Coronary artery disease
Effectiveness of Primary Percutaneous Coronary Intervention for Acute ST-Elevation Myocardial Infarction from a 5-Year Single-Center Experience

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Primary percutaneous coronary intervention (PCI) is currently viewed as the preferred reperfusion strategy in patients with ST-elevation acute myocardial infarction (STEMI). This method was introduced in our hospital in 2000. From January 1, 2000, to December 31, 2004, a total of 2,393 consecutive patients with STEMI were admitted (27% transferred from 9 non-PCI hospitals and 31 prehospital emergency units/outpatient clinics). Of these patients, 1,666 (70%) underwent urgent coronary angiography and primary PCI. Platelet glycoprotein llb/llla inhibitors were used in 40% and stent placement, in 78%. Postprocedural Thrombolysis In Myocardial Infarction (TIMI) 3 flow was documented in 86%. Intra-aortic balloon counterpulsation was used in 6%; mechanical ventilation, in 8.6%; and inotropic drugs/vasopressors, in 15.8%. Mortality rates in patients with Killip’s class I or II ranged from 1% to 4.9% without negative influence of ischemic time. In patients with Killip’s class III or IV, mortality rates increased from 18% to 54% with increasing ischemic delay up to 6 hours (p = 0.06) and remained at around 40% afterward. Independent predictors of mortality were age (odds ratio [OR] 1.29, 95% confidence interval [CI] 1.01 to 1.64, p = 0.04), resuscitated cardiac arrest (OR 2.44, 95% CI 1.18 to 5.05, p = 0.02), and postprocedural TIMI flow (OR 0.31, 95% CI 0.16 to 0.59). Overall mortality rates of patients who underwent a primary PCI strategy from 2000 to 2004 were significantly lower than in the control group of 152 consecutive patients who underwent thrombolysis from 1995 to 1996 (6.2% vs 16.4%; p <0.001). In conclusion, introduction of a primary PCI strategy significantly decreased hospital mortality in our unselected group of patients with STEMI compared with the thrombolytic era. Our study further emphasized the importance of shortening myocardial ischemic time, particularly in the presence of severe heart failure on admission.

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Methods

The study was conducted at the University Medical Center Ljubljana from January 1, 2000, to December 31, 2004. Patients with STEMI2, 3 presenting within 12 hours after the onset of symptoms (or later in case of ongoing discomfort) who underwent urgent coronary angiography and primary PCI were compared with a historic control group consisting of consecutive patients with STEMI who underwent thrombolysis from July 1, 1995, to June 30, 1996. These patients were selected from a group of 345

Results

During a 5-year study period, 2,393 patients with an evolving STEMI were treated in our hospital (Table 1). Most patients (81%) were admitted through the emergency department. The proportion of patients transferred directly to the catheterization laboratory from 9 non-PCI hospitals (distance 36 to 121 km, median 74) increased to 21% in 2004. This was true also for patients transferred directly from 31 prehospital emergency units/outpatient clinics (distance 22 to 140 km, median 47), for whom

Discussion

Our study described a large single-center experience with the introduction of primary PCI in unselected patients with STEMI, including those with resuscitated cardiac arrest and severe heart failure on admission. The proportion of patients with STEMI who underwent primary PCI in our hospital linearly increased to 84% with a concomitant decrease in the use of rescue and ischemia-driven PCI, as well as thrombolysis. These trends reflected a shift toward timely and more effective acute reperfusion

Acknowledgment

The authors recognize the contribution of the interventional cardiology team (Marko Gricar, MD, Igor Kranjec, MD, PhD, Hrvoje Reschner, MD, Radovan Starc, MD, PhD, Matjaz Sinkovec, MD, PhD, and Igor Zupan, MD, PhD) and intensive care unit team (Hugon Mozina, MD, Andrej Pernat, MD, PhD, Dusan Stajer, MD, PhD, and Tom Ploj, MD, PhD).

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