Prognostic impact of non-compliance with guidelines-recommended times to reperfusion therapy in ST-elevation myocardial infarction. The FAST-MI 2010 registry

Abstract

Current guidelines recommend short time delays from qualifying ECG to reperfusion therapy in ST-elevation myocardial infarction (STEMI) patients. Recently, however, it has been suggested that shortening door-to-balloon times might not result in lower mortality, thereby questioning the relevance of current guidelines. The aim of this study was to assess in-hospital and one-year mortality in patients with fibrinolysis or primary percutaneous coronary intervention (PPCI) according to guidelines-recommended times to reperfusion therapy. FAST-MI 2010 is a nationwide French registry including 4169 patients, of whom 1580 had ST-elevation myocardial infarction and had PPCI ( n=1289) or fibrinolysis ( n=291) as part of a pharmaco-invasive strategy. Four groups were constituted: Gr1 (within recommended times from ECG to PPCI; n=708), Gr2 (beyond recommended times from ECG to PPCI; n=581), Gr3 (time from ECG to lysis ⩽30 min, n=196), and Gr4 (time from ECG to lysis >30 min, n=95). In-hospital mortality was 3.6% in Gr2 vs. 1.0% in Gr1 and 3.2% in Gr4 vs. 1.0% in Gr3. After adjustment, hospital mortality was higher for reperfusion therapy beyond recommended times: odds ratio (OR) 3.29, 95% confidence interval (CI) 1.32-8.18; for PPCI, OR: 4.13; 95% CI: 1.50-11.35 and for fibrinolysis, OR: 2.72; 95% CI: 0.34-21.96. Likewise, one-year mortality was higher in patients with reperfusion beyond recommended times (hazard ratio 2.13, 95% CI:1.29-3.50). The results were confirmed by propensity score analyses. Early and one-year mortality were lower for ST-elevation myocardial infarction patients when the recommended timelines for reperfusion therapy were met, suggesting that, in spite of recent interrogations, compliance with current guidelines remains a clinically relevant objective.