Timing of Revascularization in Patients With Transient ST-Segment Elevation Myocardial Infarction - TRANSIENT

Jan 28, 2019
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Author/Summarized by Author:
Anthony A. Bavry, MD,MPH,FACC
Summary Reviewer:
Deepak L. Bhatt, MD, MPH, MBA, FACC
Summary Supplemental Reviewer:
Dharam J. Kumbhani, MD, SM, FACC
Trial Sponsor:
AstraZeneca and Biotronik
Date Published:
10/26/2018
Date Updated:
01/28/2019
Original Posted Date:
12/03/2018
References

Contribution To Literature:

The TRANSIENT trial failed to show that immediate invasive therapy was superior to delayed invasive therapy for transient STEMI.

Description:

The goal of the trial was to evaluate emergent percutaneous coronary intervention (PCI) (immediate invasive therapy) compared with urgent PCI (delayed invasive therapy) among patients with transient ST-segment elevation myocardial infarction (STEMI).


Study Design

  • Randomized
  • Parallel

Patients with transient STEMI were randomized to emergent PCI (immediate invasive; n = 70) versus urgent PCI (delayed invasive; n = 71). Patients randomized to delayed invasive therapy underwent coronary angiography within 24 hours if the GRACE risk score was >140 and within 72 hours if the score was ≤140.

  • Total number of enrollees: 141
  • Duration of follow-up: 30 days
  • Mean patient age: 62 years
  • Percentage female: 31%
  • Percentage with diabetes: 11%

Inclusion criteria:

  • Patients >18 years of age
  • Clinical presentation of an acute STEMI, including symptoms of any duration and STE
  • Complete normalization of STEs and resolution of symptoms on arrival to the hospital, with or without initial treatment of sublingual nitrate, heparin, P2Y12 inhibitor, and/or aspirin

Exclusion criteria:

  • History of MI, heart failure, moderate to severe valve disease, cardiomyopathy, or congenital cardiac disease
  • Thrombolytic therapy in the previous week
  • Refractory ischemia, major arrhythmias, hemodynamic instability or heart failure requiring immediate catheterization
  • Alternative causes of transient STE other than MI, such as conditions known for causing coronary vasospasm
  • Refusal or inability to give informed consent
  • Glomerular filtration rate <30 ml/min
  • Contraindications for cardiac magnetic resonance
  • Known concomitant disease with a life expectancy of <1 year

Other salient features/characteristics:

  • GRACE risk score >140: 39%
  • Location of STE: anterior 35%, inferior 55% 

Principal Findings:

The primary outcome, median infarct size, was 1.3% of the myocardium in the immediate invasive group compared with 1.5% of the delayed invasive group (p = 0.48).

Secondary outcomes, for immediate vs. delayed invasive groups:

  • Left ventricular ejection fraction (LVEF): 57.5% vs. 58.0% (p = 0.66)
  • Major adverse cardiac events at 30 days: 2.9% vs. 2.8% (p = 1.0)
  • Reinfarction at 30 days: 1.5% vs. 1.4% (p = 1.0)

Interpretation:

Among patients with transient STEMI, immediate invasive therapy was not superior to delayed invasive therapy in reducing infarct size. LVEF and major adverse cardiac events were also similar between treatment groups. Among transient STEMI patients, delayed invasive therapy guided by the GRACE risk score appears to be a safe treatment strategy. Although the trial was negative, these findings may help inform guidelines in this patient population.

References:

Lemkes JS, Janssens GN, van der Hoeven NW, et al. Timing of revascularization in patients with transient ST-segment elevation myocardial infarction: a randomized clinical trial. Eur Heart J 2019;40:283-91.

Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Cardiovascular Care Team, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Aortic Surgery, Interventions and ACS, Interventions and Imaging, Angiography, Nuclear Imaging

Keywords: Acute Coronary Syndrome, Anterior Wall Myocardial Infarction, Coronary Angiography, Myocardial Infarction, Myocardial Revascularization, Myocardium, Percutaneous Coronary Intervention, Risk Assessment, Stroke Volume, Treatment Outcome


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