Abstract
Introduction:Substantial heterogeneity exists in reperfusion strategies for patients with ST-segment myocardial infarction (STEMI) in low- and middle-income countries (LMICs). We sought to compare outcomes associated with primary percutaneous coronary intervention (PPCI) and non-primary percutaneous coronary intervention (nPPCI) reperfusion strategies in patients with STEMI in Kerala, India.Methods:We performed a retrospective analysis of patients with STEMI (n = 8665) from the Acute Coronary Syndrome Quality Improvement in Kerala (ACS QUIK) randomized trial receiving either PPCI (n = 6623) or nPPCI (n = 2042). nPPCI included all PCI strategies implemented when PPCI was not available including all post-fibrinolysis PCI strategies and PCI without fibrinolysis. Clinical outcomes among patients undergoing PPCI and nPPCI were compared after propensity-score matching. The main outcomes were the rates of in-hospital and 30-day major adverse cardiovascular events (MACE), defined as the composite of death, reinfarction, stroke, and major bleeding.Results:In the propensity-score matched cohort (n = 1266 in each group), nPPCI had longer symptom onset to hospital arrival time (347.5 vs. 195.0 minutes, p < 0.001), door to balloon time (108 minutes vs. 75 minutes, p < 0.001), and were less likely to receive a coronary stent (89.4% vs. 95%, p < 0.001), including drug-eluting stents (89.5% vs. 94.4%, p < 0.001). There were no clinically meaningful differences in discharge medical therapy. However, patients treated with nPPCI were less commonly referred for cardiac rehabilitation (20.2% vs. 24.2%; p = 0.019). In-hospital (3.6% vs. 3.3%, p = 0.74%) and 30-day (4.4% vs. 4.6%, p = 0.77) MACE did not differ between nPPCI and PPCI matched groups.Conclusion:In a large, contemporary population of STEMI patients from a LMIC, patients treated with a nPPCI reperfusion strategy had comparable short- and intermediate-term outcomes compared to PPCI despite differences in hospital presentation time and coronary stent use. These findings are reassuring but highlight the need for continued quality improvement in the delivery of STEMI care in resource-limited settings.
Highlights
Substantial heterogeneity exists in reperfusion strategies for patients with STsegment myocardial infarction (STEMI) in low- and middle-income countries (LMICs)
We focused on STEMI (n = 13,689) patients who received any type of reperfusion strategy (n = 9,852) and analyzed those patients who underwent PCI during their hospitalization (n = 8665) including patients who underwent non-primary PCI (nPPCI) (n = 2042) or primary percutaneous coronary intervention (PPCI) (n = 6623) as defined below (Figure 1)
The STREAM trial and other studies demonstrating the efficacy of PhI compared to PPCI were performed in high-income countries (HIC) with fewer patient- and system-level barriers to STEMI care and more homogeneity of reperfusion strategies compared to LMICs
Summary
Substantial heterogeneity exists in reperfusion strategies for patients with STsegment myocardial infarction (STEMI) in low- and middle-income countries (LMICs). STEMI systems of care in LMICs are evolving due to the implementation of quality improvement programs that improve access to PCI [11], the management of acute coronary syndromes (ACS) in resource-limited settings is heterogeneous and must frequently adapt to system- and patient-level factors that may hamper strict adherence to guideline-recommended care [4]. Contemporary data are needed to provide insights into gaps in guideline-based STEMI management and identify opportunities for quality improvement in LMICs. the aim of this study is to compare clinical outcomes of patients with STEMI undergoing guideline-based PPCI compared to patients receiving non-primary PCI (nPPCI) reperfusion in a resource-limited setting among patients from the Acute Coronary Syndrome Quality Improvement in Kerala (ACS QUIK) randomized trial
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