Poorer 5-year outcomes in STEMI patients receiving late pPCI
Five-year outcomes following timely primary percutaneous intervention, late primary percutaneous intervention, or a pharmaco-invasive strategy in ST-segment elevation myocardial infarction: the FAST-MI programmeLiterature - Danchin N, Popovic B, Puymirat E et al., - Eur Heart J. 2020;41(7):858-866. doi: 10.1093/eurheartj/ehz665.
Introduction and methods
The ESC guidelines for the management of acute myocardial infarction (AMI) in patients with ST-segment elevation myocardial infarction (STEMI) recommend primary percutaneous coronary intervention (pPCI) as the default strategy for treating STEMI at the acute stage. When time from diagnostic ECG to treatment exceeds 120 min, a pharmaco-invasive strategy is recommended (intravenous fibrinolysis followed by secondary coronary angiography with or without PCI) . However, direct evidence to support these guidelines is missing, and pPCI is often performed beyond recommended timelines.
This study used data from the French registry of acute ST-elevation and non-ST-elevation myocardial infarction (FAST-MI) 2005 and 2010 cohorts [2,3] and assessed the 5-year outcomes of 2942 STEMI patients who presented within 12h of symptom onset. Propensity score-matching was applied, resulting in 3 groups of patients with timely pPCI (44%, n=1288), late pPCI (>120 min from diagnostic ECG, 28%, n=830), or a pharmaco-invasive strategy (28%, n=824 with fibrinolytic therapy, of them 98% underwent coronary angiography, and 86% actually underwent PCI). 5-Year survival and a combined endpoint of death, AMI or stroke at 5 years were assessed.
- 5-Year survival was 89.3% (86.8-91.8%) for the pharmaco-invasive strategy and 81.8% (78.5-85.1%) for late pPCI (HR 1.77, 95%CI 1.28-2.44, p=0.001) in matched cohorts.
- In the matched cohorts, 5-year survival was 89.3% (86.8-91.8%) for both pharmaco-invasive and timely pPCI groups (HR 1.01, 95%CI 0.70-1.44, P=0.97).
- Combined endpoint of death, AMI or stroke at 5 years was 85.1% (82.0-88.3%) for late pPCI and 76.5% (72.8-80.2%) for the pharmaco-invasive strategy (HR 1.64, 95%CI 1.23-2.18, P=0.001), and 85.1% (82.0-88.2%) vs. 84.3% (81.2-87.6%) for timely pPCI vs. the pharmaco-invasive strategy (HR 1.08, 95%CI 0.70-1.44, P=0.64).
- In the whole population, the 5-year crude survival was 89.8% (87.6–92.0%) for the pharmaco-invasive strategy, 88.2% (86.4–90.0%) for timely pPCI, and 79.5% (76.8–82.2%) for late pPCI. Using the pharmaco-invasive strategy as reference group, the HR’s were 1.04 (95%CI 0.78–1.37) for timely pPCI and 1.47 (95%CI 1.11–1.95) for late pPCI, after full adjustment.
- For the combined endpoint of death, AMI or stroke at 5 years, the fully adjusted HR’s were 1.11 (95%CI 0.87-1.42, P=0.40) for timely pPCI and 1.46 (95%CI 1.14-1.88, P=0.003) for late pPCI, compared with the pharmaco-invasive strategy.
Patients with STEMI who received pharmaco-invasive strategy at the acute stage had an improved 5-year survival compared with pPCI performed beyond the recommended timelines. 5-Year survival and a combined endpoint of death, AMI or stroke at 5 years did not differ between timely pPCI and the pharmaco-invasive strategy. These results support the current guidelines that recommend that pPCI should be performed as early as possible after symptom onset and within 120 min of diagnostic ECG. And if this cannot be achieved, a pharmaco-invasive strategy is recommended.