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Delayed vs. Immediate Intervention in Transient STEMI
Study Questions:
What is the effect of an immediate versus a delayed invasive approach for patients with acute coronary syndrome who present with transient ST-segment elevation myocardial infarction (STEMI) on final infarct size and clinical outcome up to 1 year?
Methods:
The investigators conducted a multicenter trial, where 142 transient STEMI patients were randomized 1:1 to either delayed or immediate coronary intervention. Cardiac magnetic resonance imaging was performed at 4 days and at 4-month follow-up to assess infarct size and myocardial function. Clinical follow-up was performed at 4 and 12 months. To assess the difference between parameters at baseline and follow-up, a paired T-test was used for normally distributed data and the Wilcoxon signed rank test in case of non-normally distributed data. Data were expressed by mean and standard deviation or median and interquartile range (IQR) when appropriate. Categorical variables were compared using the Fisher’s exact test and described with percentages.
Results:
In the delayed (22.7 h) and the immediate invasive group (0.4 h), final infarct size as percentage of the left ventricle was very small (0.4%; IQR, 0.0-2.5% vs. 0.4%; IQR, 0.0-3.5%, p = 0.79) and left ventricular function was good (59.3 ± 6.5% vs. 59.9 ± 5.4%, p = 0.63). In addition, overall occurrence of major adverse cardiac events (MACE), consisting of death, recurrent infarction, and target lesion revascularization, up to 1 year was low and not different between both groups (5.7% vs. 4.4%, respectively, p = 1.00).
Conclusions:
The authors concluded that patients with transient STEMI have limited infarction and well-preserved myocardial function in general, and a delayed or immediate revascularization has no effect on functional outcome and clinical events up to 1 year.
Perspective:
This prospective, randomized study evaluating the effect of a delayed invasive strategy versus an immediate, STEMI-like, invasive strategy in patients presenting with transient STEMI reports that at 1-year follow-up, the timing of revascularization had no influence on final infarct size at 4 months or the prespecified composite endpoint of MACE, consisting of death, recurrent MI, or target lesion revascularization. Furthermore, patients with transient STEMI have very limited myocardial infarct size, a well preserved left ventricular function, and subsequently a good clinical outcome up to 1 year. It appears that the decision for the timing of intervention in transient STEMI patients can be made based on logistical considerations and in case of a competing more urgent/emergent procedure, PCI in a transient STEMI patient could be delayed until the next day.
Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Cardiovascular Care Team, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Aortic Surgery, Cardiac Surgery and Arrhythmias, Interventions and ACS, Interventions and Imaging, Magnetic Resonance Imaging
Keywords: Acute Coronary Syndrome, Magnetic Resonance Imaging, Myocardial Infarction, Myocardial Revascularization, Myocardium, Percutaneous Coronary Intervention, Secondary Prevention, Ventricular Function, Left, ESC Congress, ESC 19
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