Original Article
Impact of hypertension on infarct size in ST elevation myocardial infarction patients undergoing primary angioplasty Giuseppe De Luca a, Guido Parodi b, Roberto Sciagra` c, Benedetta Bellandi b, Vincenzo Comito b, Ruben Vergara b, Angela Migliorini b, Renato Valenti b, and David Antoniucci b
Background: Hypertension is a well known risk factor for atherosclerosis. However, data on the impact of hypertension in patients with ST-segment elevation myocardial infarction (STEMI) are inconsistent, and mainly related to studies performed in the thrombolytic era, with very few data on patients undergoing primary angioplasty. The aim of the current study was to evaluate the impact of hypertension on scintigraphic infarct size in STEMI patients undergoing primary percutaneous coronary intervention (PCI). Method: Our population is represented by 830 STEMI patients undergoing primary PCI. Infarct size was evaluated at 30 days by technetium-99m-sestamibi. Results: Hypertension was associated with more advanced age (P < 0.001), a larger prevalence of diabetes (P ¼ 0.001), female sex (P < 0.001), but lower prevalence of smoking (P < 0.001) and anterior infarction (P ¼ 0.042). No difference was observed in ischemia time, cardiogenic shock at presentation, in preprocedural thrombolysis in myocardial infarction (TIMI) flow, and collateral circulation. Hypertension did not affect the rate of postprocedural TIMI 3 flow. Hypertension did not affect infarct size [12.5% (4.1–23.8%) vs. 12.8% (4.3–24.7%), P ¼ 0.38]. Similar results were observed in subanalyses in major high-risk subgroups. No impact of hypertension on infarct size was confirmed when the analysis was conducted according to the percentage of patients with infarct size above the median [adjusted odds ratio (95% CI) ¼ 0.97 (0.72–1.33), P ¼ 0.92]. Conclusion: This study shows that among STEMI patients, undergoing primary PCI hypertension does not affect scintigraphic infarct size. Keywords: hypertension, infarct size, percutaneous coronary intervention, primary angioplasty, ST elevation myocardial infarction Abbreviations: ACS, acute coronary syndrome; CAD, coronary artery disease; LV, left ventricle; SPECT, singlephoton emission computer tomography; STEMI, STsegment elevation acute myocardial infarction; TIMI, thrombolysis in myocardial infarction
INTRODUCTION
A
vailability of pharmacologic and mechanical reperfusion therapies has significantly reduced cardiac mortality among ST-segment elevation acute myocardial infarction (STEMI) patients [1–6]. However, even though primary angioplasty has been shown to provide larger benefits as compared with thrombolysis, a suboptimal myocardial reperfusion is observed in a still relevant proportion of patients, despite optimal epicardial recanalization [7–9]. Hypertension is an established risk factor for atherosclerosis [10]. However, data on the prognostic impact of hypertension in patients with STEMI are so far inconsistent, mainly related to studies performed in the thrombolytic era [11–15]. In fact, although elevated levels of heart failure, stroke, cranial hemorrhage, and mortality risk have been shown in patients with antecedent hypertension receiving thrombolytic therapy [10–16], still controversial is the prognostic role of hypertension in terms of survival after primary angioplasty [17–20]. In particular, few data focused on the impact of hypertension on infarct size. Therefore, the aim of the current study was to evaluate the impact of hypertension on scintigraphic infarct size in STEMI patients undergoing primary angioplasty.
MATERIALS AND METHODS Our initial population included 894 patients with STEMI treated by primary angioplasty scheduled to undergo evaluation of the infarct size at 30 days after the intervention [21]. A total of 64 patients [16 women (8.7%) and 48 men (7.4%)] were excluded because of death (n ¼ 16), reinfarction (n ¼ 7), or target vessel revascularization (n ¼ 11) within 30 days from revascularization, or refusal to undergo Journal of Hypertension 2013, 31:2433–2437 a Division of Cardiology, ‘Maggiore della Carita`’ Hospital, Eastern Piedmont University, Novara, bDivision of Cardiology, Careggi Hospital and cNuclear Medicine Unit, University of Florence, Florence, Italy
Correspondence to Giuseppe De Luca, MD, PhD, Division of Cardiology, ‘Maggiore della Carita`’ Hospital, Eastern Piedmont University, Novara, Italy. Tel: +39 0321 3733141; fax: +39 0321 3733407; e-mail: [email protected] Received 29 April 2013 Revised 29 May 2013 Accepted 3 July 2013 J Hypertens 31:2433–2437 ß 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. DOI:10.1097/HJH.0b013e328364cbee
Journal of Hypertension
www.jhypertension.com
2433
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
De Luca et al.
scintigraphy (n ¼ 30). Therefore, our final population was 830 patients. All patients were admitted within 12 h from symptom onset, and received at the time of diagnosis aspirin (500 mg intravenously), heparin (60 IU/kg intravenously), b-blockers, and nitroglycerine intravenously if not contraindicated, but the decision to provide glycoprotein IIb-IIIa inhibitors was left to the discretion of the operator at the time of intervention. All patients were on dual oral antiplatelet therapy (aspirin and clopidogrel or ticlopidine) for at least 4 weeks after stent implantation. All demographic, clinical, procedural, and in-hospital and follow-up data were collected in a database. Patients were categorized as having antecedent hypertension, if this diagnosis was known by the patient to have been made by the family physician or after specialist referral and/or the admission note indicated a history of hypertension.
Coronary angiography and mechanical revascularization Selective coronary angiography was performed in multiple projections before mechanical reperfusion. Immediately after diagnostic angiography, percutaneous coronary intervention (PCI) with stenting of the infarct-related vessel was performed using standard material. Successful primary PCI was defined as thrombolysis in myocardial infarction (TIMI) grade 3 coronary flow in the treated vessel with a residual stenosis less than 20%.
Infarct size assessment As previously described [21], gated single-photon emission computed tomography (SPECT) acquisition began 60 min after technetium-99m-sestamibi injection (740 MBq), using a double-head gamma-camera equipped with high-resolution collimators, 1808 rotation arc, 32 projections, 60 s/ projection, 8 frames/heart cycle, and 64 64 matrices. The studies were reconstructed using filtered back-projection without attenuation or scatter correction and realigned along the heart axis. Perfusion defects were quantified as
percentage involvement of left ventricular wall, with the defect threshold set at 60% of peak uptake [22].
Statistical analysis Statistical analysis was performed using the SPSS, version 15.0, statistical package (SPSS, Chicago, Illinois, USA). Continuous data are expressed as the median (25th–75th percentiles) and categorical data as percentages. The analysis of variance test or Mann–Whitney U-test was appropriately used for continuous variables, according to the normality of distribution, as evaluated by the Shapiro– Wilk test. The x2 test or Fisher’s exact test was used for categorical variables. Multiple logistic regression analysis was used to evaluate the effect of hypertension on infarct size (as above the median) after adjustment for significant (P
Impact of hypertension on infarct size in ST elevation myocardial infarction patients undergoing primary angioplasty Giuseppe De Luca a, Guido Parodi b, Roberto Sciagra` c, Benedetta Bellandi b, Vincenzo Comito b, Ruben Vergara b, Angela Migliorini b, Renato Valenti b, and David Antoniucci b
Background: Hypertension is a well known risk factor for atherosclerosis. However, data on the impact of hypertension in patients with ST-segment elevation myocardial infarction (STEMI) are inconsistent, and mainly related to studies performed in the thrombolytic era, with very few data on patients undergoing primary angioplasty. The aim of the current study was to evaluate the impact of hypertension on scintigraphic infarct size in STEMI patients undergoing primary percutaneous coronary intervention (PCI). Method: Our population is represented by 830 STEMI patients undergoing primary PCI. Infarct size was evaluated at 30 days by technetium-99m-sestamibi. Results: Hypertension was associated with more advanced age (P < 0.001), a larger prevalence of diabetes (P ¼ 0.001), female sex (P < 0.001), but lower prevalence of smoking (P < 0.001) and anterior infarction (P ¼ 0.042). No difference was observed in ischemia time, cardiogenic shock at presentation, in preprocedural thrombolysis in myocardial infarction (TIMI) flow, and collateral circulation. Hypertension did not affect the rate of postprocedural TIMI 3 flow. Hypertension did not affect infarct size [12.5% (4.1–23.8%) vs. 12.8% (4.3–24.7%), P ¼ 0.38]. Similar results were observed in subanalyses in major high-risk subgroups. No impact of hypertension on infarct size was confirmed when the analysis was conducted according to the percentage of patients with infarct size above the median [adjusted odds ratio (95% CI) ¼ 0.97 (0.72–1.33), P ¼ 0.92]. Conclusion: This study shows that among STEMI patients, undergoing primary PCI hypertension does not affect scintigraphic infarct size. Keywords: hypertension, infarct size, percutaneous coronary intervention, primary angioplasty, ST elevation myocardial infarction Abbreviations: ACS, acute coronary syndrome; CAD, coronary artery disease; LV, left ventricle; SPECT, singlephoton emission computer tomography; STEMI, STsegment elevation acute myocardial infarction; TIMI, thrombolysis in myocardial infarction
INTRODUCTION
A
vailability of pharmacologic and mechanical reperfusion therapies has significantly reduced cardiac mortality among ST-segment elevation acute myocardial infarction (STEMI) patients [1–6]. However, even though primary angioplasty has been shown to provide larger benefits as compared with thrombolysis, a suboptimal myocardial reperfusion is observed in a still relevant proportion of patients, despite optimal epicardial recanalization [7–9]. Hypertension is an established risk factor for atherosclerosis [10]. However, data on the prognostic impact of hypertension in patients with STEMI are so far inconsistent, mainly related to studies performed in the thrombolytic era [11–15]. In fact, although elevated levels of heart failure, stroke, cranial hemorrhage, and mortality risk have been shown in patients with antecedent hypertension receiving thrombolytic therapy [10–16], still controversial is the prognostic role of hypertension in terms of survival after primary angioplasty [17–20]. In particular, few data focused on the impact of hypertension on infarct size. Therefore, the aim of the current study was to evaluate the impact of hypertension on scintigraphic infarct size in STEMI patients undergoing primary angioplasty.
MATERIALS AND METHODS Our initial population included 894 patients with STEMI treated by primary angioplasty scheduled to undergo evaluation of the infarct size at 30 days after the intervention [21]. A total of 64 patients [16 women (8.7%) and 48 men (7.4%)] were excluded because of death (n ¼ 16), reinfarction (n ¼ 7), or target vessel revascularization (n ¼ 11) within 30 days from revascularization, or refusal to undergo Journal of Hypertension 2013, 31:2433–2437 a Division of Cardiology, ‘Maggiore della Carita`’ Hospital, Eastern Piedmont University, Novara, bDivision of Cardiology, Careggi Hospital and cNuclear Medicine Unit, University of Florence, Florence, Italy
Correspondence to Giuseppe De Luca, MD, PhD, Division of Cardiology, ‘Maggiore della Carita`’ Hospital, Eastern Piedmont University, Novara, Italy. Tel: +39 0321 3733141; fax: +39 0321 3733407; e-mail: [email protected] Received 29 April 2013 Revised 29 May 2013 Accepted 3 July 2013 J Hypertens 31:2433–2437 ß 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. DOI:10.1097/HJH.0b013e328364cbee
Journal of Hypertension
www.jhypertension.com
2433
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
De Luca et al.
scintigraphy (n ¼ 30). Therefore, our final population was 830 patients. All patients were admitted within 12 h from symptom onset, and received at the time of diagnosis aspirin (500 mg intravenously), heparin (60 IU/kg intravenously), b-blockers, and nitroglycerine intravenously if not contraindicated, but the decision to provide glycoprotein IIb-IIIa inhibitors was left to the discretion of the operator at the time of intervention. All patients were on dual oral antiplatelet therapy (aspirin and clopidogrel or ticlopidine) for at least 4 weeks after stent implantation. All demographic, clinical, procedural, and in-hospital and follow-up data were collected in a database. Patients were categorized as having antecedent hypertension, if this diagnosis was known by the patient to have been made by the family physician or after specialist referral and/or the admission note indicated a history of hypertension.
Coronary angiography and mechanical revascularization Selective coronary angiography was performed in multiple projections before mechanical reperfusion. Immediately after diagnostic angiography, percutaneous coronary intervention (PCI) with stenting of the infarct-related vessel was performed using standard material. Successful primary PCI was defined as thrombolysis in myocardial infarction (TIMI) grade 3 coronary flow in the treated vessel with a residual stenosis less than 20%.
Infarct size assessment As previously described [21], gated single-photon emission computed tomography (SPECT) acquisition began 60 min after technetium-99m-sestamibi injection (740 MBq), using a double-head gamma-camera equipped with high-resolution collimators, 1808 rotation arc, 32 projections, 60 s/ projection, 8 frames/heart cycle, and 64 64 matrices. The studies were reconstructed using filtered back-projection without attenuation or scatter correction and realigned along the heart axis. Perfusion defects were quantified as
percentage involvement of left ventricular wall, with the defect threshold set at 60% of peak uptake [22].
Statistical analysis Statistical analysis was performed using the SPSS, version 15.0, statistical package (SPSS, Chicago, Illinois, USA). Continuous data are expressed as the median (25th–75th percentiles) and categorical data as percentages. The analysis of variance test or Mann–Whitney U-test was appropriately used for continuous variables, according to the normality of distribution, as evaluated by the Shapiro– Wilk test. The x2 test or Fisher’s exact test was used for categorical variables. Multiple logistic regression analysis was used to evaluate the effect of hypertension on infarct size (as above the median) after adjustment for significant (P
