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Electrocardiogram Score For The Selection of Reperfusion Strategy in Early Latecomers With ST-segment Elevation Myocardial Infarction
Electrocardiogram Score For The Selection of Reperfusion Strategy in Early Latecomers With ST-segment Elevation Myocardial Infarction
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ScienceDirect
Journal of Electrocardiology xx (2015) xxx xxx
www.jecgonline.com
Abstract
Objective: The clinical benefit of percutaneous coronary intervention (PCI) is controversial in STsegment elevation myocardial infarction (STEMI) patients presenting 1272 hours after symptom
onset. Several studies suggested this conflicting result was associated with myocardial area at risk
(MaR) of enrolled patients. MaR could be estimated by the electrocardiogram (ECG) score. Our
objective was to evaluate the benefits of PCI in STEMI latecomers with different MaR.
Methods: We constructed a prospective cohort involving 436 patients presenting 1272 hours after
STEMI onset and who met an inclusion criteria. 218 underwent PCI and 218 received the optimal
medical therapy (OMT) alone. Individual MaR was quantified by the combined Aldrich ST and
Selvester QRS score. The primary endpoint was a composite of cardiovascular death, reinfarction or
revascularization within two years.
Results: The 2-year cumulative primary endpoint rate was respectively 9.2% in PCI group and 5.3%
in OMT group when MaR b 35% (adjusted hazard ratio for PCI vs. OMT, 1.855; 95% confidence
interval [CI], 0.6175.575; P = 0.271), and was 12.8% in PCI group and 23.1% in OMT group
when MaR 35% (adjusted hazard ratio for PCI vs. OMT, 0.448; 95% CI, 0.2280.884;
P = 0.021).
Conclusion: The benefit of PCI for the STEMI latecomers was associated with the MaR. PCI,
compared with OMT, could significantly reduce the 2-year primary outcomes in patients with
MaR 35%, but not in ones with MaR b 35%.
2014 Elsevier Inc. All rights reserved.
Keywords:
Introduction
Primary percutaneous coronary intervention (PCI) is the
recommended treatment for patients with ST-segment elevation myocardial infarction (STEMI) within 12 hours after
ischemic symptom onset [1]. However, the clinical benefit of
PCI vs. optimal medical therapy (OMT) alone is controversial
in stable patients presenting over 12 hours timeframe [24]. A
comprehensive meta-analysis of 10 trials comparing the
efficacy of late PCI vs. medical therapy alone in 3560 patients
randomized over 12 hours after STEMI indicated this
conflicting result could be associated with enrolled patients
ischemia in the infarct-related artery territory [5].
Methods
All STEMI patients at the First Hospital of Jilin University
were recorded in a prospective cohort. Data elements included
demographic, clinical, angiographic/procedural, and follow-up
variables. Each patient had an outpatient visit at 1 month and
several follow-up phone calls using a standardized questionnaire at 6 months, 1 year, and then annually by trained
personnel to document long-term outcomes. In each contact,
details of any readmission during that time period and/or
mortality information were collected, including the date, the
place, and if the reason for readmission or death was
cardiovascular or non-cardiovascular.
Study population
Patients (1) who were over 18 years-old, (2) hospitalized
with a definitive diagnosis of new-onset STEMI through
January, 2010 to January, 2012 and (3) presented to our
department 1272 hours after symptom onset were included in
this study. This hospitalization was defined as the index
hospitalization. The exclusion criteria included patients with (1)
cardiogenic shock, electrical instability and severe congestive
heart failure (New York Heart Association III or IV) on
admission; (2) electrocardiogram presenting with complete left
or right bundle branch block, Wolff-Parkinson-White syndrome
and left ventricular hypertrophy; (3) receiving coronary artery
bypass grafting, and (4) in-hospital mortality during the index
hospitalization. In addition, (5) patients without angiographic or
complete clinical data were also excluded. Then, patients were
divided into two groups according to their treatments: receiving
PCI and OMT (PCI group) or OMT alone (OMT group). We
calculated a propensity score for each patient and matched each
PCI case to one OMT case (Fig. 1). The study was approved by
the Ethics Committee of the First Hospital of Jilin University.
Treatments
All patients received optimal medical therapy, including
aspirin, anticoagulation if indicated, angiotensin-convertingenzyme inhibition (ACEI)/angiotensin receptor blocker
(ARB), beta-blockade, and lipid-lowering therapy/plaque
stabilization, unless contraindicated. Patients were assigned
to perform coronary angiography/PCI within a few hours
after decision if the condition was permitted, and each
patients angiography record was collected.
Table 1
Baseline characteristics (N = 436).
Demographic Characteristic
Age (means SD, y)
Female (%)
Clinical characteristic
Congestive heart failure (%)
Hypertension (%)
Hyperlipidemia (%)
Diabetes mellitus (%)
COPD (%)
Renal failure (%)
Angiographic characteristic
Infarct-related artery (%)
LAD
LCX
RCA
TIMI flow grade in
infarct-related artery (%)
0
1
2
3
Collateral grade (means SD)
Multivessel disease (%)
LVEF (means SD)
Estimated MaR (%LV)
PCI group
(N = 218)
OMT group
(N = 218)
P value
61 14
59 (27.1)
61 13
58 (26.6)
0.818
0.914
118 (54.1)
117 (53.7)
13 (6.0)
52 (23.9)
6 (2.8)
7 (3.2)
100 (45.9)
113 (51.8)
19 (8.7)
58 (26.6)
9 (4.1)
12 (5.5)
0.085
0.701
0.271
0.222
0.601
0.174
113 (51.8)
36 (16.5)
69 (31.7)
114 (52.3)
38 (17.4)
66 (30.3)
0.939
0.412
206 (94.5)
6 (2.8)
4 (1.8)
2 (0.9)
0.31 0.66
25 (11.5)
50.0 13.0
35 10
211 (96.8)
3 (1.4)
3 (1.4)
1 (0.5)
0.29 0.63
39 (17.9)
48.6 11.2
34 8
0.711
0.058
0.243
0.305
SD, standard deviation; LAD, left anterior descending artery; LCX, left
circumflex coronary artery; RCA, right coronary artery; TIMI, Thrombolysis in
Myocardial Infarction; LVEF, left ventricle ejection fraction.
New York Heart Association functional class II heart failure.
Results
Baseline patients characteristics
In all, 436 STEMI patients with average follow-up of
2.7 0.6 years were enrolled in this study. Of 218 (50%)
were matched into the PCI group and the other 218 (50%)
were matched into the OMT group. A detailed description
and distribution of baseline characteristics were given in
Table 1. The baseline characteristics were all comparable
between two groups.
Treatments in two groups
In the PCI group, average time from admission to procedure
was 45 hours. 58 patients underwent immediate PCI (the
average interval from arrival: 1 hour) and 160 patients
underwent elective PCI (the average interval from arrival: 65
hours). The duration from decision (non-randomization) to
PCI was less than 6 hours. PCI was performed successfully in
205 patients (94%), and 198 had a TIMI flow grade of three
after the procedure (successful PCI defined as an open artery
with residual stenosis of less than 50% and a TIMI flow
antegrade grade of 2 or 3); 200 patients (92%) were placed at
least one stent, and 191 received drug-eluting stents;
glycoprotein IIb/IIIa antagonists was administered to 94%
patients during or after procedure. 4 patients (2%) received
thrombolysis before admission.
In the OMT group, average interval from admission to
angiography performed was 3.5 days. Only 2 patients (1%)
received thrombolysis before admission.
During 2-year follow-up or until the events occurred, the
usage rate of aspirin (96% vs. 94%, P = 0.381), betablocker (75% vs. 77%, P = 0.653), ACEI or ARB (62% vs.
65%, P = 0.486) and statin (65% vs. 57%, P = 0.077) was
similar in two groups, except for higher usage rate of
clopidogrel (65% vs. 38%, P b 0.001) in the PCI group than
the OMT group.
In all 436 patients, the average MaR was 35%, which was
similar in two groups (35% vs. 34%, P = 0.305). When 35%
was selected as the cut-off, KaplanMeier analysis showed 2year cumulative MACE incidence was similar (P = 0.278)
between two groups in patients with MaR b 35%, while PCI
group had significant lower incidence (P = 0.043) in patients
with MaR 35% (Table 2 and Fig. 3). The covariatesadjusted hazard ratio (HR) for PCI vs. OMT was 1.855 (95%
confidence intervals: 0.6175.575, P = 0.271) in the patients
with MaR b 35%, and the adjusted HR for PCI vs. OMT in
patients with MaR 35% was 0.448 (95% confidence
intervals: 0.2280.884, P = 0.021). Furthermore, the relationship between the estimated MaR and the incidence of 2-year
MACE was depicted in the Fig. 4. Two curves representing for
the PCI group and the OMT group respectively crossed around
35%. These two curves accompanied with each other before the
intersection, and separated after the intersection with significantly ascending in OMT group.
On the basis of the study definition, one reinfarction and
four revascularization events occurred due to in-stent thrombus/restenosis in PCI group with MaR b 35%, and one
reinfarction and five revascularization events occurred due to
in-stent thrombus/restenosis in PCI group with MaR 35%.
In secondary outcomes, the cumulative events of PCI group,
compared with OMT group, showed more revascularization (9
(8.3%) vs. 5(5.4%), P = 0.246) when MaR b 35%, fewer
cardiovascular death (2(1.8%) vs. 7(6.7%), P = 0.078) and
lower reinfarction (4(3.7%) vs. 11(10.8%), P = 0.045) when
MaR 35% (Table 2). As the early latecomers were
defined as 1272 hours after onset of symptoms, it was a
long timespan. A subgroup analysis therefore was performed in
order to reduce the impact of admission time. The results
showed no significant difference of benefits in different
subgroup of admission time (Fig. 5).
Discussion
Table 2
Primary and secondary outcomes.
Endpoints (2-y
cumulative event rate)
MACE (%)
Cardiovascular death (%)
Reinfarction (%)
Nonfatal reinfarction (%)
Revascularization (%)
MaR b 35%
MaR 35%
PCI (N = 109)
OMT (N = 114)
P value
PCI (N = 109)
OMT (N = 104)
P value
10 (9.2)
1 (0.9)
1 (0.9)
1 (0.9)
9 (8.3)
6 (5.3)
1 (0.9)
3 (2.6)
3 (2.6)
5 (5.4)
0.278
0.972
0.337
0.337
0.246
14 (12.8)
2 (1.8)
4 (3.7)
4 (3.7)
13 (11.9)
24 (23.1)
7 (6.7)
11 (10.8)
10 (9.9)
13 (12.8)
0.043
0.078
0.045
0.072
0.771
P values were calculated with the use of the log-rank test for KaplanMeier curves through one year of follow-up.
MACE refers to major adverse cardiovascular event including cardiovascular death, reinfarction or revascularization.
Revascularization was defined as another procedure (PCI or CABG but not include staged-procedure) performed due to recurrent coronary stenosis or
persistent chest pain after discharge from the index hospitalization.
Fig. 3. KaplanMeier curves for the primary endpoint. The primary endpoint was the composite occurrence of cardiovascular death, reinfarction, or
revascularization. KaplanMeier estimates of the cumulative event rates in the PCI group and the optimal medical therapy (OMT) group, respectively, were
11.0% and 13.8% for all enrolled patients (panel A), 9.2% and 5.3% for patients with MaR b 35% (panel B), and 12.8% and 23.1% for patients with
MaR 35% (panel C). The P value was calculated with the use of the log-rank test.
Fig. 4. Relationship between estimated MaR and primary endpoint. The scatter
plots and fixed quadratic regression curves representing for the PCI group and
the OMT group respectively were depicted for fitting the relationship between
the MaR estimated by the combined Aldrich and Selvester score and the
adjusted incidence of primary endpoints (cardiovascular death, reinfarction, or
revascularization). The incidence was calculated with adjustment for age and
sex by each three points of the MaR, fitting generalized estimating equations
with a Poisson link function. Dotted lines represent 95% confidence intervals of
predicted incidence. Two curves representing for the PCI group and the OMT
group respectively crossed around 35%. These two curves accompanied with
each other before the intersection, and separated after the intersection with
significantly ascending in OMT group. R square in PCI group was 0.876 and R
square in OMT group was 0.834.
Fig. 5. Subgroup analysis. Hazard ratios (black spots), 95% CIs (horizontal lines), cumulative 2-year primary outcomes (cardiovascular death, reinfarction, or
revascularization) for different subgroups of admission time (1248 hours and 48 hours72 hours) were shown.
with MaR 35%, but not in ones with MaR b 35%. The MaR
estimated by the combined Aldrich and Selvester score can
provide an easy and quick clinical assessment for the selection
of reperfusion strategy for early latecomers with STEMI.
Contributors
Study concept and design: Dr. Bao-Rong Chi, Dr. YuJiao Zhang, Dr. Wen Zheng, Dr. Jian Sun and Dr. Guo-Li Li.
Manuscript writing: Dr. Yu-Jiao Zhang and Dr. Wen Zheng.
Critical revision of the manuscript for important intellectual
content: Dr. Jian Sun, Dr. Bao-Rong Chi and Dr. Guo-Li Li.
Dr. Bao-Rong Chi and Dr. Wen Zheng have full access to
all of the data in the study and take responsibility for the
integrity of the data and the accuracy of the data analysis and
are the guarantors.
Conflict of interest
No conflict of interest.
Patient consent
Obtained.
Ethics approval
The Ethics Committee of the First Hospital of Jilin
University.
Conclusions
In summary, the benefit of PCI for the STEMI latecomers
was associated with the MaR. PCI, compared with OMT, could
significantly reduce the 2-year primary outcomes in patients
Acknowledgement
Research was supported by Research Funds of Jilin Provincial
Science &Technology Department (20130206021SF).
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