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TRANSIENT: Timing of revascularization does not impact outcomes in transient STEMI
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PARIS — In patients with transient STEMI, defined as those who present with STEMI but have their ST-segment elevation and symptoms completely resolve before revascularization, immediate revascularization led to similar outcomes as delayed revascularization, according to data from the TRANSIENT trial.
According to the study background, as many as 24% of patients with ACS have transient STEMI.
“Current guidelines do not contain recommendations regarding the optimal strategy in patients with transient ST-elevation,” Niels van Royen, MD, PhD, professor of interventional cardiology at Amsterdam Cardiovascular Sciences, Amsterdam University Medical Center, told Healio. “So far, only non-randomized retrospective observations have been reported. TRANSIENT was the first randomized trial to address this topic.”
The researchers randomly assigned 142 patients with transient STEMI to immediate or delayed revascularization to determine a difference in infarct size and clinical outcomes. The immediate group had revascularization at a mean of 0.4 hours, while the delayed group had revascularization at 22.7 hours. The results were presented at the European Society of Cardiology Congress and simultaneously published in JACC: Cardiovascular Interventions.
All patients underwent cardiac MRI at 4 days and 4 months to assess infarct size and myocardial function, and had clinical follow-up at 4 months and 1 year.
The final infarct size as a percentage of the left ventricle was extremely small at 0.4% in both groups (P = .79), Gladys N. Janssens, MD, from the department of cardiology at Amsterdam Cardiovascular Sciences, Amsterdam University Medical Center, and colleagues found.
LV function was not affected in both groups (delayed, 59.3%; immediate, 59.9%; P = .63), according to the researchers.
There were no significant differences in MACE, defined as death, recurrent infarction and target lesion revascularization, at 1 year (delayed, 5.7%; immediate, 4.4%; P = 1), Janssens and colleagues reported, noting that if unplanned urgent procedures in the delayed group were counted as MACE, the difference remained nonsignificant (delayed, 11.4%; immediate, 4.4%; P = .21).
“The outcome is remarkably good for both strategies with almost negligible infarct size, even smaller than the average infarct size in patients with non-STEMI,” von Royen said in an interview. “The most important implication is that you have freedom to operate as a physician. In case other patients are presented with a more urgent indication, it is safe to delay PCI in this specific cohort. On the other hand, a direct invasive approach does not harm these patients.”
In a related editorial, Robert A. Byrne, MB, BCh, PhD, senior physician at Deutsches Herzzentrum München, Technische Universität München, Munich, and Roisin Colleran, MD, from the German Centre for Cardiovascular Research in Munich, wrote that “while there seems little doubt that these patients should undergo timely coronary angiography, if symptoms resolve and the ECG on arrival at the emergency department is normal — indicating spontaneous reperfusion — deferral of catheterization can be considered. However, if the STEMI team have been activated due to the initial ECG and are already prepared for catheterization, it would seem unreasonable to defer catheterization, with no suggestion from the trial data that a delayed strategy is associated with measurable clinical benefit.” – by Erik Swain
References:
Janssens GN, et al. Abstract P3126. Presented at: European Society of Cardiology Congress; Aug. 31 to Sept. 4, 2019; Paris.
Janssens GN, et al. JACC Cardiovasc Interv. 2019;doi:10.1016/j.jcin.2019.07.018.
Disclosures: The study was funded by unrestricted research grants from AstraZeneca and Biotronik. The authors and Colleran report no relevant financial disclosures. Byrne reports he received lecture fees from B. Braun Melsungen AG, Biotronik, Boston Scientific and Micell Technologies and institutional research grants from Boston Scientific and Celenova Biosciences.