Stroke After STEMI Unusual But Carries Poor Prognosis

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Although stroke is rare in the setting of ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI), it is associated with increased morbidity and mortality, according to a study published online April 2, 2013, ahead of print in Circulation: Cardiovascular Interventions.

Researchers led by Renato D. Lopes, MD, PhD, of the Duke Clinical Research Institute (Durham, NC), reviewed data on stroke among 5,372 STEMI patients from the APEX-AMI (Assessment of Pexelizumab in Acute Myocardial Infarction) trial. The study, which randomized patients to adjunctive pexelizumab or placebo in conjunction with primary PCI, was stopped early in 2006 when the anti-inflammatory agent failed to improve outcomes. Main results were published in the Journal of the American Medical Association in January 2007.

Timing Varies Based on Stroke Type

Overall, 69 patients (1.3%) in the current subanalysis reported strokes, of which 23 were ischemic (33%), 8 hemorrhagic (12%), and 38 of unknown origin (55%). More than one-quarter of strokes (29%) were deemed moderate to severe, and 44% were of unknown severity.

Strokes occurred at a median of 6 days after primary PCI, with 27% occurring within 24 hours and 43% within 48 hours. More than half (56%) of all strokes occurred during the index hospitalization, and most (75%) had occurred within 30 days.

Six of the hemorrhagic strokes (75%) happened within 24 hours, and all occurred within 48 hours. All of these patients had undergone stenting rather than angioplasty alone, and 7 (87.5%) received heparin and ticlopidine or clopidogrel during the first 24 hours of their initial hospitalization.

According to the paper, which did not report mortality data for stroke-free patients, 90-day death rates were “substantially higher” after stroke, rising from 14% at 30 days to 25% at 90 days. In fact, 38% of the patients with a hemorrhagic stroke died. In addition, the median length of stay for patients who experienced an in-hospital stroke and survived was 10 days, compared with 5 days for those without a stroke.

Stroke was associated with an increased risk of 30-day and 90-day death, cardiogenic shock, congestive heart failure (CHF), the combined endpoint of death, cardiogenic shock, or CHF, and 30-day hospital readmission (table 1).

Table 1. Unadjusted Risk of Events: With vs. Without Stroke

 
After adjustment for baseline differences, stroke remained associated with 90-day death (adjusted HR 5.6; 95% CI 3.2-9.8; P < 0.001) and the combined endpoint of death, CHF, and cardiogenic shock (adjusted HR 2.4; 95% CI 1.2-4.7; P < 0.012).

Reaffirms PCI as ‘Gold Standard’ for STEMI

“Our results seem to show that not all stroke events in the setting of STEMI are PCI-related,” Dr. Lopes and colleagues write. “Beyond 48 hours after MI, additional mechanisms for stroke might include heart failure and atrial fibrillation-related cardiogenic emboli or proinflammatory conditions that extend beyond the coronary artery to the systemic vasculature.”

In a telephone interview with TCTMD, Dr. Lopes said this information “reaffirms PCI as the gold standard for people with STEMI.”

Ajay J. Kirtane, MD, SM, of Columbia University Medical Center (New York, NY), told TCTMD in a telephone interview that going without PCI is not an option for most of these patients.

“We certainly see strokes and they are generally very rare, fortunately, which I think is one of the reasons catheterization is so safe,” he said. “As part of an MI, you typically intervene to salvage myocardium, so it’s not [a situation where] you can say, ‘Don’t do the intervention because obviously the patient is going to have an event.’”

The study provides a thinking point for physicians, Dr. Kirtane continued. “It seems clear that you would have a greater risk of death by having a stroke. But the main thing is that operators just need to remember that there are strokes that occur as part of MIs, and everything that you can do technically to try and reduce [them] is important to do.”

‘Less Is More’

As for timing of the hemorrhagic strokes, it is most likely “related to the way we’re managing these patients from the point of view of antithrombotic therapies. . . . We are really adding a lot of antithrombotic agents early on because they are thought to be important for patients undergoing PCI, but we might be facilitating bleeding complications, particularly severe ones like hemorrhagic strokes,” Dr. Lopes said, adding that the field might be “coming to an era in which less is more.”

Although stroke is rare in this population, the authors continue, “it is nonetheless associated with significant persistent disability, increased resource use, and worse outcomes compared with patients without stroke.” Because the median age of patients with stroke was 73 years and recovery may be less satisfactory in older patients, “every effort should be directed at implementing methods to decrease this event,” they suggested.

Doing so, the authors advise, “may ultimately entail a dual approach that focuses on appropriate anticoagulation and PCI procedural techniques to reduce early strokes and strategies directed at additional potential mechanisms involved in later, post-PCI strokes.” Further understanding of factors associated with stroke in ACS patients could also “aid in the safety evaluation of novel pharmaceutical and interventional strategies, such as newer antithrombotic agents,” they add.

Study Details

Diabetes, hypertension, and hyperlipidemia were more common in the stroke group. In addition, more than twice as many stroke patients had a history of A-fib (10% vs. 4% for those without stroke), COPD (13% vs. 5%), CABG (4% vs. 2%), and documented in-hospital A-fib (16% vs. 7%).

Both patients with and without stroke were receiving aspirin, and a similar percentage of patients were taking a statin.

 

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Source:
Guptill JT, Mehta RH, Armstrong PW, et al. Stroke after primary percutaneous coronary intervention in patients with ST-segment elevation myocardial infarction: Timing, characteristics, and clinical outcomes. Circ Cardiovasc Intv. 2013;Epub ahead of print.

 

 

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