Stroke after primary percutaneous coronary intervention in patients with ST-segment elevation myocardial infarction:
Jeffrey T Guptill1, Rajendra H Mehta, Paul W Armstrong
1Duke Clinical Research Institute, Durham, NC 27705, USA.
Insights
Stroke is a rare complication after ST-elevation myocardial infarction treated with primary percutaneous coronary intervention (PCI). This complication significantly increases the risk of death and other adverse outcomes within 90 days.
Area of Science:
- Cardiology
- Neurology
- Clinical Trials
Background:
- Stroke is a rare but serious complication following acute myocardial infarction.
- Limited data exists on stroke timing, characteristics, and outcomes in ST-elevation myocardial infarction (STEMI) patients treated with primary percutaneous coronary intervention (PCI).
Purpose of the Study:
- To investigate the incidence, timing, type, and clinical outcomes of stroke in patients with STEMI undergoing primary PCI.
- To assess the association between stroke and 90-day clinical outcomes.
Main Methods:
- Analysis of 5372 patients from the APEX-AMI trial.
- Cox proportional hazards modeling was used to evaluate the relationship between stroke and outcomes, adjusting for baseline characteristics and treating stroke as a time-dependent covariate.
Main Results:
- Stroke occurred in 1.3% of patients (n=69).
- Ischemic strokes accounted for 33%, hemorrhagic for 12%, and 55% were of uncertain type.
- Stroke was significantly associated with increased 90-day mortality (adjusted HR, 5.6) and a composite endpoint of death, heart failure, or cardiogenic shock (adjusted HR, 2.4).
Conclusions:
- Stroke is an infrequent but significant complication in STEMI patients treated with primary PCI.
- Stroke is associated with substantially increased morbidity and mortality.
- Further research is needed to understand mechanisms of stroke occurring more than 48 hours after primary PCI.
Background:
Stroke is a rare but potentially devastating complication of acute myocardial infarction. Little is known about stroke timing, characteristics, and clinical outcomes in patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention (PCI).
Methods And Results:
We studied 5372 patients enrolled in the Assessment of Pexelizumab in Acute Myocardial Infarction (APEX-AMI) trial. We analyzed stroke incidence, type, timing, and association with the prespecified 90-day clinical outcomes. Cox proportional hazards modeling was performed to assess the relationship between stroke and outcomes, after adjusting baseline characteristics and analyzing stroke as a time-dependent covariate. Stroke occurred in 69 primary patients with PCI (1.3%). A third of strokes were ischemic (n=23; 33%), 12% (n=8) were hemorrhagic, and the remaining 55% (n=38) were of uncertain type. The median (25th, 75th percentile) time of stroke occurrence was 6 (3, 14) days. Overall, 43% of strokes occurred within 48 hours of PCI, and all hemorrhagic strokes occurred within 48 hours. Stroke was associated with an increased risk of 90-day death (unadjusted hazard ratio [HR], 8.0; 95% confidence interval [CI], 4.8-13.5), congestive heart failure (unadjusted HR, 3.2; 95% CI, 1.3-7.8), and 30-day hospital readmission (unadjusted HR, 3.2; 95% CI, 2.0-5.1). After adjustment, stroke was still strongly associated with 90-day death (adjusted HR, 5.6; 95% CI, 3.2-9.8) and the combination end point of death, congestive heart failure, or cardiogenic shock at 90 days (adjusted HR, 2.4; 95% CI, 1.2-4.7).
Conclusions:
Stroke is an infrequent complication in the setting of ST-segment elevation myocardial infarction treated with primary PCI but is associated with increased morbidity and mortality. Studies to determine mechanisms that may be responsible for strokes that occur >48 hours from primary PCI are warranted.
Clinical Trial Registration:
URL: http://www.clinicaltrials.gov. Unique identifier: NCT00091637.
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