Survival of Patients Undergoing Rescue Percutaneous Coronary Intervention: Development and Validation of a Predictive Tool

Study Questions:

What are the incidence and predictors of mortality in ST-segment elevation myocardial infarction (STEMI) patients undergoing rescue percutaneous coronary intervention (PCI) after failed fibrinolytic therapy?

Methods:

Using the American College of Cardiology National Cardiovascular Data Registry (NCDR), rescue PCI was defined as nonelective PCI following failed fibrinolysis in patients with continuing or recurrent myocardial ischemia. Multivariable logistic regression was used to determine mortality predictors and the C-statistic for model discrimination. The NCDR-RESCUE (NCDR–Real-World Estimator of Survival in Catheterized STEMI Patients Following Unsuccessful Earlier Fibrinolysis) score was developed using a shortened list of six preangiographic variables and 70% of the cohort; performance was subsequently validated against the remaining 30%.

Results:

Among 166,516 PCI procedures on patients with an admission diagnosis of STEMI, 8,007 (4.8%) represented rescue PCI. In-hospital mortality occurred in 464 patients (5.8%). Factors in the final model were age, glomerular filtration rate, history of congestive heart failure, insulin-treated diabetes, cardiogenic shock, and salvage status. The NCDR-RESCUE score effectively segregated individuals into six clinically meaningful risk categories, with 0.4% (0.0%-1.3%), 1.6% (0.9%-2.4%), 7.6% (5.3%-10.4%), 27.5% (20.7%-35.1%), 64.2% (49.8%-76.9%), or 100% (59.0%-100.0%) risk, respectively, of in-hospital mortality (mean ± 95% confidence interval, C-index = 0.88, Hosmer-Lemeshow p = 0.898).

Conclusions:

The authors concluded that in-hospital mortality risk among individuals undergoing rescue PCI varies from minimal to extreme, and can be calculated using the NCDR-RESCUE score.

Perspective:

The study suggests that it is possible to quickly place an individual patient after failed fibrinolytic therapy into one of six risk categories with mortality range between 0.4% in Category I to 100% in Category VI using the NCDR-RESCUE tool, derived from only six clinical input variables, all readily discernable before angiography. This tool has the potential to quickly and accurately provide the clinician with critical prognostic information to inform, triage, and guide patient and family discussions for this high-risk population, but needs to be externally validated against other databases outside of the NCDR CathPCI population.

Clinical Topics: Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Acute Heart Failure

Keywords: Shock, Cardiogenic, Thrombolytic Therapy, Myocardial Infarction, Hospital Mortality, Fibrinolysis, Heart Failure, Glomerular Filtration Rate, United States, Percutaneous Coronary Intervention


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