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Impact of diagnostic ECG-to-wire delay in STEMI patients treated with primary PCI: a DANAMI-3 substudy
Lars Nepper-Christensen1, Jacob Lønborg, Dan Eik Høfsten
1Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
Insights
Delays exceeding 120 minutes from pre-hospital electrocardiogram (ECG) to vessel wiring in ST-segment elevation myocardial infarction (STEMI) patients increase infarct size and mortality risk. However, significant myocardial salvage is still possible in a third of these patients.
Area of Science:
- Cardiology
- Medical Imaging
- Clinical Research
Background:
- ST-segment elevation myocardial infarction (STEMI) requires rapid reperfusion therapy.
- Timeliness of primary percutaneous coronary intervention (PCI) is critical for patient outcomes.
- Assessing reperfusion success using cardiovascular magnetic resonance (CMR) provides detailed insights into myocardial damage and salvage.
Purpose of the Study:
- To evaluate the impact of a prolonged ECG-to-wire time (>120 minutes) on CMR-assessed reperfusion markers.
- To determine the association between ECG-to-wire delay and clinical outcomes in STEMI patients undergoing primary PCI.
- To investigate the extent of myocardial salvage in patients experiencing significant reperfusion delays.
Main Methods:
- Retrospective analysis of 1,492 STEMI patients for clinical outcomes.
- Cardiovascular magnetic resonance (CMR) imaging performed in 748 patients to assess infarct size and myocardial salvage.
- Multivariable analysis to identify independent predictors of adverse clinical events.
Main Results:
- A delay of ECG-to-wire >120 minutes was observed in 20% of patients.
- This delay was associated with significantly larger acute infarct size and smaller myocardial salvage.
- Despite delays, 33% of patients with ECG-to-wire >120 minutes achieved substantial myocardial salvage (≥0.50).
- ECG-to-wire >120 minutes independently predicted increased risk of all-cause mortality and heart failure (HR 1.61).
Conclusions:
- Prolonged ECG-to-wire time (>120 minutes) in STEMI patients undergoing primary PCI is linked to adverse outcomes, including larger infarct size and reduced myocardial salvage.
- A significant proportion of patients treated beyond this delay still exhibit substantial myocardial salvage, highlighting potential benefits of reperfusion even with delays.
- These findings underscore the importance of minimizing reperfusion delays while acknowledging that salvage is still achievable in a subset of patients with longer treatment times.
Aims:
We aimed to evaluate the impact of delay from diagnostic pre-hospital electrocardiogram (ECG) to wiring of the infarct-related vessel (ECG-to-wire) >120 minutes on cardiovascular magnetic resonance (CMR) markers of reperfusion success and clinical outcome in patients with ST-segment elevation myocardial infarction (STEMI).
Methods And Results:
We included 1,492 patients in the analyses of clinical outcome. CMR was performed in 748 patients to evaluate infarct size and myocardial salvage. In total, 304 patients (20%) had ECG-to-wire >120 minutes, which was associated with larger acute infarct size (18% [interquartile range (IQR), 10-28] vs. 15% [8-24]; p=0.022) and smaller myocardial salvage (0.42 [IQR 0.28-0.57] vs. 0.50 [IQR 0.34-0.70]; p=0.002). However, 33% of the patients with ECG-to-wire >120 minutes still had a substantial myocardial salvage ≥0.50. In a multivariable analysis, ECG-to-wire >120 minutes was associated with an increased risk of all-cause mortality and heart failure (hazard ratio 1.61, 95% confidence interval [CI] 1.14-2.26, p=0.007).
Conclusions:
ECG-to-wire >120 minutes was associated with larger infarct size, smaller myocardial salvage and a poorer clinical outcome in STEMI patients transferred for primary percutaneous coronary intervention. However, myocardial salvage was still substantial in one third of patients treated beyond 120 minutes of delay.
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