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Published on: January 18, 2018
Five-year outcomes following timely primary percutaneous intervention, late primary percutaneous intervention, or a
Nicolas Danchin1,2, Batric Popovic3, Etienne Puymirat1,2
1Department of Cardiology, Hôpital Européen Georges Pompidou, Assistance-Publique Hôpitaux de Paris, 20 rue Leblanc, 75015 Paris, France.
Insights
Timely primary percutaneous coronary intervention (pPCI) and pharmaco-invasive strategies show similar 5-year survival for ST-elevation myocardial infarction (STEMI) patients. Late pPCI is associated with significantly poorer outcomes, highlighting the importance of timely reperfusion therapy.
Area of Science:
- Cardiology
- Interventional Cardiology
- Public Health
Background:
- Current ST-segment elevation myocardial infarction (STEMI) guidelines advocate for primary percutaneous coronary intervention (pPCI) within 120 minutes of ECG diagnosis when feasible.
- A pharmaco-invasive strategy is recommended when timely pPCI is not achievable.
- Real-world data suggest pPCI is often delayed beyond guideline recommendations, necessitating an evaluation of outcomes based on reperfusion timing.
Purpose of the Study:
- To compare 5-year patient outcomes based on the timing of primary percutaneous coronary intervention (pPCI) versus a pharmaco-invasive strategy in ST-elevation myocardial infarction (STEMI) patients.
- To assess the impact of timely (≤120 minutes) versus late (>120 minutes) pPCI on long-term survival.
- To provide evidence for guideline adherence and inform clinical practice regarding reperfusion strategies for STEMI.
Main Methods:
- Analysis of the French registry of Acute ST-elevation and non-ST-elevation Myocardial Infarction (FAST-MI) program, including STEMI patients from 2005 and 2010 cohorts who received reperfusion therapy.
- Comparison of 5-year outcomes using Cox multivariable analyses and propensity score matching for patients undergoing timely pPCI, late pPCI, or intravenous fibrinolysis (pharmaco-invasive strategy).
- Inclusion criteria focused on patients with onset-to-first call time <12 hours.
Main Results:
- Five-year survival was highest with the pharmaco-invasive strategy (89.8%).
- Survival was similar between timely pPCI (88.2%) and the pharmaco-invasive strategy (adjusted HR 1.02).
- Late pPCI (>120 minutes) was associated with significantly poorer 5-year survival (79.5%; adjusted HR 1.51) compared to the pharmaco-invasive strategy.
Conclusions:
- A significant proportion of STEMI patients receive pPCI beyond recommended timelines, leading to inferior 5-year outcomes.
- The pharmaco-invasive strategy demonstrates comparable long-term survival to timely pPCI.
- Adherence to recommended reperfusion timelines is crucial for improving long-term outcomes in STEMI management.
Aims:
ST-segment elevation myocardial infarction (STEMI) guidelines recommend primary percutaneous coronary intervention (pPCI) as the default reperfusion strategy when feasible ≤120 min of diagnostic ECG, and a pharmaco-invasive strategy otherwise. There is, however, a lack of direct evidence to support the guidelines, and in real-world situations, pPCI is often performed beyond recommended timelines. To assess 5-year outcomes according to timing of pPCI (timely vs. late) compared with a pharmaco-invasive strategy (fibrinolysis with referral to PCI centre).
Methods And Results:
The French registry of Acute ST-elevation and non-ST-elevation Myocardial Infarction (FAST-MI) programme consists of nationwide observational surveys consecutively recruiting patients admitted for acute myocardial infarction every 5 years. Among the 4250 STEMI patients in the 2005 and 2010 cohorts, those with reperfusion therapy and onset-to-first call time <12 h (n = 2942) were included. Outcomes at 5 years were compared according to type of reperfusion strategy and timing of pPCI, using Cox multivariable analyses and propensity score matching. Among those, 1288 (54%) patients had timely pPCI (≤120 min from ECG), 830 (28%) late pPCI (>120 min), and 824 (28%) intravenous fibrinolysis. Five-year survival was higher with a pharmaco-invasive strategy (89.8%) compared with late pPCI [79.5%; adjusted hazard ratio (HR) 1.51; 1.13-2.02] and similar to timely pPCI (88.2%, adjusted HR 1.02; 0.75-1.38). Concordant results were observed in propensity score-matched cohorts and for event-free survival.
Conclusion:
A substantial proportion of patients have pPCI beyond recommended timelines. As foreseen by the guidelines, these patients have poorer 5-year outcomes, compared with a pharmaco-invasive strategy.
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