Primary Percutaneous Coronary Intervention for Unprotected Left Main Disease in Patients With Acute ST-Segment Elevation Myocardial Infarction: The AMIS (Acute Myocardial Infarction in Switzerland) Plus Registry Experience

Study Questions:

What are the outcomes in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) for unprotected left main (LM) disease?

Methods:

Of 9,075 patients with STEMI enrolled in the AMIS (Acute Myocardial Infarction in Switzerland) Plus registry between 2005 and June 30, 2010, 6,666 underwent primary PCI. Of those, 348 (5.2%; mean age, 63.5 ± 12.6 years) underwent LM PCI, either isolated (n = 208) or concomitant to PCI for other vessel segments (n = 140). They were compared with 6,318 patients (94.8%; mean age, 61.9 ± 12.5 years) undergoing PCI of non-LM vessel segments only.

Results:

The LM patients had higher rates of cardiogenic shock (12.2% vs. 3.5%; p < 0.001), cardiac arrest (10.6% vs. 6.3%; p < 0.01), in-hospital mortality (10.9% vs. 3.8%; p < 0.001), and major adverse cardiac and cerebrovascular events (MACCE) (12.4% vs. 5.0%; p < 0.001) than non-LM PCI. Rates of mortality and MACCE were highest for concurrent LM and non-LM PCI (17.9% and 18.6%, respectively), intermediate for isolated LM PCI (6.3% and 8.3%, respectively), and lowest for non-LM PCI (3.8% and 5.0%, respectively). Rates of mortality and MACCE for LM PCI were higher than for non-LM multivessel PCI (10.9% vs. 4.9%, p < 0.001, and 12.4% vs. 6.4%, p < 0.001, respectively). LM disease independently predicted in-hospital death (odds ratio, 2.36; 95% confidence interval, 1.34-4.17; p = 0.003).

Conclusions:

The authors concluded that emergent LM PCI in the context of acute MI appears to have a remarkably high in-hospital survival.

Perspective:

The study suggests that emergent LM PCI in the context of acute MI, even including 12% cardiogenic shock, appears to have a remarkably high (89%) in-hospital survival. Nevertheless, patients with LM PCI had worse in-hospital outcomes than those treated with PCI of vessel segments other than LM. The study also provides important data on the outcomes of patients with STEMI undergoing simultaneous PCI of LM and other vessel segments, showing highest mortality and MACCE rates in this subgroup. The study results also support current guidelines, which recommend avoiding noninfarct-related vessel PCI in hemodynamically stable patients with STEMI.

Clinical Topics: Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Implantable Devices, SCD/Ventricular Arrhythmias, Acute Heart Failure

Keywords: Shock, Cardiogenic, Myocardial Infarction, Hospital Mortality, Cardiology, Switzerland, Heart Arrest, Percutaneous Coronary Intervention


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