Author + information
- Received April 7, 2015
- Revision received July 14, 2015
- Accepted August 27, 2015
- Published online December 28, 2015.
- Abhiram Prasad, MD∗,†,
- Bernard J. Gersh, MB, ChB, DPhil∗,
- Roxana Mehran, MD‡,§∗ (, )
- Bruce R. Brodie, MD‖,
- Sorin J. Brener, MD§,¶,
- José M. Dizon, MD#,
- Alexandra J. Lansky, MD∗∗,
- Bernhard Witzenbichler, MD††,
- Ran Kornowski, MD‡‡,
- Giulio Guagliumi, MD§§,
- Dariusz Dudek, MD, PhD‖‖ and
- Gregg W. Stone, MD§,#
- ∗Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
- †St. George’s, University of London, London, United Kingdom
- ‡The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
- §Clinical Trials Center, Cardiovascular Research Foundation, New York, New York
- ‖LeBauer Cardiovascular Research Foundation/Cone Health, Greensboro, North Carolina
- ¶New York Methodist Hospital, Brooklyn, New York
- #Center for Interventional Vascular Therapy, Division of Cardiology, Columbia University Medical Center, New York, New York
- ∗∗Yale Cardiovascular Research Program, Yale University Medical Center, New Haven, Connecticut
- ††Department of Cardiology and Pneumology, Helios Amper-Klinikum, Dachau, Germany
- ‡‡Cardiology Division, Rabin Medical Center, Petah-Tikva, Israel
- §§Ospedale Papa Giovanni XXIII, Bergamo, Italy
- ‖‖Department of Interventional Cardiology, Jagiellonian University, Krakow, Poland
- ↵∗Reprint requests and correspondence:
Dr. Roxana Mehran, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, New York 10029.
Objectives This study sought to investigate the effect of treatment delay on microvascular reperfusion in ST-segment elevation myocardial infarction (STEMI) patients from the large, multicenter, prospective HORIZONS-AMI (Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction) trial.
Background Despite restoration of epicardial blood flow during primary percutaneous coronary intervention (PCI), one-third of patients do not obtain myocardial perfusion due to impairment in the microvascular circulation.
Methods We examined the effect of symptom onset-to-balloon time (SBT) and door-to-balloon time (DBT) on myocardial reperfusion during primary PCI in STEMI, utilizing resolution of ST-segment elevation (STR) and the myocardial blush grade (MBG). The primary analysis was the relationships between SBT ≤2, >2 to 4, and >4 h and DBT ≤1, >1 to 1.5, >1.5 to 2, and >2 h with MBG and STR. Clinical risk was assessed using a modified version of the Thrombolysis In Myocardial Infarction risk score for STEMI.
Results In 2,056 patients, absent microvascular perfusion (MBG 0/1) and STR (STR <30%) after primary PCI was significantly more common in patients with longer SBT, in patients with both low and high clinical risk profiles. By multivariable analysis, SBT (p < 0.0001), anterior infarction (p < 0.0001), reference vessel diameter (p = 0.005), lesion minimum lumen diameter (p < 0.0001), hyperlipidemia (p = 0.03), and current smoking (p = 0.001) were independent predictors of MBG 0/1, whereas SBT (p = 0.007), anterior infarction (p < 0.0001), and history of renal insufficiency (p = 0.0002) were independent predictors of absent STR. DBT (p < 0.0001) was an independent predictor of MBG 0/1. MBG 0/1 and STR<30% identified patients with increased 3-year mortality.
Conclusions The present study suggests that delay in mechanical reperfusion therapy during STEMI is associated with greater injury to the microcirculation.
Dr. Gersh is a consultant for Boston Scientific, GE Healthcare, Janssen Scientific Affairs, Medispec Inc., Merck/Schering-Plough, Ortho-McNeil, and St. Jude Medical. Dr. Mehran has received institutional research grant support from The Medicines Company, Bristol-Myers Squibb/Sanofi, Eli Lilly and Company/Daiichi-Sankyo, Regado Biosciences, AstraZeneca, and STENTYS; is a consultant for Abbott Vascular, AstraZeneca, Bayer, Boston Scientific, Covidien, CSL Behring, Janssen Pharmaceuticals, Maya Medical, Merck & Co., Osprey Medical Inc., and Watermark Research Partners; is a member of the advisory board for Abbott Laboratories, Boston Scientific, Covidien, Janssen Pharmaceuticals, The Medicines Company, Merck, Sanofi, and Endothelix Inc.; and is a shareholder for Endothelix Inc. Dr. Witzenbichler is a consultant for Volcano; and has received lecture fees from Elixir Medical and Atrium Medical. Dr. Guagliumi has received grant support from Abbott Vascular, Boston Scientific, and St. Jude Medical; and is a consultant for Boston Scientific and St. Jude Medical. Dr. Dudek has received consulting and lecture fees from Abbott, Adamed, Adyton Medical Polska, Abiomed Europe, AstraZeneca, Biotronik, Balton, Bayer, B. Braun, BioMatrix, Boston Scientific, Boehringer Ingelheim, Bracco, Bristol-Myers Squibb, Comesa Polska, Cordis, Cook, Covidien Polska Sp. z o. o., DRG MedTek, Eli Lilly, EuroCor, Hammermed, GE Healthcare, Glaxo, InspireMD, Iroko Cardio International, Medianet Sp. z o.o., Medtronic, The Medicines Company, Meril Life Sciences, Merck Sharp & Dohme, Orbus-Neich, Pfizer, Possis, ProCardia Medical, Promed, REVA Medical, Sanofi-Aventis, Siemens, Solvay, Stentys, St. Jude Medical, Terumo, Tyco, and Volcano. Dr. Stone has served as a consultant for Boston Scientific. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received April 7, 2015.
- Revision received July 14, 2015.
- Accepted August 27, 2015.
- 2015 American College of Cardiology Foundation