Maartje Vis

The most common cause of cardiogenic shock is myocardial ischemia developing early or late in the course of acute myocardial infarction. The incidence of cardiogenic shock (CS) is around 7% in ST-segment elevation myocardial infarction (STEMI) patients and has remained constant over the last 20 years. Therapy should be chain based by increased patient's awareness. Early and prehospital diagnosis and treatment, with prompt transfer to a catheterization laboratory. Early revascularization is the cornerstone treatment of acute myocardial infarction complicated by cardiogenic shock. According to the guidelines, revascularization is effective up to 36 hours after the onset of CS and performed within 18 hours after the diagnosis of CS. Primary percutaneous coronary intervention (PCI) is the most efficient and easily available therapy to restore coronary flow in the infarct related artery. Although recommended, there is little evidence that immediate multivessel PCI is beneficial for C...

Despite the advances in treatment for acute ST-elevation myocardial infarction (STEMI) during the past decades for both men and women, most previous studies reported on significantly higher unadjusted in-hospital and long-term mortality rates among women compared with men. Most of these studies have been performed in the (pre-)thrombolytic and early post-thrombolytic era. Many studies reported on myocardial infarction or acute coronary syndromes and did not specifically address STEMI. Moreover, the association of gender, quality of care and mortality has not been systematically assessed. Early as well as long-term clinical outcome and delivered quality care was evaluated in an unselected cohort of 3,277 (2,367 men and 910 women) consecutive STEMI patients treated by primary PCI in a tertiary referral institution between January 1995 and 2006. Mean follow-up was 3.2+/-2.2 years. The unadjusted early and late hazards of mortality were not significantly different between men and women ...

This study sought to evaluate 30-day all-cause mortality of patients treated with primary percutaneous coronary intervention (PCI) presenting with an acute myocardial infarction (AMI) due to an unprotected left main coronary artery (ULMCA) culprit lesion. In addition, an average estimated mortality rate was extrapolated from the available data. There are limited data available on clinical outcome after primary PCI in patients presenting with AMI with unprotected left main as the infarct-related coronary artery. Medical literature databases were searched to identify cohort studies reporting on primary PCI for unprotected left main-related AMI. A total of 13 retrospective studies meeting all pre-specified criteria were included in the meta-analysis. No randomized trials were available. The primary endpoint for the meta-analysis was 30-day all-cause mortality. This meta-analysis comprises a total of 977 patients, of which 252 (26%) presented in cardiogenic shock. Thirty-day all-cause mortality was evaluated using a forest plot analysis and showed higher event rates in patients presenting with cardiogenic shock among all subgroups. The average estimated 30-day all-cause mortality was 15% in patients presenting without signs of cardiogenic shock and 55% in patients presenting with cardiogenic shock (relative risk: 3.74, 95% confidence interval [CI]: 2.95 to 4.76, p < 0.001). In this large meta-analysis of patients treated with primary PCI for AMI due to an ULMCA culprit lesion, the 30-day all-cause mortality in patients presenting with shock is much higher than in patients not presenting with shock. The estimated all-cause mortality data may serve as a benchmark for future reference.

This study aimed to compare radiation exposure of patients undergoing percutaneous coronary interventions (PCI) and coronary angiograms (CAG) accessed by the femoral route with the radial route (operator's choice). There are limited and contradictory data on the radiation exposure of patients during PCI and CAG performed by the radial route compared with the femoral route. Data on the radiation exposure of patients from 3,973 PCI and CAG procedures between June 22, 2004, and December 31, 2008, were prospectively collected and analyzed. A prediction model was made for radiation exposure (dose-area product in Gy·cm(2)) based upon the femoral access group, and the group of radial performed procedures was compared to assess differences between observed and expected radiation exposure. Median exposures of patients undergoing a PCI via the femoral route (n = 2,309) was 75 (interquartile range [IQR]: 44 to 135) Gy·cm(2) compared with 72 (IQR: 42 to 134) Gy·cm(2) for radial performed procedures (n = 1,212) (p = 0.30). Median exposure for CAGs was 44 (IQR: 31 to 69) Gy·cm(2) and 40 (IQR: 25 to 65) Gy·cm(2) for, respectively, femoral (n = 314) and radial performed procedures (n = 138), (p = 0.31). Also, the observed radiation exposure in patients undergoing radial PCI or CAGs was not higher than the expected exposure of patients as predicted by the femoral access-based prediction model (71.5 ± 2.3 Gy·cm(2) vs. 79.9 ± 1.8 Gy·cm(2,)). The study shows that even after correction for the complexity of the procedures, selected procedures performed by the radial route are not associated with higher radiation exposure of patients than selected procedures performed by the femoral route.

The general population is gradually ageing in the western world. Therefore, the number of octogenarians undergoing primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) is increasing. We aim to provide insight into temporal trends in the annual proportions of octogenarians among STEMI patients undergoing primary PCI and their clinical characteristics and outcomes over an 11-year observational period. Single-centre observational study. Between 1997 and 2007, 4506 STEMI patients were treated with primary PCI at the authors' institution. Patients aged over 80 years were identified. Temporal trends in the annual proportion of octogenarian STEMI patients and their baseline characteristics, 30-day and 1-year mortality were analysed. A total of 379 octogenarians (8.4% of the total population) was treated with primary PCI between 1997 and 2007. Over time, the annual proportion of octogenarians gradually increased from four of 113 (3.5%) in 1997 ...

Guidelines strongly recommend additional intra-aortic balloon pump (IABP) therapy in STEMI patients with cardiogenic shock (CS) treated by primary percutaneous coronary intervention (PCI). However, there is no randomised evidence suggesting survival benefit of IABP treatment in CS. It is suggested that timing of initiation of IABP therapy could be of great importance. Therefore, we compared mortality rates of IABP therapy versus no IABP therapy in the setting of STEMI complicated by CS. In addition, we investigated the effect of initiation of IABP therapy on mortality. From a cohort of 292 STEMI patients with CS treated by primary PCI, 199 patients received IABP therapy (IABP group) and 93 patients received no support (no IABP group). The IABP group was divided into two subgroups based on timing of initiation of support, i.e. 'IABP pre PCI' (n = 59) and 'IABP post PCI' (n = 140). Outcomes were assessed by propensity stratification and multivariate logistic regression...

Limited data are available on the predictors and implications of gastrointestinal (GI) bleeding in ST-segment elevation myocardial infarction (STEMI) patients treated with primary percutaneous coronary intervention (PPCI) and dual antiplatelet therapy. Predictors of and clinical outcome after GI bleeding were assessed in 2002 STEMI patients undergoing PPCI between 1-1-2003 and 31-07-2008. 139 patients suffered GI bleeding during a median follow-up of 4.9years. Predictors of GI bleeding were age, history of bleeding, anemia, baseline thrombocytopenia, previous coronary artery bypass grafting, cardiogenic shock, anterior infarction and the use of GP IIb/IIIa inhibitor. By multivariable analysis, a first occurrence of GI bleeding was associated with a twofold increase in risk of subsequent GI bleeding (hazard ratio (HR) 2.19; 95% confidence interval (CI) 1.15-4.17). GI bleeding was not significantly associated with subsequent major adverse cardiac events (HR 1.33; 95% CI 0.98-1.79), cardiac (HR 1.40; 95% CI 0.97-2.02) and all-cause mortality (HR 1.34; 95% CI 0.96-1.85), recurrent MI (HR 0.97; 95% CI 0.58-1.63), stroke (HR 1.26; 95% CI 0.57-2.79) or stent thrombosis (HR 0.71; 95% CI 0.33-1.69). Among STEMI patients undergoing PPCI, the risk of GI bleeding is related to a number of risk factors, including advanced age, previous (GI) bleeding, GP IIB/IIIA inhibitors, anterior infarction and anemia. GI bleeding does not substantially increase the risk of subsequent recurrent ischemic events in STEMI patients undergoing PPCI, whereas the risk of GI bleeding after a first occurrence is more than doubled.

To assess the predictive value of three biomarkers for mortality in ST-segment elevation myocardial infarction (STEMI) with cardiogenic shock. STEMI complicated by cardiogenic shock accounts for the majority of STEMI related deaths. Patients with STEMI and hyperglycemia, anemia or kidney dysfunction on admission have a poor prognosis. As data on the combination of those three established predictors of mortality are sparse in STEMI with cardiogenic shock, the objective of the current study was to investigate their predictive value in STEMI patients with cardiogenic shock. Between 1997 and 2005, a total of 3038 patients presented with STEMI and were treated with percutaneous coronary intervention (PCI). On admission 292 patients presented with cardiogenic shock. Glucose, hemoglobin and creatinine clearance were available in 183 out of 292 patients. Overall 1-year mortality was 34%. In multivariate logistic regression analysis, only glucose remained a strong independent predictor for m...

To study online left ventricular (LV) dynamic effects of transmural ischaemia and reperfusion during consecutive balloon coronary occlusions in the setting of percutaneous coronary intervention (PCI). In 10 consecutive unselected patients with stable angina (seven males, mean age 62 ± 3 years) who underwent elective PCI, LV dynamics were continuously recorded using a pressure-conductance catheter to simultaneously measure pressure and volume (PV-loop). The effects of a prolonged balloon coronary occlusion (148 ± 19 s) and a second occlusion on various LV function parameters were studied, as well as recovery of these parameters after reperfusion. Ischaemia caused an immediate (<5 s) decrease in diastolic function, followed by a decrease in contractile function, indicated by a rightward shift of the PV-loop, and a decreased dP/dtmax and ejection fraction. All parameters recovered within two minutes after reperfusion. The second occlusion caused a more rapid and more pronounced decr...

Accelerated idioventricular rhythm (AIVR) is very frequently observed in primary percutaneous coronary intervention (PCI), however knowledge of the haemodynamic effects is lacking. We studied an ST-segment elevation myocardial infarction cohort of 128 consecutive patients (aged 62±11 years) in whom AIVR occurred following reperfusion during primary PCI. Mean systolic blood pressure (SBP), diastolic blood pressure (DBP) and heart rate were determined during periods of AIVR and sinus rhythm. We grouped patients according to the infarct-related artery and the site of the coronary occlusion. AIVR caused an immediate reduction in SBP (130±27 vs. 98±22 mmHg, p<0.001) and DBP (80±19 vs. 69±16 mmHg, p<0.001) and a small increase in heart rate (78±12 vs. 83±11 bpm, p<0.001) as compared to sinus rhythm, irrespective of infarct-related artery. Both absolute as well as relative reduction in SBP were more pronounced in distal than proximal left coronary artery (LCA) occlusions (36±16 vs...

Myocardial injury is a common complication during cardiac surgery and percutaneous coronary intervention and is associated with postprocedural cardiovascular morbidity and mortality. Limited data have been reported about the occurrence of myocardial damage associated with transcatheter aortic valve implantation (TAVI). Therefore, our purpose was to investigate the incidence, predictors, and prognostic value of myocardial injury during TAVI. We studied 119 patients (aged 81±8 years; 47 male) who had undergone a TAVI with the Medtronic-CoreValve bioprosthesis. Serum creatine kinase-MB (CK-MB) and cardiac troponin T (cTnT) levels were measured before and after the procedure. Myocardial injury was defined as a postprocedural increase of CK-MB and/or cTnT level >5 times the upper reference limit. After TAVI, the incidence of myocardial injury was 17%, which was independently predicted by procedural duration (in minutes) (odds ratio [OR], 1.04; 95% CI, 1.01-1.06), preprocedural β-block...

This study sought to investigate the prognostic value of access site bleeding (ASB) and non-ASB for recurrent ischemic outcomes and mortality in patients with ST-segment elevation myocardial infarction (STEMI). The prognostic value of ASB-related complications after STEMI is subject to debate. The prognostic value of ASB and non-ASB for 1-year mortality, recurrent myocardial infarction (MI), stent thrombosis, and stroke was investigated in 2,002 STEMI patients undergoing primary percutaneous coronary intervention. In addition, we performed a meta-analysis of studies investigating the prognostic value of ASB and non-ASB in patients undergoing percutaneous coronary intervention. Seventy-four patients (3.7%) were treated by radial access. ASB developed in 124 patients (6.3%) and non-ASB developed in 102 (5.2%). By multivariable analysis, ASB was not associated with a higher risk of 1-year mortality (hazard ratio [HR]: 1.03; p = 0.89), recurrent MI (HR: 1.16; p = 0.64), stent thrombosis (HR: 0.55; p = 0.42), or stroke (HR: 0.47; p = 0.31). Non-ASB was independently associated with 1-year mortality (HR: 2.77; p < 0.001) and stent thrombosis (HR: 3.10; p = 0.021), but not with recurrent MI and stroke. In a meta-analysis including 495,630 patients, non-ASB was associated with a greater adjusted risk of subsequent 1-year mortality than ASB (HR: 1.66; 95% CI: 1.56 to 1.76 and HR: 1.21; 95% CI: 1.11 to 1.31). In STEMI, ASB was not significantly associated with 1-year clinical outcomes, whereas non-ASB was significantly associated with 1-year mortality and stent thrombosis. These results taken together with those of previous studies indicate a greater risk of subsequent mortality in patients with non-ASB.

Unfractionated heparin is the most commonly used anticoagulant in ST-elevation myocardial infarction (STEMI) and its effect can be monitored with activated partial thromboplastin time (aPTT). However, the optimal aPTT range during heparin therapy after primary percutaneous coronary intervention (PCI) is yet to be defined. A mean aPTT was calculated of all aPTT measurements in the first 24 hours after pPCI in a total of 1,876 STEMI patients. Mean aPTT measurements were stratified into four categories; < 1.5 times the upper limit of normal (ULN), 1.5 - 2.0 times ULN (the therapeutic group), 2.01 - 3.99 times ULN, and ≥ 4 times ULN. Compared to patients with a therapeutic aPTT, patients with aPTTs < 1.5 times ULN had no increase in recurrent ischaemic events and had similar rates of bleeding complications. Patients with a mean aPTT ≥ 4 times ULN had higher rates recurrent ischaemic and haemorrhagic complications. After multivariable analyses, aPTT ratios ≥ 4 times ULN were no longer associated with recurrent ischaemic events, but remained a strong predictor of severe and moderate bleeding (hazard ratio [HR] 4.64, p = 0.016 and HR 2.27, p = 0.052). In conclusion, in 1,876 STEMI patients treated with pPCI, low aPTTs in the first 24 hours after PCI were not associated with an increase in ischaemic events, whereas high aPTT values were associated with more frequent bleeding complications. These results indicate no clear benefit as well as a safety concern with heparin treatment after primary PCI.

We evaluated 30-day and 1-year clinical outcomes after percutaneous or surgical coronary revascularisation in patients with unprotected left main coronary artery (ULMCA)-related acute myocardial infarction (AMI). Single-centre registry. Between January 1998 and December 2008, 84 patients with ULMCA-related AMI underwent revascularisation treatment in our institution (55 underwent percutaneous coronary intervention (PCI), 29 underwent coronary artery bypass graft surgery (CABG)). One-year clinical follow-up was obtained for all patients. Univariable and multivariable analyses were performed to find predictors for 30-day mortality and treatment allocation. In the PCI-group, all-cause mortality was 64% at 30 days and 69% at 1 year. In the CABG-group, this was 24% at 30 days and 1 year. Independent predictors of 30-day mortality were cardiogenic shock (HR 2.83), thrombolysis in MI (TIMI) 0/1 flow (HR 2.27) and diabetes mellitus (HR 2.65). Treatment allocation to PCI was primarily determined by TIMI 0/1 flow on baseline angiogram (OR 150). In patients with TIMI 2/3 flow on initial angiogram, treatment allocation was determined by presentation with cardiogenic shock (OR 5.61), year of inclusion (OR 1.72), and distal/bifurcation disease (OR 0.11). Thirty-day mortality was high in patients presenting with an ULMCA-related AMI, both in the PCI as in the CABG-treatment group. Presentation with cardiogenic shock, TIMI 0/1 flow on initial angiogram and diabetes mellitus were independently predicting of 30-day mortality, whereas treatment allocation was primarily determined by presentation with TIMI 0/1 flow.

Despite improvement in prognosis for ST-elevation myocardial infarction (STEMI) patients, mortality remains high in STEMI patients presenting with cardiogenic shock (CS). Right ventricular (RV) dysfunction is an established independent predictor for adverse prognosis in STEMI patients without CS. The purpose of our study was to determine the prognostic value of RV dysfunction on admission in STEMI patients presenting in CS. Two hundred and ninety-two consecutive STEMI patients with CS on admission were treated by primary percutaneous coronary intervention (PCI) from January 1997 through March 2005. RV function was assessed by measurement of tricuspid annular plane systolic excursion (TAPSE) on early echocardiography in 184 of 292 patients. Right ventricular dysfunction was defined as a TAPSE of <or=14 mm. Right ventricular dysfunction was present on early echocardiography in 70 of 184 patients (38%). The Kaplan-Meier estimate for overall 4-year survival was 57%. Kaplan-Meier estimates for 4-year survival in patients with and without RV dysfunction were 33 and 73%, respectively (P< 0.001). Cox-regression analysis revealed a hazard ratio of 2.1 (95% CI 1.3-3.4, P = 0.002) for RV dysfunction when adjusted for age, glucose on admission, and LVEF < 40%. In patients with and without RV dysfunction, the right coronary artery was the infarct-related artery in 41 and 28% of patients, respectively (P = 0.06). In STEMI patients presenting with CS on admission and treated with primary PCI, RV dysfunction as assessed by echocardiography is an independent predictor for long-term mortality.

To evaluate the impact of multivessel disease (MVD) with and without a chronic total occlusion (CTO) on early and late mortality in ST-elevation myocardial infarction (STEMI) patients with and without cardiogenic shock (CS). A total of 5018 STEMI patients were treated with primary percutaneous coronary intervention and stratified according to the presence of CS and the extent of coronary artery disease into single vessel disease (SVD), MVD without a CTO, and MVD with a CTO. We performed a landmark mortality analysis up to 5-year follow-up with a landmark set at 30 days. In patients without CS (n = 4409), only MVD with a CTO was an independent predictor for 30-day [hazard ratio (HR) 2.8, P < 0.01] and 5-year mortality (HR 1.7, P < 0.01), whereas MVD without a CTO was not associated with increased mortality. In CS patients (n = 609), MVD with and without a CTO were independent predictors for 30-day mortality (HR 2.2, P < 0.01 and HR 1.8, P < 0.01). In 30-day CS survivors, only MVD with a CTO was associated with a trend towards increased mortality (HR 1.7, P = 0.06). In non-CS STEMI patients with MVD, the presence of a co-existing CTO in a non-infarct-related artery drives early and late mortality. In patients with CS, MVD with and without a CTO were predictors for short-term mortality.

In patients with obstructive coronary artery disease (CAD), the growth of collateral arteries, i.e. arteriogenesis, can preserve myocardial tissue perfusion and function. Monocytes modulate this process, supplying locally the necessary growth factors and degrading enzymes. Knowledge on factors involved in human arteriogenesis is scarce. Thus, the aim of the present study is to identify targets in monocytes that are critical for arteriogenesis in patients with CAD. A total of 50 patients with a chronic total coronary occlusion were dichotomized according to their collateral flow index. From each patient, RNA was isolated from unstimulated peripheral blood monocytes, monocytes stimulated by lipopolysaccharide (LPS) or interleukin (IL)-4, and from macrophages. Increased mRNA expression of galectin-2 was found in three out of four monocytic cell types of patients with a low capacity of the collateral circulation (P= 0.03 for unstimulated monocytes; P= 0.02 for LPS-stimulated monocytes; P= 0.20 for IL-4-stimulated monocytes; P= 0.02 for macrophages). Additionally, galectin-2 mRNA expression was significantly associated with the rs7291467 polymorphism in LGALS2 encoding galectin-2 in all four monocytic cell types. Patient with the rs7291467 CC genotype displayed highest galectin-2 expression, and also tended to have a lower arteriogenic response. To evaluate the effect of galectin-2 on arteriogenesis in vivo, we used a murine hindlimb model. Treatment with galectin-2 markedly impaired the perfusion restoration at Day 7. Collectively, these results identify galectin-2 as a novel inhibitor of arteriogenesis. Modulation of galectin-2 may constitute a new therapeutic strategy for the stimulation of arteriogenesis in patients with CAD.