Timing of events in STEMI patients treated with immediate PCI or standard medical therapy: implications on optimisation of timing of treatment from the CARESS-in-AMI trial.
OBJECTIVE
Early angioplasty after thrombolysis is now recommended for ST-elevation myocardial infarction, but the current guidelines propose a wide time-window ranging between 3 and 24h after lytic administration. To identify the optimal timing for PCI after thrombolysis, we analyzed frequency and time course of the adverse events in patients randomized in the multicenter CARESS-in-AMI trial.


METHODS
598 high-risk patients with STEMI recruited in the CARESS-in-AMI study, were divided into the Immediate PCI group (IMM, n=298), Rescue PCI group (RES, n=107) and Standard Treatment Arm without rescue PCI (STA, n=193).


RESULTS
RES patients had worse pre-procedural TIMI flow and post-procedural blush grade. At 30 days, there were 23 deaths: 11 (10.3%) in RES, 9 (3%) in IMM and 3 (1.6%) in STA (p<0.001). There were 22 episodes of refractory ischemia or re-infarction: 17 (8.8%) in the STA group, 4 (1.6%) in IMM and 1 (0.9%) in RES (p<0.001). In the RES group 10/11 (90.9%) deaths occurred before day 5. In the STA group, all deaths and the majority of ischemic events occurred after day 3. A reduction of risk of death was observed if PCI after thrombolysis was performed within 3.35 h from initial hospitalization.


CONCLUSIONS
The mortality benefit of immediate referral to PCI after pharmacological treatment for STEMI derives from a reduction in the time to reperfusion of patients with failed thrombolysis in need of rescue PCI. In patients with evidence of successful reperfusion, "elective" PCI within 3 days may be sufficient to reduce the recurrent ischemic events.
Dimopoulos
Konstantinos
K
Royal Brompton Hospital & Imperial College, London, UK.
Dudek
Dariusz
D
Piscione
Federico
F
Mielecki
Waldemar
W
Savonitto
Stefano
S
Borgia
Francesco
F
Murena
Ernesto
E
Manari
Antonio
A
Gaspardone
Achille
A
Ochala
Andrzej
A
Zmudka
Krzysztof
K
Bolognese
Leonardo
L
Steg
Philippe Gabriel
PG
Flather
Marcus
M
Di Mario
Carlo
C
D015906:Angioplasty, Balloon, Coronary / Q000009:adverse effects; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000628:therapy*; D015912:Thrombolytic Therapy; D013997:Time Factors