Outcomes after delayed primary percutaneous coronary intervention vs. pharmaco-invasive strategy in ST-segment
Jarle Jortveit1, Are Hugo Pripp2, Sigrun Halvorsen3
1Department of Cardiology, Sørlandet Hospital, Arendal, Box 783, Stoa, 4809 Arendal, Norway.
Insights
For ST-segment elevation myocardial infarction (STEMI) patients not receiving timely primary percutaneous coronary intervention (pPCI), a pharmaco-invasive (P-I) strategy shows better long-term survival than delayed or late pPCI. However, P-I strategies may increase bleeding complications.
Area of Science:
- Cardiology
- Interventional Cardiology
- Acute Coronary Syndromes
Background:
- Primary percutaneous coronary intervention (pPCI) is the gold standard for ST-segment elevation myocardial infarction (STEMI) if performed within 120 minutes.
- Optimal reperfusion strategy for STEMI patients unable to receive timely pPCI remains unclear.
- Pharmaco-invasive (P-I) strategy offers an alternative when timely pPCI is not feasible.
Purpose of the Study:
- To compare long-term outcomes of delayed/late pPCI versus a P-I strategy in STEMI patients.
- To evaluate the impact of reperfusion strategies on mortality and bleeding complications.
- To inform clinical decision-making for STEMI management when timely pPCI is unavailable.
Main Methods:
- Retrospective analysis of STEMI patients from the Norwegian Myocardial Infarction Registry (NORMI) (2013-2019).
- Inclusion criteria: STEMI diagnosis, symptom onset to first medical contact ≤12 hours, available timelines.
- Comparison groups: timely pPCI, delayed pPCI (121-180 min), late pPCI (>180 min), and P-I strategy.
Main Results:
- A total of 13,221 STEMI patients met inclusion criteria.
- Mortality was higher in delayed pPCI (aHR 1.3) and late pPCI (aHR 1.4) compared to the P-I strategy.
- Bleeding complications were more frequent in the P-I strategy group.
Conclusions:
- In STEMI patients not receiving timely pPCI, a P-I strategy is associated with improved long-term survival.
- Delayed or late pPCI in this patient group is linked to increased mortality.
- While P-I strategies may increase bleeding risk, they offer a survival benefit over delayed interventions.
Aims:
Primary percutaneous coronary intervention (pPCI) is the preferred reperfusion strategy in patients with ST-segment elevation myocardial infarction (STEMI) provided it can be performed within 120 min from diagnosis. However, it is unclear whether pPCI or a pharmaco-invasive (P-I) strategy is the best choice in patients who cannot receive timely pPCI. The aim of the present study was to compare outcomes after delayed and late pPCI vs. a P-I strategy in STEMI patients who did not receive timely pPCI.
Methods And Results:
All patients with STEMI registered in the Norwegian Myocardial Infarction Registry (NORMI) between 2013 and 2019, with ≤12 h from symptom onset to first medical contact and available timelines were included in the study. The primary outcome was all-cause mortality, and follow-up was through 2019. A total of 21 121 (27% of 78 368) STEMI patients were registered in the NORMI. Among patients who met the inclusion criteria, 7238 (54%) patients underwent timely pPCI, 1537 (11%) delayed pPCI (121-180 min), 1012 (7%) late pPCI (>180 min), and 2338 (17%) patients were treated with a P-I strategy. After a median follow-up time of 2.5 years, mortality was higher in the delayed pPCI [adjusted hazard ratio (HR) 1.3, 95% confidence interval (CI) 1.0-1.5] and in the late pPCI group (adjusted HR 1.4, 95% CI 1.1-1.7) compared to the P-I strategy group, but bleeding complications were more frequent after P-I strategy.
Conclusions:
In STEMI patients who did not receive timely percutaneous coronary intervention, a P-I strategy seemed to be associated with better long-term survival compared to delayed/late pPCI.
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