Impact of presentation and transfer delays on complete ST-segment resolution before primary percutaneous coronary
Enrico Fabris1, Arnoud Van't Hof, Christian W Hamm
1Cardiology Department, Isala Clinics, Zwolle, the Netherlands.
Insights
Achieving complete ST-segment resolution (STR) before primary percutaneous coronary intervention (PCI) predicts better outcomes. Early heparin and ticagrelor administration, especially with longer transfer delays, can improve pre-PCI STR.
Area of Science:
- Cardiology
- Interventional Cardiology
- Emergency Medicine
Background:
- ST-segment resolution (STR) is a key indicator of reperfusion success in ST-elevation myocardial infarction (STEMI).
- Predicting and achieving complete STR before primary percutaneous coronary intervention (PCI) may improve patient outcomes.
- The ATLANTIC trial investigated treatment strategies in STEMI patients undergoing PCI.
Purpose of the Study:
- To identify predictors of complete ST-segment resolution (STR) prior to primary percutaneous coronary intervention (PCI).
- To evaluate the impact of pre-PCI STR on clinical outcomes in STEMI patients.
- To analyze the role of pre-hospital (pre-H) treatments in achieving reperfusion.
Main Methods:
- Analysis of ECGs from the ATLANTIC trial, including pre-hospital (pre-H-ECG) and pre-PCI ECGs.
- Definition of complete STR as ≥70% ST-segment elevation resolution.
- Multivariable analysis to identify independent predictors of complete STR and its association with 30-day MACCE and mortality.
Main Results:
- Complete STR occurred in 12.8% of patients before PCI and was associated with significantly lower 30-day MACCE and mortality.
- Independent predictors of complete STR included shorter time to pre-H-ECG, use of heparins before pre-PCI-ECG, and shorter time from pre-H-ECG to pre-PCI-ECG.
- In the pre-H ticagrelor group, complete STR was linked to a longer pre-H-ECG to pre-PCI-ECG delay, suggesting a benefit of early drug administration.
Conclusions:
- Optimizing treatment timing and early administration of anticoagulants and ticagrelor can facilitate pre-PCI reperfusion.
- Pre-hospital treatment strategies, particularly in patients with anticipated long transfer delays, may enhance drug activity and improve outcomes.
- Reducing patient delay and ensuring timely medication are crucial for achieving successful reperfusion prior to PCI.
Aims:
The aim of this study was to identify predictors of complete ST-segment resolution (STR) pre-primary percutaneous coronary intervention (PCI) in patients enrolled in the ATLANTIC trial.
Methods And Results:
ECGs recorded at the time of inclusion (pre-hospital [pre-H]-ECG) and in the catheterisation laboratory before angiography (pre-PCI-ECG) were analysed by an independent core laboratory. Complete STR was defined as ≥70%. Complete STR occurred pre-PCI in 12.8% (204/1,598) of patients and predicted lower 30-day composite MACCE (OR=0.10, 95% CI: 0.002-0.57, p=0.001) and total mortality (OR=0.16, 95% CI: 0.004-0.95, p=0.035). Independent predictors of complete STR included the time from index event to pre-H-ECG (OR=0.94, 95% CI: 0.89-1.00, p=0.035), use of heparins before pre-PCI-ECG (OR=1.75, 95% CI: 1.25-2.45, p=0.001) and time from pre-H-ECG to pre-PCI-ECG (OR=1.09, 95% CI: 1.03-1.16, p=0.005). In the pre-H ticagrelor group, patients with complete STR had a significantly longer delay between pre-H-ECG and pre-PCI-ECG compared to patients without complete STR (median 53 [44-73] vs. 49 [38.5-61] mins, p=0.001); however, this was not observed in the control group (in-hospital ticagrelor) (50 [40-67] vs. 49 [39-61] mins, p=0.258).
Conclusions:
Short patient delay, early administration of anticoagulant and ticagrelor if a long transfer delay is expected may help to achieve reperfusion prior to PCI. Pre-H treatment may be beneficial in patients with longer transfer delays, allowing the drug to become biologically active.
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