Culprit Lesion Coronary Intervention Before Complete Angiography in ST-Elevation Myocardial Infarction: A Randomized
Nir Levi1, Rafael Wolff2, Rami Jubeh1
1Jesselson Integrated Heart Center, The Eisenberg R&D Authority, Shaare Zedek Medical Center, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel.
Insights
Performing culprit lesion percutaneous coronary intervention (PCI) before complete coronary angiography (CAG) significantly reduces reperfusion times in ST-elevation myocardial infarction (STEMI) patients. This strategy improves timely treatment, though larger trials are needed to confirm clinical outcome benefits.
Area of Science:
- Cardiology
- Interventional Cardiology
- Acute Coronary Syndromes
Background:
- Rapid reperfusion in ST-elevation myocardial infarction (STEMI) is crucial for improved patient outcomes.
- While pre-hospital and diagnostic delays are studied, intraprocedural strategies to shorten reperfusion times are less explored.
Purpose of the Study:
- To compare the effectiveness of culprit lesion percutaneous coronary intervention (PCI) performed before complete diagnostic coronary angiography (CAG) versus the traditional approach of complete CAG followed by culprit lesion PCI.
- To evaluate the impact of procedural sequencing on reperfusion times in STEMI patients.
Main Methods:
- An open-label, prospective, randomized clinical trial involving 216 STEMI patients undergoing primary PCI.
- Patients were randomized 1:1 to either undergo culprit lesion PCI first or complete CAG first.
- The primary outcome measure was the "needle-to-balloon" time, aiming for 10 minutes or less.
Main Results:
- The group undergoing culprit lesion PCI before CAG achieved significantly shorter mean "needle-to-balloon" times (11.4 minutes) compared to the group undergoing CAG first (17.3 minutes).
- A "needle-to-balloon" time of 10 minutes or less was achieved by 51.1% of patients in the PCI-first group versus 19.1% in the CAG-first group (OR, 4.4; P < .001).
- No significant differences in adverse events or mortality rates (in-hospital, 30-day, 1-year) were observed between the two groups.
Conclusions:
- Performing culprit lesion PCI before complete CAG is an effective strategy for reducing reperfusion times in STEMI patients.
- This procedural optimization has the potential to improve timely myocardial reperfusion.
- Larger clinical trials are warranted to validate these findings and assess the long-term impact on clinical outcomes.
Importance:
Rapid reperfusion during primary percutaneous coronary intervention (PCI) is associated with improved outcomes among patients with ST-elevation myocardial infarction (STEMI). Although attempts at reducing the time from STEMI diagnosis to arrival at the catheterization laboratory have been widely investigated, intraprocedural strategies aimed at reducing the time to reperfusion are lacking.
Objective:
To evaluate the effect of culprit lesion PCI before complete diagnostic coronary angiography (CAG) vs complete CAG followed by culprit lesion PCI on reperfusion times among patients with STEMI.
Design, Setting, And Participants:
This open-label, prospective, randomized clinical trial was conducted between April 1, 2021, and August 31, 2022, among patients admitted to a tertiary center in Jerusalem, Israel, with a diagnosis of STEMI undergoing primary PCI. All patients were followed up for 1 year. Analysis was on an intention-to-treat basis.
Intervention:
Patients were randomized in a 1:1 ratio to undergo either culprit lesion PCI before complete CAG or complete CAG followed by culprit lesion PCI.
Main Outcomes And Measures:
A needle-to-balloon time of 10 minutes or less.
Results:
A total of 216 patients were randomized, with 184 patients (mean [SD] age, 62.9 [12.2] years; 155 men [84.2%]) included in the final intention-to-treat analysis; 90 patients (48.9%) were randomized to undergo culprit lesion PCI before CAG, and 94 (51.1%) were randomized to undergo to CAG followed by PCI. Patients who underwent culprit lesion PCI before complete CAG had a shorter mean (SD) needle-to-balloon time (11.4 [5.9] vs 17.3 [13.3] minutes; P < .001). The primary outcome of a needle-to-balloon time of 10 minutes or less was achieved for 51.1% of patients (46 of 90) who underwent culprit lesion PCI before CAG and for 19.1% of patients (18 of 94) who underwent complete CAG followed by culprit lesion PCI (odds ratio, 4.4 [95% CI, 2.2-9.1]; P < .001). Rates of adverse events were similar between groups. In a subgroup analysis, the effect of culprit lesion PCI before complete CAG on the primary outcome was consistent. There were no differences in rates of in-hospital, 30-day, and 1-year all-cause mortality.
Conclusions And Relevance:
In this randomized clinical trial of patients with STEMI, culprit lesion PCI before complete CAG resulted in shorter reperfusion times. Larger trials are needed to validate these results and to evaluate the effect on clinical outcomes.
Trial Registration:
ClinicalTrials.gov Identifier: NCT05415085.
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