Comparative early and late outcomes after primary percutaneous coronary intervention in ST-segment elevation and
David A Cox1, Gregg W Stone, Cindy L Grines
1Mid Carolina Cardiology, Charlotte, Durham, North Carolina, USA.
Insights
Patients with non-ST-segment elevation myocardial infarction (NSTEMI) treated with primary percutaneous coronary intervention (PCI) face treatment delays and higher rates of target vessel revascularization, despite similar mortality to STEMI patients.
Area of Science:
- Cardiology
- Interventional Cardiology
- Acute Coronary Syndromes
Background:
- Outcomes after primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) are well-defined.
- Prognosis for patients undergoing primary PCI for non-ST-segment elevation myocardial infarction (NSTEMI) is less established.
- Acute myocardial infarction (MI) requires timely reperfusion therapy.
Purpose of the Study:
- To compare the outcomes of patients with acute myocardial infarction (MI) with and without ST-segment elevation (STEMI) treated with primary percutaneous coronary intervention (PCI).
- To evaluate the impact of treatment delays and angiographic features on patient prognosis after primary PCI for NSTEMI versus STEMI.
Main Methods:
- A randomized trial comparing balloon angioplasty versus stenting, with or without abciximab, in 2,082 patients with acute MI.
- Subgroup analysis of 1,725 STEMI patients and 239 NSTEMI patients.
- Assessment of time-to-hospital arrival, door-to-balloon time, Thrombolysis In Myocardial Infarction (TIMI) flow, ejection fraction, and 1-year major adverse cardiac events (MACE).
Main Results:
- NSTEMI patients experienced longer delays in hospital arrival and door-to-balloon times compared to STEMI patients.
- NSTEMI patients presented with more favorable baseline angiographic features (TIMI grade 3 flow) and higher ejection fraction.
- At 1 year, NSTEMI patients had similar mortality but significantly higher rates of MACE, primarily driven by ischemic target vessel revascularization.
Conclusions:
- Patients with NSTEMI treated with primary PCI face significant treatment delays and a worse prognosis regarding target vessel revascularization compared to STEMI patients.
- Despite favorable baseline characteristics and similar reperfusion success, NSTEMI patients exhibit increased adverse events.
- Efforts to reduce reperfusion times in NSTEMI patients are crucial to improve outcomes.
Abstract:
We determined the outcomes of patients with acute ST-segment elevation (STE) myocardial infarction (STEMI) and non-STEMI (NSTEMI) after primary percutaneous coronary intervention (PCI). The prognosis after primary PCI in STEMI has been extensively studied and defined. Outcomes of patients who undergo primary PCI for NSTEMI are less well established. In total, 2,082 patients with ongoing chest pain for > 30 minutes consistent with acute MI were randomized to balloon angioplasty versus stenting, each with/without abciximab. Of 1,964 patients, STEMI was present in 1,725 (87.8%) and NSTEMI in 239 (12.2%). Compared with STEMI, those with NSTEMI were more likely to have delayed time-to-hospital arrival (2.4 vs 1.8 hours, p = 0.0002) and increased door-to-balloon time (3.2 vs 1.9 hours, p < 0.0001). Patients with NSTEMI were more likely to have Thrombolysis In Myocardial Infarction grade 3 flow at baseline (37.3% vs 19.4%, p < 0.0001) and higher ejection fraction (58.7% vs 55.8%, p = 0.001), but similar rates of postprocedural Thrombolysis In Myocardial Infarction grade 3 flow. At 1 year, patients with NTEMI had similar mortality (3.4% vs 4.4%, p = 0.40) but higher rates of major adverse cardiac events (24.0% vs 16.6%, p = 0.007) that was driven by more frequent ischemic target vessel revascularization (21.8% vs 11.9%, p <0.0001). In conclusion, patients with acute MI without STE who are treated with primary PCI have marked delays to treatment, similar late mortality, and increased rates of ischemic target vessel revascularization compared with patients with STEMI, despite more favorable angiographic features at presentation and similar reperfusion success. The adverse prognosis of patients with NSTEMI should be recognized and efforts made to decrease reperfusion times.
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