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Outcome of STEMI Patients With Reperfusion Delay of 120 Minutes or More Treated With the Pharmacoinvasive Approach vs
Alexandre Angers-Goulet1,2, Olivier Bouchard2, Simon Bérubé1,2
1Centre Hospitalier Université de Sherbrooke (CHUS), Sherbrooke, Québec, Canada.
Insights
Primary percutaneous coronary intervention (PPCI) is safer than fibrinolysis for ST-segment elevation myocardial infarction (STEMI) patients presenting >120 minutes after first medical contact (FMC). Delayed PPCI reduces risks of intracranial hemorrhage and severe bleeding.
Area of Science:
- Cardiology
- Emergency Medicine
- Clinical Trials
Background:
- ST-segment elevation myocardial infarction (STEMI) treatment involves primary percutaneous coronary intervention (PPCI) and fibrinolysis.
- The optimal treatment threshold for PPCI versus fibrinolysis, especially beyond 120 minutes from first medical contact (FMC), remains debated.
- Limited research exists on outcomes for STEMI patients treated after the 120-minute window in the current PPCI and fibrinolysis era.
Purpose of the Study:
- To compare the safety and efficacy of delayed PPCI versus fibrinolysis in STEMI patients presenting beyond 120 minutes from FMC.
- To evaluate net adverse clinical events, including mortality, re-infarction, revascularization, stroke, and bleeding.
- To analyze specific bleeding complications, particularly intracranial hemorrhage.
Main Methods:
- Retrospective analysis of 536 STEMI patients treated between 2016-2020 at a PPCI-capable hospital.
- Inclusion of patients treated with PPCI within 120-240 minutes of FMC or with fibrinolysis.
- Comparison of net adverse clinical events (NACE) and bleeding outcomes between the delayed PPCI and fibrinolysis groups.
Main Results:
- No significant difference in NACE between delayed PPCI (2.8%) and fibrinolysis (3.7%) groups (P=0.61).
- Significantly lower rates of intracranial hemorrhage (0% vs 2.8%, P=0.008) in the PPCI group.
- Significantly lower rates of major bleeding (BARC 3 or 5) in the PPCI group (0.9% vs 3.7%, P=0.048).
Conclusions:
- Delayed PPCI (120-240 min FMC-to-balloon) appears safer than fibrinolysis for STEMI patients.
- PPCI significantly reduces the risk of intracranial hemorrhage and severe bleeding compared to fibrinolysis.
- Further validation in larger randomized trials is recommended.
Background:
Primary percutaneous coronary intervention (PPCI) and fibrinolysis have proved to be major discoveries regarding treatment of ST-segment elevation myocardial infarction (STEMI). The threshold at which PPCI becomes less favourable than fibrinolysis remains unclear and controversial. Trials have studied the impact of delayed reperfusion in relation to symptom onset, but to our knowledge, none have focused on the outcome of patients past the expected 120-minute window regarding first medical contact (FMC) in the concomitant era of PPCI and fibrinolysis.
Methods:
STEMI patients who presented to a single PPCI-capable hospital, in the period from 2016 to 2020, and were treated with PPCI within 120 -240 minutes after FMC, and those who received fibrinolysis, were included. Outcomes of patients treated with delayed PPCI were compared to those of patients treated with fibrinolysis. The primary endpoint was a net adverse clinical event composite of all-cause mortality, myocardial re-infarction, ischemia-driven target-vessel revascularization, disabling stroke, and major bleeding at discharge.
Results:
Inclusion criteria were met for 536 STEMI patients, 429 treated with PPCI and 107 treated with fibrinolysis. The primary endpoint (net adverse clinical events) was not significantly different between the 2 groups (2.8% vs 3.7%, P = 0.61). However, intracranial hemorrhage (0% vs 2.8%, P = 0.008) and bleeding (BARC 3 or 5) (0.9% vs 3.7%, P = 0.048) significantly favoured the PPCI group.
Conclusions:
This retrospective study suggests that delayed PPCI may be a safer approach than fibrinolysis in patients with an FMC-to-balloon time of > 120 minutes, owing to reduction in the risk of intracranial and severe bleeding. These retrospective observations should be validated in larger randomized trials.
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