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Implications of ischaemic area at risk and mode of reperfusion in ST-elevation myocardial infarction
Kevin R Bainey1, Claudio Fresco2, Yinggan Zheng1
1Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada.
Insights
The extent of ST-segment deviation on baseline ECGs in ST-elevation myocardial infarction (STEMI) patients correlates with 30-day adverse events. However, reperfusion strategy effectiveness is not influenced by the degree of myocardial jeopardy.
Area of Science:
- Cardiology
- Emergency Medicine
- Clinical Trials
Background:
- Uncertainty exists regarding the optimal reperfusion strategy for ST-elevation myocardial infarction (STEMI) with extensive myocardium at risk.
- Early reperfusion therapy aims to limit infarct size and improve outcomes in STEMI patients.
- The STREAM trial investigated early fibrinolysis versus primary percutaneous coronary intervention.
Purpose of the Study:
- To determine if the extent of baseline ST-segment deviation on ECGs in STEMI patients predicts response to reperfusion therapy.
- To investigate the association between ST-segment changes and clinical outcomes following reperfusion.
- To explore potential interactions between ST-segment deviation and reperfusion strategy efficacy.
Main Methods:
- Analysis of baseline ECGs from 1859 STEMI patients in the STREAM trial.
- Quantification of ST-segment elevation (∑STE) and ST-segment deviation (∑STD) and categorization into quartiles.
- Exploration of associations between ∑STE/∑STD quartiles and the primary endpoint (30-day death/shock/heart failure/re-infarction) for fibrinolysis vs. primary PCI.
Main Results:
- A progressive increase in 30-day adverse events was observed with increasing quartiles of baseline ∑STE and ∑STD.
- Both ∑STE and ∑STD were associated with the primary endpoint.
- No significant interaction was found between baseline ∑STE or ∑STD quartiles and the efficacy of either reperfusion strategy on clinical outcomes.
Conclusions:
- Baseline ECG ST-segment deviation in STEMI is associated with 30-day clinical events.
- The extent of jeopardized myocardium, indicated by ST-segment changes, does not appear to influence the effectiveness of early reperfusion strategies (fibrinolysis vs. primary PCI).
- These findings suggest that reperfusion strategy choice in STEMI may not need to be guided by the initial degree of ST-segment deviation.
Objective:
Uncertainty exists concerning the relative merits of pharmacological versus mechanical coronary reperfusion in patients presenting early with ST-elevation myocardial infarction (STEMI) with extensive myocardium at risk. Accordingly, we investigated whether the extent of baseline ST-segment shift was related to the response of either reperfusion modality in patients with STEMI presenting within 3 h of symptoms.
Methods:
We analysed baseline ECGs from 1859 patients enrolled in the STrategic Reperfusion Early After Myocardial Infarction (STREAM) trial. The sum of ST-segment elevation (∑STE) and ST-segment deviation (∑STD) was categorised into quartiles and associations with the primary endpoint (30-day death/shock/congestive heart failure/re-myocardial infarction) for each reperfusion strategy (early fibrinolysis vs primary percutaneous coronary intervention) were explored.
Results:
Overall, there was a progressive rise in the 30-day primary endpoint according to quartiles of baseline ∑STE (10.3% (0-5 mm), 12.4% (5.5-8.5 mm), 12.1% (9-13.5 mm), 17.6% (> 14.0 mm), p = 0.008) and ∑STD (9.0% (0-9 mm), 13.5% (9.5-14 mm), 14.7% (14.5-20 mm), 15.3% (> 20 mm), p = 0.019). Both ∑STE and ∑STD were associated with the primary endpoint (∑STE: p = 0.071; ∑STD: p = 0.024). However, there was no interaction between quartiles of baseline ∑STE or ∑STD and efficacy of either reperfusion strategy on the 30-day clinical outcomes (∑STE: p (interaction) = 0.696; ∑STD: p (interaction) = 0.542).
Conclusions:
These data demonstrate an association between ∑STE or ∑STD on the baseline ECG and clinical events at 30 days following reperfusion therapy in STEMI. More importantly, the response to different reperfusion strategies was not influenced by the extent of jeopardised myocardium.
Trial Registration Number:
NCT00623623; Post-results.
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