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Postconditioning with Lactate-enriched Blood for Cardioprotection in ST-segment Elevation Myocardial Infarction
Published on: May 28, 2019
Clinical outcomes in ST-segment elevation myocardial infarction patients undergoing percutaneous coronary
Miklos Rohla1, Fabrice Temperli1, George C M Siontis1
1Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Freiburgstrasse 18, 3010 Bern, Switzerland.
Insights
Percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) presenting after 12 hours showed less favorable outcomes. However, very late PCI (after 48 hours) was as safe as late PCI, with no excess events.
Area of Science:
- Cardiology
- Interventional Cardiology
- Acute Coronary Syndromes
Background:
- Current guidelines do not recommend routine revascularization for ST-segment elevation myocardial infarction (STEMI) presenting more than 48 hours after symptom onset.
- Understanding the outcomes associated with delayed percutaneous coronary intervention (PCI) in STEMI is crucial for optimizing treatment strategies.
Purpose of the Study:
- To compare the outcomes of STEMI patients undergoing PCI based on the total ischemic time.
- To evaluate the safety and efficacy of PCI in patients presenting with STEMI at different time intervals after symptom onset.
Main Methods:
- Analysis of STEMI patients from the Bern-PCI registry and SPUM-ACS registry (2009-2019).
- Patients were categorized into early (<12 h), late (12-48 h), and very late (>48 h) presenters based on symptom-to-balloon time.
- Co-primary endpoints at 1 year were all-cause mortality and target lesion failure (TLF).
Main Results:
- A total of 6589 STEMI patients undergoing PCI were analyzed; 73.9% were early, 17.2% late, and 8.9% very late presenters.
- All-cause mortality and TLF were significantly higher in late and very late presenters compared to early presenters.
- No significant difference in mortality or TLF was observed between very late and late presenters.
Conclusions:
- PCI performed more than 12 hours after STEMI symptom onset was associated with less favorable outcomes.
- While benefits seem uncertain, very late PCI (after 48 hours) did not demonstrate an excess in adverse events compared to late PCI, suggesting it is a safe option.
- Factors such as heart failure, impaired renal function, and prior gastrointestinal bleeding, rather than treatment delay itself, were identified as key drivers of adverse outcomes.
Aims:
Routine revascularization in patients with ST-segment elevation myocardial infarction (STEMI) presenting >48 h after symptom onset is not recommended.
Methods And Results:
We compared outcomes of STEMI patients undergoing percutaneous coronary intervention (PCI) according to total ischaemic time. Patients included in the Bern-PCI registry and the Multicenter Special Program University Medicine ACS (SPUM-ACS) between 2009 and 2019 were analysed. Based on symptom-to-balloon-time, patients were categorized as early (<12 h), late (12-48 h), or very late presenters (>48 h). Co-primary endpoints were all-cause mortality and target lesion failure (TLF), a composite of cardiac death, target vessel myocardial infarction, and target lesion revascularization at 1 year. Of 6589 STEMI patients undergoing PCI, 73.9% were early, 17.2% late, and 8.9% very late presenters. The mean age was 63.4 years, and 22% were female. At 1 year, all-cause mortality occurred more frequently in late vs. early [5.8 vs. 4.4%, hazard ratio (HR) 1.34, 95% confidence interval (CI) 1.01-1.78, P = 0.04] and very late (6.8%) vs. early presenters (HR 1.59, 95% CI 1.12-2.25, P < 0.01). There was no excess in mortality comparing very late and late presenters (HR 1.18, 95% CI 0.79-1.77, P = 0.42). Target lesion failure was more frequent in late vs. early (8.3 vs. 6.5%, HR 1.29, 95% CI 1.02-1.63, P = 0.04) and very late (9.4%) vs. early presenters (HR 1.47, 95% CI 1.09-1.97, P = 0.01), and similar between very late and late presenters (HR 1.14, 95% CI 0.81-1.60, P = 0.46). Following adjustment, heart failure, impaired renal function, and previous gastrointestinal bleeding, but not treatment delay, were the main drivers of outcomes.
Conclusion:
PCI >12 h after symptom onset was associated with less favourable outcomes, but very late vs. late presenters did not have an excess in events. While benefits seem uncertain, (very) late PCI appeared safe.
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