock, TIMI 0/1 flow on initial angiogram and diabetes mellitus were independently predicting of 30-day mortality, whereas treatment allocation was primarily determined by presentation with TIMI 0/1 flow.
Acute myocardial infarction (AMI) due to a thrombotic occlusion of the unprotected left main coronary artery (ULMCA) is a clinically catastrophic event. Presumably, a substantial number of patients die before being able to contact emergency medical care, and probably only a small number of them reaches the hospital. These patients are critically ill, often presenting with cardiogenic shock and serious ventricular arrhythmias, resulting in a high in-hospital mortality rate. AMI due to an ULMCA culprit lesion accounts for only 0.8–4% of all primary percutaneous coronary interventions (PPCI). Clinical outcomes after PPCI in patients with AMI with a ULMCA culprit lesion are reported in small-sized registries, consisting of 6–300 patients. Reports on patients treated with coronary artery bypass graft (CABG) surgery for ULMCA-related AMI are scarce, including only few case reports and two small registries.
According to the current European Society of Cardiology (ESC), the American Heart Association/American College of Cardiology (AHA/ACC) guidelines, and the Appropriate Use Criteria for Coronary Revascularization Focused Update, CABG is the preferred treatment of non-urgent ULMCA disease, whereas PCI may be considered in patients with high surgical risk. However, no specific recommendations are given concerning treatment modality for AMI due to an ULMCA culprit lesion. As data is limited, reporting clinical outcomes for this specific patient subgroup remains important. In this single-centre study, we evaluated 30-day and 1-year clinical outcomes after percutaneous or surgical coronary revascularisation in patients presenting with AMI due to a ULMCA culprit lesion. Furthermore, to evaluate the clinical decision-making process, and to reveal potential selection bias for each treatment modality, we performed multivariable analyses to identify predictors of the decision to treat by percutaneous or surgical revascularisation. Finally, multivariable analyses were performed to identify prognostic indicators of 30-day all-cause mortality.
Abstract and Introduction
Abstract
Objectives We evaluated 30-day and 1-year clinical outcomes after percutaneous or surgical coronary revascularisation in patients with unprotected left main coronary artery (ULMCA)-related acute myocardial infarction (AMI).
Design Single-centre registry.
Patients Between January 1998 and December 2008, 84 patients with ULMCA-related AMI underwent revascularisation treatment in our institution (55 underwent percutaneous coronary intervention (PCI), 29 underwent coronary artery bypass graft surgery (CABG)).
Methods One-year clinical follow-up was obtained for all patients. Univariable and multivariable analyses were performed to find predictors for 30-day mortality and treatment allocation.
Results In the PCI-group, all-cause mortality was 64% at 30 days and 69% at 1 year. In the CABG-group, this was 24% at 30 days and 1 year. Independent predictors of 30-day mortality were cardiogenic shock (HR 2.83), thrombolysis in MI (TIMI) 0/1 flow (HR 2.27) and diabetes mellitus (HR 2.65). Treatment allocation to PCI was primarily determined by TIMI 0/1 flow on baseline angiogram (OR 150). In patients with TIMI 2/3 flow on initial angiogram, treatment allocation was determined by presentation with cardiogenic shock (OR 5.61), year of inclusion (OR 1.72), and distal/bifurcation disease (OR 0.11).
Conclusions Thirty-day mortality was high in patients presenting with an ULMCA-related AMI, both in the PCI as in the CABG-treatment group. Presentation with cardiogenic shock, TIMI 0/1 flow on initial angiogram and diabetes mellitus were independently predicting of 30-day mortality, whereas treatment allocation was primarily determined by presentation with TIMI 0/1 flow.
Introduction
Acute myocardial infarction (AMI) due to a thrombotic occlusion of the unprotected left main coronary artery (ULMCA) is a clinically catastrophic event. Presumably, a substantial number of patients die before being able to contact emergency medical care, and probably only a small number of them reaches the hospital. These patients are critically ill, often presenting with cardiogenic shock and serious ventricular arrhythmias, resulting in a high in-hospital mortality rate. AMI due to an ULMCA culprit lesion accounts for only 0.8–4% of all primary percutaneous coronary interventions (PPCI). Clinical outcomes after PPCI in patients with AMI with a ULMCA culprit lesion are reported in small-sized registries, consisting of 6–300 patients. Reports on patients treated with coronary artery bypass graft (CABG) surgery for ULMCA-related AMI are scarce, including only few case reports and two small registries.
According to the current European Society of Cardiology (ESC), the American Heart Association/American College of Cardiology (AHA/ACC) guidelines, and the Appropriate Use Criteria for Coronary Revascularization Focused Update, CABG is the preferred treatment of non-urgent ULMCA disease, whereas PCI may be considered in patients with high surgical risk. However, no specific recommendations are given concerning treatment modality for AMI due to an ULMCA culprit lesion. As data is limited, reporting clinical outcomes for this specific patient subgroup remains important. In this single-centre study, we evaluated 30-day and 1-year clinical outcomes after percutaneous or surgical coronary revascularisation in patients presenting with AMI due to a ULMCA culprit lesion. Furthermore, to evaluate the clinical decision-making process, and to reveal potential selection bias for each treatment modality, we performed multivariable analyses to identify predictors of the decision to treat by percutaneous or surgical revascularisation. Finally, multivariable analyses were performed to identify prognostic indicators of 30-day all-cause mortality.
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