Early survival after acute myocardial infarction with ST-segment elevation: What could be improved? Insights from France PCI French registry

Abstract

Early mortality post-ST-segment elevation myocardial infarction (STEMI) in France remains high. The multicentre France Percutaneous Coronary Intervention Registry includes every patient undergoing coronary angiography in France. We analyzed the prevalence and impact of unmodifiable and modifiable risk factors on 30-day survival in patients experiencing STEMI. Patients admitted for STEMI between 01/2014 and 12/2016 were included in the analysis. Patients with nonobstructive coronary artery disease, with cardiogenic shock or cardiac arrest without STEMI, were excluded. Prehospital, clinical and procedural data were collected prospectively by the cardiologist in the cath lab using medical reporting software. Information on outcomes, including mortality, was obtained by a dedicated research technician by phone calls or from medical records. Marginal Cox proportional hazards regression was used to test the predictive value for survival at 30 days in a multivariable analysis. Included were 2590 patients (74% men) aged 63 ± 14 years. During the first month, 174 patients (6.7%) died. After adjustment, unmodifiable variables significantly associated with reduced 30-day survival were: age > 80 years (prevalence 15%; hazard ratio [HR] 2.7; 95% confidence interval [CI] 1.5-4.7), chronic kidney disease (2%; HR 5.3; 95% CI 2.6-11.1), diabetes mellitus (14%; HR 1.6; 95% CI 1.0-2.5), anterior or circumferential electrical localization (39%; HR 2.0; 95% CI 1.4-2.9), and Killip class 2, 3, or 4 (7%; HR 3.4; 95% CI 1.9-5.9; 2%; HR 10.1; 95% CI 5.3-19.4; 4%; HR 18; 95% CI 10.8-29.8, respectively). Among modifiable variables, total ischemic time > 3 hours (68%; HR 1.8; 95% CI 1.1-3.0), lack of appropriate premedication (18%; HR 2.2; 95% CI 1.5-3.3), and post-PCI TIMI < 3 (6%; HR 4.9; 95% CI 3.2-7.6) were significantly associated with reduced 30-day survival. Most predictors of 30-day survival post-STEMI are unmodifiable, but outcomes might be improved by optimizing modifiable factors, most importantly ischemic time and appropriate premedication.

Figure 1.

Study flow chart. The France PCI Registry enrolled every patient undergoing angiography and/or percutaneous coronary intervention in a participating cath lab. This study analyses data from January 2014 to December 2016. Angio = angiography, LTFU = lost to follow-up, PCI = percutaneous coronary intervention.

Figure 2.

Prevalence and impact of prognostic factors (unmodifiable and modifiable) on STEMI patients 30 days survival according to univariate and multivariate analysis. Impact on 30-d survival is shown on the right of the list of prognostic factors. The forest plot shows the results of univariate analysis (white boxes) and multivariate analysis (black boxes), using a logarithmic scale. To the right of the forest plot, hazard ratio, 95% confidence interval, and P value from the multivariate analyses are summarized. Prevalence is shown to the left of the list of prognostic factors. STEMI = ST-segment elevation myocardial infarction.