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| ORIGINAL ARTICLE |
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| Year : 2022 | Volume
: 12
| Issue : 4 | Page : 173-177 |
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Outcomes of Percutaneous Coronary Intervention in the Young
Satya Bharathi Lakshmi Vanaparty, Lalita Nemani, Jahangir Basha Sheik
Department of Cardiology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| Date of Submission | 16-Mar-2022 |
| Date of Decision | 16-May-2022 |
| Date of Acceptance | 18-May-2022 |
| Date of Web Publication | 19-Dec-2022 |
Correspondence Address:
Dr. Satya Bharathi Lakshmi Vanaparty
Department of Cardiology, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad - 500 082, Telangana
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jicc.jicc_8_22
Background: The incidence of coronary artery disease in the young is constantly rising. Understanding the outcomes of percutaneous coronary intervention (PCI) in young adults is necessary. This study aims to assess the procedural outcomes, inhospital and 1 year clinical outcomes of PCI in the young (<40-year-old). Methods: This is a prospective, observational study carried out in the Department of Cardiology at Nizam's Institute of Medical Sciences. The study included all subjects ≤40 years of age and has undergone PCI from January 1, 2019 to December 31, 2019 in our institute. Results: The study included 207 patients with a mean age of 36.01 ± 3.72 years and 72.46% males. Acute coronary syndrome was seen in 79.2% patients with ST elevation myocardial infarction (STEMI) being the most common. The median time interval of presentation in STEMI was 12–48 h (73%). Major adverse cardiac events (MACE) over 1-year were seen in 3.8% patients. Severe left ventricular (LV) dysfunction at presentation was an independent factor for acute (P = 0.04) and 1-year mortality (P = 0.0058). It was also associated with angina and chronic heart failure (CHF). Slow flow was significantly associated with mortality (P = 0.0254) and adverse 1 year outcomes. It was significantly associated with persistent LV dysfunction and recurrent CHF. Conclusion: Success rate after PCI is high in the young. 1 year outcome is very good with low mortality and MACE events. Severe LV dysfunction and slow flow are independent predictors of poor prognosis at 1 year.
Keywords: Coronary artery disease, outcomes, percutaneous coronary intervention, young
How to cite this article:
Lakshmi Vanaparty SB, Nemani L, Sheik JB. Outcomes of Percutaneous Coronary Intervention in the Young. J Indian coll cardiol 2022;12:173-7 |
How to cite this URL:
Lakshmi Vanaparty SB, Nemani L, Sheik JB. Outcomes of Percutaneous Coronary Intervention in the Young. J Indian coll cardiol [serial online] 2022 [cited 2023 Feb 8];12:173-7. Available from: https://www.joicc.org/text.asp?2022/12/4/173/364218 |
| Introduction | |  |
Coronary artery disease (CAD) in the young accounts for only 3% of all CAD cases but the figures are on constant rise.[1] Latest studies have shown the prevalence of acute coronary events of 2%–6% in the young.[2] However, autopsy studies have documented the presence of progressive CAD in nearly 50% of the young even in the absence of documented CAD.[3] Smoking, obesity, diabetes, and dyslipidemia have been associated with early atherosclerosis and CAD in the young.[4] Premature CAD is considered as an aggressive form of atherosclerosis.[5] It is associated with significant morbidity and has socioeconomic impact. The protective effect of young age is overcome by the presence of multiple lifestyle related risk factors in the young with CAD. Young patients who have undergone percutaneous coronary intervention (PCI) are generally considered to be at low procedural risk.[6] Short-term results are good, and the few studies available on long-term prognosis are acceptable.[7],[8] However, longer life expectancy and the progressive nature of the CAD exposes the young to higher risk of recurrences.
Many studies have reported about the clinical profile, risk factors and angiographic profile of myocardial infarction (MI) in young, however, there is lack of data on in-hospital and long-term clinical outcomes of PCI among younger adults (d40 years of age). Understanding the outcomes of PCI in these patients and the impact of revascularization on their recovery and rehabilitation are important. This study aims to assess the procedural outcomes, in-hospital events, and 1-year clinical outcomes of young patients (a40 years) with CAD who underwent PCI.
| Methods | | |
This is a prospective, observational study carried out in the Department of Cardiology at Nizam's institute of medical sciences. The study included all subjects ≤40 years of age and have undergone PCI from January 1, 2019 to December 31, 2019 in our institute. Data were collected regarding patient baseline characteristics, risk factor profile, and clinical presentation. Clinical examination, baseline investigations, and previous interventions are noted. Cardiac status at index PCI procedure, PCI procedure details, and procedural complications and outcome data are collected including in hospital events. Patients were followed up at regular intervals for 1 year through telephonic communications and hospital visits to monitor long-term events.
Angiographic success was defined as residual stenosis <30% with TIMI-III flow. Procedural success was defined as angiographic success with no occurrence of any procedural complications. Procedural complications included: (1) slow flow, (2) abrupt closure-no-reflow, (3) dissection, and (4) coronary perforation. Slow flow was defined as thrombolysis in MI (TIMI) grading 2 flow; No-reflow as TIMI-0 or 1 in a dilated segment with previously documented antegrade flow. Persistence of contrast in a focal segment after washout from remaining portion of vessel was defined as dissection and extravasation of contrast material was defined as perforation and graded accordingly.
Clinical success was defined as procedural success without any in-hospital complications such as postprocedural MI, decompensation of heart failure, cerebrovascular accident, emergency coronary artery bypass graft (CABG), major bleed, tamponade, cardiogenic shock, significant ventricular arrhythmia, cardiopulmonary arrest during PCI and death. Deaths from any cause (cardiac and noncardiac) were taken into consideration. Periprocedural infarction was defined as >3 times rise in creatine phosphokinase MB isoenzyme. An emergency CABG was defined as that performed immediately after PCI.
Primary end point was major adverse cardiac events (MACE) which included any one of the following in the 1-year follow-up: (1) MI, (2) death, (3) need for target lesion revascularization (TLR), and (4) need for target vessel revascularization (TVR). TVR was defined as a subsequent PCI in the index vessel, including revascularization for restenosis or progressive CAD. TLR was defined as a subsequent PCI within 5 mm proximal or distal to the index lesion. Secondary end point included symptomatic status such as heart failure requiring admissions, angina, and repeat PCI. Repeat PCI included any unplanned PCI during the follow-up period, including TVR and TLR but excluding staged PCI.
Statistical analysis
The numerical variables are presented as mean ± standard deviation, and the categorical variables are summarized by raw numbers and percentages. The statistical analysis of the data collected was done by SAS software version 9.2 (Amonk NY: IBM corp). The continuous variables were compared using the Student's t-test; and the categorical variables were compared using Pearson's Chi-square test. A “P < 0.05” was considered as statistically significant.
| Results | | |
The study included 207 patients with a mean age of 36.01 ± 3.72 years and 72.46% males. The baseline characteristics are mentioned in [Table 1]. Fifty-six patients (27.05%) patients had one traditional risk factor, 69 (33.3%) patients had two, 28 (13.5%) had ≥3 risk factors and 26.08% had no traditional risk factors. Majority (94.20%) had normal body mass index, 2.9% were overweight, and 2.9% were obese. Acute coronary syndrome was seen in 79.2% patients with ST elevation MI (STEMI) being the most common [Table 1]. The median time interval of presentation in STEMI was 12–48 h (73%), and anterior wall MI was predominant (63.8%). Primary PCI was performed in 11 (3.54%) patients, and 12 (7.3%) received thrombolysis. Five patients (3.54%) presented in cardiogenic shock, three (2.12%) with complete heart block, and one patient with acute ischemic stroke. Echo performed at admission [Table 1] showed left ventricular (LV) dysfunction in 123 patients (59.42%), right ventricular dysfunction in two (<1%) and moderate-severe mitral regurgitation in 4 patients (1.9%).
On coronary angiogram, 151 patients (72.98%) had single vessel disease, 40 patients (19.3%) had double vessel disease, 13 patients (6.28%) had triple vessel disease, and 3 patients (1.44%) had left main disease. The left anterior descending artery (LAD-75.84%) was most involved followed by right coronary artery (29.46%) and left circumflex artery (18.3%). In the patients presenting with STEMI, the most common culprit artery was LAD. Recanalized LAD was seen in 10 (7.0%) cases and spontaneous coronary artery dissection in one (0.48%) patient.
A total of 272 drug eluting stents were implanted. Single vessel stenting was done in 151 (72.95%) patients, two vessels stenting in 40 (19.38%), three vessels in 12 (6.28%), and one (1.4%) had left main stenting. Access was radial in 96.62% and femoral in 3.38%. The mean diameter and mean length of the stent was 2.98 ± 0.35 (range 2.25–4.00 mm) and 23.34 ± 8.79 (range 8–48 mm), respectively. Peri-procedural Glycoprotein 2b3a inhibitors were given in 14 (6.76%) patients. Intra-aortic Balloon pump was inserted in six patients (2.9%) and temporary pacemaker in three (1.44%) patients.
Angiographic success was achieved in 93.23%, procedural success in 92.75%, and clinical success in 92.27%. There was one case of cardiopulmonary arrest during PCI due to refractory ischemic ventricular arrhythmia. The procedural complications and in-hospital outcome are mentioned in [Table 2]. There were no major vascular complications. Only one patient with acute renal failure needed postprocedure dialysis.
Primary end point at 1-year is shown in [Table 3]. MACE over 1-year was seen in 3.8% patients. There were four deaths (1.94%) and all of them were cardiac. Secondary end point was seen in 4.8% patients. Persistent severe LV dysfunction was seen in 16 (7.73%) patients, and 6 (2.9%) of them had recurrent congestive heart failure requiring hospitalization. Of the seven cases which underwent a second PCI, only one was for TLR.
Analysis of factors associated with adverse outcome [Table 4] showed hypertension to be associated with persistent severe LV dysfunction (P = 0.0172)) over 1-year and predisposed to increased long-term mortality (P = 0.09). Diabetes mellitus was a risk factor for recurrent CHF (P = 0.054), and alcohol also predisposed to heart failure over the long-term (P = 0.07). Severe LV dysfunction at presentation was an independent factor for acute (P = 0.04) and 1-year mortality (P = 0.0058). It was also associated with angina and chronic heart failure (CHF). Slow flow was significantly associated with mortality (P = 0.0254) and adverse 1 year outcome. It was significantly associated with persistent LV dysfunction and recurrent CHF.
| Discussion | | |
Majority of the patients in our study had at least one conventional risk factor for CAD, strongly supporting the fact that lifestyle related risk factors strongly contribute to premature CAD.[9] The major risk factors associated with CAD in our study are hypertension, diabetes, smoking and alcohol consumption. Unlike previous studies, obesity and dyslipidemia were not significant factors. Alcohol consumption in moderate quantities is protective against CAD, but young alcoholics tend to consume alcohol excessively and binge drinking is common.[10],[11],[12] This drinking pattern in addition to having no beneficial effect on HDL cholesterol may increase LDL levels and has transient detrimental effect on thrombosis, hypertension, and arrhythmias.[13] Concomitant smoking offsets the beneficial effects of alcohol. Obesity is a common cause of CAD in the western studies but not in Indian studies.[7],[14],[15] The high prevalence of lifestyle-related risk factors in the young CAD emphasize the need for primordial, primary and secondary prevention in this population to prevent index and recurrent coronary events. Despite the presence of significant risk factors, CAD is less extensive and less complex in the young evident by the high incidence of single vessel disease and type A/B1 lesions on angiogram. Significant incidence of thrombus and recanalized vessel on angiogram are seen in the acute coronary events contributing to slow flow.[16]
PCI was associated with high success rate (93%) in par with previous studies with low incidence of periprocedural complication. Slow flow or no-reflow after PCI was commonly noticed which could be attributed to higher incidence of thrombus in the young. TIMI flow < II was a significant contributor of short-term and long-term adverse outcome. It strongly correlated with LV dysfunction.[17],[18] The present study supports slow flow/no-reflow as a factor associated with adverse outcome. Cardiogenic shock at presentation despite IABP insertion was high for in-hospital and long-term mortality.
Delayed presentation after index coronary event is a major contributor to severe LV dysfunction at presentation predisposing to adverse cardiac events in the long run.[19] This is evident in our study where the average time of presentation was 16 h. This could be attributed to young people unsuspecting MI and underplay their symptoms. Delayed presentation results in significant loss of viable myocardium and LV dysfunction. Measures to educate the young people about the risk factors, presenting symptoms, continued efforts to minimize the delays in transfer and intervention in STEMI patients may improve the outcomes.
Outcome was favorable with symptomatic improvement in majority. There was significant improvement in LV function. Survival rates over 1 year were high with low incidence of adverse events. The implementation of guideline-directed optimal medical therapy in nearly all patients could be one reason behind it. Existing literature supports the fact that younger patients carry a better prognosis in the early period after the MI. However, Cole et al.[2] had reported a higher mortality especially in patients with diabetes and ejection fraction <30%. Our study also shows a good prognosis in young after MI except in those with severe LV dysfunction. Rate of revascularization was low 2.8% and primarily for nontarget lesions in our study. The rate of revascularization at 3 years' follow-up was 17.1% in the PROSPECT study and 16.8% in the coronary artery disease in young adults (CRAGS) study. The rate of revascularization was primarily for nontarget lesion, 12.9% and 11.6% for culprit and nonculprit lesion in the PROSPECT study; and 7.8% and 6.9% in the CRAGS study.
Persistent LV dysfunction is the major factors associated with poor long-term outcomes. Every possible measure should be taken to avoid LV dysfunction which implies early initiation of appropriate treatment. Once diagnosed with LV dysfunction, these patients should be adequately followed up, prescribed optimized medical management to prevent LV remodeling, and undergo device therapy such as cardiac resynchronization therapy and implantable cardioverter-defibrillator where-ever indicated. Lifestyle modification which includes cessation of smoking, adequate control of diabetes and hypertension, optimal weight management, and correction of lipid abnormalities are bound to be important in the management of these patients, however, risk factor modification could be challenging in this subset.
| Conclusion | | |
Success rate after PCI is high in the young with very few peri-procedural complications despite the presence of significant risk factors. 1 year outcome is very good with low mortality and occurrence of adverse events. Severe LV dysfunction is in independent predictor of poor prognosis at 1 year. Early initiation of appropriate treatment for CAD is crucial. Repeat revascularization is primarily for nonculprit lesion indicating the aggressive progressive nature of atherosclerosis in this subset. Secondary prevention plays an important role in improving long-term outcome following and index event, but risk factor management could be quite challenging in the young.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Andersson C, Vasan R. Epidemiology of cardiovascular disease in young individuals. Nat Rev Cardiol 2018;15:230-40.  |
| 2. | Cole JH, Miller JI 3 rd, Sperling LS, Weintraub WS. Long-term follow-up of coronary artery disease presenting in young adults. J Am Coll Cardiol 2003;41:521-8. |
| 3. | Garg M, Agraval AD, Kataria SP. Coronary atherosclerosis and myocardial infarction: An autopsy study. J Indian Acad Forensic Med 2011 33:39-42. |
| 4. | Vikulova DN, Grubisic M, Zhao Y, Lynch K, Humphries KH, Pimstone SN, et al. Premature atherosclerotic cardiovascular disease: Trends in incidence, risk factors, and sex-related differences, 2000 to 2016. J Am Heart Assoc 2019;8:e012178. |
| 5. | Collet JP, Zeitouni M, Procopia N, Hulot JS, Silvain J, Kerneis M, et al. Long-term evolution of premature coronary artery disease. J Am Coll Cardiol 2019;74:1868-78. |
| 6. | Konishi H, Miyauchi K, Kasai T, Tsuboi S, Ogita M, Naito R, et al. Long-term prognosis and clinical characteristics of young adults (≤40 years old) who underwent percutaneous coronary intervention. J Cardiol 2014;64:171-4. |
| 7. | Zimmerman FH, Cameron A, Fisher LD, Ng G. Myocardial infarction in young adults: Angiographic characterization, risk factors and prognosis (Coronary Artery Surgery Study Registry). J Am Coll Cardiol 1995;26:654-61. |
| 8. | Kofflard MJ, de Jaegere PP, van Domburg R, Ruygrok P, van den Brand M, Serruys PW, et al. Immediate and long-term clinical outcome of coronary angioplasty in patients aged 35 years or less. Br Heart J 1995;73:82-6. |
| 9. | EgredM, Viswanathan G, Davis GK. Myocardial infarction in young adults. Postgrad Med J 2005;81:741-5. |
| 10. | Hines LM, Rimm EB. Moderate alcohol consumption and coronary heart disease: A review. Postgrad Med J 2001;77:747-52. |
| 11. | Roy A, Prabhakaran D, Jeemon P, Thankappan KR, Mohan V, Ramakrishnan L, et al. Impact of alcohol on coronary heart disease in Indian men. Atherosclerosis 2010;210:531-5. |
| 12. | Yusuf S, Hawken S, Ounpuu S, Dans T, Avezum A, Lanas F, et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): Case-control study. Lancet 2004;364:937-52. |
| 13. | Mostofsky E, van der Bom JG, Mukamal KJ, Maclure M, Tofler GH, Muller JE, et al. Risk of myocardial infarction immediately after alcohol consumption. Epidemiology 2015;26:143-50. |
| 14. | Giruzzi M, Schargradsky W, Rozslonik J. The frequency of the family history of AMI in patients with AMI. Am J Cardiol 1997;802:122-7. |
| 15. | Pais P, Pogue J, Gerstein H. The risk factors for acute MI in Indians a case control study. Lancet 1996;348:358-63. |
| 16. | Fajar JK, Heriansyah T, Rohman MS. The predictors of no reflow phenomenon after percutaneous coronary intervention in patients with ST elevation myocardial infarction: A meta-analysis. Indian Heart J 2018;70 Suppl 3:S406-18. |
| 17. | Brooks GC, Lee BK, Rao R, Lin F, Morin DP, Zweibel SL, et al. Predicting persistent left ventricular dysfunction following myocardial infarction: The PREDICTS study. J Am Coll Cardiol 2016;67:1186-96. |
| 18. | Mazhar J, Mashicharan M, Farshid A. Predictors and outcome of no-reflow post primary percutaneous coronary intervention for ST elevation myocardial infarction. Int J Cardiol Heart Vasc 2016;10:8-12. |
| 19. | Wu X, Mintz GS, Xu K, Lansky AJ, Witzenbichler B, Guagliumi G, et al. The relationship between attenuated plaque identified by intravascular ultrasound and no-reflow after stenting in acute myocardial infarction: The HORIZONS-AMI (Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction) trial. JACC Cardiovasc Interv 2011;4:495-502. |
[Table 1], [Table 2], [Table 3], [Table 4]
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