Abhiram Prasad1, Bernard J Gersh2, Roxana Mehran3, Bruce R Brodie4, Sorin J Brener5, José M Dizon6, Alexandra J Lansky7, Bernhard Witzenbichler8, Ran Kornowski9, Giulio Guagliumi10, Dariusz Dudek11, Gregg W Stone12. 1. Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota; St. George's, University of London, London, United Kingdom. 2. Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota. 3. The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York; Clinical Trials Center, Cardiovascular Research Foundation, New York, New York. Electronic address: roxana.mehran@mssm.edu. 4. LeBauer Cardiovascular Research Foundation/Cone Health, Greensboro, North Carolina. 5. Clinical Trials Center, Cardiovascular Research Foundation, New York, New York; New York Methodist Hospital, Brooklyn, New York. 6. Center for Interventional Vascular Therapy, Division of Cardiology, Columbia University Medical Center, New York, New York. 7. Yale Cardiovascular Research Program, Yale University Medical Center, New Haven, Connecticut. 8. Department of Cardiology and Pneumology, Helios Amper-Klinikum, Dachau, Germany. 9. Cardiology Division, Rabin Medical Center, Petah-Tikva, Israel. 10. Ospedale Papa Giovanni XXIII, Bergamo, Italy. 11. Department of Interventional Cardiology, Jagiellonian University, Krakow, Poland. 12. Clinical Trials Center, Cardiovascular Research Foundation, New York, New York; Center for Interventional Vascular Therapy, Division of Cardiology, Columbia University Medical Center, New York, New York.
Abstract
OBJECTIVES: This study sought to investigate the effect of treatment delay on microvascular reperfusion in ST-segment elevation myocardial infarction (STEMI) patients from the large, multicenter, prospective HORIZONS-AMI (Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction) trial. BACKGROUND: Despite restoration of epicardial blood flow during primary percutaneous coronary intervention (PCI), one-third of patients do not obtain myocardial perfusion due to impairment in the microvascular circulation. METHODS: We examined the effect of symptom onset-to-balloon time (SBT) and door-to-balloon time (DBT) on myocardial reperfusion during primary PCI in STEMI, utilizing resolution of ST-segment elevation (STR) and the myocardial blush grade (MBG). The primary analysis was the relationships between SBT ≤2, >2 to 4, and >4 h and DBT ≤1, >1 to 1.5, >1.5 to 2, and >2 h with MBG and STR. Clinical risk was assessed using a modified version of the Thrombolysis In Myocardial Infarction risk score for STEMI. RESULTS: In 2,056 patients, absent microvascular perfusion (MBG 0/1) and STR (STR <30%) after primary PCI was significantly more common in patients with longer SBT, in patients with both low and high clinical risk profiles. By multivariable analysis, SBT (p < 0.0001), anterior infarction (p < 0.0001), reference vessel diameter (p = 0.005), lesion minimum lumen diameter (p < 0.0001), hyperlipidemia (p = 0.03), and current smoking (p = 0.001) were independent predictors of MBG 0/1, whereas SBT (p = 0.007), anterior infarction (p < 0.0001), and history of renal insufficiency (p = 0.0002) were independent predictors of absent STR. DBT (p < 0.0001) was an independent predictor of MBG 0/1. MBG 0/1 and STR<30% identified patients with increased 3-year mortality. CONCLUSIONS: The present study suggests that delay in mechanical reperfusion therapy during STEMI is associated with greater injury to the microcirculation.
RCT Entities:
OBJECTIVES: This study sought to investigate the effect of treatment delay on microvascular reperfusion in ST-segment elevation myocardial infarction (STEMI) patients from the large, multicenter, prospective HORIZONS-AMI (Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction) trial. BACKGROUND: Despite restoration of epicardial blood flow during primary percutaneous coronary intervention (PCI), one-third of patients do not obtain myocardial perfusion due to impairment in the microvascular circulation. METHODS: We examined the effect of symptom onset-to-balloon time (SBT) and door-to-balloon time (DBT) on myocardial reperfusion during primary PCI in STEMI, utilizing resolution of ST-segment elevation (STR) and the myocardial blush grade (MBG). The primary analysis was the relationships between SBT ≤2, >2 to 4, and >4 h and DBT ≤1, >1 to 1.5, >1.5 to 2, and >2 h with MBG and STR. Clinical risk was assessed using a modified version of the Thrombolysis In Myocardial Infarction risk score for STEMI. RESULTS: In 2,056 patients, absent microvascular perfusion (MBG 0/1) and STR (STR <30%) after primary PCI was significantly more common in patients with longer SBT, in patients with both low and high clinical risk profiles. By multivariable analysis, SBT (p < 0.0001), anterior infarction (p < 0.0001), reference vessel diameter (p = 0.005), lesion minimum lumen diameter (p < 0.0001), hyperlipidemia (p = 0.03), and current smoking (p = 0.001) were independent predictors of MBG 0/1, whereas SBT (p = 0.007), anterior infarction (p < 0.0001), and history of renal insufficiency (p = 0.0002) were independent predictors of absent STR. DBT (p < 0.0001) was an independent predictor of MBG 0/1. MBG 0/1 and STR<30% identified patients with increased 3-year mortality. CONCLUSIONS: The present study suggests that delay in mechanical reperfusion therapy during STEMI is associated with greater injury to the microcirculation.
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