Follow-Up Outcomes of Pre-Hospital Thrombolysis and Primary PCI in Outer Metropolitan Management of STEMI

Abstract

Background: Primary PCI (pPCI) is preferred management with improved outcomes in STEMI [[1]Keeley E.C. et al.Comparison of primary and facilitated percutaneous coronary interventions for ST-elevation myocardial infarction: quantitative review of randomised trials.The Lancet. 2006; 367 (doi:10.1016/s0140-6736(06)68148-8): 579-588Abstract Full Text Full Text PDF PubMed Scopus (458) Google Scholar], however previous reviews demonstrate comparable, in-hospital results for early, pre-hospital thrombolysis in regional centres with large catchment zones [[2]May, A. et al. (2016). Review of In-Hospital Outcomes of Thrombolysis and Primary PCI in Outer Metropolitan Management of STEMI. Heart, Lung and Circulation, Volume 25, S63.Google Scholar]. Methods: Retrospective analysis of patients presenting with STEMI at two outer metropolitan centres over a 5-year period (2014–2019), where PCI was available during working hours, with a strategy of pre-hospital thrombolysis otherwise. Patients were excluded if incomplete data precluded follow-up. The primary outcome was a composite of major adverse cardiac events (MACE) including myocardial infarction (MI), unplanned revascularisation, readmission for heart failure and all-cause mortality. Secondary outcomes included severe bleeding, TIMI-III flow rates and death from any cause. Follow up was conducted to 1-year from the index event. Results: 450 consecutive patients presented with STEMI, with 425 analysed after exclusions. 117 (27.5%) underwent pPCI while 308 (72.5%) had initial thrombolysis. Average age was 63.9 years and 76.9% were male. Of the thrombolysis group, 56.5% successfully re-perfused while 43.5% required rescue PCI (rPCI) and 296 (96%) underwent coronary angiography. Rates of TIMI-III flow post angiogram were higher in the thrombolysis group 96.0% vs 85.9% (p = 0.0147). There were no significant differences in MACE at 1-month or 1-year or all-cause mortality. Major bleeding was higher at 1-month after thrombolysis 4.5% vs 2.6% (p = 0.36) but did not reach significance, likely due to inadequate power. Conclusion: Our experience shows pre-hospital thrombolysis remains a safe alternative to pPCI, especially in regional centres, with no clinically significant differences in 1- and 12-month outcomes.