Impact of High-Degree Atrioventricular Block on No-Reflow Phenomenon and Prognosis in Patients with St-Segment Elevation Myocardial Infarction

Abstract

Introduction: Although it has been established that high-degree atrioventricular block (HAVB) is associated with mortality in the course of ST segment elevation myocardial infarction (STEMI), the mechanisms by which this AV block cause mortality are not yet fully understood. In this study we aimed: (i) to investigate the relationship between HAVB and no-reflow, which has been repeatedly shown to be associated with both short- and long-term mortality; (ii) to determine the effect of both HAVB and no-reflow on in-hospital and long-term mortality.

Patients and Methods: A total of 1.217 patients who underwent primary percutaneous coronary intervention (pPCI) were divided into two groups, according to HAVB development, and were further divided according to no-reflow development. Independent predictors of no-reflow were investigated. Furthermore, patients were compared in terms of in-hospital and long-term mortality. 

Results: In the present study, 47 patients (3.8%) suffered from HAVB and 150 patients (12.3%) had no-reflow. HAVB was an independent predictor of no-reflow [odds ratio (OR): 3.127, 95% confidence interval (CI): 1.215-9.056; p= 0.006]. In survival analysis, both HAVB and no-reflow were associated with in-hospital (19.1% vs. 3.2%; p< 0.001 and 10.7% vs. 2.9%; p< 0.001, respectively) and long-term (15.7% vs. 6.2%; p= 0.037 and 14.1% vs. 5.5%; p< 0.001, respectively) mortality.

Conclusion: To our knowledge, this is the first study in the literature to examine the effect of HAVB on reperfusion success. In this study, we found that HAVB emerged with STEMI is associated with long-term mortality and to short-term mortality. Also HAVB was an independent predictor of no-reflow, and patients who had no-reflow had a worse prognosis both in short- and long-term follow-up.

Keywords

• High grade AV block,ST segment elevation myocardial infarction,no-reflow

St-Segment Yükselmeli Miyokart İnfarktüslü Hastalarda Yüksek Dereceli Atriyoventriküler Bloğun No-reflow Fenomenine ve Prognoza Etkisi

Abstract

Giriş: ST segment yükselmeli miyokart infarktüsü (STEMİ) seyrinde yüksek dereceli atriyoventriküler bloğun (HAVB) mortalite ile ilişkili olduğu tespit edilmiş olsa da AV bloğunun mortaliteye hangi mekanizmalarla neden olduğu, net olarak ortaya konulmamıştır. Bu çalışmada, (i) HAVB ile hem kısa hem de uzun dönem mortalite ile ilişkili olduğu defalarca gösterilen no-reflow arasındaki ilişkiyi (ii) hem HAVB hem de no-reflow’un hastane içi ve uzun dönem mortaliteye etkisini araştırmayı amaçladık.

Hastalar ve Yöntem: Primer perkütan koroner girişim (pPCI) yapılan toplam 1217 hasta, HAVB gelişip gelişmemesine, daha sonra da no-reflow gelişip gelişmemesine göre iki gruba ayrıldı. No-reflow’un bağımsız prediktörleri araştırıldı. Son olarak da hastalar, hastane içi ve uzun dönem mortalite açısından karşılaştırıldı.

Bulgular: Bu çalışmada, 47 (%3.8) hastada HAVB, 150 (%12.3) hastada no-reflow izlendi. HAVB, no-reflow’un bağımsız bir prediktörü olarak saptandı (OR: 3.127, %95 CI: 1.215-9.056; p= 0.006). Sağkalım analizinde HAVB ve no-reflow’da hastane içi mortalite (sırasıyla %19.1’e karşı %3.2; p< 0.001 ve %10.7’ye karşı %2.9; p< 0.001) ve uzun dönem mortalite (sırasıyla %15.7’ye karşı %6.2; p= 0.037 ve %14.1’e karşı %5.5; p< 0.001) daha yüksek olarak izlendi.

Sonuç: Bu çalışmada, STEMİ ile ortaya çıkan HAVB’nin, kısa döneme ek olarak, uzun dönem mortalite ile de ilişkili olduğu tespit edildi. HAVB ile sağkalımla ileri derecede korelasyonu olan reperfüzyon başarısının ilişkisini gösteren bu ilk çalışmada, HAVB’nin no-reflow için bağımsız bir prediktör olduğunu ve no-reflow’u olan hastaların hem kısa hem de uzun dönem izlemlerinde kötü prognoza sahip olduğunu ortaya koyduk.

Keywords

• Yüksek dereceli atriyoventriküler blok,ST segment yükselmeli miyokart infarktüsü,no-reflow

References

1. 1. Kosmidou I, Redfors B, Dordi R, Dizon JM, McAndrew T, Mehran R, et al. Incidence, predictors, and outcomes of high-grade atrioventricular block in patients with st-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention (from the HORIZONS-AMI Trial). Am J Cardiol 2017;119:1295-301.
2. 2. Meine TJ, Al-Khatib SM, Alexander JH, Granger CB, White HD, Kilaru R, et al. Incidence, predictors, and outcomes of high-degree atrioventricular block complicating acute myocardial infarction treated with thrombolytic therapy. Am Heart J 2005;149:670.
3. 3. Lee SN, Hwang YM, Kim GH, Kim JH, Yoo KD, Kim CM, et al. Primary percutaneous coronary intervention ameliorates complete atrioventricular block complicating acute inferior myocardial infarction. Clin Interv Aging 2014;9:2027-31.
4. 4. Singh SM, FitzGerald G, Yan AT, Brieger D, Fox KA, López-Sendón J, et al. High-grade atrioventricular block in acute coronary syndromes: insights from the global registry of acute coronary events. Eur Heart J 2015;36:976-83.
5. 5. Gang UJ, Hvelplund A, Pedersen S, Iversen A, Jøns C, Abildstrøm SZ, et al. High-degree atrioventricular block complicating ST-segment elevation myocardial infarction in the era of primary percutaneous coronary intervention. Europace 2012;14:1639-45.
6. 6. Kloner RA, Ganote CE, Jennings RB. The “no-reflow” phenomenon after temporary coronary occlusion in the dog. J Clin Invest 1974;54:1496-508.
7. 7. Wu KC, Zerhouni EA, Judd RM, Lugo-Olivieri CH, Barouch LA, Schulman SP, et al. Prognostic significance of microvascular obstruction by magnetic resonance imaging in patients with acute myocardial infarction. Circulation 1998;97:765-72.
8. 8. Ndrepepa G, Tiroch K, Keta D, Fusaro M, Seyfarth M, Pache J, et al. Predictive factors and impact of no reflow after primary percutaneous coronary intervention in patients with acute myocardial infarction. Circ Cardiovasc Interv 2010;3:27-33.

9. 9. Bouleti C, Mewton N, Germain S. The no-reflow phenomenon: State of the art. Arch Cardiovasc Dis 2015;108:661-74.
10. 10. Steg PG, James SK, Atar D, Badano LP, Blömstrom-Lundqvist C, Borger MA, et al. Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology (ESC). ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J 2012;33:2569-619.
11. 11. SYNTAX score calculator. Available from: http://www.syntaxscore.com (SYNTAX working-group. Accessed date: February-December 2016).
12. 12. Gibson CM, Cannon CP, Murphy SA, Marble SJ, Barron HV, Braunwald E. TIMI Study Group. Relationship of the TIMI myocardial perfusion grades, flow grades, frame count, and percutaneous coronary intervention to long-term outcomes after thrombolytic administration in acute myocardial infarction. Circulation 2002;105:1909-13.
13. 13. Shacham Y, Leshem-Rubinow E, Steinvil A, Keren G, Roth A, Arbel Y. High degree atrioventricular block complicating acute myocardial infarction treated with primary percutaneous coronary intervention: incidence, predictors and outcomes. Isr Med Assoc J 2015;17:298-301.
14. 14. Metivier F, Marchais SJ, Guerin AP, Pannier B, London GM. Pathophysiology of anaemia: focus on the heart and blood vessels. Nephrol Dial Transplant 2000;15(Suppl 3):S514-8.
15. 15. Kim KH, Jeong MH, Ahn Y, Kim YJ, Cho MC, Kim W; Other Korea Acute Myocardial Infarction Registry Investigators. Differential Clinical Implications of High-Degree Atrioventricular Block Complicating ST-Segment Elevation Myocardial Infarction according to the Location of Infarction in the Era of Primary Percutaneous Coronary Intervention. Korean Circ J 2016;46:315-23.
16. 16. Auffret V, Loirat A, Leurent G, Martins RP, Filippi E, Coudert I, et al. High-degree atrioventricular block complicating ST segment elevation myocardial infarction in the contemporary era. Heart 2016;102:40-9.
17. 17. Piana RN, Paik GY, Moscucci M, Cohen DJ, Gibson CM, Kugelmass AD, et al. Incidence and treatment of ‘no-reflow’ after percutaneous coronary intervention. Circulation 1994;89:2514-8.
18. 18. Taniyama Y, Ito H, Iwakura K, Masuyama T, Hori M, Takiuchi S, et al. Beneficial effect of intracoronary verapamil on microvascular and myocardial salvage in patients with acute myocardial infarction. J Am Coll Cardiol 1997;30:1193-9.
19. 19. Engler RL, Schmid-Schönbein GW, Pavelec RS. Leukocyte capillary plugging in myocardial ischemia and reperfusion in the dog. Am J Pathol 1983;111:98-111.
20. 20. Tops LF, Schalij MJ, Bax JJ. The effects of right ventricular apical pacing on ventricular function and dyssynchrony implications for therapy. J Am Coll Cardiol 2009;54:764-76.