Pharmaco-invasive strategy for ST-segment elevation myocardial infarction treatment

Abstract

Purpose: Primary PCI is the preferred strategy of reperfusion in STEMI. But in real life many STEMI patients present to non–PCI capable hospital and often cannot undergo timely primary PCI due to expected logistic delays and therefore receive fibrinolysis. Current guidelines recommend transfer of all STEMI patients to PCI-capable center for coronarography with a view to revascularization within 24 hours after lysis. But the place of such pharmaco-invasive strategy of reperfusion in STEMI management system is not well defined. We evaluated the effectiveness of treatment of STEMI patients, using these two strategies of reperfusion in real world settings. Methods: A retrospective analysis of treatment of 427 STEMI patients that underwent PCI at a single center from January 1, 2011 to December 31, 2011 was performed. All patients were divided into 2 groups depending on strategy of reperfusion: the first one – primary PCI (294 patients), the second one included 133 patients that underwent PCI after fibrinolysis (rescue and routine early coronary intervention) at non–PCI capable referral hospital. All patients received heparin, loading dose of aspirin and clopidogrel. In the primary PCI group the median time from symptoms onset to balloon was 160 minutes with an interquartile range of 110 to 230 minutes, 77.9% of patients were delivered directly to our center, the rest were transferred from the nearest hospitals. In the pharmaco-invasive group the median time from symptoms onset to needle was 95 minutes (the interquartile range of 70 to140 min), the median time from lysis to PCI – 11.5 hours (the interquartile range of 8.5 to 17.0 hours). The study endpoints included in-hospital mortality and the rate of major adverse cardiac and cerebrovascular events (MACCE), defined as composite of death, myocardial infarction, stroke and repeat revascularization at a mean 14.7±5.2 months of follow-up. Results: The in-hospital mortality was 4.4% in the primary PCI group and 5.2% in pharmaco-invasive group, p=0.638. There was no significant difference between the groups in the incidence of major bleeding. At 14.7±5.2 months of follow up the difference between the groups in the incidence of MACCE was also insignificant (10.9% patients in the first group and 13.5% in the second group had at least one MACCE, p=0.782). Conclusions: In real world settings when timely primary PCI is not possible due to long transfer times to PCI-capable hospital a pharmaco-invasive strategy combining fibrinolysis with an obligatory use of PCI has short-term and long-term results that are comparable to those of primary PCI.