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Optimized Management of Endovascular Treatment for Acute Ischemic Stroke
Published on: January 18, 2018
Cerebrovascular events after a primary percutaneous coronary intervention strategy for acute ST-segment-elevation
Eugenia Nikolsky1, Roxana Mehran2, George D Dangas2
1From the Cardiology Department, Rambam Health Care Campus and the Technion-Israel Institute of Technology, Haifa, Israel (E.N.); Cardiovascular Research Foundation, New York, NY (R.M., G.D.D., K.X., R.P., P.G., S.J.B., G.W.S.); Icahn School of Medicine at Mount Sinai, New York, NY (R.M., G.D.D.); Helios Amper-Klinikum, Dachau, Germany (B.W.); Ospedale Papa Giovanni XXIII, Bergamo, Italy (G.G.); Rabin Medical Center, Petach-Tikva, Israel (R.K.); Hôpital du Sacré-Coeur de Montréal, Québec, Canada (P.G.); Columbia University Medical Center, New York, NY (P.G., G.W.S.); and New York Methodist Hospital, Brooklyn (S.J.B.). e_nikolsky@rambam.health.gov.il.
Insights
Cerebrovascular events occurred in 2.0% of ST-segment-elevation myocardial infarction patients treated with primary percutaneous coronary intervention. These events, often disabling, increased mortality and other complications.
Area of Science:
- Cardiology
- Neurology
- Clinical Trials
Background:
- ST-segment-elevation myocardial infarction (STEMI) patients face heightened risk of cerebrovascular events.
- Primary percutaneous coronary intervention (PCI) is a key STEMI management strategy.
- Understanding cerebrovascular event incidence, predictors, and outcomes in STEMI is crucial.
Purpose of the Study:
- To assess the incidence of cerebrovascular events in STEMI patients managed with primary PCI.
- To identify predictors of cerebrovascular events in this patient population.
- To evaluate the implications of cerebrovascular events on mortality, reinfarction, and bleeding.
Main Methods:
- Analysis of data from the Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction (HORIZONS-AMI) trial.
- Inclusion of 3602 patients with STEMI managed with a primary PCI strategy.
- 3-year follow-up to record cerebrovascular events, mortality, and other adverse outcomes.
Main Results:
- 2.0% of STEMI patients (72/3602) experienced cerebrovascular events within 3 years.
- Stroke occurred in 63 patients (92.1% ischemic), with over half being disabling.
- Predictors included older age, low creatinine clearance, coronary artery bypass grafting, anemia, and diabetes.
Conclusions:
- Cerebrovascular events occurred in 2.0% of STEMI patients treated with primary PCI, with higher rates after coronary artery bypass grafting.
- These events were frequently disabling and significantly associated with increased 3-year mortality.
- Cerebrovascular events strongly correlated with higher rates of reinfarction, ischemia-driven revascularization, and major bleeding.
Background:
Patients with ST-segment-elevation myocardial infarction are at increased risk of cerebrovascular events. We assessed the incidence, predictors, and implications of cerebrovascular events in patients with ST-segment-elevation myocardial infarction managed with a primary percutaneous coronary intervention strategy.
Methods And Results:
In the Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction (HORIZONS-AMI) trial, 72 of 3602 patients (2.0%) experienced at least 1 cerebrovascular event (stroke: 63 patients; transient ischemic attack: 12 patients) during the 3-year follow-up (40.3% within 30 days, 20.8% between 30 days and 1 year, and 38.9% between 1 and 3 years). Stroke was ischemic in 58 (92.1%) patients and hemorrhagic in 5 (7.9%) patients. More than half of all strokes (52.3%) were disabling. By principal management strategy, cerebrovascular events developed in 2.0%, 14.9%, and 1.9% of patients triaged to primary percutaneous coronary intervention, coronary artery bypass grafting, and medical therapy, respectively (P<0.0001). Cerebrovascular events were independently predicted by older age, creatinine clearance <60 mL/min, treatment with coronary artery bypass grafting, anemia, and diabetes mellitus. Cerebrovascular events were associated with significantly increased rates of 3-year mortality (20.5% versus 6.5%; P<0.0001), as well as reinfarction (14.3% versus 3.8%; P=0.0007), ischemia-driven target vessel revascularization (22.8% versus 13.0%; P=0.006), and major bleeding (23.5% versus 8.4%; P<0.0001).
Conclusions:
In HORIZONS-AMI, cerebrovascular events within 3 years after ST-segment-elevation myocardial infarction in patients undergoing a primary percutaneous coronary intervention management strategy occurred in 2.0% of patients and were most frequent after coronary artery bypass grafting. Cerebrovascular events were often disabling and were strongly associated with high rates of death, reinfarction, recurrent ischemia, and major bleeding.
Clinical Trial Registration:
URL: http://www.clinicaltrials.gov. Unique identifier: NCT00433966.
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