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Pharmaco-invasive strategy may be viable alternative to primary PCI in patients with STEMI
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In patients with STEMI, the use of a pharmaco-invasive strategy appears to yield shorter symptom-to-reperfusion time, higher culprit-vessel patency and comparable 12-month clinical outcome vs. primary PCI, according to recent findings.
In the study, researchers identified 9,759 patients with STEMI enrolled in the KAMIR registry between November 2005 and December 2011. KAMIR is Korea’s first nationwide, multicenter data-collection registry intended for documenting the outcomes of patients with acute MI.
Patients chosen for the current analysis were aged at least 18 years, with STEMI less than 12 hours from symptom onset, who were eligible for fibrinolysis or primary PCI. Fibrinolysis procedures were performed in-hospital, and of the 881 patients who underwent fibrinolysis, 843 (96%) underwent coronary angiography and 726 underwent a pharmaco-invasive strategy, defined as fibrinolysis followed by PCI. Eighteen patients who underwent facilitated PCI, defined as fibrinolysis followed by immediate PCI (within 3 hours of fibrinolysis), were excluded. After this exclusion was applied, the pharmaco-invasive group consisted of 708 patients who underwent rescue/urgent or routine elective pharmaco-invasive treatment.
They were compared 8,878 patients who underwent primary PCI. The researchers adjusted for bias by using propensity scores, which were calculated for the likelihood of receiving pharmaco-invasive treatment using a logistic regression model consisting of 35 covariates. According to the researchers, 706 patients receiving pharmaco-invasive treatment were matched to 706 patients undergoing primary PCI.
The primary endpoint was the occurrence of MACE, defined as the composite of all-cause mortality, recurrent MI, target lesion revascularization and CABG at 12 months. Secondary endpoints included death from any cause, recurrent MI, target vessel revascularization and CABG.
In the propensity-matched cohort, the pharmaco-invasive treatment group had shorter time to reperfusion therapy (165 vs. 241 minutes; P < .001) and higher rate of pre-PCI TIMI grade 3 (50.4% vs. 13.7%; P < .001), the researchers wrote.
The difference in time from symptom onset to first medical contact, shorter in the pharmaco-invasive group vs. the primary PCI group in the overall cohort, was attenuated in the propensity-matched cohort. However, the pharmaco-invasive group still had shorter time from symptom onset to the start of reperfusion therapy (median, 165 vs. 241 minutes; P < .001) and time from first medical contact to start of reperfusion therapy (median, 80 vs. 145 minutes; P < .001).
There was no difference in the rates of in-hospital major bleeding and stroke, the researchers wrote.
At 12 months, the two strategies yielded comparable rates of mortality (4.4% in the pharmaco-invasive group vs. 4.1% in the primary PCI group) and MACE (7.5% vs. 7.8%). There was an equal distribution of 12-month MACE between the pharmaco-invasive strategy and primary PCI when PCI-related delay was approximately 100 minutes, according to the researchers.
“In real practice, many transferred patients with [STEMI] do not receive timely primary PCI, while fibrinolytic therapy is underutilized,” the researchers wrote. “In such patients, [pharmaco-invasive] strategy may be instrumental in reducing total ischemic time and improving outcomes.” – by Jennifer Byrne
Disclosure: The researchers report no relevant financial disclosures.
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