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Survival of patients undergoing rescue percutaneous coronary intervention: development and validation of a predictive
Sukesh C Burjonroppa1, Paul D Varosy, Sunil V Rao
1Fort Worth Heart PA, Fort Worth, Texas 76104, USA. sukeshbc@yahoo.com
Insights
The NCDR-RESCUE score predicts in-hospital mortality risk for patients undergoing rescue percutaneous coronary intervention (PCI) after ST-elevation myocardial infarction. This tool helps stratify patients into distinct risk categories for better clinical decision-making.
Area of Science:
- Cardiology
- Interventional Cardiology
- Health Outcomes Research
Background:
- ST-segment elevation myocardial infarction (STEMI) patients may require emergent percutaneous coronary intervention (PCI) if fibrinolytic therapy fails.
- Rescue PCI is indicated for ongoing myocardial ischemia despite initial treatment.
- Understanding mortality risk in this high-risk group is crucial for patient management.
Purpose of the Study:
- To develop and validate a predictive tool for in-hospital mortality risk following rescue PCI.
- To identify key pre-angiographic predictors of mortality in this patient population.
- To create the NCDR-RESCUE score for risk stratification.
Main Methods:
- Utilized the National Cardiovascular Data Registry (NCDR) to identify patients undergoing rescue PCI.
- Defined rescue PCI as nonelective PCI after failed fibrinolysis for STEMI.
- Employed multivariable logistic regression to identify mortality predictors and developed the NCDR-RESCUE score using 70% of the cohort, validating it on the remaining 30%.
Main Results:
- Identified 8,007 (4.8%) rescue PCI cases among 166,516 STEMI PCI procedures, with 5.8% in-hospital mortality.
- Key mortality predictors included age, glomerular filtration rate, heart failure history, diabetes, cardiogenic shock, and salvage status.
- The NCDR-RESCUE score effectively stratified patients into 6 risk categories, demonstrating strong discrimination (C-index = 0.88) and calibration (Hosmer-Lemeshow p = 0.898).
Conclusions:
- In-hospital mortality risk in rescue PCI patients spans a wide spectrum, from minimal to extreme.
- The NCDR-RESCUE score provides an easily calculable tool for assessing this risk.
- This score can aid in patient and family counseling and inform referring physician decisions.
Objectives:
This study sought to develop a tool for predicting an individual's risk of mortality following rescue percutaneous coronary intervention (PCI).
Background:
Although fibrinolytic therapy is appropriate and improves survival for certain ST-segment elevation myocardial infarction patients, a substantial proportion suffer ongoing myocardial ischemia, a class I indication for emergent percutaneous coronary intervention (rescue PCI).
Methods:
Using the National Cardiovascular Data Registry (NCDR), rescue PCI was defined as nonelective PCI following failed fibrinolysis in patients with continuing or recurrent myocardial ischemia. Multivariable logistic regression was used to determine mortality predictors and the C-statistic for model discrimination. The NCDR-RESCUE (Real-World Estimator of Survival in Catheterized STEMI Patients Following Unsuccessful Earlier Fibrinolysis) score was developed using a shortened list of 6 pre-angiographic variables and 70% of the cohort; performance was subsequently validated against the remaining 30%.
Results:
Among 166,516 PCI procedures on patients with an admission diagnosis of ST-segment elevation myocardial infarction, 8,007 (4.8%) represented rescue PCI. In-hospital mortality occurred in 464 (5.8%). Factors in the final model were age, glomerular filtration rate, history of congestive heart failure, insulin-treated diabetes, cardiogenic shock, and salvage status. The NCDR-RESCUE score effectively segregated individuals into 6 clinically meaningful risk categories, with 0.4% (0.0% to 1.3%), 1.6% (0.9% to 2.4%), 7.6% (5.3% to10.4%), 27.5% (20.7% to 35.1%), 64.2% (49.8% to 76.9%), or 100% (59.0% to 100.0%) risk, respectively, of in-hospital mortality (mean ± 95% confidence interval, C-index = 0.88, Hosmer-Lemeshow p = 0.898).
Conclusions:
In-hospital mortality risk among individuals undergoing rescue PCI varies from minimal to extreme and can be easily calculated using the NCDR-RESCUE score. This information can be of value in counseling patients, families, and referring caregivers.
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