Mintz, Gary S.

Abstract Objectives We sought to identify clinical, electrocardiographic (ECG), and angiographic characteristics that are predictive of 3‐year mortality after primary percutaneous coronary intervention (PCI) in patients with non‐anterior ST‐elevation myocardial infarction (NA‐STEMI) from the Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction (HORIZONS‐AMI) trial. Background Which patients with NA‐STEMI undergoing PCI have a poor prognosis is uncertain. Methods NA‐STEMI was defined as ST‐segment elevation in lateral (V5, V6, I, aVL), inferior (II, III, aVF), or inferolateral (I, II, III, aVF, and V5‐V6) ECG leads or posterior myocardial infarction with ST‐segment depression of ≥1 mm in ≥2 contiguous anterior leads. Cox regression was used to identify independent predictors of 3‐year mortality. Missing data were imputed using multiple imputation. Results In HORIZONS‐AMI, 2,578/3,602 patients had no prior coronary artery bypass grafting, underwent single‐vessel PCI, and had baseline ECG data assessed in an independent core laboratory. Among them, 1,495 (58.0%) had NA‐STEMI. Patients with NA‐STEMI had lower 3‐year mortality risk than those with anterior STEMI (4.5% versus 7.1%, P = 0.004). The independent predictors of increased 3‐year mortality in NA‐STEMI were older age (median > 59.0 years), diabetes, reduced LVEF (≤50%), Killip class ≥2, post‐procedure TIMI flow 0–2 versus 3, renal insufficiency, and ST‐resolution <30% at 60 min post‐PCI. Patients with 0, 1, 2, 3, and ≥4 of these risk factors had 3‐year mortality rates of 1.8%, 2.3%, 3.1%, 6.1%, and 36.3%, respectively ( P < 0.0001). Conclusions Although NA‐STEMI carries a better prognosis than anterior STEMI, high‐risk patient cohorts with NA‐STEMI may be identified who have substantial 3‐year mortality.

Abstract This Consensus Document is the first of two reports summarizing the views of an expert panel organized by the European Association of Percutaneous Cardiovascular Interventions (EAPCI) on the clinical use of intracoronary imaging including intravascular ultrasound (IVUS) and optical coherence tomography (OCT). The first document appraises the role of intracoronary imaging to guide percutaneous coronary interventions (PCIs) in clinical practice. Current evidence regarding the impact of intracoronary imaging guidance on cardiovascular outcomes is summarized, and patients or lesions most likely to derive clinical benefit from an imaging-guided intervention are identified. The relevance of the use of IVUS or OCT prior to PCI for optimizing stent sizing (stent length and diameter) and planning the procedural strategy is discussed. Regarding post-implantation imaging, the consensus group recommends key parameters that characterize an optimal PCI result and provides cut-offs to guide corrective measures and optimize the stenting result. Moreover, routine performance of intracoronary imaging in patients with stent failure (restenosis or stent thrombosis) is recommended. Finally, strengths and limitations of IVUS and OCT for guiding PCI and assessing stent failures and areas that warrant further research are critically discussed.

BackgroundPresence of Q waves on the presenting electrocardiogram (ECG) in patients with ST‐segment elevation myocardial infarction (STEMI) has been associated with worse prognosis; however, whether the prognostic value of Q waves is influenced by baseline characteristics and/or rapidity of revascularization based on the guideline‐based metric of door‐to‐balloon time remains unknown.HypothesisWe hypothesized that Q waves in the presenting ECG will be predictive of long term mortality regardless of time to reperfusion.MethodsThe Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction (HORIZONS‐AMI) trial enrolled 3602 patients with STEMI undergoing primary percutaneous coronary intervention. We stratified patients without prior history of myocardial infarction or coronary revascularization according to presence or absence of pathological Q waves on their presenting ECG. Associations between Q waves, death, and cardiovascular outcomes within 3 years were assessed using Cox proportional hazards regression.ResultsAmong 2723 patients with evaluable ECGs, 1084 (39.8%) had Q waves on their presenting ECG. Male sex and time from symptom onset to balloon inflation were independent predictors of presence of Q waves. Patients with Q waves had higher adjusted risks of all‐cause death (adjusted hazard ratio: 1.45, 95% confidence interval: 1.02‐2.05, P = 0.04) and cardiac death (adjusted hazard ratio: 1.72, 95% confidence interval: 1.08‐2.72, P = 0.02). The association between Q waves and cardiac death was consistent regardless of sex, diabetes status, target vessel, or door‐to‐balloon time (Pinteraction > 0.4 for all).ConclusionsPresence of Q waves on the presenting ECG in patients undergoing primary percutaneous coronary intervention due to STEMI is an independent predictor of mortality and adds prognostic value, regardless of sex or rapidity of revascularization.