Quantitative Analysis of the Impact of Total Ischemic Time on Myocardial Perfusion and Clinical Outcome in Patients With ST-Elevation Myocardial Infarction

doi:10.1016/j.amjcard.2011.07.010

The American Journal of Cardiology

Volume 108, Issue 11, 1 December 2011, Pages 1536-1541

https://doi.org/10.1016/j.amjcard.2011.07.010 Get rights and content

Early reperfusion of the infarct-related coronary artery is an important issue in improvement of outcomes after ST-segment elevation myocardial infarction (STEMI). In this study, the clinical significance of total ischemic time on myocardial reperfusion and clinical outcomes was evaluated in patients with STEMI treated with primary percutaneous coronary intervention and thrombus aspiration and additional triple-antiplatelet therapy. Total ischemic time was defined as time from symptom onset to first intracoronary therapy (first balloon inflation or thrombus aspiration). All patients with STEMI treated with primary percutaneous coronary intervention with total ischemic times ≥30 minutes and <24 hours from 2005 to 2008 were selected. Ischemic times were available in 1,383 patients, of whom 18.4% presented with total ischemic times ≤2 hours, 31.2% >2 to 3 hours, 26.8% >3 to 5 hours, and 23.5% >5 hours. Increased ischemic time was associated with age, female gender, hypertension, and diabetes. Patients with total ischemic times <5 hours more often had myocardial blush grade 3 (40% to 45% vs 22%, p <0.001) and complete ST-segment resolution (55% to 60% vs 42%, p = 0.002) than their counterparts with total ischemic times >5 hours. In addition, patients with total ischemic times ≤5 hours had lower 30-day mortality (1.5% vs 4.0%, p = 0.032) than patients with total ischemic times >5 hours. In conclusion, in this contemporary cohort of patients with STEMI treated with primary percutaneous coronary intervention, triple-antiplatelet therapy, and thrombus aspiration, short ischemic time was associated with better myocardial reperfusion and decreased mortality. After a 5-hour period in which outcomes remain relatively stable, myocardial reperfusion becomes suboptimal and mortality increases.

Section snippets

Methods

We performed an analysis of ischemic time data from consecutive patients with STEMI presenting to the University Medical Center of Groningen from January 2005 to July 2008. Inclusion criteria were symptoms of chest pain suggestive of acute myocardial infarction lasting ≥30 minutes and <24 hours before hospital admission, electrocardiographic findings of ST-segment elevation >0.1 mV in ≥2 leads, and the performance of a primary PCI procedure. Exclusion criteria were the presence of cardiogenic

Results

From January 2005 to July 2008, 1,731 consecutive patients with STEMI were treated with primary PCI at our hospital (Figure 1). Ischemic time was available in 1,383 patients, (79.9%) of all 1731 STEMI patients. Of these, 255 patients (18.4%) had ischemic times ≤2 hours, 432 patients (31.2%) ad times >2 to 3 hours, 371 patients (26.8%) had times >3 to 5 hours, and 325 patients (23.5%) had times >5 hours. The median ischemic time was 3.1 hours (interquartile range 2.3 to 4.8). As listed in Table 1

Discussion

In this contemporary cohort of patients with STEMI treated with primary PCI, thrombus aspiration, and triple-antiplatelet therapy, myocardial reperfusion, as assessed by angiography (MBG of 3) and electrocardiography (ST-segment resolution >70%), was better in patients with total ischemic times ≤5 hours than in those with longer ischemic times. Interestingly, if ischemic time can be limited to ≤5 hours, the duration of ischemia seems to only modestly influence myocardial reperfusion. Most

References (29)

M. Francone et al.
Impact of primary coronary angioplasty delay on myocardial salvage, infarct size, and microvascular damage in patients with ST-segment elevation myocardial infarction: insight from cardiovascular magnetic resonance
J Am Coll Cardiol
(2009)
G. Tarantini et al.
Duration of ischemia is a major determinant of transmurality and severe microvascular obstruction after primary angioplasty: a study performed with contrast-enhanced magnetic resonance
J Am Coll Cardiol
(2005)
B.R. Brodie et al.
Importance of time to reperfusion for 30-day and late survival and recovery of left ventricular function after primary angioplasty for acute myocardial infarction
J Am Coll Cardiol
(1998)
B.R. Brodie et al.
Impact of time to treatment on myocardial reperfusion and infarct size with primary percutaneous coronary intervention for acute myocardial infarction (from the EMERALD trial)
Am J Cardiol
(2007)
D. Antoniucci et al.
A randomized trial comparing primary infarct artery stenting with or without abciximab in acute myocardial infarction
J Am Coll Cardiol
(2003)
T.A. Mabin et al.
Intracoronary thrombus: role in coronary occlusion complicating percutaneous transluminal coronary angioplasty
J Am Coll Cardiol
(1985)
A.W. van ‘t Hof et al.
Clinical value of 12-lead electrocardiogram after successful reperfusion therapy for acute myocardial infarction
Lancet
(1997)
G. De Luca et al.
Symptom-onset-to-balloon time and mortality in patients with acute myocardial infarction treated by primary angioplasty
J Am Coll Cardiol
(2003)
E. Boersma et al.
Early thrombolytic treatment in acute myocardial infarction: reappraisal of the golden hour
Lancet
(1996)
M. Gierlotka et al.
Reperfusion by primary percutaneous coronary intervention in patients with ST-segment elevation myocardial infarction within 12 to 24 hours of the onset of symptoms (from a prospective national observational study [PL-ACS])
Am J Cardiol
(2011)

M. Sejersten et al.

Feasibility and safety of prehospital administration of bivalirudin in patients with ST-elevation myocardial infarction

Am J Cardiol

(2009)

U. Zeymer et al.

Randomized comparison of eptifibatide versus abciximab in primary percutaneous coronary intervention in patients with acute ST-segment elevation myocardial infarction: results of the EVA-AMI trial

J Am Coll Cardiol

(2010)

G. Montalescot et al.

Prasugrel compared with clopidogrel in patients undergoing percutaneous coronary intervention for ST-elevation myocardial infarction (TRITON-TIMI 38): double-blind, randomised controlled trial

Lancet

(2009)

K.A. Reimer et al.

The wavefront phenomenon of ischemic cell death1. Myocardial infarct size vs duration of coronary occlusion in dogs

Circulation

(1977)

Cited by (22)

Prognostic value and clinical usefulness of PIANO score in patients undergoing primary percutaneous coronary intervention
2023, International Journal of Cardiology
In our previous study, the PIANO score was constructed to predict the occurrence of no-reflow phenomenon in patients undergoing primary percutaneous coronary intervention (PCI). In the current analysis, we sought to evaluate the prognostic value and clinical usefulness of the PIANO score in this population.
Patients with acute myocardial infarction (AMI) undergoing primary PCI were consecutively enrolled and followed up in this register. The endpoint of interest was all-cause mortality at 2 years after the procedure. The clinical benefits of thrombus aspiration (TA) during primary PCI in certain subgroups were also evaluated as exploratory analyses.
A total of 2100 patients were identified, and 54.3% had high (≥8) PIANO score. After 2-year follow-up, patients with high PIANO score had higher risk of all-cause mortality after adjustment for propensity score (6.7% vs. 3.1%, adjusted hazard ratio = 2.11 [1.21–3.68], p = 0.008), especially in the first month (adjusted hazard ratio = 2.33 [1.17–4.65], p = 0.017). Restricted cubic spline analysis indicated the linear association between the PIANO score and 2-year all-cause mortality (nonlinear p = 0.556). Further analysis demonstrated that TA did not reduce all-cause mortality in the overall patients, as well as in those with visible thrombus, high thrombus burden, or occlusive lesions. However, the PIANO score defined “high-risk” (PIANO score ≥ 8) patients could benefit from it.
The PIANO score had potential prognostic value in patients with AMI undergoing primary PCI. It might also be helpful for identifying patients who would benefit from TA. These observations require further confirmation in future studies.
Total ischemic time and age as predictors of PCI failure in STEMIs: A systematic review
2023, American Journal of the Medical Sciences
When feasible, primary percutaneous coronary intervention (PCI) is the definitive intervention for ST-elevation myocardial infarction (STEMI). However, cardiac tissue reperfusion is not always achievable after opening the infarct-related artery. Studies have investigated associating factors and scoring for the “no-reflow” phenomenon. This paper aims to systematically establish the predictive values of total ischemic time and patient age as factors of coronary no-reflow in patients undergoing primary PCI.
A systematic search was performed using EBSCOhost, including CINAHL Complete, Academic Search Premier, MEDLINE with Full Text, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews. Search results were compiled utilizing Zotero reference manager and exported to Covidence.org for screening, selection, and data extraction by two independent reviewers. The Newcastle-Ottawa Quality Assessment Scale for Cohort Studies was used to evaluate the eight selected studies.
The initial search resulted in 367 articles, with eight meeting the inclusion criteria with a total of 7060 participants. Our systematic review demonstrated that for patients older than 60 years, the odds of the no-reflow phenomenon increased 1.53- 2.53 times. Additionally, patients with increased total ischemic time had 1.147- 4.655 times the odds of no-reflow incidence.
Patients older than 60 years with a total ischemic time >4–6 h are at higher risk of PCI failure due to the no-reflow phenomenon. Therefore, new guidelines and more research to prevent and treat this physiologic occurrence are essential to improve coronary reperfusion after primary PCI.
Determinants of total ischemic time in primary percutaneous coronary interventions: A prospective analysis
2018, Indian Heart Journal
Citation Excerpt :
Longer ischemic times are associated with increase in microvascular obstruction, which further increases the infarct size. The total ischemic time, measured from symptom onset to the provision of reperfusion therapy is thus of significant importance for the outcomes of patients with STEMI.5 There are fewer studies which assessed the factors that cause longer total ischemic time.6
To assess the factors contributing to longer total ischemic times in ST elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PPCI).
Three hundred forty-six patients who underwent PPCI from July 2016 to June 2017 were studied. From time for the patient to recognize the symptoms, time was divided into 11 stages, any reason for delay was observed.
Mean window period was 6.7 ± 9.8 hours. Mean time to recognize the symptoms, reach first medical contact and prehospital management were 150.2 ± 140.5 min, 58.5 ± 57.0 min and 36.3 ± 38.0 min, respectively. Mean time for the patients brought in ambulance was 82.4 ± 59.8 min whereas for those transported in other vehicles was 130.4 ± 59.7 min (p = < 0.0001). Mean door to electrocardiogram (ECG) time, decision for PPCI, consent time and STEMI team activation time were 6.2 ± 3.1 min, 8.3 ± 4.5 min, 12.6 ± 16.2 min and 10.7 ± 8.2 min, respectively. Mean time for financial process and mean sheath to balloon time were 9.1 ± 6.9 min and 21.8 ± 11.7 min, respectively. Door to balloon time (DTB) was <90 min in 81% of the patients, mean DTB was 72.0 ± 33.0 min. Mean DTB for cases performed during night was 72.6 ± 32.9 min, whereas for those performed during day was 60.3 ± 30.2 min (p < 0.05). Total 30 day mortality was 2.9%. Mortality among DTB <90 min was 1.4%, mortality among DTB > 90 min was 9% (p < 0.05).
The main contributor for longer total ischemic time was the time taken for the patient to recognize the symptoms. DTB of <90 min can be achieved with effective hospital strategies.
Impact of total ischemic time on manual thrombus aspiration benefit during primary percutaneous coronary intervention
2018, American Heart Journal
The benefits of manual thrombus aspiration (TA) during primary percutaneous coronary intervention (pPCI) for ST-elevation myocardial infarction (STEMI) remain uncertain. We assessed the influence of total ischemic time (TIT) on clinical outcomes among STEMI patients undergoing manual TA during pPCI.
We conducted a retrospective study of patients enrolled in the Acute Myocardial Infarction in Switzerland Plus registry. STEMI patients undergoing pPCI with (TA group) or without (PCI-alone group) manual TA were stratified based on short (<3 hours), intermediate (3-6 hours), and long (>6 hours) TIT. The primary endpoint was in-hospital all-cause mortality. The secondary endpoint was in-hospital major adverse cardiac events (MACE), a composite of all-cause death, myocardial reinfarction and stroke.
Between 2008 and 2014, 4’154 patients (TA 48%) were included. Risk-adjusted in-hospital all-cause mortality was not different between TA and PCI-alone groups (OR 1.29; 95%CI 0.83-1.98; p=0.26), whereas there was significantly increased risk of MACE (OR 1.52; 95%CI 1.05-2.19; p=0.03) in patients treated with manual TA compared with PCI-alone. There was no significant difference between manual TA and PCI-alone with respect to risk-adjusted all-cause mortality according to TIT groups, but risk-adjusted MACE rates were significantly higher in the group of patients with long TIT treated with manual TA compared with PCI-alone (OR 2.42; 95%CI 1.16-5.04; p=0.02).
In a large registry of STEMI patients, manual TA was not associated with lower risk-adjusted in-hospital all-cause mortality compared with PCI-alone regardless of TIT but was associated with significantly greater risk of MACE. In patients with prolonged TIT, manual TA was associated with higher risk-adjusted MACE rates compared with PCI-alone.
Symptom-to-Balloon Time is a Strong Predictor of Adverse Events Following Primary Percutaneous Coronary Intervention: Results From the Australian Capital Territory PCI Registry
2017, Heart Lung and Circulation
Citation Excerpt :
One study indicated that 32.6% of patients over 70 years experienced atypical symptoms which were captured in a timely manner only on account of home telecardiography [21]. The presence of diabetes prolonged symptom to FMC time by a median of 35 minutes in our cohort, in keeping with other reports [22,23]. In a large study from the US, adjusted delays in presentation were 19 minutes longer for those aged 70–79 compared to those aged 60 years and under, and 18 minutes longer for diabetics [15].
Notwithstanding improvements in door-to-balloon time, adverse event rates after primary PCI have remained steady. We analysed the effect of symptom-to-balloon (STB) time, a reflection of total ischaemic time, on major adverse cardiovascular events (MACE) and explored predictors of prolonged STB time.
The study population included 1002 consecutive patients (22.4% women) with a mean age of 62.3±13.2 years, who underwent primary PCI during 2008-2014. Groups were compared for STB ≤ and >240 min. Primary endpoint was one-year MACE, a composite of death, reinfarction, stent thrombosis or target vessel revascularisation.
Symptom-to-balloon time was available in 893 patients of which 588 (65.8%) had STB ≤240 min and 305 (34.2%) had STB >240 min. The incidence of one-year MACE increased significantly in a stepwise manner with increasing STB time (p for trend=0.003). Symptom-to-balloon time was an independent predictor of one-year MACE along with age >70 years, final TIMI flow <3, three vessel disease, cardiogenic shock and out-of-hospital cardiac arrest. We also performed a multivariate analysis to determine predictors of delayed treatment. Predictors of STB time >240 min were age >70 years, female gender, diabetes, absence of prehospital catheter laboratory activation and presentation to a non-PCI centre.
Incidence of MACE was strongly correlated with STB time and STB time was an independent predictor of MACE. We have identified specific subgroups with prolonged STB times (age >70, female gender, diabetes, absence of prehospital activation and presentation to a non-PCI centre). This information should inform future studies and strategies to minimise delays in these subgroups for improved outcomes.
Symptom-Onset-To-Balloon Time, ST-Segment Resolution and In-Hospital Mortality in Patients With ST-Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention in China: From China Acute Myocardial Infarction Registry
2016, American Journal of Cardiology
Animal and imaging study evidence favors early reperfusion for acute myocardial infarction. However, in clinical trials, the effect of symptom-onset-to-balloon (S2B) time on clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (pPCI) has been inconsistent. Moreover, there are few data regarding the ischemic time in China. A total of 3,877 consecutive patients with STEMI with available S2B time undergoing pPCI from January 2013 to September 2014 at 108 hospitals that participated in the China Acute Myocardial Infarction registry were included and stratified into 3 S2B groups: <6 hours, 6 to 12 hours, >12 hours S2B time was tested in multivariate logistic regression analyses as an independent risk factor of mortality (primary outcome), major adverse cardiovascular and cerebrovascular events (MACCE), and impaired myocardial perfusion (secondary outcomes). The median S2B time was 5.5 (3.75 to 8.50) hours. Longer S2B time was associated with higher in-hospital mortality (<6 hours: 2.7%; 6 to 12 hours: 3.4%; >12 hours: 4.9%; p = 0.047) and ST-segment resolution <50% (<6 hours: 16.7%; 6 to 12 hours: 19.2%; >12 hours: 24.3%; p = 0.002) but not MACCE. In multivariate-adjusted analysis, S2B >12 hours remained associated with ST-segment resolution <50% (odds ratio 1.53, 95% confidence interval 1.16 to 2.01, p = 0.002) but not with in-hospital mortality (odds ratio 1.673, 95% confidence interval 0.95 to 2.94, p = 0.073). In conclusion, median S2B time in patients with STEMI undergoing pPCI was longer than that in registry studies from other countries. Longer S2B time was associated with impaired myocardial perfusion but not with in-hospital mortality or MACCE.

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Coronary artery diseaseQuantitative Analysis of the Impact of Total Ischemic Time on Myocardial Perfusion and Clinical Outcome in Patients With ST-Elevation Myocardial Infarction

Section snippets

Methods

Results

Discussion

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Lancet

J Am Coll Cardiol

Lancet

Am J Cardiol

Am J Cardiol

J Am Coll Cardiol

Lancet

The wavefront phenomenon of ischemic cell death1. Myocardial infarct size vs duration of coronary occlusion in dogs

Circulation

Coronary artery disease
Quantitative Analysis of the Impact of Total Ischemic Time on Myocardial Perfusion and Clinical Outcome in Patients With ST-Elevation Myocardial Infarction