Abstract Background Contemporary guidelines support the use of a pharmaco-invasive (PI) strategy with immediate transfer to a percutaneous coronary intervention (PCI)-capable hospital for ST-elevation myocardial infarction (STEMI) when timely primary PCI (pPCI) is unattainable. However, when reperfusion with fibrinolysis fails to occur, rescue PCI is recommended. Methods In a pre-specified analysis from STREAM-2, we explored patients randomized to PI treatment and compared those receiving half-dose tenecteplase who required rescue intervention to those with successful fibrinolysis undergoing scheduled angiography. To provide context for those randomized pPCI, we also explored the relationship between site of randomization, i.e., community hospital (CH) versus ambulance on clinical outcomes. Resolution of ST-elevation following angiography and the composite of 30-day all-cause death, shock, heart failure and reinfarction, as well as safety, reflected by stroke and non-intracranial bleeding, were measured. Results Of the 583 patients in the current study, 168 patients required rescue intervention 43.5%, 218 patients had successful fibrinolysis scheduled for angiography and 197 were randomized to pPCI. Rescue PCI patients, compared to those undergoing scheduled angiography, had less ST resolution ≥50% (76.3% versus 92.5%, P0.001) and worse clinical composite outcomes at 30 days (16.7% versus 6.0%, P0.001) with a higher risk of intracranial hemorrhage (2.4% versus 0.5%). Intermediate outcomes were observed for patients undergoing pPCI (ST resolution ≥50%: 78.7%; 30-day composite outcome: 12.2%). Rescue intervention deployed in CH patients required 10 minutes longer compared to ambulance patients: however, there was similar ST resolution ≥50% (72.2% versus 80.5%, P=0.219) and comparable 30-day composite outcome (17.6% versus 15.7%, relative risk RR 0.97, 95% confidence interval CI 0.50 - 1.87), irrespective of location. pPCI required 48 minutes longer in CH patients, but resulted in similar outcomes to ambulance patients (ST resolution ≥50%: 77.0% versus 80.2%, P=0.595; 30-day composite outcome: 9.3% versus 15.6%, RR 1.57, 95% CI 0.72-3.41, respectively). Conclusion Contemporary PI with half-dose tenecteplase in older patients requiring rescue intervention led to less ST resolution and worse 30-day outcomes compared to those with successful fibrinolysis receiving scheduled angiography. Notably, delays to deploying rescue PCI in CH patients were shortened over those previously achieved thereby resulting in similar outcomes to those randomized in the ambulance. Our results reinforce the benefits of functional hub and spoke models with rapid transfer to a PCI-capable facility.
Bainey et al. (Sat,) studied this question.