Optimal timing of percutaneous coronary intervention for non-ST elevated myocardial infarction with congestive heart
Yongwhan Lim1, Min Chul Kim1, Joon Ho Ahn1
1Department of Cardiovascular Medicine, Chonnam National University Medical School/Hospital, Gwangju, South Korea.
Insights
Optimal timing for percutaneous coronary intervention (PCI) in non-ST-elevation myocardial infarction (NSTEMI) with heart failure (HF) depends on HF severity. Delayed PCI (after 24 hours) showed better outcomes for patients with severe HF (Killip class 3).
Area of Science:
- Cardiology
- Interventional Cardiology
- Heart Failure Management
Background:
- Non-ST-elevation myocardial infarction (NSTEMI) frequently co-occurs with heart failure (HF), presenting complex management challenges.
- The optimal timing for percutaneous coronary intervention (PCI) in NSTEMI patients with concurrent HF remains a critical clinical question.
Purpose of the Study:
- To investigate the impact of early versus delayed PCI on clinical outcomes in NSTEMI patients with varying degrees of heart failure.
- To determine if HF severity, stratified by Killip classification, influences the benefit of early revascularization.
Main Methods:
- A prospective, multicenter registry study in South Korea included 762 NSTEMI patients with HF.
- Patients were classified by Killip class (2 or 3) and underwent either early (≤24 hours) or delayed (>24 hours) PCI.
- Primary outcome was all-cause mortality at two months, with secondary outcomes including cardiovascular death, cardiogenic shock, and HF readmission.
Main Results:
- In Killip class 3 patients, delayed PCI was associated with significantly lower 2-month mortality (6.1% vs. 15.8%) and in-hospital cardiogenic shock (4.3% vs. 14.1%) compared to early PCI.
- Multivariate analysis confirmed a reduced risk of 2-month mortality (HR=0.38) and in-hospital cardiogenic shock (HR=0.29) with delayed PCI in Killip class 3 patients.
- No significant differences in outcomes were observed between early and delayed PCI for Killip class 2 patients.
Conclusions:
- The optimal timing for PCI in NSTEMI patients with HF should be individualized based on HF severity.
- Delayed PCI (after 24 hours) is a safer and more effective strategy for patients with NSTEMI and severe heart failure (Killip class 3).
- For NSTEMI patients with less severe HF (Killip class 2), the timing of PCI does not appear to significantly impact major adverse outcomes.
Objectives:
This study investigated the optimal timing for percutaneous coronary intervention (PCI) in patients with NSTEMI complicated by heart failure (HF).
Methods:
In total, 762 patients with NSTEMI and HF in a multicenter, prospective registry in South Korea were classified according to the Killip classification (Killip class 2, n = 414 and Killip class 3, n = 348) and underwent early (within 24 h) and delayed (after 24 h) PCI. The primary outcome was all-cause mortality which was further analyzed with landmark analysis with two months as a cut-off. Secondary outcomes were cardiovascular death, in-hospital cardiogenic shock (CS), readmission due to HF, and acute myocardial infarction during follow-up.
Results:
Delayed PCI was associated with lower rates of 2-month mortality (6.1 % vs. 15.8 %, p = 0.007) and in-hospital CS (4.3 % vs. 14.1 %, p = 0.003), along with lower risks of 2-month mortality (hazard ratio [HR] = 0.38, 95 % confidence interval [CI] = 0.18-0.83, p = 0.014), in-hospital CS (HR = 0.29, 95 % CI = 0.12-0.71, p = 0.006) in multivariate Cox models of Killip class 3 patients. There was no statistical difference of incidence and risk of all predefined outcomes according to varying timing of PCI in Killip 2 patients.
Conclusions:
Based on these results, the timing of PCI in patients with NSTEMI complicated by HF should be determined based on HF severity. Delayed PCI should be considered in patients with NSTEMI and more severe HF.
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