Pharmacoinvasive Strategy Versus Primary Percutaneous Coronary Intervention in Patients With ST-Segment-Elevation
Doo Sun Sim1, Myung Ho Jeong2, Youngkeun Ahn1
1From the Department of Cardiovascular Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea (D.S.S., M.H.J., Y.A.); Division of Cardiology, Yeungnam University Hospital, Daegu, Republic of Korea (Y.J.K.); Division of Cardiology, Kyungpuk National University Hospital, Daegu, Republic of Korea (S.C.C.); Department of Cardiology, Busan National University Hospital, Republic of Korea (T.J.H.); Department of Cardiology, Chungnam National University Hospital, Daejon, Republic of Korea (I.W.S.); Department of Cardiology, Chunbuk National University Hospital, Jeonju, Republic of Korea (J.K.C.); Department of Cardiovascular Medicine, Kyung Hee University Hospital, Seoul, Republic of Korea (C.J.K.); Department of Cardiology, Chungbuk National University Hospital, Cheongju, Republic of Korea (M.C.C.); Department of Cardiology, Korea University Guro Hospital, Seoul (S.-W.R.); Division of Cardiology, Konyang University Hospital, Daejon, Republic of Korea (J.H.B.); Division of Cardiology, Catholic University Hospital, Seoul, Republic of Korea (K.B.S.); and Department of Cardiology, Asan Medical Center, Seoul, Republic of Korea (S.J.P.).
Insights
Pharmacoinvasive strategy for ST-segment-elevation myocardial infarction offers faster reperfusion and better vessel patency than primary percutaneous coronary intervention (PPCI). Clinical outcomes at 12 months were similar, indicating comparable effectiveness.
Area of Science:
- Cardiology
- Interventional Cardiology
- Acute Coronary Syndromes
Background:
- Previous studies suggested pharmacoinvasive strategy (PS) favorably compares to primary percutaneous coronary intervention (PPCI).
- Real-world data on PS versus PPCI for ST-segment-elevation myocardial infarction (STEMI) is limited.
- This study assesses the clinical impact of PS compared to PPCI in STEMI patients.
Purpose of the Study:
- To compare the 12-month clinical outcomes of pharmacoinvasive strategy versus primary percutaneous coronary intervention in real-world STEMI patients.
- To evaluate time to reperfusion and culprit-vessel patency between the two treatment strategies.
- To determine the conditions for equipoise between PS and PPCI.
Main Methods:
- Retrospective analysis of the Korea Acute Myocardial Infarction Registry.
- Identified STEMI patients receiving either PS (fibrinolysis followed by PCI) or PPCI.
- Propensity-matched analysis comparing 12-month clinical outcomes (n=706 per group).
Main Results:
- The pharmacoinvasive group had significantly shorter time to reperfusion (165 vs. 241 minutes) and higher pre-PCI Thrombolysis in Myocardial Infarction grade 3 (50.4% vs. 13.7%).
- Major bleeding and stroke incidences were similar between groups during hospitalization.
- Twelve-month rates of death (4.4% vs. 4.1%) and major adverse cardiac events (7.5% vs. 7.8%) were comparable.
Conclusions:
- Pharmacoinvasive strategy in STEMI patients resulted in shorter reperfusion times and improved culprit-vessel patency compared to PPCI.
- Both strategies demonstrated similar 12-month clinical outcomes, including death and major adverse cardiac events.
- Equipoise for major adverse cardiac events was observed when PCI-related delays were approximately 100 minutes.
Background:
The Strategic Reperfusion Early After Myocardial Infarction trial and the French Registry of Acute ST-elevation or Non-ST-elevation Myocardial Infarction 2015 suggested that pharmacoinvasive strategy compares favorably with primary percutaneous coronary intervention (PPCI). We sought to assess the clinical impact of pharmacoinvasive strategy compared with PPCI in real-world patients with ST-segment-elevation myocardial infarction.
Methods And Results:
We used the Korea Acute Myocardial Infarction Registry to identify ST-segment-elevation myocardial infarction patients receiving either pharmacoinvasive strategy defined as fibrinolysis followed by percutaneous coronary intervention (rescue/urgent or routine elective; n=708) or PPCI (n=8878). Patients receiving facilitated percutaneous coronary intervention within 3 hours from fibrinolysis were excluded. Propensity-matched 12-month clinical outcome was compared. In the propensity-matched cohort (n=706 in each group), the pharmacoinvasive group had shorter time to reperfusion therapy (165 versus 241 minutes; P<0.001) and higher rate of pre-percutaneous coronary intervention Thrombolysis in Myocardial Infarction grade 3 (50.4% versus 13.7%; P<0.001). Incidences of major bleeding and stroke during hospitalization were not different. Twelve-month rates of death and major adverse cardiac events (composite of death, recurrent myocardial infarction, target-vessel revascularization, and coronary artery bypass graft surgery) were similar between pharmacoinvasive strategy and PPCI: 4.4% versus 4.1% and 7.5% versus 7.8%, respectively. Equipoise between pharmacoinvasive strategy and PPCI for 12-month major adverse cardiac events occurred when percutaneous coronary intervention-related delay was ≈100 minutes.
Conclusions:
ST-segment-elevation myocardial infarction patients receiving pharmacoinvasive treatment, compared with PPCI, had shorter time to reperfusion, higher culprit-vessel patency, and similar 12-month clinical outcome.
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