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      Efficacy and Safety of Pharmacoinvasive Strategy Compared to Primary Percutaneous Coronary Intervention in the Management of ST-Segment Elevation Myocardial Infarction: A Prospective Country-Wide Registry

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          Abstract

          Background:

          A pharmacoinvasive reperfusion strategy is recommended for ST-elevation myocardial infarction (STEMI) patients when primary percutaneous coronary intervention (PCI) cannot be achieved in a timely fashion. This is based on a limited number of trials. The effectiveness of this strategy in the real-world is unclear.

          Objectives:

          To compare the effectiveness of pharmacoinvasive strategy versus primary PCI using a nationwide prospective registry of STEMI patients.

          Methods:

          We examined 936 STEMI patients from the reperfusion in ST-elevation myocardial infarction in Kuwait (REPERFUSE Kuwait) registry who underwent either primary PCI or pharmacoinvasive reperfusion. A composite outcome was measured based on death, congestive heart failure, reinfarction or stroke prospectively ascertained during hospital stay and up to one-year follow-up. The association between reperfusion strategy and the composite outcome was assessed using multivariate regression and Poisson proportional hazard model.

          Results:

          Compared to the pharmacoinvasive group, those undergoing primary PCI had higher Killip class on presentation and required more blood transfusions during hospitalization. There was no significant difference between primary PCI and pharmacoinvasive strategy with regards to the incidence of the composite outcome during the in-hospital period (RR = 1.0; 95% CI 0.98–1.02; p = 0.96) after adjustment for possible confounders. Over one-year follow-up, the survival of the two groups was not different (p = 0.66). The incidence of major bleeding was similar in both groups.

          Conclusion:

          STEMI patients treated with a pharmacoinvasive strategy have comparable outcomes to those treated with primary PCI with no increased risk of major bleeding. These real-world data support the use of a pharmacoinvasive strategy when primary PCI cannot be achieved in a timely fashion.

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          Most cited references18

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          Recent trends in the incidence, treatment, and outcomes of patients with STEMI and NSTEMI.

          David McManus, Joel M. Gore, Jorge Yarzebski … (2011)
          despite the widespread use of electrocardiographic changes to characterize patients presenting with acute myocardial infarction, little is known about recent trends in the incidence rates, treatment, and outcomes of patients admitted for acute myocardial infarction further classified according to the presence of ST-segment elevation. The objectives of this population-based study were to examine recent trends in the incidence and death rates associated with the 2 major types of acute myocardial infarction in residents of a large central Massachusetts metropolitan area. We reviewed the medical records of 5383 residents of the Worcester (MA) metropolitan area hospitalized for either ST-segment elevation acute myocardial infarction (STEMI) or non-ST-segment acute myocardial infarction (NSTEMI) between 1997 and 2005 at 11 greater Worcester medical centers. the incidence rates (per 100,000) of STEMI decreased appreciably (121 to 77), whereas the incidence rates of NSTEMI increased slightly (126 to 132) between 1997 and 2005. Although in-hospital and 30-day case-fatality rates remained stable in both groups, 1-year postdischarge death rates decreased between 1997 and 2005 for patients with STEMI and NSTEMI. the results of this study demonstrate recent decreases in the magnitude of STEMI, slight increases in the incidence rates of NSTEMI, and decreases in long-term mortality in patients with STEMI and NSTEMI. Our findings suggest that acute myocardial infarction prevention and treatment efforts have resulted in favorable decreases in the frequency of STEMI and death rates from the major types of acute myocardial infarction. 2011 Elsevier Inc. All rights reserved.
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            Fibrinolysis or primary PCI in ST-segment elevation myocardial infarction.

            Paul W Armstrong, Anthony Gershlick, Patrick Goldstein … (2013)
            It is not known whether prehospital fibrinolysis, coupled with timely coronary angiography, provides a clinical outcome similar to that with primary percutaneous coronary intervention (PCI) early after acute ST-segment elevation myocardial infarction (STEMI). Among 1892 patients with STEMI who presented within 3 hours after symptom onset and who were unable to undergo primary PCI within 1 hour, patients were randomly assigned to undergo either primary PCI or fibrinolytic therapy with bolus tenecteplase (amended to half dose in patients ≥75 years of age), clopidogrel, and enoxaparin before transport to a PCI-capable hospital. Emergency coronary angiography was performed if fibrinolysis failed; otherwise, angiography was performed 6 to 24 hours after randomization. The primary end point was a composite of death, shock, congestive heart failure, or reinfarction up to 30 days. The primary end point occurred in 116 of 939 patients (12.4%) in the fibrinolysis group and in 135 of 943 patients (14.3%) in the primary PCI group (relative risk in the fibrinolysis group, 0.86; 95% confidence interval, 0.68 to 1.09; P=0.21). Emergency angiography was required in 36.3% of patients in the fibrinolysis group, whereas the remainder of patients underwent angiography at a median of 17 hours after randomization. More intracranial hemorrhages occurred in the fibrinolysis group than in the primary PCI group (1.0% vs. 0.2%, P=0.04; after protocol amendment, 0.5% vs. 0.3%, P=0.45). The rates of nonintracranial bleeding were similar in the two groups. Prehospital fibrinolysis with timely coronary angiography resulted in effective reperfusion in patients with early STEMI who could not undergo primary PCI within 1 hour after the first medical contact. However, fibrinolysis was associated with a slightly increased risk of intracranial bleeding. (Funded by Boehringer Ingelheim; ClinicalTrials.gov number, NCT00623623.).
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              Hospital delays in reperfusion for ST-elevation myocardial infarction: implications when selecting a reperfusion strategy.

              Debra Murphy, Brahmajee K. Nallamothu, Brant C. Gibson … (2006)
              It has been suggested that the survival benefit associated with primary percutaneous coronary intervention (PPCI) in ST-segment elevation myocardial infarction may be attenuated if door-to-balloon (DB) time is delayed by >1 hour beyond door-to-needle (DN) times for fibrinolytic therapy. Whereas DB times are rapid in randomized trials, they are often prolonged in routine practice. We hypothesized that in clinical practice, longer DB-DN times would be associated with higher mortality rates and reduced PPCI survival advantage. We also hypothesized that in addition to PPCI delays, patient risk factors would significantly modulate the relative survival advantage of PPCI over fibrinolysis. DB-DN times were calculated by subtracting median DN time from median DB time at a hospital using data from 192,509 patients at 645 National Registry of Myocardial Infarction hospitals. Hierarchical models that adjusted simultaneously for both patient-level risk factors and hospital-level covariates were used to evaluate the relationship between PCI-related delay, patient risk factors, and in-hospital mortality. Longer DB-DN times were associated with increased mortality (P<0.0001). The DB-DN time at which mortality rates with PPCI were no better than that of fibrinolysis varied considerably depending on patient age, symptom duration, and infarct location. As DB-DN times increase, the mortality advantage of PPCI over fibrinolysis declines, and this advantage varies considerably depending on patient characteristics. As indicated in the American College of Cardiology/American Heart Association guidelines, both the hospital-based PPCI-related delay (DB-DN time) and patient characteristics should be considered when a reperfusion strategy is selected.
              Article 0 comments Cited 71 times – based on 0 reviews     Review now
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                Author and article information

                Contributors
                Professor Mohammad Zubaid
                Journal
                Journal ID (nlm-ta): Ann Glob Health
                Journal ID (iso-abbrev): Ann Glob Health
                Journal ID (issn): 2214-9996
                Title: Annals of Global Health
                Publisher: Ubiquity Press
                ISSN (Electronic): 2214-9996
                Publication date (Electronic, pub): 05 February 2020
                Publication date Collection: 2020
                Volume: 86
                Issue: 1
                Electronic Location Identifier: 13
                Affiliations
                [1 ]Department of Medicine, Faculty of Medicine, Kuwait University, KW
                [2 ]Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, US
                [3 ]Environmental Health Department, T.H. Chan School of Public Health, Harvard University, Boston, MA, US
                [4 ]Division of Cardiology, Department of Medicine, Mubarak Alkabeer Hospital, Ministry of Health, KW
                [5 ]Department of Cardiology, Salman Aldabous Cardiac Centre, Ministry of Health, KW
                [6 ]Division of Cardiology, Department of Medicine, Alfarwaniya Hospital, Ministry of Health, KW
                [7 ]Department of Cardiology, Sabah Alahmad Cardiac Centre, Ministry of Health, KW
                [8 ]Department of Cardiology, Chest Diseases Hospital, Ministry of Health, KW
                [9 ]Division of Cardiology, Department of Medicine, Aljahra Hospital, Ministry of Health, KW
                [10 ]Ciccarone Center for Prevention of Cardiovascular Disease, Johns Hopkins University, Baltimore, Maryland, US
                Author notes
                Corresponding author: Mohammad Zubaid, MB, ChB ( zubaid@ 123456hsc.edu.kw )
                Article
                DOI: 10.5334/aogh.2632
                PMC ID: 7006601
                PubMed ID: 32064231
                SO-VID: 2d6a208b-88f9-431f-b7aa-feaa287890a1
                Copyright © Copyright: © 2020 The Author(s)
                License:

                This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC-BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. See http://creativecommons.org/licenses/by/4.0/.

                History
                Funding
                Boehringer Ingelheim, Gulf.
                Categories
                Subject: Original Research

                Data availability:

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