Korea University Guro Hospital, Seoul, Korea * Chonnam National University Hospital, Gwangju, Korea

Transcription

1 Left Main Disease versus Non Left Main Disease in Acute Myocardial Infarction Patients in Real world Clinical Practice : Lessons from Korea Acute Myocardial Infarction Registry (KAMIR) Seung-Woon Rha*, Sureshkumar Ramasamy, Kanhaiya L. Poddar, Ji Young Park, Kang-Yin Chen, Cheol Ung Choi, Chang Gyu Park, Hong Seog Seo, Dong Joo Oh, Myung Ho Jeong* Korea University Guro Hospital, Seoul, Korea * Chonnam National University Hospital, Gwangju, Korea

2 Abstract Background: There are limited data regarding the prognosis of acute myocardial infarction (AMI) patients (pts) with Left main coronary artery (LMCA) disease as compared with those of pts with non left main disease patients. Methods: The study population consisted of 7038 consecutive acute AMI pts enrolled in the Korea Acute Myocardial Infarction Registry (KAMIR) study. We compared the clinical outcomes of AMI pts with LMCA disease (n=154, 2.18%) to those of pts with non- LMCA disease (n=6884, 97.82%) who underwent percutaneous coronary intervention (PCI) with DES. Results: The baseline clinical and procedural characteristics were balanced between pts with LMCA disease to those of pts with non- LMCA disease except higher number of elderly patients, prior ischemic heart disease pts, higher triple vessel disease, higher number of stents, larger diameter size stents, higher usage of unfractionated heparin, Glycoprotein IIb IIIa inhibitors, Cilostazol were noted in the left main group. In hospital mortality (p=015,0r 6.432) and developments of cardiogenic shock in the hospital were higher in the LMCA group on the multivariate analysis. At 8 months, the major clinical outcomes including Total major cardiovascular events (MACE), cumulative mortality, Any MI, and repeat Revascularization, were higher in LMCA group. (Table). Conclusion: The prevalence of LMCA disease was in less proportion (3.43%) in the AMI setting but showed worst eight month major clinical outcomes due to very high in hospital mortality, higher Total MACE, Cumulative mortality, Repeat revacularization and cumulative recurrent MI inspite of the drug eluting stents implantation.

3 Background 1. Patients (Pts) with acute myocardial infarction (AMI) caused by acute occlusion in left main coronary artery (LMCA) lesion is usually fatal and critical clinical setting in real world clinical practice. 2. However, there are limited data regarding the prognosis of AMI pts with LMCA disease as compared with those of pts with non left main disease patients.

4 Purpose To predict the midterm clinical outcomes after the percutaneous coronary interventions (PCI) with drug-eluting stent (DES) implantation in the Left main vs Non Left Main AMI Patients.

5 Methods 1. Study Population ; The study population consisted of 7038 consecutive AMI pts enrolled in the Korea Acute Myocardial Infarction Registry (KAMIR). 2. Study groups ; We compared the clinical outcomes of AMI pts with LMCA disease (n=154 pts, 2.18%) to those of pts with non- LMCA disease (n=6884 pts, 97.82%) who underwent percutaneous coronary intervention (PCI) with DES.

6 Methods 3. Antiplatelet therapy 1) All pts received Aspirin; 100 mg orally, indefinitely 2) All pts received Clopidogrel (Plavix ) preloaded mg before PCI, followed by daily administration of 75 mg and encouraged to continue at least for 1 year. 3) In case of suspicious higher risk of stent thrombosis; Routine triple antiplatelets (Aspirin, Clopidogrel and Cilostazol) for one month, then changed to dual antiplatelets

7 Methods 4. Antithrombotic therapy 1) Enoxaparin (Clexane ); 60mg bid before PCI and after PCI during the hospital stay (within 7 days). 2) Unfractionated Heparin; a bolus of 50 U/kg prior to PCI for 1 st one hour 3) GP IIbIIIa blocker (Reopro ); depend on physician s discretion

8 Methods 5. Percutaneous Coronary Intervention (PCI) Procedure 1) A variety of atheroablative devices were not utilized and mostly simple predilation or was performed to get an adequate luminal diameter which was necessary to accommodate the unexpanded DES or BMS and their delivery system. 2) Thrombus aspiration was done using Thrombuster II catheter or Export catheter if there were significant angiographic visible thrombi in the target lesion before stenting. 6. Study End Points ; Individual clinical hard endpoints and total major adverse cardiac events (MACE) at 12 months were evaluated.

9 Statistics 1. All statistical analyses were performed using SPSS Continuous variables were expressed as means ± standard deviation and were compared using Student s t-test. 3. Categorical data were expressed as percentages and were compared using chi-square statistics or Fisher s exact test. 4. Multivariate analysis was used to test the association of Total occlusion of IRA with 12 month MACE 5. A P-value of 0.05 was considered statistically significant.

10 Results

11 Results 1. Baseline Characteristics ; The baseline clinical and procedural characteristics were balanced between pts with LMCA disease to those of pts with non- LMCA disease except higher number of elderly patients, prior ischemic heart disease pts, higher triple vessel disease, higher number of stents, larger diameter size stents, higher usage of unfractionated heparin, Glycoprotein IIb IIIa inhibitors, Cilostazol were noted in the left main group.

12 Results 2. In-hospital Clinical Outcomes ; In hospital mortality (p=015,0r 6.432) and developments of cardiogenic shock in the hospital were higher in the LMCA group on the multivariate analysis. 3. Mid-term Clinical Outcomes ; At 8 months, the major clinical outcomes including total MACE, cumulative mortality, Any MI, and repeat revascularization (target lesion & vessel revascularization; TLR & TVR), were higher in LMCA group (Table).

13 Twelve-Month Clinical Outcomes (on Multivariate analysis) Variables, N (%) LMCA Group (n=154 pts) Non-LMCA Group (n=6884 pts) P value Total deaths 23 (14.9) 320 (4.6) 0.006* Cardiac Deaths 19 (12.3) 184 (2.7) 0.010* Any MI 11 (7.1) 115 (1.7) 0.033* Repeat Revascularization 12 (7.8) 292 (4.2) 0.023* TLR-PCI 4 (2.6) 72 ( 1.0) TVR-PCI 8 (5.2) 116 (1.7) CABG 3 (1.9) 30 (0.4) Total MACE 40 (26.0) 741 (10.8) <0.001*

14 Conclusion The prevalence of LMCA disease was in less proportion (3.43%) in the AMI setting but showed worst cumulative eight-month major clinical outcomes due to very high in-hospital mortality, cumulative mortality, repeat revascularizations recurrent MI and higher total MACE in spite of the DES implantation.