Percutaneous Myocardial Revascularization in Late-Presenting Patients With STEMI
Why the study?
The optimal management of STEMI patients presenting late (>12 hours following symptom onset) remains under debate.
Does coronary revascularization reduce mortality in STEMI patients presenting 12 to 48 hours after symptom onset?
Structured PICO
Does coronary revascularization reduce mortality in STEMI patients presenting 12 to 48 hours after symptom onset?
P
Population
1,077 STEMI patients presenting between 12 and 48 hours after symptom onset (latecomers), excluding those treated with fibrinolysis and those who died within 2 days after admission.
I
Intervention
Coronary revascularization within 48 hours after hospital admission
C
Comparator
No revascularization within 48 hours
O
Outcome
All-cause death at 30-day follow-up and long-term (median 58 months)hard clinical
Coronary revascularization in STEMI patients presenting 12 to 48 hours after symptom onset is associated with significantly lower short- and long-term mortality.
Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“These new data strengthen the current European guidelines that recommend performing a PCI on STEMI patients up to 48 hours after symptom onset.”
“Interestingly, female sex was not related to late arrival in our cohort, whereas it was suggested in previous works. This difference we observed with older studies might be caused by an increasing awareness among physicians and the population of acute MI symptoms in female patients, because these are more likely to be atypical.”
“For the patients selected for revascularization, the treating physicians, understanding that there is negative clinical trial data in these late-presenters, made a decision to treat them. There has to be some reason for that, and I think that manifests in the difference in clinical outcomes. If you look at the order of magnitude, the relative difference of one strategy versus the other dwarves the revascularization benefit of primary PCI in a normal-presenter. There's clearly something else at play than just the benefit of revascularization.”
Implication
Should not yet change practice for late-presenting STEMI; leaves open true revascularization benefit pending RCTs given selection bias.
Abstract
BACKGROUND The optimal management of patients with ST-segment elevation myocardial infarction (STEMI) presenting late->12 hours following symptom onset-is still under debate. OBJECTIVES The purpose of this study was to describe characteristics, temporal trends, and impact of revascularization in a large population of latecomer STEMI patients. METHODS The authors analyzed the data of 3 nationwide observational studies from the FAST-MI (French Registry of Acute ST-elevation and non-ST-elevation Myocardial Infarction) program, conducted over a 1-month period in 2005, 2010, and 2015. Patients presenting between 12 and 48 hours after symptom onset were classified as latecomers. RESULTS A total of 6,273 STEMI patients were included in the 3 cohorts, 1,169 (18.6%) of whom were latecomers. After exclusion of patients treated with fibrinolysis and patients deceased within 2 days after admission, 1,077 patients were analyzed, of whom 729 (67.7%) were revascularized within 48 hours after hospital admission. At 30-day follow-up, all-cause death rate was significantly lower among revascularized latecomers (2.1% vs 7.2%; P < 0.001). After a median follow-up of 58 months, the rate of all-cause death was 30.4 (95% CI: 25.7-35.9) per 1,000 patient-years in the revascularized latecomers group vs 78.7 (95% CI: 67.2-92.3) per 1,000 patient-years in the nonrevascularized latecomers group (P < 0.001). In multivariate analysis, revascularization of latecomer STEMI patients was independently associated with a significant reduction of mortality occurrence during follow-up (HR: 0.65 [95% CI: 0.50-0.84]; P = 0.001). CONCLUSIONS Coronary revascularization of latecomer STEMI patients is associated with better short and long-term clinical outcomes.
Discussion
No takes yet. Share an insight, caveat, or question.
Cite This Study
Bouisset et al. (2021) studied this question.