Key result
Immediate invasive therapy for late-presenting AMI shows no significant association with lower in-hospital mortality.
Why the study?
Patients presenting with ST-elevation myocardial infarction over 12 hours after chest pain onset derive less benefit from fibrinolysis and were excluded from most primary angioplasty trials, leaving it unclear if an invasive strategy is beneficial.
Does immediate invasive therapy improve in-hospital outcomes compared to conservative therapy in patients presenting with AMI >12 hours after chest pain onset?
Observational
Yes
Does immediate invasive therapy improve in-hospital outcomes compared to conservative therapy in patients presenting with AMI >12 hours after chest pain onset?
Effect estimate: OR 0.73 (95% CI 0.53-1.01)
Absolute Event Rate: 3.5% vs 5%
p-value: p=0.036
In patients presenting with late STEMI (>12 hours), the apparent mortality benefit of early invasive therapy is largely driven by selection bias, with propensity-matched multivariate analysis showing only a non-significant trend toward improved survival.
Non-significant mortality trend after bias adjustment does not support invasive therapy in late STEMI; leaves open confirmation by randomized trials.
OBJECTIVES: This study was designed to compare the in-hospital outcome of patients presenting with >12 h from onset of chest pain and acute ST elevation myocardial infarction (AMI) who received either immediate invasive or conservative therapy. BACKGROUND: The benefits of fibrinolytic therapy diminish in patients presenting with AMI and onset of chest pain >12 h. Primary angioplasty has been suggested as a possible treatment for such patients, but they have been excluded from most trials of primary angioplasty. It remains unclear if an invasive treatment strategy is beneficial to these patients. METHODS: Patients presenting with >12 h of chest pain and AMI were identified from the National Registry of Myocardial Infarction 2 database. Patients receiving invasive therapy <6 h after hospital admission were compared with those receiving conservative therapy. Short-term outcomes were compared on the basis of the initial therapy received. To help control for baseline differences in the groups, patients were matched with controls by propensity score methodology. RESULTS: On preliminary analysis, in-hospital outcome was improved in terms of recurrent ischemia, angina, myocardial infarction and mortality in patients receiving initial invasive therapy (odds ratio [OR] = 0.67; 95% confidence interval [CI] 0.49 to 0.92 for mortality). After matching by propensity score, the mortality benefit persisted on bivariate analysis (3.5% vs. 5.0%, p = 0.036), though on multivariate analysis, only a non-significant but strong trend toward decreased mortality remained (OR = 0.73; 95% CI 0.53 to 1.01). CONCLUSIONS: Patients receiving early invasive therapy had lower risk features on presentation. Selection bias may play an important role in choosing these patients' course of treatment and their subsequent outcomes. Certain patients presenting with AMI and duration of chest pain >12 h may benefit from early invasive therapy. These patients could be characterized in a randomized trial.
No takes yet. Share an insight, caveat, or question.
Elad et al. (2002) conducted an observational in Acute ST elevation myocardial infarction (AMI) presenting >12 h after chest pain onset. Immediate invasive therapy vs. Conservative therapy was evaluated on In-hospital mortality (OR 0.73, 95% CI 0.53-1.01, p=0.036). Immediate invasive therapy for AMI presenting >12 hours after symptom onset was associated with a non-significant trend toward decreased in-hospital mortality (OR 0.73; 95% CI 0.53-1.01).
Synapse has enriched 4 closely related papers on similar clinical questions. Consider them for comparative context: