| Abstract1.Prognostic value of ST-segment resolution alone or in combination with TIMI flow after primary percutaneous coronary intervention in patients with ST-segment elevation myocardial infarction[Background]Primary percutaneous coronary intervention(PCI)has become the preferred reperfusion strategy for ST-segment elevation myocardial infarction(STEMI)for opening infracted-related artery.However,there is no guideline-level recommendation regarding how to define successful primary PCI in clinical practice.[Objective]To provide a basis for defining the successful primary PCI in clinical practice by analyzing the long-term prognostic value of ST-segment regression(STR)alone or in combination with Thrombolysis In Myocardial Infarction(TIMI)flow after primary PCI in STEMI patients.[Methods]A total of 19112 patients with STEMI were admitted to the China Acute Myocardial Infarction(CAMI)Registry between January 1,2013 and September 30,2014.The present study included 5966 STEMI patients with available data of STR evaluated after primary PCI,dividing into different groups based on different level of STR:STR<50%,STR≥50%,and complete STR(i.e.,ST-segment back to the equipotential line).The primary clinical outcome was 2-year all-cause death.Risk factors of 2-year all-cause mortality were analyzed by Cox multiple regression model and the hazard ratios(HR)and the 95%confidence interval(CI)were evaluated.In the subgroup analysis,successful STR(included STR≥50%and complete STR)were combined with TIMI flow and 4 groups were generated:successful STR+ TIMI flow 3,successful STR+ TIMI flow 0-2,STR<50%+TIMI flow 3,STR<50%+ TIMI flow 0-2,and the 2-year all-cause mortality were compared.To assess the added prognostic value of the combination of STR and TIMI flow beyond the Global Registry of Acute Coronary Events(GRACE)hospital discharge risk score(GRACE risk score),C-index,continuous net reclassification improvement(NRI),and integrated discrimination improvement(IDI)were calculated.[Results]Among the study cohort,there were 1227,3837,and 902 patients with STR<50%,STR≥50%,and complete STR respectively.The 2-year all-cause mortality in the STR<50%group was 11.7%,which was significantly higher than that in the STR≥50%group(5.6%)and the ST-segment complete regression group(5.1%)(P<0.001).Multivariable adjustment showed that STR≥50%(HR:0.45,95%CI:0.36-0.56)and complete STR(HR:0.48,95%CI:0.34-0.67)were independent predictors of all-cause mortality at 2 years.The concordance between STR and TIMI flow occurred in 79.2%of patients.During the follow-up,the lowest 2-year all-cause mortality was observed in the successful STR+TIMI flow 3 group(4.8%),intermediate mortality was observed in the successful STR+TIMI flow 0-2 group(8.9%)and STR<50%+TIMI flow 3 group(8.4%),and the highest mortality was observed in the STR<50%+TIMI flow 0-2 group(29.4%).Successful STR combined with TIMI flow significantly improved the ability of GRACE risk score to discrimination and reclassification of 2-year mortality(C value:0.748,P=0.011;NRI:0.318,P<0.001;IDI:0.022,P<0.001).[Conclusions]STR was an independent predictor of long-term all-cause death after primary PCI in STEMI patients,while STR combined with TIMI had a stronger long-term prognostic value.The results of this study support the combination of STR and TIMI flow as a simple and reliable evaluation index to define successful primary PCI in clinical practice.Abstract 2.Long-term survival outcome for patients with ST-segment elevation myocardial infarction with fibrinolytic therapy in China[Background]Although primary percutaneous coronary intervention(PCI)has been considered as the preferred method for early recanalization of the infarct-related artery for ST-segment elevation myocardial infarction(STEMI),it is difficult to popularize among primary hospitals in China due to the restriction of the medical conditions,geographical challenging and technical capabilities.geographical location,medical conditions and technical capability of operators.Fibrinolytic therapy remains the main reperfusion strategy for STEMI patients admitting in most of the Chinese primary hospitals.However,there has been no contemporary large-scale population-based study for evaluating the long-term prognosis of STEMI patients treated with fibrinolytic therapy in China.[Objective]To provide information for optimizing the use of fibrinolytic therapy for STEMI in China by analyzing its utilization and efficacy of fibrinolytic therapy and evaluating the long-term survival outcomes in this population.[Methods]A total of 19,112 STEMI patients from 108 hospitals were enrolled in the China Acute Myocardial Infarction(CAMI)Registry study between January 2013 and September 2014.Those who received fibrinolytic therapy were retrospectively included and divided into successful and failed fibrinolysis groups based on indirect measures of vascular recanalization.The primary clinical outcome was the 2-year all-cause death.A multivariate Cox proportional risk model was used to determine the association between successful fibrinolysis and 2-year all-cause mortality,and the hazard ratio(HR)and the 95%confidence interval(CI)were calculated.The multi-factor Logistics proportional risk model was used to find independent predictors of successful fibrinolysis,and the odds ratios(OR)were expressed with 95%CI.[Results]There were 1823 STEMI patients(9.5%)enrolled in the CAMI registry underwent fibrinolysis and 1428(78.3%)could achieve successful fibrinolysis.Patients with successful fibrinolysis were more likely to receive reperfusion within 3 hours of onset than those with failed fibrinolysis(39.4%vs 29.7%,P<0.001).Only 80 patients(20.3%)in the failed fibrinolysis group received rescue PCI within 24 hours after treatment.The percentages of streptokinase,urokinase,alteplase and reteplase in successful and failed fibrinolysis groups were 0.8%vs 0.1%,32.8%vs 54.5%,19.0%vs 14.8%,47.4%vs 29.7%,respectively.Cox multivariate regression analysis showed that the risk of 2-year all-cause death was significantly lower in patients with successful fibrinolysis than in those with failed fibrinolysis(8.5%vs 29.0%,HR:0.27,95%:0.20-0.35,P<0.001).Logistic multivariate regression analysis showed that the use of fibrin-specific agents(including alteplase and reteplase)(OR:2.47,95%CI:1.96-3.12,P<0.001),symptom to needle time<3 h(OR:1.40,95%CI:1.09-1.80,P=0.008),anterior myocardial infarction(OR:0.56,95%CI:0.44-0.71,P<0.001),and Killip class≥ Ⅱ(OR:0.58,95%CI:0.44-0.76,P<0.001)were an independent predictors of successful fibrinolysis.[Conclusions]In CAMI registry,only nearly 10%of STEMI patients received fibrinolysis therapy.Nearly 80%of them could achieve successful fibrinolysis,with a significantly benign long-term prognosis than those with failed fibrinolysis.Quality improvement initiatives,including shortening the treatment delay,increasing the use of fibrin-specific agents,and fast referral for rescue mechanical revascularization in patients with failed fibrinolysis,should be taken to further improve the management of fibrinolytic-treated patients in China.Abstract 3.Long-term survival outcome of different reperfusion strategies for ST-segment elevation myocardial infarction in Chinese county-level hospitals[Background]The mortality rate of acute myocardial infarction(AMI)in rural areas of China has significantly exceeded the urban level since 2013.As a key element of the primary health care system,Chinese county hospitals provide medical services mainly to the rural population.However,no prior studies have analyzed the long-term prognosis of patients with ST-segment elevation myocardial infarction(STEMI)admitted in county hospitals treated with different reperfusion strategies.[Objective]To compare the long-term survival of STEMI patients who received different reperfusion strategies in Chinese county-level hospitals and provide information for further optimization of the implementation of reperfusion therapy for STEMI patients in county-level hospitals,so as to reduce the death burden related to cardiovascular disease in rural China.[Methods]A total of 108 hospitals from 31 provinces and cities in mainland China participated in the China AMI(CAMI)registry between January 2013 and September 2014 and 32 of them were county-level hospitals((in the county-level cities with surrounding rural areas).The present study retrospectively enrolled STEMI patients admitted in county hospitals in the CAMI registry study.Patients were divided into three groups based on different reperfusion strategies:fibrinolysis,primary percutaneous coronary intervention(PCI),and no reperfusion.The primary clinical outcome was the 2-year all-cause death.Risk factors for the 2-year all-cause death were analyzed using the Cox multivariable regression model.In the subgroup analysis,fibrinolysis-treated patients were further divided into successful and failed groups based on indirect measures of vascular recanalization,and 2-year all-cause mortality rates were compared between the successful fibrinolysis group vs.primary PCI group,and the failed fibrinolysis group vs.no reperfusion group,respectively.[Result]A total of 2514 STEMI patients admitted to county-level hospitals enrolled in the CAMI registry,of which 1080(42.9%)received reperfusion therapy and were divided into fibrinolysis group(n=664,61.5%)and primary PCI group(n=416,38.5%).The most common reason for missing reperfusion therapy was prehospital delay>12 hours(43%).The 2-year all-cause mortality was lower in the fibrinolysis group(14.5%,HR:0.59,95%CI:0.44-0.80,P<0.001)and in the primary PCI group(6.8%,HR:0.32,95%CI:0.22-0.48,P<0.001)compared with those without reperfusion therapy(28.5%).510 of fibrinolytic-treated patients could(76.8%)achieve successful fibrinolysis.Only 17.7%of patients with failed thrombolysis underwent rescue PCI within 24 hours after treatment.There was no difference in 2-year all-cause mortality between successful fibrinolysis and primary PCI(8.8%vs 6.8%,HR:1.53,95%CI:0.85-2.73,P=0.155).Failed fibrinolysis,however,predicted a similar mortality(33.1%)compared with no reperfusion(33.1%vs 28.5%,HR:1.30,95%CI:0.93-1.81,P=0.125).[Conclusion]In Chinese county-level hospitals,the use of reperfusion therapy among STEMI patients was insufficient,which was mainly attributed to prehospital delay.The poor long-term survival outcome was observed in patients with failed thrombolysis and those without reperfusion therapy.Quality improvement initiatives are warranted to improve the management in this population,especially in the popularization of public health education and rapid referral for mechanical revascularization in case of failed fibrinolysis during clinical practice. |
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