Recent Advances in the Treatment of ST-Segment Elevation Myocardial Infarction

Associations of changes in patient characteristics and management with decrease in mortality rates of men and women with ST-elevation myocardial infarction - a propensity score-matched analysis

INTRODUCTION

The aim of this study is to estimate how much of the recent decrease in mortality among patients with myocardial infarction with ST-segment elevation (STEMI) can be attributed to improved treatment strategies, and how much it is related to changes in baseline clinical characteristics, and to compare these findings for men and women.

MATERIAL AND METHODS

This was a retrospective analysis of 32,790 patients with STEMI from the Polish Registry of Acute Coronary Syndromes PL-ACS hospitalised in 2005 and 2011. Changes in treatment strategies including pharmacotherapy were analysed. Observed in-hospital and 12-month mortality rates were compared with the outcomes in the groups matched on the propensity scores.

RESULTS

There was a substantial improvement in STEMI patient management between 2005 and 2011 in Poland. It included greater use of percutaneous coronary interventions and other guideline-based adjunctive therapies, and it was associated with a significant decline in in-hospital mortality. Relative 12-month mortality reduction rates were less pronounced and more related to changes in patients' clinical characteristics. Higher mortality risk reductions were observed in women and were driven by relatively more positive changes in their baseline risk profiles when compared to men.

CONCLUSIONS

The progress in the treatment strategies has helped to achieve better survival rates in STEMI patients. However, the ongoing changes in clinical characteristics of patients also played an important role, especially in women. Clinicians should focus on modifiable risk factors and post-discharge management to possibly prolong the positive aspects of in-hospital efforts.

Survival benefit from recent changes in management of men and women with ST-segment elevation myocardial infarction treated with percutaneous coronary interventions

BACKGROUND

Nowadays, the majority of patients with myocardial infarction with ST-segment elevation (STEMI) are treated with primary percutaneous coronary interventions (PCI). In recent years, there have been ongoing improvements in PCI techniques, devices and concomitant pharmacotherapy. However, reports on further mortality reduction among PCI-treated STEMI patients remain inconclusive. The aim of this study was to compare changes in management and mortality in PCI-treated STEMI patients between 2005 and 2011 in a real-life setting.

METHODS

Data on 79,522 PCI-treated patients with STEMI from Polish Registry of Acute Coronary Syndromes (PL-ACS) admitted to Polish hospitals between 2005 and 2011 were analyzed. First, temporal trends of in-hospital management in men and women were presented. In the next step, patients from 2005 and 2011 were nearest neighbor matched on their propensity scores to compare in-hospital, 30-day and 1-year mortality rates and in-hospital management strategies and complications.

RESULTS

Some significant changes were noted in hospital management including shortening of median times from admission to PCI, increased use of drug-eluting stents, potent antiplatelet agents but also less frequent use of statin, beta-blockers and angiotensin converting enzyme inhibitors and angiotensin II receptor blockers. There was a strong tendency toward preforming additional PCI of non-infarct related arteries, especially in women. After propensity score adjustment there were significant changes in inhospital but not in 30-day or 1-year mortality rates between 2005 and 2011. The results were similar in men and women.

CONCLUSIONS

There were apparent changes in management and significant in-hospital mortality reductions in PCI-treated STEMI patients between 2005 and 2011. However, it did not result in 30-day or 1-year survival benefit at a population level. There may be room for improvement in the use of guideline-recommended pharmacotherapy.

The effects of fibrinolytic before referring STEMI patients: A systematic review and meta-analysis

BACKGROUND

Accessibility of primary percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI) in primary care settings is limited. Referring patients to PCI-capable hospitals might increase cardiac events. Hence, fibrinolytic injection before referring patients to PCI-capable settings decreases cardiac events, however, the effect of fibrinolytic injection before the referral has not been systematically evaluated. This study aimed to systematically review the effect of fibrinolytic injection before referring patients with STEMI to PCI-capable settings.

METHODS

A systematic search with Embase, Cochrane CENTRAL, Google scholar, and PubMed was conducted. Studies conducted in patients with STEMI presented to non PCI-capable settings and compared fibrinolytic injection with no injection before referring patients to PCI-capable settings were included. The primary outcome was the composite outcomes of major adverse cardiac events (MACEs) at 30 days. Meta-analyses were performed using random-effect model.

RESULTS

Of 912 articles, three RCTs and three non-RCTs were included. Based on RCTs, fibrinolytic injection before the referral has failed to decrease MACEs compared to non-fibrinolytic injection [relative risk (RR) 1.18; 95% confidence interval (CI), 0.89-1.57, p = 0.237]. Fibrinolytic injection has also failed to decrease mortality, re-infarction, and ischemic stroke. On the other hand, fibrinolytic injection was associated with a higher risk of major bleeding.

CONCLUSIONS

In non PCI-capable settings, fibrinolytic injection before referring patients with STEMI to PCI-capable settings has no clinical benefit but could increase risk of major bleeding. Clinicians might more carefully consider whether fibrinolytic injection should be used in patients with STEMI before the referral.

Prognostic Factors in Patients With Stemi Undergoing Primary PCI in the Clopidogrel Era: Role of Dual Antiplatelet Therapy at Admission and the Smoking Paradox on Long-Term Outcome

BACKGROUND

Several clinical and laboratory variables have an impact on the prognosis of STEMI patients undergoing PPCI; however, little is known about the role of ongoing DAPT at the time of the event and the smoking status as prognostic factors affecting the outcome of these patients.

METHODS AND RESULTS

Seven-hundred and thirteen consecutive STEMI patients undergoing PPCI, admitted to the S. Anna and S. Sebastiano Hospital (Caserta, Italy) and to the OLV Clinic (Aalst, Belgium), between March 2009 and December 2011, were retrospectively enrolled. Rescue PCI was the only exclusion criterion. Primary end-point was the combination of death for all causes, re-infarction, stroke, and target lesion revascularization (TLR). Patients already on DAPT at admission (26.4%) showed a significant increase in the event rate at univariate analysis (HR 2.34, CI 1.62-3.75, P < 0.05), while current smokers (56.5%) had a lower event rate, as compared to non-smokers (HR 0.67, CI 0.46-0.96, P < 0.05). In smoking patients already on DAPT at admission, a lower event rate was observed than in non-smoking patients on DAPT. Although, patients already on DAPT had a higher-risk profile (renal impairment, ongoing statin treatment, ST resolution <50%, and Killip class >1 were more frequently present than in patients not on DAPT), Cox regression analysis confirmed that both DAPT (HR 1.74, 95%CI 1.20-2.53, P < 0.01) and smoking status (HR 0.69, 95%CI 0.48-1.00, P < 0.05) retained their statistical significance, as they and were significantly associated with a worse and a better outcome, respectively, underlying their role as independent prognostic factors.

CONCLUSIONS

Not being a current smoker and ongoing DAPT at admission, in patients with STEMI undergoing PPCI, represent independent negative prognostic value.

Predictors of in-Hospital Mortality of ST-Segment Elevation Myocardial Infarction Patients Undergoing Interventional Treatment. An Analysis of Data from the RO-STEMI Registry

BACKGROUND

ST-segment elevation myocardial infarction (STEMI) remains a leading cause of morbidity and mortality worldwide. Primary percutaneous coronary intervention (pPCI) is the preferred therapy for STEMI if it is done within 120 min from the first medical contact, by an experienced team in a high-volume center. The aim of this study was to assess the clinical characteristics and predictors of in-hospital mortality of patients with STEMI treated by percutaneous coronary interventions (PCIs).

METHODS

We analyzed data from 15,076 STEMI patients enrolled in the RO-STEMI registry (ROmanian ST-Elevation Myocardial Infarction registry). Patients were divided into 2 groups: PCI (11.669; 77%) and conservative treated (3.407; 23%). PCI group includes both pPCI treated patients (84.3%), and patients undergoing rescue PCI (6.4%) and late PCI (9.3%).

RESULTS

The mean age of STEMI patients was 62.7+/-12.7 years. 70% were males. Patients treated by PCI were younger (61.4+/-12.2 versus 67.2+/-13.3, p< 0.0001) and more often men (80% versus 71%, p< 0.0001). They were less likely to have acute heart failure (Killip class II-IV) at admission (p< 0.0001). During admission, patients treated by PCI received more often dual antiplatelet therapy (97.6% versus 90.8%, p< 0.0001), statins (96.3% versus 87.5%, p< 0.0001), beta-blockers (83.8% versus 73.2%, p< 0.0001), and RAAS blockers (82.6% versus 66.4%, p< 0.0001). Overall in-hospital mortality was 7.1%: 4.1% in the PCI group and 15.7% in the conservative treated group. Multivariate analysis showed that, after adjusting for all clinical variables, Killip class II-IV at admission (OR: 9.2; 95%CI: 6.2-13.6; p< 0.0001), LVEF< 35% (OR: 3.8; 95%CI: 2.6-5.4; p< 0.0001), age older than 65 years (OR: 2.2; 95%CI: 1.5-3.2; p< 0.0001), and anterior location of myocardial infarction (OR: 2.1; 95% CI: 1.5-3; p< 0.0001) remained independent predictors for in-hospital mortality for STEMI patients treated interventionally.

CONCLUSION

Advanced Killip class, depressed LVEF, advanced age, and anterior location were the most powerful independent predictors of in-hospital mortality in STEMI patients who underwent interventional treatment.