Adverse event rates following primary PCI for STEMI at US and non-US hospitals: three-year analysis from the
Patrick Tobbia1, Bruce R Brodie, Bernhard Witzenbichler
1LeBauer Cardiovascular Research Foundation and Moses Cone Hospital, Greensboro, NC 27408, USA.
Insights
Patients with ST-elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI) in the US experienced worse outcomes compared to international sites. These disparities in major adverse cardiac events and mortality persisted after risk adjustment.
Area of Science:
- Cardiology
- Interventional Cardiology
- Health Services Research
Background:
- ST-segment elevation myocardial infarction (STEMI) is a critical cardiovascular emergency.
- Primary percutaneous coronary intervention (PCI) is the standard reperfusion therapy for STEMI.
- Variations in healthcare systems may influence patient outcomes.
Purpose of the Study:
- To compare outcomes of STEMI patients treated with primary PCI at US versus international sites.
- To identify potential factors contributing to outcome differences.
Main Methods:
- Analysis of the HORIZONS-AMI trial data, randomizing 3,602 STEMI patients.
- Comparison of baseline characteristics and clinical outcomes between US (n=814) and OUS (n=2,788) patients.
- Three-year follow-up for mortality, reinfarction, major adverse cardiac events (MACE), major bleeding, and net adverse clinical events (NACE).
Main Results:
- US patients had higher rates of diabetes, prior infarction, bypass surgery, and renal insufficiency.
- OUS patients had longer door-to-balloon times but more radial access.
- At three years, US patients showed significantly higher mortality, reinfarction, MACE, major bleeding, and NACE compared to OUS patients, persisting after risk adjustment.
Conclusions:
- STEMI patients undergoing primary PCI at US sites experienced higher rates of adverse events than those at OUS sites.
- These outcome disparities remained significant even after adjusting for baseline risk factors.
- Reasons for differences may include unmeasured confounders, reporting variations, or distinct systems of care and treatment.
Aims:
To examine outcomes in patients with ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI) at US sites versus sites outside the US (OUS).
Methods And Results:
In the HORIZONS-AMI trial 3,602 STEMI patients in 11 countries were randomised to primary PCI with bivalirudin versus heparin + glycoprotein IIb/IIIa inhibitors. US patients (n=814) had more diabetes, prior infarction, prior bypass surgery, and renal insufficiency. OUS patients (n=2,788) had longer door-to-balloon times, more radial access, fewer bypass surgeries, and were discharged more often on beta-blockers and statins. At three years US patients had higher mortality (9.7% vs. 6.0%, p=0.0003), reinfarction (10.2% vs. 6.4%, p=0.001), major adverse cardiac events (MACE; 28.2% vs. 20.1%, p<0.0001), major bleeding (16.9% vs. 6.4%, p<0.0001) and net adverse clinical events (NACE; 36.6% vs. 23.8%, p<0.0001), which persisted after adjusting for baseline risk.
Conclusions:
In the HORIZONS-AMI trial, STEMI patients undergoing primary PCI at US versus OUS sites had higher rates of adverse events, which persisted after adjusting for baseline risk. The reasons for these differences are not clear but may be due to unmeasured confounders, different thresholds for event reporting, or valid differences in systems of care and treatments.
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