ST-segment resolution and prognosis after facilitated versus primary percutaneous coronary intervention in acute
Ingo Eitel1, Annegret Franke, Gerhard Schuler
1Department of Internal Medicine/Cardiology, University of Leipzig-Heart Center, Strümpellstr. 39, 04289, Leipzig, Germany. ingoeitel@gmx.de
Insights
Facilitated percutaneous coronary intervention (PCI) in ST-elevation myocardial infarction (STEMI) improves ST-segment resolution (STR) but does not reduce mortality compared to primary PCI. Further research is needed to clarify the role of facilitated PCI strategies.
Area of Science:
- Cardiology
- Interventional Cardiology
- Acute Coronary Syndromes
Background:
- Complete ST-segment resolution (STR) is a key indicator of favorable prognosis in ST-elevation myocardial infarction (STEMI).
- The optimal reperfusion strategy for STEMI patients presenting early remains debated.
- Limited studies compare facilitated versus primary percutaneous coronary intervention (PCI) regarding early reperfusion (STR).
Purpose of the Study:
- To evaluate early ST-segment resolution (STR) and subsequent prognosis in patients with STEMI undergoing facilitated PCI versus primary PCI.
- To compare the effectiveness of different reperfusion strategies in STEMI.
Main Methods:
- A meta-analysis of 14 trials (1990-2008) involving 6,439 STEMI patients.
- Patients were assigned to either facilitated PCI or primary PCI.
- Primary endpoint: STR before and after PCI. Secondary endpoints: short-term (30-90 days) and 6-month all-cause mortality.
Main Results:
- Facilitated PCI significantly increased the likelihood of achieving STR before and after PCI (OR pre-PCI 1.59; OR post-PCI 1.69).
- Facilitation agents included glycoprotein IIb/IIIa inhibitors, fibrinolysis, or combination therapy.
- Despite improved STR, mortality rates were similar between facilitated and primary PCI groups (OR 1.11).
Conclusions:
- Prehospital facilitated PCI leads to higher rates of complete STR compared to primary PCI.
- Enhanced early reperfusion via facilitated PCI did not significantly improve patient outcomes.
- Current data suggest facilitated PCI offers no advantage over primary PCI in STEMI.
Background:
Complete ST-segment resolution (STR) is associated with favorable prognosis in ST-elevation myocardial infarction (STEMI). The optimal reperfusion strategy in patients with STEMI presenting early after symptom-onset is still a matter of debate. So far, there are only a few studies comparing the effect of facilitated and primary percutaneous coronary intervention (PCI) on early myocardial reperfusion assessed by STR. The objective of this meta-analysis was, therefore, to evaluate the extent of early STR and subsequent prognosis in facilitated versus primary PCI.
Methods:
From 1990 to 2008, we identified 14 trials of patients with STEMI reporting STR data assigned to facilitated or primary PCI. The primary endpoint of this pooled analysis was STR before and after PCI. Clinical efficacy outcomes included short-term all-cause mortality at 30-90 days and mortality after 6 months.
Results:
Together, these 14 trials randomly assigned 6,439 patients (3,605 to facilitated PCI, 2,834 to primary PCI). The facilitation agents were platelet glycoprotein IIb/IIIa inhibitors in nine (1,589 patients), fibrinolysis in three (1,037 patients), and the combination of platelet glycoprotein IIb/IIIa inhibitors plus reduced-dose fibrinolysis in three trials (979 patients). STR data were available in 4,105 patients (2,215 facilitated PCI, 1,890 primary PCI). Patients undergoing facilitated PCI were significantly more likely to achieve STR before catheterization and after PCI [OR pre-PCI 1.59 (CI 1.3, 1.90); OR post-PCI 1.69 (CI 1.28, 2.24)]. Despite this significantly improved surrogate parameter of effective myocardial reperfusion, mortality was similar between groups [OR 1.11 (CI 0.84, 1.45)].
Conclusions:
Prehospital initiated facilitated PCI results in a higher percentage of complete STR before and after PCI when compared with primary PCI. However, this enhanced early reperfusion did not significantly improve the outcome after facilitated PCI. Therefore, the current data suggest that facilitated PCI does not offer an advantage over primary PCI. The results from ongoing clinical trials in STEMI patients presenting early (<3 h) after symptom-onset with more effective antithrombotic co-therapy will provide guidance regarding the utility of a facilitated PCI strategy.
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