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Published on: May 28, 2019
Infarct Size, Shock, and Heart Failure: Does Reperfusion Strategy Matter in Early Presenting Patients With ST-Segment
Jay Shavadia1, Yinggan Zheng1, Neda Dianati Maleki1
1Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada (J.S., Y.Z., N.D.M., P.W.A.).
Insights
A pharmacoinvasive strategy for ST-segment elevation myocardial infarction may reduce infarct size, leading to fewer complications like cardiogenic shock and heart failure compared to primary PCI, especially in smaller infarcts.
Area of Science:
- Cardiology
- Interventional Cardiology
Background:
- A pharmacoinvasive (PI) strategy for ST-segment elevation myocardial infarction (STEMI) showed a trend towards reduced 30-day cardiogenic shock and heart failure compared to primary percutaneous coronary intervention (PPCI).
- The study investigated the relationship between infarct size (IS) and these outcomes.
Purpose of the Study:
- To evaluate the association between infarct size and 30-day outcomes (cardiogenic shock and congestive heart failure) in STEMI patients treated with either a pharmacoinvasive (PI) strategy or primary percutaneous coronary intervention (PPCI).
- To determine if infarct size influences the effectiveness of different reperfusion strategies.
Main Methods:
- Analysis of data from 1701 patients in the Strategic Reperfusion Early After Myocardial Infarction (STREAM) trial, randomized to PI or PPCI.
- Infarct size was categorized into small, medium, and large based on peak cardiac biomarker levels.
- The association between IS and 30-day shock and congestive heart failure was examined for each treatment group.
Main Results:
- PPCI patients had a higher proportion of large infarcts compared to PI patients (51.6% vs. 48.4%), despite similar ischemic times.
- Increasing infarct size correlated with increased shock and heart failure in both groups, except for the small IS group.
- In the small IS group, PI was associated with significantly lower rates of shock and heart failure (4.4% vs. 11.6%, P=0.026) and higher rates of aborted myocardial infarction (72.7% vs. 54.3%, P=0.005).
Conclusions:
- The pharmacoinvasive strategy appears to alter infarct size patterns, leading to more medium and fewer large infarcts compared to PPCI.
- In patients with small infarcts, the PI strategy resulted in more aborted myocardial infarctions and fewer instances of 30-day shock and congestive heart failure.
Background:
A pharmacoinvasive (PI) strategy for early presenting ST-segment elevation myocardial infarction nominally reduced 30-day cardiogenic shock and congestive heart failure compared with primary percutaneous coronary intervention (PPCI). We evaluated whether infarct size (IS) was related to this finding.
Methods And Results:
Using the peak cardiac biomarker in patients randomized to PI versus PPCI within the Strategic Reperfusion Early After Myocardial Infarction (STREAM) trial, IS was divided into 3 groups: small (≤2 times the upper limit normal [ULN]), medium (>2 to ≤5 times the upper limit normal) and large (>5 times the upper limit normal). The association between IS and 30-day shock and congestive heart failure was subsequently examined. Data on 1701 of 1892 (89.9%) patients randomized to PI (n=853, 50.1%) versus PPCI (n=848, 49.9%) within STREAM were evaluated. A higher proportion of PPCI patients had a large IS (PI versus PPCI: small, 49.8% versus 50.2%; medium, 56.9% versus 43.1%; large, 48.4% versus 51.6%; P=0.035), despite comparable intergroup ischemic times for each reperfusion strategy. As IS increased, a parallel increment in shock and congestive heart failure occurred in both treatment arms, except for the small IS group. The difference in shock and congestive heart failure in the small IS group (4.4% versus 11.6%, P=0.026) in favor of PI likely relates to higher rates of aborted myocardial infarction with the PI strategy (72.7% versus 54.3%, P=0.005). After adjustment, a trend favoring PI persisted in this subgroup (relative risk 0.40, 95% CI 0.15 to 1.06, P=0.064); no difference in treatment-related outcomes was evident in the other 2 groups.
Conclusion:
A PI strategy appears to alter the pattern of IS after ST-segment elevation myocardial infarction, resulting in more medium and fewer large infarcts compared with PPCI. Despite a comparable number of small infarcts, PI patients in this group had more aborted myocardial infarctions and less 30-day shock and congestive heart failure.
Clinical Trial Registration:
URL: http://ClinicalTrials.gov. Unique identifier: NCT00623623.
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