ObjectiveDeferred revascularisation based upon fractional flow reserve (FFR >0.80) is associated with a low incidence of target lesion failure (TLF). Whether deferred revascularisation is also as safe in diabetes mellitus (DM) patients is unknown.MethodsAll DM patients and the next consecutive Non-DM patients who underwent a FFR-assessment between 1/01/2010 and 31/12/2013 were included, and followed until 1/07/2015. Patients with lesions FFR >0.80 were analysed according to the presence vs. absence of DM, while patients who underwent index revascularisation in FFR-assessed or other lesions were excluded. The primary endpoint was the incidence of TLF; a composite of target lesion revascularisation (TLR) and target vessel myocardial infarction (TVMI).ResultsA total of 250 patients (122 DM, 128 non-DM) who underwent deferred revascularisation of all lesions (FFR >0.80) were compared. At a mean follow up of 39.8 ± 16.3 months, DM patients compared to non-DM had a higher TLF rate, 18.1 vs 7.5 %, logrank p ≤ 0.01, Cox regression-adjusted HR 3.65 (95 % CI 1.40–9.53, p < 0.01), which was largely driven by a higher incidence of TLR (17.2 vs. 7.5 %, HR 3.52, 95 % CI 1.34–9.30, p = 0.01), whilst a non-significant but numerically higher incidence of TVMI (6.1 vs. 2.0 %, HR 3.34, 95 % CI 0.64–17.30, p = 0.15) was observed.ConclusionsThis study, the largest to directly compare the clinical outcomes of FFR-guided deferred revascularisation in patients with and without DM, shows that DM patients are associated with a significantly higher TLF rate. Whether intravascular imaging, additional invasive haemodynamics or stringent risk factor modification may impact on this higher TLF rate remains unknown.
a small cohort of patients. 9 Recently, Spyridopoulos et al showed that SI is an independent and stronger predictor of long-term mortality in older patients with STEMI. 10 In that study, however, an unusual definition of CS (SBP <100 mmHg with HR >100 beats/min) was used, which makes it difficult to compare the results with previous studies and to extrapolate it into daily practice. Furthermore, they did not assess the optimal cut-off for SI, but used a self-chosen cut-off, which was different from previous studies. 8, 9 The independent prognostic value of SI as compared with CS in STEMI treated with primary PCI, is therefore still unclear. The aim of this study was to evaluate the independent impact of SI on 1-year mortality in a large cohort of patients with STEMI (largest until now), treated by primary PCI, and to compare this with CS. MethodsData for this study were collected from the prospective cohort of patients with STEMI at the Isala Hart Centrum, Zwolle, The Netherlands, from January 2000 to December 2011. Patients were diagnosed with STEMI if they had C ardiogenic shock (CS) has previously been shown to be a strong and independent predictor of both short-term and long-term mortality in patients with ST-elevation myocardial infarction (STEMI). 1 Although the incidence of CS in patients with STEMI has declined in the past decades, the mortality due to CS remains high (approximately 50%) despite all advances in management, medication and technology. 2 Early identification of the pre-shock state might play an important role in improving the prognosis of CS in STEMI patients.Several studies in non-cardiac shock patients suggested that shock index (SI), the ratio of heart rate (HR) to systolic blood pressure (SBP), is a sensitive tool for early recognition of septic, hypovolemic or obstructive shock. 3-7 The combination of HR and SBP may be more powerful than either HR or SBP alone, because early stages of shock are also taken into account. Therefore, SI can be a good marker of pre-shock. The predictive importance of SI in patients with STEMI has been shown in a recent study, but that study investigated only short-term mortality, and only 12% of the patients were treated by primary percutaneous coronary intervention (PCI). Background: Cardiogenic shock (CS) is a strong predictor of mortality in patients with ST-elevation myocardial infarction (STEMI), but there is evidence that shock index (SI), taking into account both blood pressure and heart rate, is a more sensitive and powerful predictor. We investigated the independent impact of SI and CS on 30-day and 1-year mortality in patients with STEMI, treated by primary percutaneous coronary intervention (PCI).
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