ST上昇型心筋梗塞における1時間以内のプライマリ経皮的冠動脈インターベンション：早期治療患者からの洞察

Whereas reperfusion benefit in ST-elevation myocardial infarction (STEMI) is time-dependent, outcome data from very early primary percutaneous coronary intervention (PPCI) are limited. The STREAM-1 and -2 trials provided a unique opportunity to assess this issue. We evaluated electrocardiographic (ECG), angiographic, and clinical outcomes of early presenting STEMI patients undergoing PPCI, focusing on those treated <60 minutes of randomization.

We analyzed STEMI patients from STREAM-1 (n=1892) and STREAM-2 (n=604) trials presenting <3 hours of symptom onset who underwent PPCI. Endpoints included ECG (ST segment resolution, Q waves), angiographic (TIMI flow grade), 30-day composite of all-cause death, shock, heart failure, reinfarction, safety outcomes, and 1-year mortality.

Patients undergoing PPCI <60 minutes of randomization (29.2%) were younger, more frequently male, and had shorter total ischemic times than those undergoing PPCI >60 minutes. ST resolution and TIMI flow outcomes were similar, but significantly fewer patients in the rapid PPCI group had Q waves on discharge ECG (58.2 vs. 71.9%, P <0.001). The 30-day composite outcome was lower in the <60 minutes group (10.1 versus 14.8%, RR 0.68 (95% CI 0.47-0.98) P=0.04), associated with a significant 62% reduction in cardiogenic shock (P=0.0008), and also had lower 1-year mortality (4.0 versus 7.2%; RR 0.56 (0.31-1.01), P(logrank)=0.047. After inverse probability weighted adjustment, the 30-day composite outcome and cardiogenic shock were RR 0.74 (0.50-1.08), P=0.116 and RR 0.45 (0.22-0.91), P=0.027, respectively, and the 1 year mortality was RR 0.70 (0.39-1.26), P=0.235. Safety endpoints were similar in both groups.

Substantial opportunity exists to improve outcomes for early-presenting STEMI patients undergoing PPCI. Establishing a first medical contact-to-PPCI time of <60 minutes provides incremental benefit.

gov registration numbers: NCT00623623 (https://clinicaltrials.gov/study/NCT00623623), NCT02777580 (https://clinicaltrials.gov/study/NCT02777580).