title: Relationship between risk stratification at admission and treatment effects of early invasive management following fibrinolysis: insights from the Trial of Routine ANgioplasty and Stenting After Fibrinolysis to Enhance Reperfusion in Acute Myocardial Infarction (TRANSFER-AMI).
abstract: OBJECTIVE
  We sought to determine the effectiveness of early routine percutaneous coronary intervention (PCI) post-fibrinolysis for ST-elevation myocardial infarction (STEMI) in relation to baseline risk status.
  
  
  RESULTS
  In this post hoc subgroup analysis of Trial of Routine Angioplasty and Stenting after Fibrinolysis to Enhance Reperfusion in Acute Myocardial Infarction (TRANSFER-AMI), we stratified 1059 STEMI patients receiving tenecteplase into low-intermediate [Global Registry of Acute Coronary Events (GRACE) risk score<155; n=889] vs. high-risk (GRACE risk score ≥155; n=170) groups, based on the GRACE risk score for in-hospital mortality. There was a significant interaction between treatment assignment and risk status for the composite endpoint of death/re-MI at 30 days (P for interaction<0.001). Compared with the standard treatment, pharmacoinvasive therapy (early routine PCI) was associated with a lower rate of death/re-MI at 30 days in the low-intermediate risk stratum (8.1 vs. 2.9%, P<0.001), but a higher rate of death/re-MI in the high-risk group (13.8 vs. 27.8%, P=0.025). We found similar heterogeneity in the treatment effects on 30-day mortality and death/re-MI at 1 year (P for interaction=0.008 and 0.001, respectively), when the GRACE risk score was analysed as a continuous variable (P for interaction<0.001) and when patients were stratified by the Thrombolysis In Myocardial Infarction (TIMI) risk score (P for interaction=0.001).
  
  
  CONCLUSIONS
  We observed a strong heterogeneity in the treatment effects of a pharmacoinvasive strategy after fibrinolysis for STEMI, which is associated with improved outcomes only among patients with a low-intermediate GRACE risk score. Conversely, the early invasive strategy is associated with worse outcomes in high-risk patients. These novel findings should be considered exploratory only and require confirmation in other trials and meta-analyses.
  
  
  BACKGROUND
  http://www.clinicaltrials.gov/ct2/show/NCT00164190 ClinicalTrials.gov number, NCT00164190.
authors.affiliation: Terrence Donnelly Heart Centre, Division of Cardiology, St Michael's Hospital, and University of Toronto, Toronto, Ontario, Canada, M5B 1W8.
authors.forename: Andrew T
authors.initials: AT
authors.lastname: Yan
authors.forename: Raymond T
authors.initials: RT
authors.lastname: Yan
authors.forename: Warren J
authors.initials: WJ
authors.lastname: Cantor
authors.forename: Bjug
authors.initials: B
authors.lastname: Borgundvaag
authors.forename: Eric A
authors.initials: EA
authors.lastname: Cohen
authors.forename: David H
authors.initials: DH
authors.lastname: Fitchett
authors.forename: Vladimir
authors.initials: V
authors.lastname: Dzavik
authors.forename: John
authors.initials: J
authors.lastname: Ducas
authors.forename: Mary
authors.initials: M
authors.lastname: Tan
authors.forename: Amparo
authors.initials: A
authors.lastname: Casanova
authors.forename: Shaun G
authors.initials: SG
authors.lastname: Goodman
mesh_terms: D000368:Aged; D015906:Angioplasty, Balloon, Coronary; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000628:therapy*; D015425:Myocardial Reperfusion / Q000379:methods*; D012008:Recurrence; D018570:Risk Assessment; D015607:Stents; D000077785:Tenecteplase; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use*; D016896:Treatment Outcome
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator; D000077785:Tenecteplase