Angioplastia coronaria en el infarto agudo de miocardio: ¿en qué pacientes es menos probable obtener una reperfusión coronaria adecuada?Coronary Angioplasty in the Acute Myocardial Infarction: in which Patients is it less Likely to Obtain an Adequate Coronary Reperfusion?

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Introducción

En los pacientes con infarto agudo de miocardio tratados mediante angioplastia primaria, la incapacidad de obtener una reperfusión coronaria adecuada se asocia a una mayor mortalidad. El objetivo del estudio fue identificar qué características predicen una menor tasa de éxito angiográfico de la angioplastia realizada en la fase aguda del infarto.

Pacientes y métodos

La población de estudio está constituida por los 790 pacientes con infarto que fueron tratados mediante angioplastia en las primeras 12 h de evolución en nuestro centro desde 1991 a 1999. Se definió éxito angiográfico en presencia de una estenosis residual inferior al 50% y un flujo TIMI 2 o 3 tras el procedimiento.

Resultados

Se obtuvo éxito angiográfico en 736 pacientes (93,2%), y un flujo TIMI 3 en 652 (82,5%). Los pacientes con fracaso angiográfico tuvieron mayor mortalidad intrahospitalaria que aquellos con éxito angiográfico (48% frente al 10%; p < 0,01). Se asociaron a una menor tasa de éxito angiográfico la edad superior a 65 años (91 frente al 95%; p = 0,02), la ausencia de tabaquismo (90 frente al 96%; p < 0,01), el infarto previo (87 frente al 94%; p < 0,01), el tratamiento trombolítico previo (83 frente al 94%; p = 0,02), el shock (80 frente al 95%; p < 0,01), la localización indeterminada (67 frente al 93%; p < 0,01), la localización no inferior (92 frente al 96%; p = 0,04), el bloqueo de rama izquierda (64 frente al 94%; p < 0,01), la enfermedad multivaso (91 frente al 95%; p = 0,02), la fracción de eyección del ventrículo izquierdo inferior a 0,40 (89 frente al 97%; p < 0,01), la no utilización de stent (90 frente al 96%; p < 0,01) y el empleo de balón de contrapulsación (82 frente al 95%; p < 0,01). En el análisis multivariado, los predictores independientes de fracaso angiográfico fueron: el bloqueo de rama izquierda (odds ratio [OR], 12,95; IC del 95%, 3,00-53,90), el shock (OR, 4,20; IC del 95%, 1,95- 8,75), la no utilización de stent (OR 3,44; IC del 95%, 1,71- 7,37), y el infarto previo (OR, 2,82; IC del 95%, 1,29-5,90).

Conclusión

La angioplastia permite obtener la recanalización de la arteria coronaria en la mayor parte de los pacientes con infarto agudo de miocardio. Algunas variables, sin embargo, pueden identificar algunos subgrupos de pacientes en los que la obtención de un resultado angiográfico adecuado puede resultar más difícil.

Introduction

In patients with acute myocardial infarction treated with primary angioplasty, the inability to achieve successful coronary reperfusion is associated with higher mortality. The objective of the study was to identify which characteristics may predict a lower angiographic success rate in patients with acute myocardial infarction treated with coronary angioplasty.

Patients and methods

The study population is constituted by the 790 patients with acute myocardial infarction that were treated with angioplasty within the 12 hours after the onset of symptoms from 1991 to 1999 at our institution. A successful angiographic result was considered in presence of a residual stenosis < 50% and a TIMI flow 2 or 3 after the procedure.

Results

A successful angiographic result and a final TIMI 3 flow were achieved in 736 (93.2%) and 652 (82.5%) patients, respectively. In-hospital mortality was higher in patients with angiographic failure than in those with angiographic successful result (48 vs. 10%; p < 0.01). Age under 65 (91 vs. 95%; p = 0.02), non smoking (90 vs. 96%; p < 0,01), previous infarction (87 vs. 94%; p < 0.01), angioplasty after failed thrombolysis (83 vs. 94%; p = 0.02), cardiogenic shock (80 vs. 95%; p < 0.01), undetermined location (67 vs. 93%; p < 0.01), non-inferior location (92 vs. 96%; p = 0.04), left bundle branch block (64 vs. 94%; p < 0.01), multivessel disease (91 vs. 95%; p = 0.02), left ventricular ejection fraction < 0.40 (89 vs. 97%; p < 0.01), no utilization of coronary stenting (90 vs. 96%; p < 0.01), and use of intraaortic balloon counterpulsation pump (82 vs. 95%; p < 0.01) were associated with a lower angiographic success rate. In the multivariable analysis, the following were independent predictors for angiographic failure: left bundle branch block (odds ratio [OR], 12.95; CI 95%, 3.00-53.90), cardiogenic shock (OR, 4.20; CI 95%, 1.95-8.75), no utilization of coronary stent (OR, 3.44; CI 95%, 1.71-7.37), and previous infarction (OR, 2.82; CI 95%, 1.29-5.90).

Conclusion

Coronary angioplasty allows a successful coronary recanalization in most patients with acute myocardial infarction. Some basic characteristics, however, may identify some subsets in which a successful angiographic result may be more difficult to obtain.

Bibliografía (57)

  • E.E. Ribeiro et al.

    Randomized trial of direct coronary angioplasty versus intravenous streptokinase in acute myocardial infarction

    J Am Coll Cardiol

    (1993)
  • S.G. Ellis et al.

    Predictors of success for coronary angioplasty performed for acute myocardial infarction

    J Am Coll Cardiol

    (1988)
  • J.B. Bedotto et al.

    Failed direct coronary angioplasty for acute myocardial infarction: in-hospital outcome and predictors of death

    J Am Coll Cardiol

    (1993)
  • B.E. Jaski et al.

    Outcome of urgent percutaneous transluminal angioplasty in acute myocardial infarction: comparison of single-vessel versus multivessel coronary artery disease

    Am Heart J

    (1992)
  • E.D. Grassman et al.

    Predictors of success and major complications for primary transluminal percutaneous angioplasty in acute myocardial infarction. An analysis of the 1990 to 1994 Society for Cardiac Angiography and Interventions Registries

    J Am Coll Cardiol

    (1997)
  • R. Moreno et al.

    Resultados de la angioplastia primaria en pacientes con enfermedad multivaso

    Rev Esp Cardiol

    (1998)
  • S.B. Laster et al.

    Incidence and importance of thrombolysis in myocardial infarction grade 3 flow after primary percutaneous transluminal coronary angioplasty for acute myocardial infarction

    Am J Cardiol

    (1996)
  • D. Hasdai et al.

    Smoking status and outcome after primary coronary angioplasty for acute myocardial infarction

    Am Heart J

    (1999)
  • D. Himbert et al.

    Heterogeneity of prognosis in patient subsets treated by primary coronary angioplasty during acute myocardial infarction

    Am J Cardiol

    (1998)
  • E.B. Sgarbossa et al.

    Acute myocardial infarction and complete bundle branch block at hospital admission: clinical characteristics and outcome in the thrombolytic era. GUSTO-I investigators. Global Utilization of Streptokinase and t-PA (tissue plasminogen activator) for Occluded Coronary Arteries

    J Am Coll Cardiol

    (1998)
  • M.D. Hibbard et al.

    Percutaneous transluminal coronary angioplasty in patients with cardiogenic shock

    J Am Coll Cardiol

    (1992)
  • S. Gottlieb et al.

    Smoking and prognosis after acute myocardial infarction in the thrombolytic era (Israeli Thrombolytic National Survey)

    J Am Coll Cardiol

    (1996)
  • D.R. Holmes et al.

    Effect of age on outcome with primary angioplasty versus thrombolysis

    J Am Coll Cardiol

    (1999)
  • J.K. Kahn et al.

    Results of primary angioplasty for acute myocardial infarction in patients with multivessel coronary artery disease

    J Am Coll Cardiol

    (1990)
  • R. Moreno et al.

    Determining whether acute myocardial infarction in patients with previous coronary bypass grafting is the result of a narrowing of a bypass conduit or of a native coronary artery

    Am J Cardiol

    (1997)
  • A. Vogt et al.

    Impact of early perfusion of the infarct-related artery on short-term mortality after thrombolysis for acute myocardial infarction: retrospective analysis of four german multicencer studies

    J Am Coll Cardiol

    (1993)
  • G.S. Werner et al.

    Causes of failed angioplasty for acute myocardial infarction assessed by intravascular intrasound

    Am Heart J

    (1997)
  • T.R. Porter et al.

    The clinical implications of no reflow demonstrated with intravenous perfluorocarbon containing microbubles following restoration of thrombolysis in myocardial infarction (TIMI) 3 flow in patients with acute myocardial infarction

    Am J Cardiol

    (1998)
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