Benefit of facilitated percutaneous coronary intervention in high-risk ST-segment elevation myocardial infarction patients presenting to nonpercutaneous coronary intervention hospitals.
OBJECTIVE
We hypothesized that patients most likely to benefit would be those at high risk with a shorter duration of acute ischemia and who required transfer for percutaneous coronary intervention (PCI).


BACKGROUND
The FINESSE (Facilitated Intervention with Enhanced Reperfusion Speed to Stop Events) study failed to demonstrate an improvement in the 90-day composite clinical end point of early treatment with abciximab plus half-dose reteplase (combination-facilitated PCI) or abciximab alone.


METHODS
We performed a retrospective analysis of 2,452 patients in this double-blind, placebo-controlled study. Patients were stratified by Thrombolysis In Myocardial Infarction (TIMI) risk score for ST-segment elevation myocardial infarction (STEMI), presentation to a spoke (no PCI available) or hub site, and symptom-to-randomization time. Outcomes included the primary composite end point of death, ventricular fibrillation after 48 h, cardiogenic shock, and congestive heart failure through day 90 as well as 1-year mortality.


RESULTS
Mortality for all patients at 1 year was directly related to TIMI risk score (23 of 1,223 = 1.9% in patients with score <3 and 145 of 1,229 = 11.8% with score > or =3, p < 0.001). Patients with TIMI risk score > or =3 and presentation to a spoke site with a symptom-to-randomization time < or =4 h had significantly better 1-year survival if treated with combination-facilitated PCI (hazard ratio [HR]: 0.351, p = 0.01) as well as 90-day composite outcome (HR: 0.45, p = 0.009). A trend for improved survival was also observed in patients with TIMI score > or =3 and spoke site alone (HR: 0.549, p = 0.06).


CONCLUSIONS
Facilitation of PCI with a combination of abciximab and half-dose reteplase improved survival at 1 year in high-risk patients presenting to a spoke hospital with symptom-to-randomization time < or =4 h. Further prospective study of facilitated PCI in this subgroup of patients is warranted.
Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA. howard.herrmann@uphs.upenn.edu
Howard C
HC
Herrmann
Jiandong
J
Lu
Bruce R
BR
Brodie
Paul W
PW
Armstrong
Gilles
G
Montalescot
Amadeo
A
Betriu
Franz-Joseph
FJ
Neuman
Mark B
MB
Effron
Elliot S
ES
Barnathan
Eric J
EJ
Topol
Stephen G
SG
Ellis
D000077284:Abciximab; D015906:Angioplasty, Balloon, Coronary / Q000009:adverse effects / Q000401:mortality; D000911:Antibodies, Monoclonal / Q000009:adverse effects / Q000627:therapeutic use*; D003131:Combined Modality Therapy; D004311:Double-Blind Method; D005343:Fibrinolytic Agents / Q000009:adverse effects / Q000627:therapeutic use*; D006297:Health Services Accessibility; D006470:Hemorrhage / Q000139:chemically induced; D006801:Humans; D007140:Immunoglobulin Fab Fragments / Q000009:adverse effects / Q000627:therapeutic use*; D053208:Kaplan-Meier Estimate; D015337:Multicenter Studies as Topic; D009203:Myocardial Infarction / Q000401:mortality / Q000628:therapy*; D010360:Patient Transfer; D010975:Platelet Aggregation Inhibitors / Q000009:adverse effects / Q000627:therapeutic use*; D016032:Randomized Controlled Trials as Topic; D011994:Recombinant Proteins / Q000009:adverse effects / Q000627:therapeutic use; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D015912:Thrombolytic Therapy / Q000009:adverse effects / Q000401:mortality; D013997:Time Factors; D010959:Tissue Plasminogen Activator / Q000009:adverse effects / Q000627:therapeutic use*; D016896:Treatment Outcome
D000911:Antibodies, Monoclonal; D005343:Fibrinolytic Agents; D007140:Immunoglobulin Fab Fragments; D010975:Platelet Aggregation Inhibitors; D011994:Recombinant Proteins; C087896:reteplase; D010959:Tissue Plasminogen Activator; D000077284:Abciximab