Scholarly article on topic 'Clinical and angiographic profile of young patients undergoing primary percutaneous coronary intervention'

Clinical and angiographic profile of young patients undergoing primary percutaneous coronary intervention Academic research paper on "Health sciences"

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{"Myocardial infarction" / "Young adult" / Angioplasty / "Infarto do miocárdio" / "Adulto jovem" / Angioplastia}

Abstract of research paper on Health sciences, author of scientific article — Pedro Beraldo de Andrade, Fábio Salerno Rinaldi, Igor Ribeiro de Castro Bienert, Robson Alves Barbosa, Marcos Henriques Bergonso, et al.

Abstract Background The current decline observed in mortality rate among patients with ST-segment elevation acute myocardial infarction can be attributed not only to the increased use of reperfusion strategies, but also to a change in the demographic profile of this population, notably the reduction in mean age. Methods We retrospectively reviewed all patients undergoing primary percutaneous coronary intervention in the period from April 2010 to December 2014. The primary objective was the characterization of the most prevalent risk factors, the angiographic nature of the lesions, the technical aspects of the procedure, and in-hospital clinical outcomes in patients aged ≤ 45 years, comparing them to those aged > 45 years. Results Among 489 patients with acute myocardial infarction, 54 were ≤ 45 years, and 435 were > 45 years. Young patients exhibited a higher prevalence of smoking and obesity, while patients > 45 years were more likely to have hypertension, diabetes mellitus, dyslipidemia, and previous myocardial infarction. Primary percutaneous coronary intervention in young patients was associated with the use of fewer guide catheters, shorter fluoroscopy time, and higher percentage of direct stent implantation. Young patients exhibited good in-hospital outcomes, with lower rate of adverse cardiac events (3.7% vs. 9.2%; p = 0.30). Conclusions Patients aged ≤ 45 years accounted for approximately 10% of cases of ST-segment elevation acute myocardial infarction and exhibited high prevalence of modifiable risk factors.

Academic research paper on topic "Clinical and angiographic profile of young patients undergoing primary percutaneous coronary intervention"

Rev Bras Cardiol Invasiva. 2015;23(2):91-95

Original Article

Clinical and angiographic profile of young patients undergoing primary percutaneous coronary intervention

Pedro Beraldo de Andradea*, Fâbio Salerno Rinaldia, Igor Ribeiro de Castro Bienerta, Robson Alves Barbosaa, Marcos Henriques Bergonsoa, Milena Paiva Brasil de Matosa, Mara Flâvia Mamedio de Souzaa, Ederlon Ferreira Nogueirab, Sérgio Kreimerc, Vinicius Cardozo Estevesc, Marden André Tebetc, Luiz Alberto Piva e Mattosc, André Labrunieb

a Irmandade da Santa Casa de Misericôrdia de Marilia, Marilia, SP, Brazil b Hospital do Coraçao de Londrina, Londrina, PR, Brazil c Rede D'Or Sao Luiz, Sao Paulo, SP, Brazil

ARTICLE INFO ABSTRACT

Background: The current decline observed in mortality rate among patients with ST-segment elevation acute myocardial infarction can be attributed not only to the increased use of reperfusion strategies, but also to a change in the demographic profile of this population, notably the reduction in mean age. Methods: We retrospectively reviewed all patients undergoing primary percutaneous coronary intervention in the period from April 2010 to December 2014. The primary objective was the characterization of the most prevalent risk factors, the angiographic nature of the lesions, the technical aspects of the procedure, and in-hospital clinical outcomes in patients aged < 45 years, comparing them to those aged > 45 years. Results: Among 489 patients with acute myocardial infarction, 54 were < 45 years, and 435 were > 45 years. Young patients exhibited a higher prevalence of smoking and obesity, while patients > 45 years were more likely to have hypertension, diabetes mellitus, dyslipidemia, and previous myocardial infarction. Primary percutaneous coronary intervention in young patients was associated with the use of fewer guide catheters, shorter fluoroscopy time, and higher percentage of direct stent implantation. Young patients exhibited good in-hospital outcomes, with lower rate of adverse cardiac events (3.7% vs. 9.2%; p = 0.30). Conclusions: Patients aged < 45 years accounted for approximately 10% of cases of ST-segment elevation acute myocardial infarction and exhibited high prevalence of modifiable risk factors.

© 2015 Sociedade Brasileira de Hemodinamica e Cardiología Intervencionista. Published by Elsevier Editora Ltda.

This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/Iicenses/by-nc-nd/4.0/).

Perfil clínico e angiográfico de pacientes jovens submetidos à intervençâo coronária percutânea primária

RESUMO

Introdujo: O atual declínio observado na taxa de mortalidade entre pacientes com infarto do miocárdio com supradesnivelamento do segmento ST pode ser atribuido nao apenas a maior utilizado de estratégias de reperfusao, mas também a uma mudanza no perfil demográfico dessa populado, notadamente a redugao em sua média de idade.

Métodos: Foram analisados retrospectivamente todos os pacientes submetidos a intervengao coronária percutanea primária no período de abril de 2010 a dezembro de 2014. O objetivo primário foi a caracterizagao dos fatores de risco mais prevalentes, a natureza angiográfica das lesoes, os aspectos técnicos do procedimento e a evolugao clínica hospitalar de pacientes jovens, com idade < 45 anos, comparando-os aqueles com idade > 45 anos.

Resultados: Dentre 489 pacientes com diagnóstico de infarto agudo do miocárdio, 54 tinham idade < 45 anos e 435, idade > 45 anos. Pacientes jovens exibiram maior prevaléncia de tabagismo e obesidade, enquanto pacientes > 45 anos eram mais propensos a apresentar hipertensao arterial sistémica, diabetes melito, dislipidemia e infarto do miocárdio antigo. Intervengao coronária percutanea primária em jovens associou-se ao uso de menor quantidade de cateteres-guia, menor tempo de fluoroscopia e maior porcentual de implante direto de stent. Pacientes jovens exibiram boa evolugao hospitalar, com reduzida taxa de eventos cardíacos adversos (3,7% vs. 9,2%; p = 0,30).

DOI of original article: http://dx.doi.Org/10.1016/j.rbci.2015.12.005

* Corresponding author: Avenida Vicente Ferreira, 828, Jardim Maria Izabel, CEP: 17515-900, Marilia, SP, Brazil. E-mail: pedroberaldo@gmail.com (P.B. de Andrade).

Peer Review under the responsability of Sociedade Brasileira de Hemodinâmica e Cardiologia Intervencionista.

0104-1843/© 2015 Sociedade Brasileira de Hemodinâmica e Cardiologia Intervencionista. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Article history: Received 23 February 2015 Accepted 30 April 2015

Keywords:

Myocardial infarction Young adult Angioplasty

Palavras-chave: Infarto do miocárdio Adulto jovem Angioplastia

Conclusöes: Pacientes com idade < 45 anos representaram aproximadamente 10% dos casos de infarto agudo do miocárdio com supradesnivelamento do segmento ST e exibiram elevada prevaléncia de fatores de risco modificáveis.

© 2015 Sociedade Brasileira de Hemodinamica e Cardiología Intervencionista. Publicado por Elsevier Editora Ltda. Este é um artigo Open Access sob a licenca de CC BY-NC-ND (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction

Data from the National Institutes of Health and from USA government agencies indicate that coronary artery disease was responsible for one in seven deaths in that country in 2011.1 It is estimated that, each year, 635,000 Americans are hospitalized for acute coronary syndrome. Although the mortality rate for ST-segment elevation acute myocardial infarction (STEMI) has decreased significantly - from 11.5%, in 1990, to 8.0%, in 2006-, this decrease can be attributed not only to advances in clinical pharmacotherapy and in reperfusion strategies, notably primary percutaneous coronary intervention (PCI), but also to changes in the demographic profile of patients.

Among these changes, the decline in the mean age of patients affected by STEMI stands out. A review of four French registries involving 6,707 people indicated a mean decrease from 66.2 to 63.3 years over the course of 15 years.2 In Brazil, the National Registry of Cardiovascular Interventions (Central Nacional de Intervençoes Cardiovasculares - CENIC), encompassing 20,004 procedures in a 5-year period (2006-2010), recorded a mean age of 60.8 years among patients with STEMI.3

The in-hospital and late outcomes of young patients with stable coronary artery disease in our country were recently characterized, attesting to a good long-term prognosis.45 However, clinical and angiographic information about this population in the acute phase of STEMI are scarce. Thus, the aim of this study was to obtain more information on this subject.

Methods

Study population

All patients diagnosed with STEMI undergoing primary PCI in a single center performing a large volume of procedures (> 70 primary PCls/year) were analyzed retrospectively. Patients aged < 45 years were classified as young patients, based on previous publications on the subject.6-8

The primary aim of this study was the characterization of the most prevalent risk factors in young patients with STEMI, angiographic nature of lesions, technical details of primary PCI, and in-hospi-tal clinical evolution, with emphasis on mortality rate, reinfarction, stroke, stent thrombosis, and the occurrence of major bleeding, comparing them to patients aged > 45 years.

Procedures

A 12-lead electrocardiogram, plus V3R, V4R, V7, and V8 leads in inferior infarction, were performed at hospital admission and 30-60 minutes after the procedure. Therapeutic interventions followed recommendations and practices established by the existing guidelines.910 Anticoagulation was obtained with unfractionated heparin (UFH) 100 U/kg IV and dual antiplatelet therapy with a loading dose of 300 mg of acetylsalicylic acid, plus clopidogrel 600 mg or ticagre-lor 180 mg. The radial approach was the first choice of vascular access. Manual thrombus aspiration and use of glycoprotein llb/llla inhibitors were at the discretion of the operator. Dosages of creatine

kinase MB isoenzyme (CK-MB) were performed every 6 hours, until a decrease in the level of this marker was observed.

Definitions

The following risk factors were assessed: smoking - active smoker, or abstinence from smoking occurring in less than 6 months; hypercholesterolemia (low density lipoprotein-cholesterol -LDL-C > 160 mg/dL); systemic arterial hypertension (systolic blood pressure > 140 mmHg and/or diastolic blood pressure > 90 mmHg); diabetes mellitus (two fasting plasma glucose levels > 125 mg/dL on different days); family history of heart disease (atherosclerosis diagnosed in parents or siblings < 55 years for men and < 65 for women); prior manifestation of atherosclerotic disease (previous myocardial infarction, percutaneous or surgical revascularization procedure, stroke); and chronic renal failure (glomerular filtration rate < 60 mL/min or serum creatinine > 1.5 mg/dL).

Regarding electrocardiographic location, acute myocardial infarction was classified as an anterior (anteroseptal, anterior, anterolateral, and extensive anterior) or inferior (inferior, lateral, and dorsal) event. Door-to-balloon time was defined as the interval between hospital admission and crossing of the lesion with a predilation balloon, manual thrombus aspiration catheter, or stent. Angiographic success was defined as a PCI with reduction of target stenosis to < 20% diameter, maintaining or restoring normal antegrade flow (Thrombolysis in Myocardial Infarction - TIMl grade 3). Major bleeding was defined as a Type 3 or 5 bleeding according to the definition of the Bleeding Academic Research Consortium: type 3 - (3a) bleeding with hemoglobin decrease > 3 and < 5 g/dL or with red blood cell transfusion; (3b) bleeding with hemoglobin decrease > 5 g/dL, or cardiac tamponade, or bleeding requiring surgical intervention, or bleeding requiring the use of intravenous vasoactive drugs; (3c) intracranial hemorrhage, or subcategories confirmed by autopsy, imaging studies, or lumbar puncture, or intraocular bleeding with vision impairment; Type 5 - (5a) likely fatal bleeding; (5b) final fatal bleeding.11

Statistical analysis

Qualitative variables were summarized in absolute frequencies and percentages, and quantitative data were expressed as mean ± standard deviation. To compare groups, the Chi-squared test or Fisher's exact test for qualitative variables and Student's t-test or the Mann-Whitney test for quantitative variables were used. Results with p < 0.05 were considered statistically significant.

Results

From April 2010 to December 2014, 2,674 PCls were carried out; of these, 489 (18.3%) occurred in patients with STEMI in the first 12 hours of sympton onset. Of these patients, 54 (11%) were aged < 45 years (mean 40.7 years, range 36-45 years), and 435 were aged > 45 years (mean 64.2 years, range 46-96 years).

Young patients exhibited a higher prevalence of smoking (72.2% vs. 40.5%; p < 0.0001) and obesity (35.2% vs. 21.6%; p = 0.04), while patients > 45 years showed a greater propensity to present systemic arterial hypertension (69.7% vs. 40.7%; p < 0.0001), diabetes mellitus (33.3% vs. 14.8%; p = 0.005), dyslipidemia (34.0% vs. 13.0%; p = 0.002), and previous myocardial infarction (9.4% vs. 0.0%; p = 0.02; Table 1).

Anterior wall infarction was more frequent (50.9%), with stenting in 90.4% of procedures, predominantly with bare-metal stents (98.6%); manual aspiration thrombectomy, radial access, and glycoprotein Ilb/IIIa inhibitors were used in 57.5%, 94.3%, and 47.0% of the cases, respectively, with no difference between groups (Table 2). Primary PCI in young patients was associated with the use of fewer guide catheters (1.1 vs. 1.3, p = 0.02), shorter fluoroscopy time (10.0 ± 4.4 vs. 15.3 ± 23.1 min; p = 0.09), and a higher percentage of direct stenting (61.1% vs. 47.1%; p = 0.06).

Table 1

Basal clinical and demographic characteristics.

The overall angiographic success rate was high (92.2%); and young patients exhibited good in-hospital evolution, with reduced mortality (1.9% vs. 6.7%; p = 0.23) and reinfarction (1.9% vs. 1.8%; p > 0.99) rates and no occurrence of stroke, stent thrombosis, and major bleeding (Table 3).

Discussion

Although hospitalizations for acute myocardial infarction currently present a downward trend, this is not observed in young patients.12 Consequently, the statistics show a decline in the mean age of STEMI cases, as well as in mortality rate, and these findings are justified by the prognostic impact of advanced age in this high-risk scenario, representing one of its main determinants of morbidity and mortality.13

Variable General Age < 45 years Age > 45 years p-value

(n = 489) (n = 54) (n = 435)

Male gender, n (%) 338 (69.1) 34 (63.0) 304 (69.9) 0.35

Age, years 61.6 ± 12.4 40.7 ± 3.7 64.2 ± 10.5 < 0.0001

Body mass index, kg/m2 27.0 ± 4.9 28.5 ± 5.3 26.8 ± 4.8 0.02

Obesity, n (%) 113 (23.1) 19 (35.2) 94 (21.6) 0.04

Systemic arterial hypertension, n (%) 325 (66.5) 22 (40.7) 303 (69.7) < 0.0001

Diabetes mellitus, n (%) 153 (31.3) 8 (14.8) 145 (33.3) 0.005

Insulin user 23 (15.0) 2 (25.0) 21 (14.5) 0.34

Dyslipidemia, n (%) 155 (31.7) 7 (13.0) 148 (34.0) 0.002

Current smoker, n (%) 215 (44.0) 39 (72.2) 176 (40.5) < 0.0001

Positive family history of CAD, n (%) 91 (18.6) 15 (27.8) 76 (17.5) 0.09

Previous myocardial infarction, n (%) 41 (8.4) 0 (0.0) 41 (9.4) 0.02

Prior PCI, n (%) 42 (8.6) 1 (1.9) 41 (9.4) 0.07

Prior CABG, n (%) 7 (1.4) 0 (0.0) 7 (1.6) > 0.99

Stroke, n (%) 17 (3.5) 0 (0.0) 17 (3.9) 0.24

Chronic renal failure, n (%) 15 (3.1) 0 (0.0) 15 (3.4) 0.39

CAD: coronary artery disease; PCI: percutaneous coronary intervention; CABG: coronary artery bypass graft.

Table 2

Angiographic and procedural characteristics.

Variable General Age < 45 years Age > 45 years p-value

(n = 489) (n = 54) (n = 435)

De novo injury, n (%) 483 (98.8) 53 (98.1) 430 (98.9) 0.51

In-stent restenosis, n (%) 6 (1.2) 1 (1.9) 5 (1.1) 0.51

Location, n (%) 0.56

Anterior 249 (50.9) 240 (49.1) 30 (55.6) 24 (44.4) 219 (50.3) 216 (49.7)

Inferior

Duration of the procedure, minutes 41.6 ± 19.1 38.1 ± 14.6 42.0 ± 19.6 0.16

Fluoroscopy time, minutes 14.5 ± 19.0 10.0 ± 4.4 15.3 ± 23.1 0.09

Door-to-balloon time, minutes 64.9 ± 34.9 63.6 ± 46.5 65.3 ± 29.9 0.71

Manual aspiration thrombectomy, n (%) 281 (57.5) 34 (63.0) 247 (56.8) 0.47

Direct stent implantation, n (%) 238 (58.9) 33 (61.1) 205 (47.1) 0.06

Post-dilation, n (%) 278 (56.9) 27 (50.0) 251 (57.7) 0.31

Access route, n (%) 0.16

Radial 461 (94.3) 54 (100.0) 407 (93.6)

Femoral 23 (4.7) 5 (1.0) 0 (0.0) 0 (0.0) 23 (5.3) 5 (1.1)

Culprit lesion, n (%) 0.51

Left anterior descending artery 247 (50.6) 30 (55.6) 217 (49.9)

Right coronary artery 185 (37.8) 21 (38.9) 164 (37.7)

Left circumflex artery 55 (11.2) 3 (5.5) 52 (12.0)

Left main coronary artery 2 (0.4) 0 (0.0) 2 (0.4)

Glycoprotein IIb/IIIa inhibitor, n (%) 230 (47.0) 31 (57.4) 199 (45.7) 0.11

Number of catheters 1.3 ± 0.6 1.1 ± 0.4 1.3 ± 0.6 0.018

Diameter of the catheter, n (%) > 0.99

5 F 1 (0.2) 0 (0.0) 1 (0.2)

6 F 487 (99.6) 54 (100.0) 433 (99.6)

7 F 1 (0.2) 0 (0.0) 1 (0.2)

PCI type, n (%) 0.81

Balloon angioplasty Stenting Number of stents 47 (9.6) 442 (90.4) 1.1 ± 0.5 4 (7.4) 50 (92.6) 1.1 ± 0.6 43 (9.9) 392 (90.1) 1.1 ± 0.5

> 0.99

Stent type, n (%) > 0.99

Drug-eluting stent Bare-metal stent 6 (1.4) 436 (98.6) 2 (4.0) 48 (96.0) 4 (1.0) 388 (99.0)

Intra-aortic balloon, n (%) 2 (0.4) 0 (0.0) 2 (0.5) > 0.99

PCI: percutaneous coronary intervention.

Table 3

In-hospital efficacy and safety outcomes.

Variable General Age < 45 years Age > 45 years p-value

(n = 489) (n = 54) (n = 435)

Angiographic success, n (%) 451 (92.2) 51 (94.4) 400 (92.0) 0.79

MACE, n (%) 42 (8.6) 2 (3.7) 40 (9.2) 0.30

Death, n (%) 30 (6.1) 1 (1.9) 29 (6.7) 0.23

Reinfarction, n (%) 9 (1.8) 1 (1.9) 8 (1.8) > 0.99

Stroke, n (%) 1 (0.2) 0 (0.0) 1 (0.2) > 0.99

In-hospital stent thrombosis, n (%) 9 (1.8) 0 (0.0) 9 (2.1) 0.61

Acute 2 (0.4) 7 (1.4) 0(0.0) 0(0.0) 2 (0.5) 7 (1.6)

Subacute

Major bleeding, n (%) 4 (0.8) 0(0.0) 4 (0.9) > 0.99

MACE: major adverse cardiac events (death, reinfarction, stroke, stent thrombosis, or major bleeding).

Data from registries such as FAST-MI (French Registry of Acute ST-Elevation or non-ST-elevation Myocardial Infarction) still show increased prevalence of smoking (from 32.0% to 40.9%) and obesity (from 14.3% to 20.1%) in the population of myocardial infarction patients over the past 15 years.2 In the USA, among young individuals aged 18-44 years, 22.9% of men and 16.6% of women are smokers, and 69% of the general population is classified as obese or overweight.1

In assessing the population of young patients with an acute myocardial infarction diagnosis, the percentage of smokers can reach up to 74%, as in the CRAGS (Coronary Artery Disease in Young Adults) study.14 It is known that smoking contributes negatively in the regulation cascades engaged in preventing coronary occlusion, besides promoting changes in tissue plasminogen activator response to bra-dykinin. Furthermore, the hypercoagulability state and endothelial dysfunction present in smokers predispose to the formation of intra-coronary thrombi.15

In the present study, patients aged < 45 years represented 11% of all STEMI cases (37% female), with high prevalence of modifiable risk factors such as obesity (35.2%) and smoking (72.2 %), and lower percentages of hypertension, dyslipidemia, diabetes mellitus, and previous myocardial infarction. The characteristics of procedures

- for instance, a lower mean number of catheters used, shorter fluoroscopy time, and higher percentage of direct stent implantation

- suggest less angiographic complexity in this subgroup, as well as a low rate of major adverse cardiac events during hospitalization, exemplified by mortality rates of 1.9% vs. 6.7% in patients > 45 years. Similar findings were reported by the London Chest Hospital, a reference center for chest pain, which, from 2004 to 2012, registered 3,618 primary PCIs. Patients aged < 45 years constituted 10.1% of the sample, and smoking had a prevalence of 62.7%, with a 30-day mortality of 1.6%.16

Together, these data reflect the importance of instituting health policies that address young people and target primary or secondary prevention, with emphasis on changes in lifestyle, particularly smoking cessation, regular physical activity, and a balanced diet to maintain proper weight. These are low-cost actions with great potential for reducing the incidence of new cases of myocardial infarction in this population.

Study limitations

This analysis had the following limitations: its observational and unicentric nature, the limited sample size, lack of long-term clinical follow-up, as well as non-performance of routine diagnostic tests for illicit drugs such as cocaine, a known promoter of coronary spasm and hypercoagulability in an environment of sympathetic activity exacerbation, which represents a common cause of acute coronary syndrome in young people.

Conclusions

Patients aged < 45 years represented approximately 10% of cases of ST-segment elevation acute myocardial infarction, showed high prevalence of modifiable risk factors, especially smoking, favorable in-hospital clinical outcome after primary percutaneous coronary intervention, and less technical complexity when compared to patients > 45 years. Health policies addressing changes in lifestyle are low-cost actions, with potential impact on reducing future events in this population.

Funding source

None declared.

Conflicts of interest

The authors declare no conflicts of interest.

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