Myocardial salvage after primary percutaneous coronary intervention in patients with ST-elevation myocardial infarction presenting early versus late after symptom onset

  • Thomas Stiermaier
  • Ingo Eitel
  • Suzanne de Waha
  • Janine Pöss
  • Georg Fuernau
  • Holger Thiele
  • Steffen Desch
Original Paper

Abstract

Primary percutaneous coronary intervention (PCI) is the treatment of choice in patients with ST-elevation myocardial infarction (STEMI) presenting within 12 h of symptom onset. A benefit in the subacute stage is less clear. The aim of the present analysis was to compare myocardial salvage and infarct size between patients with early and late reperfusion after STEMI. We compared cardiac magnetic resonance (CMR) data from a randomized controlled trial (RCT) in STEMI patients presenting within 12 h (n = 695) and a RCT of subacute STEMI patients presenting between 12 and 48 h (n = 93) after symptom onset. CMR imaging was performed 3.9 ± 6.3 days after myocardial infarction. Analyses were performed for an unmatched cohort comprising all patients (n = 788) and a cohort matched for area at risk (n = 186). In the overall cohort, area at risk was similar in both groups [37.1 ± 16.1% of left ventricular mass (%LV) vs. 38.3 ± 16.2%LV; p = 0.50]. Compared to STEMI patients with early reperfusion, patients with late PCI demonstrated larger infarct size (18.0 ± 12.5%LV vs. 28.9 ± 16.9%LV; p < 0.01) and higher extent of microvascular obstruction (1.5 ± 2.9%LV vs. 2.7 ± 4.1%LV; p = 0.01). Myocardial salvage index was significantly smaller in patients with late reperfusion (52.1 ± 25.9 vs. 27.4 ± 26.0; p < 0.01). Analysis of the matched cohorts confirmed the decreased myocardial salvage (p < 0.01) and increased infarct size (p < 0.01) in case of late reperfusion. Compared to patients with timely primary PCI, late reperfusion after STEMI results in decreased myocardial salvage and increased infarct size. However, salvageable myocardium was also found in subacute stages of STEMI.

Keywords

ST-elevation myocardial infarction Cardiac magnetic resonance imaging Myocardial salvage Late reperfusion 

Abbreviations

AAR

Area at risk

CMR

Cardiac magnetic resonance

IS

Infarct size

%LV

Percentage of left ventricular mass

MVO

Microvascular obstruction

MS

Myocardial salvage

MSI

Myocardial salvage index

PCI

Percutaneous coronary intervention

RCT

Randomized controlled trial

SPECT

Single photon emission computed tomography

STEMI

ST-elevation myocardial infarction

TIMI

Thrombolysis in myocardial infarction

Notes

Compliance with ethical standards

Conflict of interest

The author(s) declare that they have no competing interests.

References

  1. 1.
    Reimer KA, Jennings RB (1979) The “wavefront phenomenon” of myocardial ischemic cell death. II. Transmural progression of necrosis within the framework of ischemic bed size (myocardium at risk) and collateral flow. Lab Invest 40:633–644PubMedGoogle Scholar
  2. 2.
    O’Gara PT, Kushner FG, Ascheim DD, Casey DE Jr, Chung MK, de Lemos JA et al (2013) 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 61:e78–e140CrossRefPubMedGoogle Scholar
  3. 3.
    Windecker S, Kolh P, Alfonso F, Collet JP, Cremer J, Falk V et al (2014) 2014 ESC/EACTS Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J 35:2541–2619CrossRefPubMedGoogle Scholar
  4. 4.
    Schomig A, Ndrepepa G, Kastrati A (2006) Late myocardial salvage: time to recognize its reality in the reperfusion therapy of acute myocardial infarction. Eur Heart J 27:1900–1907CrossRefPubMedGoogle Scholar
  5. 5.
    LATE Study Group (1993) Late Assessment of Thrombolytic Efficacy (LATE) study with alteplase 6–24 h after onset of acute myocardial infarction. Lancet 342:759–766CrossRefGoogle Scholar
  6. 6.
    EMERAS (Estudio Multicentrico Estreptoquinasa Republicas de America del Sur) Collaborative Group (1993) Randomised trial of late thrombolysis in patients with suspected acute myocardial infarction. Lancet 342:767–772CrossRefGoogle Scholar
  7. 7.
    Schomig A, Ndrepepa G, Mehilli J, Schwaiger M, Schuhlen H, Nekolla S et al (2003) Therapy-dependent influence of time-to-treatment interval on myocardial salvage in patients with acute myocardial infarction treated with coronary artery stenting or thrombolysis. Circulation 108:1084–1088CrossRefPubMedGoogle Scholar
  8. 8.
    Busk M, Kaltoft A, Nielsen SS, Bottcher M, Rehling M, Thuesen L et al (2009) Infarct size and myocardial salvage after primary angioplasty in patients presenting with symptoms for <12 h vs. 12–72 h. Eur Heart J 30:1322–1330CrossRefPubMedGoogle Scholar
  9. 9.
    Schomig A, Mehilli J, Antoniucci D, Ndrepepa G, Markwardt C, Di Pede F et al (2005) Mechanical reperfusion in patients with acute myocardial infarction presenting more than 12 h from symptom onset: a randomized controlled trial. JAMA 293:2865–2872.CrossRefPubMedGoogle Scholar
  10. 10.
    Hadamitzky M, Langhans B, Hausleiter J, Sonne C, Kastrati A, Martinoff S et al (2013) The assessment of area at risk and myocardial salvage after coronary revascularization in acute myocardial infarction: comparison between CMR and SPECT. JACC Cardiovasc Imaging 6:358–369CrossRefPubMedGoogle Scholar
  11. 11.
    Francone M, Bucciarelli-Ducci C, Carbone I, Canali E, Scardala R, Calabrese FA et al (2009) Impact of primary coronary angioplasty delay on myocardial salvage, infarct size, and microvascular damage in patients with ST-segment elevation myocardial infarction: insight from cardiovascular magnetic resonance. J Am Coll Cardiol 54:2145–2153CrossRefPubMedGoogle Scholar
  12. 12.
    Thiele H, Wohrle J, Hambrecht R, Rittger H, Birkemeyer R, Lauer B et al (2012) Intracoronary versus intravenous bolus abciximab during primary percutaneous coronary intervention in patients with acute ST-elevation myocardial infarction: a randomised trial. Lancet 379:923–931CrossRefPubMedGoogle Scholar
  13. 13.
    Eitel I, Wohrle J, Suenkel H, Meissner J, Kerber S, Lauer B et al (2013) Intracoronary compared with intravenous bolus abciximab application during primary percutaneous coronary intervention in ST-segment elevation myocardial infarction: cardiac magnetic resonance substudy of the AIDA STEMI trial. J Am Coll Cardiol 61:1447–1454CrossRefPubMedGoogle Scholar
  14. 14.
    Desch S, Stiermaier T, De Waha S, Lurz P, Gutberlet M, Sandri M et al (2016) Thrombus aspiration in patients with ST-elevation myocardial infarction presenting late after symptom onset. JACC Cardiovasc Interv 9:113–122CrossRefPubMedGoogle Scholar
  15. 15.
    Desch S, Wohrle J, Hambrecht R, Rittger H, Birkemeyer R, Lauer B et al (2013) Intracoronary versus intravenous abciximab bolus in patients with ST-segment elevation myocardial infarction: 1-year results of the randomized AIDA STEMI trial. J Am Coll Cardiol 62:1214–1215CrossRefPubMedGoogle Scholar
  16. 16.
    Thiele H, Wohrle J, Neuhaus P, Brosteanu O, Sick P, Prondzinsky R et al (2010) Intracoronary compared with intravenous bolus abciximab application during primary percutaneous coronary intervention: design and rationale of the Abciximab Intracoronary versus intravenously Drug Application in ST-Elevation Myocardial Infarction (AIDA STEMI) trial. Am Heart J 159:547–554CrossRefPubMedGoogle Scholar
  17. 17.
    Thiele H, Kappl MJ, Conradi S, Niebauer J, Hambrecht R, Schuler G (2006) Reproducibility of chronic and acute infarct size measurement by delayed enhancement-magnetic resonance imaging. J Am Coll Cardiol 47:1641–1645CrossRefPubMedGoogle Scholar
  18. 18.
    Yusuf S, Lopez R, Maddison A, Sleight P (1981) Variability of electrocardiographic and enzyme evolution of myocardial infarction in man. Br Heart J 45:271–280CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Milavetz JJ, Giebel DW, Christian TF, Schwartz RS, Holmes DR Jr, Gibbons RJ (1998) Time to therapy and salvage in myocardial infarction. J Am Coll Cardiol 31:1246–1251CrossRefPubMedGoogle Scholar
  20. 20.
    Rentrop KP, Feit F, Sherman W, Stecy P, Hosat S, Cohen M et al (1989) Late thrombolytic therapy preserves left ventricular function in patients with collateralized total coronary occlusion: primary end point findings of the Second Mount Sinai-New York University Reperfusion Trial. J Am Coll Cardiol 14:58–64CrossRefPubMedGoogle Scholar
  21. 21.
    Kloner RA, Shook T, Antman EM, Cannon CP, Przyklenk K, Yoo K et al (1998) Prospective temporal analysis of the onset of preinfarction angina versus outcome: an ancillary study in TIMI-9B. Circulation 97:1042–1045CrossRefPubMedGoogle Scholar
  22. 22.
    Andersen HR, Nielsen TT, Rasmussen K, Thuesen L, Kelbaek H, Thayssen P et al (2003) A comparison of coronary angioplasty with fibrinolytic therapy in acute myocardial infarction. N Engl J Med 349:733–742CrossRefPubMedGoogle Scholar
  23. 23.
    Boersma E (2006) Does time matter? A pooled analysis of randomized clinical trials comparing primary percutaneous coronary intervention and in-hospital fibrinolysis in acute myocardial infarction patients. Eur Heart J 27:779–788CrossRefPubMedGoogle Scholar
  24. 24.
    Ndrepepa G, Kastrati A, Mehilli J, Antoniucci D, Schomig A (2009) Mechanical reperfusion and long-term mortality in patients with acute myocardial infarction presenting 12–48 h from onset of symptoms. JAMA 301:487–488CrossRefPubMedGoogle Scholar
  25. 25.
    Hochman JS, Lamas GA, Buller CE, Dzavik V, Reynolds HR, Abramsky SJ et al (2006) Coronary intervention for persistent occlusion after myocardial infarction. N Engl J Med 355:2395–2407CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Steg PG, Thuaire C, Himbert D, Carrie D, Champagne S, Coisne D et al (2004) DECOPI (DEsobstruction COronaire en Post-Infarctus): a randomized multi-centre trial of occluded artery angioplasty after acute myocardial infarction. Eur Heart J 25:2187–2194CrossRefPubMedGoogle Scholar
  27. 27.
    Abbate A, Biondi-Zoccai GG, Appleton DL, Erne P, Schoenenberger AW, Lipinski MJ et al (2008) Survival and cardiac remodeling benefits in patients undergoing late percutaneous coronary intervention of the infarct-related artery: evidence from a meta-analysis of randomized controlled trials. J Am Coll Cardiol 51:956–964CrossRefPubMedGoogle Scholar
  28. 28.
    Kim HW, Van Assche L, Jennings RB, Wince WB, Jensen CJ, Rehwald WG et al (2015) Relationship of T2-weighted MRI myocardial hyperintensity and the ischemic area-at-risk. Circ Res 117:254–265CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer Science+Business Media Dordrecht 2017

Authors and Affiliations

  • Thomas Stiermaier
    • 1
    • 2
  • Ingo Eitel
    • 1
    • 2
  • Suzanne de Waha
    • 1
    • 2
  • Janine Pöss
    • 1
    • 2
  • Georg Fuernau
    • 1
    • 2
  • Holger Thiele
    • 1
    • 2
  • Steffen Desch
    • 1
    • 2
  1. 1.University Heart Center Lübeck, Medical Clinic II (Cardiology/Angiology/Intensive Care Medicine)University Hospital Schleswig-HolsteinLübeckGermany
  2. 2.German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/LübeckLübeckGermany

Personalised recommendations