CARDIOVASCULAR JOURNAL OF AFRICA • Vol 23, No 9, October 2012
AFRICA
499
who were treated using emergency PCI compared to STDMI
patients who went without revascularisation. Moreover, the
PCI success rate was significantly higher in STDMI compared
to STEMI patients (
p
=
0.012).
All these factors indicate that
emergency CAG and PCI, when appropriate, should be used in
all STDMI patients.
Early versus delayed invasive intervention in patients with
ACS without ST-segment elevation was studied in the TIMACS
trial.
29
Early intervention did not differ greatly from delayed
intervention in preventing the primary outcome, but it did reduce
the rate of the composite secondary outcome of death, MI or
refractory ischaemia, and was superior to delayed intervention
in high-risk patients.
Our study demonstrates the apparent positive development in
invasive reperfusion treatment for acute myocardial infarction.
Some form of reperfusion therapy was used in 89.1% of STEMI
and 69.8% of NSTEMI patients. Of those, emergency PCI was
used in 88.1% of STEMI and in 61.8% of NSTEMI patients.
By comparison, in the GRACE study (1999–2000),
30
the use
of pPCI was a relatively rare reperfusion modality in STEMI.
Lytic therapy was used in more than 75% of patients who
received reperfusion therapy; only 62% of STEMI patients
received any form of reperfusion. The in-hospital fatality rates
were 7% in STEMI and 6% in NSTEMI patients (
p
=
0.0459).
This positive and increasing trend of invasive treatment in AMI
patients should be minimally maintained in STEMI cases, and
there should be an effort made to increase the number in STDMI
patients.
The presence of bundle brunch block(s) (BBBs) is associated
with poor outcomes in patients suffering from an AMI. In our
MI population, these patients represented the highest risk group,
with in-hospital mortality more than double that of STDMI
or STEMI patients. Patients with BBBs were older and more
frequently had a history of diabetes mellitus. The mean left
ventricular ejection fraction was lower compared with AMI
patients without BBBs (
p
<
0.001).
These findings support the
results of Guerrero
et al
.
31
who sought to evaluate the outcome of
patients with AMI and BBBs, who were treated using emergency
PCI. The in-hospital mortality was significantly different (LBBB
14.6%
vs RBBB 7.4% vs no BBB 2.8%).
Patients presenting with minor or no ECG abnormalities
(
without ST-segment shifts and without a bundle branch block)
had the lowest mortality compared with all other groups (2.9%,
p
<
0.001).
Additionally, heart failure was rare (Killip class I on
admission was seen in 84.5% of all patients in this group).
Limitations
This study was based on the data from a registry that was
retrospectively analysed. The very short follow-up period was
a limitation. Our results did not evaluate long-term outcomes.
No data were collected regarding previous or in-hospital drug
treatment. Post-discharge treatment (secondary prevention) was
also not studied.
Conclusions
The results of our study demonstrate that ST-depressionAMI may
represent an emergency similar to ST-elevation AMI. Therefore
it would be accompanied by the same need for emergency
coronary angiography and PCI when appropriate. STDMI
patients in our study had comparable in-hospital mortality and
were much closer, relative to treatment strategies and outcomes,
to STEMI patients than to AMI patients without ST-segment
shifts. Therefore, in the ‘post-thrombolytic’ era, emergency CAG
and PCI, when appropriate, should be considered for high-risk
patients with STDMI.
This work was supported by the Charles University Prague, research project
UNCE204010.
References
1.
Davies MJ, Thomas AC. Plaque fissuring – the cause of acute myocar-
dial infarction, sudden ischaemic death, and crescendo angina.
Br Heart
J
1985;
53
: 363–373.
2.
Falk E, Shah PK, Fuster V. Coronary plaque disruption.
Circulation
1995;
92
: 657-671.
3.
Falk E: Pathogenesis of atherosclerosis.
J Am Coll Cardiol
2006;
47
:
C7–12.
4.
Virmani R, Kolodgie FD, Burke AP, Farb A, Schwartz SM. Lessons
from sudden coronary death: A comprehensive morphological clas-
sification scheme for atherosclerotic lesions.
Arterioscler Thromb Vasc
Biol
2000;
20
: 1262–1275.
5.
Rittersma SZ, van der Wal AC, Koch KT,
et al.
Plaque instability
frequently occurs days or weeks before occlusive coronary thrombosis:
A pathological thrombectomy study in primary percutaneous coronary
intervention.
Circulation
2005;
111
: 1160–1165.
6.
Brilakis ES, Reeder GS, Gersh BJ. Modern management of acute
myocardial infarction.
Curr Probl Cardiol
2003;
28
: 7–127.
7.
Keeley EC, Grines CL. Primary coronary intervention for acute
myocardial infarction.
J Am Med Assoc
2004;
291
: 736–739.
8.
Dalby M, Bouzamondo A, Lechat P, Montalescot G. Transfer for
primary angioplasty versus immediate thrombolysis in acute myocar-
dial infarction: A meta-analysis.
Circulation
2003;
108
: 1809–1814.
9.
Hochman JS, Sleeper LA, Webb JG,
et al
.
Early revascularization in
acute myocardial infarction complicated by cardiogenic shock. Shock
investigators. Should we emergently revascularize occluded coronaries
for cardiogenic shock.
N Engl J Med
1999;
341
: 625–634.
10.
Kastrati A, Mehilli J, Nekolla S,
et al.
A randomized trial comparing
myocardial salvage achieved by coronary stenting versus balloon angio-
plasty in patients with acute myocardial infarction considered ineligible
for reperfusion therapy.
J Am Coll Cardiol
2004;
43
: 734–741.
11.
Widimsky P, Groch L, Zelizko M, Aschermann M, Bednar F,
Suryapranata H. Multicentre randomized trial comparing transport to
primary angioplasty vs immediate thrombolysis vs combined strategy
for patients with acute myocardial infarction presenting to a community
hospital without a catheterization laboratory. The PRAGUE study.
Eur
Heart J
2000;
21
: 823–831.
12.
Widimsky P, Budesinsky T, Vorac D,
et al.
Long distance transport for
primary angioplasty vs immediate thrombolysis in acute myocardial
infarction. Final results of the randomized national multicentre trial –
PRAGUE-2.
Eur Heart J
2003;
24
: 94–104.
13.
Van de Werf F, Bax J, Betriu A,
et al
.
Management of acute myocardial
infarction in patients presenting with persistent ST-segment elevation:
The task force on the management of ST-segment elevation acute
myocardial infarction of the European Society of Cardiology.
Eur Heart
J
2008;
29
: 2909–2945.
14.
Cannon CP, Weintraub WS, Demopoulos LA,
et al
.
Comparison of
early invasive and conservative strategies in patients with unstable
coronary syndromes treated with the glycoprotein iib/iiIa inhibitor
tirofiban.
N Engl J Med
2001;
344
: 1879–1887.
15.
Invasive compared with non-invasive treatment in unstable coronary-
artery disease: Frisc ii prospective randomised multicentre study.
Fragmin and fast revascularisation during instability in coronary artery
disease investigators.
Lancet
1999;
354
: 708–715.
16.
Wallentin L, Lagerqvist B, Husted S, Kontny F, Stahle E, Swahn E.
Outcome at 1 year after an invasive compared with a non-invasive
strategy in unstable coronary-artery disease: The frisc ii invasive
randomised trial. frisc ii investigators. Fast revascularisation during
