Pharmacoinvasive strategy for ST-segment elevation myocardial infarction: wading through the treatment options

Metrics of care and cardiovascular outcomes in patients with ST-elevation myocardial infarction treated with pharmacoinvasive strategy: a decade-long network in a populous city in Brazil

BACKGROUND

Pharmacoinvasive strategy is an effective myocardial reperfusion therapy when primary percutaneous coronary intervention (p-PCI) cannot be performed in a timely manner.

METHODS

Authors sought to evaluate metrics of care and cardiovascular outcomes in a decade-long registry of a pharmacoinvasive strategy network for the treatment of ST-elevation myocardial infarction (STEMI). Data from a local network including patients undergoing fibrinolysis in county hospitals and systematically transferred to the tertiary center were accessed from March 2010 to September 2020. Numerical variables were described as median and interquartile range. Area under the curve (AUC-ROC) was used to analyze the predictive value of TIMI and GRACE scores for in-hospital mortality.

RESULTS

A total of 2,710 consecutive STEMI patients aged 59 [51-66] years, 815 women (30.1%) and 837 individuals with diabetes (30.9%) were analyzed. The time from symptom onset to first-medical-contact was 120 [60-210] minutes and the door-to-needle time was 70 [43-115] minutes. Rescue-PCI was required in 929 patients (34.3%), in whom the fibrinolytic-catheterization time was 7.2 [4.9-11.8] hours, compared to 15.7 [6.8-22,7] hours in those who had successful lytic reperfusion. All cause in-hospital mortality occurred in 151 (5.6%) patients, reinfarction in 47 (1.7%) and ischemic stroke in 33 (1.2%). Major bleeding occurred in 73 (2.7%) patients, including 19 (0.7%) cases of intracranial bleeding. C-statistic confirmed that both scores had high predictive values for in-hospital mortality, demonstrated by TIMI AUC-ROC of 0.80 [0,77-0.84] and GRACE AUC-ROC of 0.86 [0.83-0.89].

CONCLUSION

In a real world registry of a decade-long network for the treatment of ST-elevation myocardial infarction based on the pharmacoinvasive strategy, low rates of in-hospital mortality and cardiovascular outcomes were observed, despite prolonged time metrics for both fibrinolytic therapy and rescue-PCI. Register Clinicaltrials.gov NCT02090712 date of first registration 18/03/2014.

Cardiogenic shock after ST elevation myocardial infarction and IABP-SHOCK II risk score validation in a cohort treated with pharmacoinvasive strategy

Objective

To validate the Intra-aortic Balloon Pump in Cardiogenic Shock II (IABP-SHOCK II) score in patients with cardiogenic shock after ST elevation myocardial infarction (STEMI) treated with pharmacoinvasive strategy (PhIS) and to analyse the influence of ischaemia time on different risk strata.

Methods

We analysed 2143 patients with STEMI who underwent reperfusion with tenecteplase in primary health services between May 2010 and April 2017 and were transferred to a tertiary hospital for cardiac catheterisation and continuity of care. Those who evolved to cardiogenic shock were scored as low (0-2), moderate (3-4) or high (5-9) risk of death in 30 days and pairwise-log-rank test was used to compare strata. Time intervals between symptoms onset and lytic (pain-to-needle) and fibrinolytic-catheterisation were also compared.

Results

Cardiogenic shock occurred in 212 (9.9%) individuals. The 30-day mortality using the IABP-SHOCK II score was 26.6% for low-risk (n=94), 53.2% for moderate-risk (n=62) and 76% for high-risk (n=25) analysed patients (p<0.001). Validation of the score showed good discrimination for death, area under the curve of 0.73 (CI: 0.66 to 0.81; p<0.001). The median intervals of pain-to-needle and fibrinolytic-catheterisation showed no association with the group stratification (220 vs 251 vs 200 min; p=0.22 and 390 vs 435 vs 315 min; p=0.18, respectively).

Conclusions

In patients with cardiogenic shock after STEMI treated with PhIS, risk stratification using IABP-SHOCK II score was adequate. There was no influence of pain-to-needle and fibrinolytic-catheterisation times on the ability to the score model stratification.