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Predictors of Major Cardiac Events
in the Late Follow-Up in Patients
Treated With PTCA During Q Wave AMI

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

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

SUMMARY
Background: The objective of the present study is to analyze Clinical and/or Angiographic predictors of combined Major Adverse Cardiac Events (MACE) [Death (D), Heart Failure (HF), Myocardial Revascularization (MR), new Q wave AMI, Post AMI Angina (PIA)]in the follow-up of patients (pts) treated with PTCA in Q wave AMI.
Methods: From 8/94 until 8/99 we carried out 135 PTCA in the course of an AMI [Primary (PA): 84 pts, Rescue (RA): 51 pts] with a Primary Success of 90.3% and an In-Hospital mortality of 11.1% (15/135). A mean follow-up of 28.2 months (1 to 64 months) was obtained in the remaining 120 pts.
Results: During the first month the incidence of MACE was 14.1% due to MR for Multivessel Disease (MVD) 10 pts, PIA 4 pts and HF 3 pts. In the long term evolution the rate of MACE was 18.3% due to MR 7 pts, D 7 pts and HF 8 pts. With Kaplan Meier curves it was observed that the survival rate was 95% at one year, without necessity of MR in 80% and event free survival in 70 %. Weren´t predictors of MACE the Risk Factors, PA or RA, previous AMI, lesion length, angled, ostial or bifurcational lesions, tortuous access, reference diameter, neither the use of Stent. The univariate analysis showed that there was greater incidence of MACE in pts with MVD [1vessel:17/74 (22.9%), MVD:20/46 (43.4%)-p<0.031], inferior AMI [Anterior: 18/64 (28.1%), Inferior: 16/35 (45.7%), Other: 3/21 (14.2%)- p<0.037] and calcified lesions [Ca+ yes:14/28 (50%), Ca+ no: 23/92 (25%)- p<0.023]. Multivariate analysis showed that age (Odds Ratio: 1.06-p<0.005), male gender (Odds Ratio: 3.7-p<0.049), delayed time to admission (Odds Ratio:0.82-p<0.022), calcification (Odds Ratio:3.09-p<0.015) and PTCA Failures (Odds Ratio:12.7-p<0.0008) were predictors of MACE.
Conclusions: 1) Age, gender, MVD, calcified lesions and delayed time to admission were independent predictors of MACE. 2) Those pts with PTCA failures had greater incidence of MACE. 3) Pts with inferior AMI had an augmented incidence of MACE; more analysis should be made in this sense.

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INTRODUCTION
   The AMI is secondary to arterial occlusion for rupture of the atheroesclerotic plaque (1). The reperfusion therapy with trombolytics drugs has been very effective in these patients (2-5) although with a medium index of repermeabilization of the culprit vessel. The Transluminal Coronary Angioplasty has demonstrated to be the best treatment to restore the flow in the artery as much primary like rescue angioplasty (6-11). The rate of immediate success of these patients is high (6 -13);however some of them evolve so much in the intra-hospital phase like in the follow-up with heart events that influences in its quality of life and costs of health. The objective of the present study is to analyze possible clinical and/or angiographics predictors of combined major cardiac events (death, heart failure, post AMI angina, new AMI, myocardial revascularization ) in the follow-up of patients treated with PTCA in Q wave AMI.

MATERIAL AND METHOD
   From August of 1994 to August of 1999, were admitted 239 patients with a transmural AMI with less than 12 hours of evolution of which 135 were derived for the realization of PTCA [84 pts to primary PTCA (35.1%) and 51 pts to rescue PTCA (32.9%)] being achieved a primary success of 90.3% (122/135) with an intra-hospital mortality of 11.1% (15/135). A mean follow-up of 28.2 month (1 to 64 month)was obtained in the remaining 120 pts.
   Definition of primary success: It was considered primary success a residual obstruction < 30% with TIMI 3 flow and without major complications.
   Definition of failure: The failure 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 complications.
   Definition of major complication: Death, emergency surgical revascularization or worsening of the clinical picture (Killip-Kimbal to class 3- 4).
   Combined Major Cardiac Events (MACE): Death, heart failure, post AMI angina, new AMI, myocardial revascularization.
   Statistical analysis: The continuous variables are expressed as half ± 1 SD and the qualitative ones as proportions. The proportions were analyzed by means of determination of differences among standard error. The Student's test was used to compare 2 stockings, and the Chi square to compare proportions (the Fisher correction was used when it was necessary). Were also used the Walk's test, Mann - Whitney's test and multivariate analysis for logistical regression with multiple regression coefficient for event yes / no, determining the statistical significance (p < 0.05). The survival free of events in the pursuit was considered by means of the method of Kaplan-Meier.

RESULTS
   During the first month the incidence of MACE was of 14.1% (17/120) being secondary to myocardial revascularization necessity(TLR) for multiple vessel disease in 10 pts, post AMI angina in 4 pts and heart failure in 3 pts. In the far follow-up the rate of MACE was of 18.3%: myocardial revascularization in 7 pts, 7 deaths and 8 pts with heart failure. By Kaplan - Meier's analysis we observe that the survival freedom of MACE was 95% in the first year without necessity of TLR in 80% and free of MACE in a 70%. (Figure 1)

   There were not predictors of MACE the risk factors (tobacco, diabetes, hipercholesterolemia, hypertension), primary or rescue PTCA, previous AMI, lesion length, angle, ostium or bifurcation localization, tortuous access, reference diameter, neither use of Stent. (Table 1, 2, 3)

   The univariate analysis showed that there was bigger incidence of MACE in pts with multiple vessel disease, inferior localization and calcification. (Table 3)

   In the multivariate analysis for logistical regression we observe that the age, the male gender, the evolution's time of the AMI, the presence of calcification and the PTCA failures were predictors of MACE. (Table 4)

DISCUSSION
   The benefits of the mechanical reperfusion by the angioplasty have been outstanding from their beginnings (14-15) so much when it is direct as of rescue (6-12), but we know that a percentage of these patients evolves with MACE that reduces the initial success. Several papers have followed the clinical evolution trying to determine which are the probable predictors of these events (13). Our results show that the clinical /angiographics characteristics in the studied population is comparable with the literature(6-13,17-19), being the primary success similar to that of other registers, as much in direct PTCA as of rescue. It is interesting to stress that the MACE post AMI was observed fundamentally during the first year of follow-up being arrived to a stability plateau in most of the cases during at least the 5 subsequent years. We have not found here to the analyzed risk factors as predictors of MACE, contrary to other studies where there was a tendency to more mortality in the diabetic patients (6, 20), there being you also observed to the female gender as event predictor in opposition with this study where by means of the multivariate analysis the predictor was the male gender. The age, multiple vessel disease and the calcified lesions are predictors of worse evolution due to more affection grade. The early admission (evolution's time of AMI) and the success of the treatment, as in other studies, demonstrated as predictors of good evolution, influenced for to obtain or not TIMI 3 flow. Finally we don't have clear the reason why the pts with inferior AMI (multivariate analysis) had bigger incidence of events, we believe that more analysis should be made in this sense.

CONCLUSIONS
   1) Age, gender, multiple vessel disease, calcified lesions and delayed time to admission were independent predictors of MACE.

   2) Those pts with PTCA failures had greater incidence of MACE.

   3) Pts with inferior AMI had an augmented incidence of MACE; more analysis should be made in this sense.

REFERENCES

1. Fuster V, Badimon L, Badimon JJ, et al: The pathogenesis of coronary artery disease and the acute coronary syndrome. N Engl J Med 1992; 326:242-250, 310.

2. De Wood MA, Spores J, Notske R,et al: Prevalence of total coronary oclussion during the early hours of transmural myocardial infarction. N Engl J Med

3. Fibrinolytic Therapy Trialist (FTT) Collaborative Group indications for fibrinolytic therapy in suspected acute myocardial infarction: Collaborative over view of early mortality and major morbility results from all randomized trial of more than 1000 patients. Lancet 1994; 343:311.

4. An international randomized trial comparating four thrombolytic strategies for acute myocardial infarctions. GUSTO trial. N Engl J Med;329:673-682

5. ISIS 3. A randomized comparation streptokinase vs. tissue plasminogen activator vs. anisteplase and / or aspirin alone among 41.299 cases of suspected acute myocardial infarction. Lancet 1992; 339: 753-70.

6. O'Neill W, Stone G, Grines C, et al: Predictors of In-Hospital and 6-Month outcome After Acute Myocardial Infarction in the Reperfusion Era. PAMI trial. J Am Coll Cardiol 1995;25:370/7.

7. Ziljstra F, de Boer MJ, Hoorntje JCA, et al: A comparison of inmediate coronary angioplasty with intravenous streptokinase in acute myocardial infarction. N Engl J Med 1993;328:673-679.

8. Zijlstra F, Hoorntje JCA, Boer MJ, et al. Long-term of Primary Angioplasty as Compared with Thrombolytic Therapy for Acute Myocardial Infarction. N Engl J Med 1999; 341:1413-1419.

9. Weaver WD, Simes RJ, Betriú A, et al: Comparation of primary coronary angioplasty and intravenous thrombolytic therapy for acute myocardial infarction: A quantitative review. JAMA 1997;278 (23): 2093-8.

10. Gibbson RJ, Holmes D, Reeder GS, et al: Inmediate angioplasty compared with the administration of a thrombolytic agent followed by conservative treatment for myocardial infarction. N Engl J Med 1993; 328: 685-691.

11. Ellis SG, Ribiero da Silva, Heyndrickx G, et al: Randomized comparation of rescue angioplasty with conservative management of patient with early failure of thrombolytic for acute anterior myocardial infarction. Circulation 1991; 90: 2280-2284.

12. Leguizamón JH, Nauwerk R, Torresani EM, y col. Angioplastia coronaria en 115 pacientes cursando un IAM: 4 años de experiencia. Parte 1 Angioplastia de rescate. Rev Arg de Cardiol 1991;Vol59, nº 5, TLP 5.

13. Ferroni F, Baratta S, Bang JH y col. CONAREC V. Rev Arg de Cardiología.. 1999; Vol 67:163-174.

14. Grüntzig AR: Transluminal dilatation of coronary artery stenosis. Lancet 1978; 1:263.

15. Hartzler GO, Ruthenford BD, , et al Early and late results of coronary angioplasty without antecedent thrombolytic therapy for acute myocardial infarction. Am J Cardiol;1989; 64:1221.

16. Trongé JE. Cardiología 2000. Bertolasi CA (ed) Buenos Aires, Intermédica 2000. Cap 29. Tomo 3. pag 1917- 1960.

17. Weaver WD, Simes RJ, Betriú A, et al. The Primary Angioplasty vs Thrombolysis Collaboration Group: Comparation of primary coronary angioplasty and intravenous thrombolytic therapy for acute myocardial infarction. A quantitative review.JAMA 1997; 278: 2093-2098.

18. TIMI II study group. Comparation of invasive and conservative strategies after treatment with intravenous tissue plasminogen activator in acute myocardial infarction. Results of the thrombolysis in Myocardial Infarction. N Engl J Med 1989;320:618.

19. Gruppo Italiano per lo studio della streptochinassi nello'Infarto Miocardico:Long terms effects of intravenous thrombolytic in acute myocardial infarction. GISSI study. Lancet 1997; 2:871.

20. Moreno R, García E, Soriano J y col. Early Coronary Angioplasty for Acute Myocardial Infarction: Predictors of a Poor Outcome Non-Selected. J Invas Cardiol 2001;13 (3): 202-210.

 

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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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