Key result
Primary percutaneous coronary intervention reduced reinfarction compared to thrombolysis in late-presenting STEMI patients with grade 3 ischemia (0% vs 12.2%, p<0.001).
Why the study?
Does primary percutaneous coronary intervention reduce 30-day mortality or reinfarction compared to thrombolytic treatment in STEMI patients stratified by electrocardiographic ischaemia grade and symptom duration?
RCT (n=1,319)
Does primary percutaneous coronary intervention reduce 30-day mortality or reinfarction compared to thrombolytic treatment in STEMI patients stratified by electrocardiographic ischaemia grade and symptom duration?
Absolute Event Rate: 1.4% vs 6.9%
Absolute Risk Reduction: 5.5%
p-value: p=0.10
Electrocardiographic ischaemia grading and symptom duration can identify STEMI patients at particularly high risk of reinfarction with thrombolysis who derive significant benefit from primary PCI.
ECG ischaemia grade plus symptom duration may refine STEMI reperfusion choice; extends DANAMI-2 subgroup analysis without altering primary trial conclusions.
OBJECTIVE: To determine whether ischaemia grade (GI) on the presenting ECG and duration of symptoms can identify subgroups of patients who would derive more benefit than the general population of patients with ST segment elevation acute myocardium infarction (STEMI) from primary percutaneous coronary intervention (pPCI) over thrombolytic treatment (TT) in reducing mortality or reinfarction. METHODS: 1319 DANAMI-2 (Danish trial in Acute Myocardial Infarction-2) patients were classified as having grade 2 ischaemia (GI2; ST segment elevation without terminal QRS distortion) or grade 3 ischaemia (GI3; ST segment elevation with terminal QRS distortion in > or = 2 adjacent leads), and were divided into early and late groups split by the median time (3 h) from symptom onset to treatment. Outcomes were 30-day mortality and reinfarction. RESULTS: Mortality was significantly higher for GI3 than for GI2 (9.7% v 4.8%, p < 0.001) and doubled for patients presenting late (GI2: 6.0% v 3.3%, p = 0.01; GI3: 12.5% v 4.7%, p = 0.05). Overall mortality did not differ significantly between pPCI and TT; however, a 5.5% absolute mortality reduction was seen in GI3 treated early with pPCI (1.4% v 6.9%, p = 0.10). Reinfarction rate was particularly high among GI3 patients presenting late and treated with TT (12.2%). pPCI in such patients significantly reduced the rate of reinfarction (0%, p < 0.001). Logistic regression analysis showed that age (odds ratio (OR) 1.09, 95% confidence interval (CI) 1.06 to 1.12, p < 0.001), prior angina (OR 2.56, 95% CI 1.44 to 4.54, p = 0.001), heart rate (OR 1.03, 95% CI 1.01 to 1.04, p = 0.001) and GI3 (OR 1.91, 95% CI 1.06 to 3.44, p = 0.031) were independently associated with mortality, whereas the sum of ST segment elevation was not. CONCLUSIONS: GI3 is an independent predictor of mortality among patients with STEMI. Mortality increased significantly with symptom duration in both GI2 and GI3. pPCI may be especially beneficial for patients with GI3 presenting early, whereas patients with GI3 presenting late and treated with TT are at particular risk of reinfarction.
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Sejersten et al. (2006) conducted an RCT in ST segment elevation acute myocardium infarction (STEMI) (n=1,319). Primary percutaneous coronary intervention (pPCI) vs. Thrombolytic treatment (TT) was evaluated on 30-day mortality in patients with grade 3 ischemia treated early (p=0.10). Primary percutaneous coronary intervention reduced reinfarction compared to thrombolysis in late-presenting STEMI patients with grade 3 ischemia (0% vs 12.2%, p<0.001).
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