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Published on: June 12, 2021
Fibrinolysis vs. primary percutaneous coronary intervention for ST-segment elevation myocardial infarction
Saraschandra Vallabhajosyula1,2,3,4,5, Dhiran Verghese4,5, Malcolm R Bell1
1Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA.
Insights
Initial fibrinolysis is a viable treatment for ST-segment elevation myocardial infarction cardiogenic shock (STEMI-CS), showing comparable mortality to primary percutaneous coronary intervention (PPCI). This large study found similar outcomes, including organ failure and hospital stay, with lower costs for fibrinolysis.
Area of Science:
- Cardiology
- Interventional Cardiology
- Acute Coronary Syndromes
Background:
- Limited contemporary data exist on initial fibrinolysis use in ST-segment elevation myocardial infarction with cardiogenic shock (STEMI-CS).
- Understanding treatment outcomes is crucial for managing this high-risk patient population.
Purpose of the Study:
- To compare the in-hospital outcomes of STEMI-CS patients treated with initial fibrinolysis versus primary percutaneous coronary intervention (PPCI).
Main Methods:
- A comparative effectiveness study utilizing the National (Nationwide) Inpatient Sample (2009-2017).
- Adult STEMI-CS admissions receiving pre-hospital/in-hospital fibrinolysis were compared to those receiving PPCI.
- Exclusion criteria included alternate fibrinolysis indications and medical/surgical management without fibrinolysis. Outcomes assessed included mortality, organ failure, complications, length of stay, costs, and palliative care use.
Main Results:
- Over 5297 (fibrinolysis) and 110,452 (PPCI) admissions were analyzed.
- The fibrinolysis group had higher rates of hemorrhagic complications but comparable all-cause in-hospital mortality (adjusted OR 0.97; 95% CI 0.90-1.05).
- Comparable rates of acute organ failure, hospital length of stay, palliative care referrals, and do-not-resuscitate status were observed, with lesser hospitalization costs in the fibrinolysis group.
Conclusions:
- Initial fibrinolysis demonstrates comparable in-hospital mortality to PPCI in STEMI-CS patients in the contemporary era.
- Fibrinolysis in STEMI-CS is associated with similar major adverse outcomes and lower costs, suggesting its continued role in select cases.
Aims:
There are limited contemporary data on the use of initial fibrinolysis in ST-segment elevation myocardial infarction cardiogenic shock (STEMI-CS). This study sought to compare the outcomes of STEMI-CS receiving initial fibrinolysis vs. primary percutaneous coronary intervention (PPCI).
Methods:
Using the National (Nationwide) Inpatient Sample from 2009 to 2017, a comparative effectiveness study of adult (>18 years) STEMI-CS admissions receiving pre-hospital/in-hospital fibrinolysis were compared with those receiving PPCI. Admissions with alternate indications for fibrinolysis and STEMI-CS managed medically or with surgical revascularization (without fibrinolysis) were excluded. Outcomes of interest included in-hospital mortality, development of non-cardiac organ failure, complications, hospital length of stay, hospitalization costs, use of palliative care, and do-not-resuscitate status.
Results:
During 2009-2017, 5297 and 110 452 admissions received initial fibrinolysis and PPCI, respectively. Compared with those receiving PPCI, the fibrinolysis group was more often non-White, with lower co-morbidity, and admitted on weekends and to small rural hospitals (all P < 0.001). In the fibrinolysis group, 95.3%, 77.4%, and 15.7% received angiography, PCI, and coronary artery bypass grafting, respectively. The fibrinolysis group had higher rates of haemorrhagic complications (13.5% vs. 9.9%; P < 0.001). The fibrinolysis group had comparable all-cause in-hospital mortality [logistic regression analysis: 28.8% vs. 28.5%; propensity-matched analysis: 30.8% vs. 30.3%; adjusted odds ratio 0.97 (95% confidence interval 0.90-1.05); P = 0.50]. The fibrinolysis group had comparable rates of acute organ failure, hospital length of stay, rates of palliative care referrals, do-not-resuscitate status use, and lesser hospitalization costs.
Conclusions:
The use of initial fibrinolysis had comparable in-hospital mortality than those receiving PPCI in STEMI-CS in the contemporary era in this large national observational study.
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