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PTCA Failures in Q Wave AMI.
In-Hospital and Long Term Evolution

Torresani, E.M.; Weisshein, N.;
Martino, G.; Hrabar, A.; Fernández, A.;
Buján, L.; De Benedetti, L.; Alvarez,
C.; Cohen, M.; Leguizamón, J.H.

Dpto de Cardiología, Sanatorio Modelo Quilmes, Buenos Aires, Argentina

SUMMARY
Background: PTCA of the culprit vessel in Q wave AMI has increased the reperfusion indexes and had a favorable impact on the In-Hospital and long term events, however is not clear the behaviors in the face of the Failures(F). The purpose of the present study is to analyze the evolution of the PTCA F in Q wave AMI and to compare them with those of successful cases.
Methods: From 8/94 until 8/99,239 pts with AMI < 12 hs were admitted; 84 pts were treated with Primary (PA) and 51 pts with Rescue (RA) PTCA. There were 107 male (79.2%) with an age of 51.1 ± 25.6 years, current smokers 97/135 (71.8%), Hypertension 70/135 (51.8%), Diabetes 28/135 (20.7%), Hypercholesterolemia 53/135 (39.2%), previous AMI 15/135 (11.1%), multi-vessel disease 57/135 (42.2%), with a Killip-Kimball (KK): KK1-54/135 (40%), KK2-42/135 (31.1%) , KK3-11/135 (8.1%) and KK4 -28/135 (20.7%). The vessel treated was LAD 73/135 (54%), RCA 43/135 (31.8%), LCX16/135 (11.8%) and Saphenous Vein Graft 3/135 (2.2%). Stenting was indicated in 55 pts (40.7%) due to suboptimal results (recoil, dissection and/or >30% residual stenosis). All KK4 pts were also treated with IABP. Primary Success (PS) was defined as a residual obstruction < 30% with TIMI 3 Flow without Major Complications (death or emergency CABG) and it was of 90.3%.
Results: There were 13 F : TIMI < 2 Flow (8/13 or 61.5%), non dilatable artery (1/13 or 7.6%) or inability to cross the occlusion (4/13 or 30.7%). Global In-Hospital mortality was 11.1% (15/135) for PTCA pts, having shown significant differences in F [F: 5/13 (38.4%), PS:10/122 (8.1%) p<0.0065]. Regarding the incidence of combined Major Cardiac Events (MACE) (Death, Heart Failure and TLR) there were no significant differences in the first month follow-up [F:1/8 (12.5%), PS:16/112 (13.1%)-p=0.999] but they were in the first year of follow-up [F: 4/7 (57.1%) , PS: 18/96 (18.7%)-p<0.03].
Conclusions: 1) Although the index of F of PTCA in AMI is low, the In-Hospital mortality and combined MACE in the first year follow-up are still high. 2) Another adjunctive therapeutics should be evaluated.

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INTRODUCTION
   The mechanical reperfusion by Transluminal Coronary Angioplasty (PTCA), either primary (PA) or rescue(RA) in the face of the failure of the thrombolysis changed the evolution of the acute myocardial infarction(AMI) patients, diminishing the in-hospital mortality and with less events in the follow-up. (1-2-3). Although the primary success obtained is high (4-5-6) and the percentage of failures lower, it would defines a group of patient whose evolution to short and medium term would not be favourable so (7-8). We believe that it would be beneficial to analyse the events that happen in the patients with PTCA failures and comparing them with the successful cases, in order to modify or to determine new behaviours. The objective of the present study is to analyse the evolution of the PTCA failures in the AMI patients and to compare them with that of the successful cases.

MATERIAL AND METHODS
   Between 8/94 - 8/99, 239 pts with AMI < 12 hs evolution were admitted, being treated with PTCA 135 pts (56.4%), primary(AP) 84 pts and of rescue(AR) 51 pts due to negative clinical reperfusion syndrome post thrombolytic. The population characteristics are summarized in Table 1.

   Were observed multiple vessel disease in 57 patients (42.2%), being the culprit vessel: Left Descending Artery 73/135 (54%), Right Coronary Artery 43/135 (31.8%), Left Circumflex Artery 16/135 (11.8%) and saphenous by-pass graft 3/135 (2.2%). After identifying the culprit vessel by coronariography , carried out initially balloon PTCA being complemented with Stent in case of recoil, dissection and/or residual stenosis >30%,being used in 55 pts (40.7%); all the Killip-Kimball (KK) 4 patients were also treated with Intra Aortic Balloon Pump (IABP).

    Definition of primary success: It was considered primary success (PS) to a residual obstruction smaller than 30%, with TIMI 3 flow (9) and without major complications.
   Definition of failure: It was defined as the impossibility of achieving primary success for difficulty in to cross or to dilate the obstruction appropriately or not to achieve TIMI 3 flow in absence of major complications.
   Definition of major complication: Death, emergency surgical revascularization or worsening of the clinical picture (Killip-Kimball to grades 3-4).
   Statistical analysis: Were used the Fisher`s test, Chi square test, Wilk`s test and Student`s t test . The proportions were analyzed by means of determination of differences among standard error. The continuous variables were expressed as mean ± 1 SD.

RESULTS
   Of the 135 patients treaties with PTCA (PA or RA), 13 failures were consigned, due to TIMI < 3 flow in 8 patients (8/13-61.5%), artery non dilatable in 1 (1/13-7.6%) or for not being able to cross the occlusion with the guide wire in 4 patients (4/13-30.7%) (Table 2). The global in-hospital mortality was of 11.1% (15/135), being differs statistically significant among the patients with successful PTCA (10/122) with to mortality of 8.1% in front of the failures (5/13) with to mortality of 38.4%, p < 0.0065 (Tables 3 and 4). A mean follow-up of 28.2 month (1 to 64 month)was obtained in the remaining 120 pts.The incidence of major combined cardiac events (death, heart failure, myocardial revascularization), it was not different during the first month: 12.5% (1/8) in the failures and 13.1% (16/122) in the patients with successful PTCA, p = 0.099, reaching differs statistically significant to the 12 months with 57.1 % of heart events in the failures (4/7) and 18.7% (18/96) in the successful ones, p < 0.03 (Tables 5, 6 and 7).

DISCUSSION
   It is certain the value of the reperfusion treatment in the Q wave AMI (10-11-12) so much with the use of systemic trhombolytics as likewise in form mechanics by transluminal coronary angioplasty. Due to the limitations of the thrombolytic therapy and in centers that have the infrastructure and appropriate technical preparation, the PTCA would be considered as of first election therapy (AP) (13-14) and in the face of the failures of the thrombolytics (RA) (15). In our study, we demonstrate that the rate of failures of the PTCA (9.7%) (16-17) in the context of the AMI smaller than 12 hs evolution, is comparable with it shown at international level, having in spite of its scarce number, a great weight due to the high morbility and mortality that bears and that it differentiates it firmly so much in-hospital and in the far evolution results with those of successful PTCA. For this reason we thinks about the necessity to evaluates alternative treatments, heading to reduces this discharge it appraises, like it could be the support with IABP and later surgical myocardial revascularization (18-19-20) in those you marry that the territory involved by the responsible artery is important with severe deterioration of the ventricular function with worse Killip Kimbal or cause valvular dysfunction with hemodynamic repercussion. Finally the most common causes of failure is given by the impossibility in obtaining TIMI 3 flow in spite of to get(21)a residual obstruction < 30% or with Stent near to the 0%;with this situation we found a relation with the greater time interval to admission and with worse Killip-Kimbal. The alterations in the microcirculation generated by the biggest time of occlusion and / or worsened by the worst clinical picture of admission and / or spontaneous or promote microembolus generated by the mechanical instrumentation are the responsible. Probably some pts could improve the flow by pharmacological means (22-24) (Verapamilo, Diltiazem, Inhibitors IIb-IIIa, Adenosine, etc) and / or the Intra Aortic Balloon Pump support; we believe that in this sense another studies should be made.

CONCLUSIONS
   1) Although the index of failures of PTCA in AMI is low, the In-Hospital mortality and combined major cardiac events in the first year follow-up are still high.

   2) Another adjunctive therapeutics should be evaluated.

REFERENCES

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16. Brodie BR et al. : Timing and mechanism of death determined clinically after primary angioplasty for acute myocardial infarction. Am J Cardiol 1997 Jun 15;79 (12): 1586-91.

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19. Early revascularization in acute myocardiol infarction complicated by cardiogenic shock. N Engl J Med 1999; 341:625-634.

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24. van den Brand M and Ronner EF. The use of platelet glycoprotein IIb/IIIa receptor antagonists during the acute phase of myocardial infarction. Semin Intervent Cardiol 1999;4:85-87.

 

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2nd Virtual Congress of Cardiology

Dr. Florencio Garófalo
Steering Committee
President
Dr. Raúl Bretal
Scientific Committee
President
Dr. Armando Pacher
Technical Committee - CETIFAC
President
fgaro@fac.org.ar
fgaro@satlink.com
rbretal@fac.org.ar
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