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NORDISTEMI: Early intervention after fibrinolysis in patients with STEMI linked to reduced death, reinfarction
Reduction in outcomes was significant when compared with more conventional therapy.
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European Society of Cardiology Congress 2009
Patients transferred to immediate angiography and percutaneous coronary intervention after fibrinolysis had reductions in hard outcomes when compared with a more conservative approach.
The researchers for the NORDISTEMI trial enrolled 266 patients presenting with acute STEMI and assigned them to receive either thrombolytic therapy with immediate transfer angiography and PCI, or to more standard management in community hospitals. The primary endpoint was a composite of death, reinfarction, stroke or new ischemia at 12 months.
According to the researchers, there was a trend towards reduction for death, reinfarction stroke or new ischemia in the early-intervention group (HR=0.72; 95% CI, 0.44-1.18). When compared with the conservative treatment group, the combined endpoint in the early-intervention group was reduced at 12 months (6.0% vs. 15.9%; HR=0.36; 95% CI, 0.16-0.81). The researchers reported no differences in bleeding or infarct size between the two treatment groups.
“Our study indicates a potential for improving reperfusion strategies for patients living in rural areas with long transport distances,” Sigrun Halvorsen, MD, PhD, an associate professor of medicine at Ullevaal University in Oslo, Norway, said in a press release. “This may be achieved by applying a well-organized pharmaco-invasive approach, including prehospital thrombolysis and rapid transfer to a PCI center.”
Halvorsen S. #1844. Presented at: European Society of Cardiology Congress 2009; August 29-September 2, 2009; Barcelona.
The results are a bit puzzling in that an endpoint with fewer variables is significant at one year, but the endpoint with four (death, stroke, reinfarction and ischemia) is not significant. I am not sure how to interpret that, except that both groups must have had recurrent ischemia in varying amounts to offset the fewer variable differences. More important is another way to look at the endpoints – at 30 days, an early invasive strategy including ischemia was significantly better. At 12 months, this difference is no longer significant, but still signals being better (P = .18). For all of the outcomes, death is, once again, not the driver. As these data show, it is recurrent ischemia at 30 days that clearly makes the difference and allows PCI to “win.” In addition, in the study, patients undergoing “conservative” therapy still had a 79% PCI rate. Hence, ischemia-driven PCI occurred in a large percentage of those transferred late and evaluated conservatively. Overall, this study supports that PCI in acute MI has a place early (if possible), but even after lysis, late PCI is frequently needed (driven by clinical ischemia).
– Peter C. Block, MD
Cardiology Today Co-Section Editor