Reperfusion by Primary Percutaneous Coronary Intervention in Patients With ST-Segment Elevation Myocardial Infarction Within 12 to 24 Hours of the Onset of Symptoms (from a Prospective National Observational Study [PL-ACS])

Study Questions:

Is there benefit of reperfusion by percutaneous coronary intervention (PCI) performed between 12-24 hours of symptom onset in patients presenting with ST-elevation myocardial infarction (STEMI)?

Methods:

The authors analyzed the outcome of 2,036 patients with STEMI presenting 12-24 hours from onset of symptoms and enrolled in the Polish Registry of Acute Coronary Syndromes from June 2005 to August 2006. Patients with cardiogenic shock, pulmonary edema, or treated with thrombolysis were excluded. Propensity matching was used to adjust for the nonrandom use of primary PCI.

Results:

An invasive approach was applied to 910 (44.7%) patients, with the majority (92%) of them undergoing PCI. Patients treated with PCI were less sick and younger than those treated conservatively, although the main determinant of use of PCI was admission to a PCI-capable hospital. Patients with an invasive approach had lower mortality at 1 year compared with patients treated with a conservative approach (9.3% vs. 17.9%, p < 0.0001). The benefit of an invasive approach remained significant after multivariate adjustment (hazard ratio [HR], 0.73; 95% confidence interval [CI], 0.56-0.96) and in a propensity-matched analysis (HR, 0.73; 95% CI, 0.58-0.99).

Conclusions:

PCI in patients with STEMI who present within 12-24 hours of symptom onset may be associated with survival benefit.

Perspective:

While the benefit of primary PCI in patients presenting within 12 hours is clearly established, it is not clear if there is a benefit of PCI in patients who present late. The OAT trial suggested that those who present 3-28 days after MI have no benefit from late PCI. In the BRAVE 2 trial, a smaller infarct size was observed in those who underwent PCI after presenting between 12-48 hours after symptoms (JAMA 2005;293:2865-72). In this observational study, there was long-term survival benefit of PCI in patients presenting within 12-24 hours. Although there are no definitive randomized data demonstrating a reduction in hard events, in the absence of any evidence of harm, based on these studies, it would be reasonable to offer PCI to patients who present late provided the symptom-to-balloon time is less than 48 hours.

Clinical Topics: Acute Coronary Syndromes, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Acute Heart Failure, Interventions and ACS

Keywords: Hospitals, Shock, Cardiogenic, Pulmonary Edema, Registries, Acute Coronary Syndrome, Avena sativa, Cardiology, Percutaneous Coronary Intervention


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