Myocardial Revascularization Strategies in ST Elevation Myocardial Infarction Without Urgent Revascularization:
Pierre Deharo1, Alizée Porto2, Thierry Bourguignon3
1Département de Cardiologie, CHU Timone, Marseille, France; Aix Marseille Univ, Inserm, Inra, C2VN, Marseille, France; Aix-Marseille Université, Faculté de Médecine, Marseille, France.
Insights
For ST-segment elevation myocardial infarction (STEMI) patients not receiving early revascularization, surgical procedures showed better outcomes than percutaneous coronary intervention (PCI). This suggests surgery is a viable alternative for selected STEMI patients.
Area of Science:
- Cardiology
- Interventional Cardiology
- Cardiac Surgery
Background:
- ST-segment elevation myocardial infarction (STEMI) is a critical condition requiring timely intervention.
- The optimal revascularization strategy for STEMI patients not undergoing immediate (<48 hours) intervention remains a subject of investigation.
- Percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) surgery are primary revascularization methods.
Purpose of the Study:
- To compare the clinical outcomes of STEMI patients treated with PCI versus CABG when revascularization occurs between 48 hours and 90 days post-initial hospitalization.
- To evaluate the association of surgical versus percutaneous revascularization with mortality, rehospitalization, and major adverse events.
Main Methods:
- Analysis of a French administrative hospital discharge database (2010-2019) for STEMI patients undergoing first PCI or CABG between 48 hours and 90 days.
- Utilized propensity score matching to create comparable groups for outcome analysis.
- Compared rates of all-cause death, cardiovascular death, heart failure rehospitalization, stroke, and major bleeding.
Main Results:
- In a matched cohort of 12,012 patients, surgical revascularization was linked to significantly lower rates of all-cause death (5.1% vs. 7.1%) and cardiovascular death (2.6% vs. 3.1%).
- Rehospitalization for heart failure was less frequent following CABG (5.5% vs. 7.5%).
- Major bleeding events were more common after PCI (4.6% vs. 6.1%), while stroke incidence did not differ significantly.
Conclusions:
- For STEMI patients who do not receive urgent revascularization, surgical revascularization is associated with superior outcomes compared to PCI.
- Individual consideration of CABG as an alternative to PCI is warranted in this patient population.
- Delayed revascularization in STEMI may benefit from a surgical approach for improved survival and reduced heart failure readmissions.
Objective:
To analyze the outcomes of patients presenting with ST-segment elevation myocardial infarction (STEMI) without early (<48 hours) revascularization, according to percutaneous versus surgical revascularization.
Patients And Methods:
Based on the French administrative hospital discharge database, the study collected information for all consecutive patients seen for a STEMI in France between January 1, 2010, to June 31, 2019, who underwent either a first percutaneous coronary intervention (PCI) or a first coronary artery bypass graft between 48 hours and 90 days after the index hospitalization. Propensity score matching was used for the analysis of outcomes.
Results:
Of 71,365 patients with STEMI in the analysis, 59,340 patients underwent PCI and 12,025 patients underwent coronary artery bypass graft. In a matched analysis of 12,012 patients by arm, surgical revascularization was associated with lower rates of all cause (5.1% vs 7.1%; hazard ratio [HR], 0.70; 95% CI, 0.66 to 0.75) and cardiovascular (2.6% vs 3.1%; HR, 0.83; 95% CI, 0.76 to 0.91) death. Rehospitalization for heart failure was less often reported after surgery (5.5% vs 7.5%; HR, 0.76; 95% CI, 0.71 to 0.81) whereas stroke incidence was not statistically different between the two arms (2.1% vs 2.3%; HR, 0.90; 95% CI, 0.80 to 1.00). Major bleeding was less often reported in the PCI arm (4.6% vs 6.1%; HR, 1.31; 95% CI, 1.22 to 1.41).
Conclusion:
In patients with STEMI who did not undergo urgent revascularization (ie, within 48 hours after presentation), surgical revascularization was associated with better outcomes and should be individually considered as an alternative to PCI.
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