Extended Pharmacoinvasive PCI Compared to Primary PCI: Insights From Madras Medical College STEMI Registry

In low- and middle-income countries, timely primary percutaneous coronary intervention (PPCI) for ST-elevation myocardial infarction (STEMI) is often limited. When timely PPCI is not feasible, current guidelines recommend a pharmacoinvasive strategy with routine angiography and percutaneous coronary intervention (PCI), if indicated, within 3 - 24 hours after fibrinolysis; however, the role of PCI beyond 24 hours remains uncertain. We compared clinical outcomes of PPCI versus extended pharmacoinvasive PCI (ePIPCI; PCI performed 3 to 48 hours after fibrinolysis) in STEMI. We analyzed the Madras Medical College STEMI Registry (September 2018 to October 2019), comparing patients undergoing PPCI with those receiving ePIPCI, including subgroups treated at 3 to 24 and 24 to 48 hours after fibrinolysis. Outcomes included in-hospital complications, in-hospital mortality, and 1-year all-cause mortality. Of the 2,499 STEMI patients enrolled, 248 underwent PPCI and 210 ePIPCI; among the remainder, 1,091 (43.7%) received fibrinolysis only, 825 (33.0%) had no revascularization, and 125 (5.0%) underwent delayed PCI. In-hospital complications (23.0% vs 21.5%; RR 1.05, 95% CI 0.75 to 1.48; p = 0.78), in-hospital mortality (4.4% vs 1.4%; RR 3.11, 95% CI 0.88 to 10.98; p = 0.07), and 1-year mortality (8.5% vs 7.4%; RR 1.14, 95% CI 0.59 to 2.19; p = 0.70) were similar between PPCI and ePIPCI. Outcomes were comparable between the 3 to 24-hour and 24 to 48-hour post-fibrinolysis subgroups. In multivariable analysis of the full cohort, index-hospitalization PCI was independently associated with lower in-hospital mortality (adjusted OR 0.36, 95% CI 0.21 to 0.62; p <0.001). In conclusion, PCI up to 48 hours after fibrinolysis yielded outcomes comparable to PPCI, supporting an extended pharmacoinvasive strategy in resource-limited settings.