title: Outcomes of a pharmacoinvasive strategy for successful versus failed fibrinolysis and primary percutaneous intervention in acute myocardial infarction (from the STrategic Reperfusion Early After Myocardial Infarction [STREAM] study).
abstract: Although a fibrinolytic pharmacoinvasive strategy is recommended for patients with ST elevation myocardial infarction (STEMI) unable to undergo timely primary percutaneous coronary intervention (PCI), there are limited data addressing outcomes specific to those with successful or unsuccessful pharmacologic reperfusions. Accordingly, we evaluated a contemporary pharmacoinvasive strategy for failed and successful reperfusions within the STrategic Reperfusion Early After Myocardial infarction study. Of 1,823 per-protocol-treated patients with STEMI, we examined clinical outcomes and angiographic and electrocardiographic metrics in 3 groups as follows: fibrinolysis requiring rescue (rescue, n = 348), fibrinolysis with scheduled angiography (scheduled, n = 516), and primary PCI (n = 927). Compared with pharmacoinvasive patients undergoing scheduled angiography, rescue patients were more likely to have anterior wall myocardial infarction, more baseline ST-segment elevation and deviation, as well as Q waves in the distribution of their ST elevation. Residual ST elevation ≥ 2 mm 30 minutes after angiography occurred in 27.9%, 7.9%, and 24.8% of patients who underwent rescue, scheduled, and primary PCI, respectively. Thirty-day composite event rates (all-cause death, cardiogenic shock, heart failure, and reinfarction) were 18.7%, 5.5%, and 13.9%; all-cause death: 6.1%, 2.1%, and 3.9%; cardiogenic shock: 7.5%, 2.0%, and 5.4%; heart failure: 11.8%, 2.3%, and 7.6%; and reinfarction: 1.5%, 1.4%, and 2.2%, for rescue, scheduled, and primary PCI, respectively. Compared with successfully reperfused patients undergoing scheduled angiography, the adjusted relative risk of the primary outcome was 2.92 (95% confidence interval 1.92 to 4.45) in rescue patients. In conclusion, pharmacoinvasive-treated patients requiring rescue angiography had greater baseline risk with more co-morbidities and worse 30-day outcomes compared with successful fibrinolytic-treated patients. Residual ST elevation after reperfusion assists in defining prognosis.
authors.affiliation: Department of Medicine, Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada.
authors.forename: Robert C
authors.initials: RC
authors.lastname: Welsh
authors.affiliation: Department of Cardiovascular Sciences, University Hospital Gasthuisberg, Leuven, Belgium.
authors.forename: Frans
authors.initials: F
authors.lastname: Van de Werf
authors.affiliation: Department of Medicine, Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada.
authors.forename: Cynthia M
authors.initials: CM
authors.lastname: Westerhout
authors.affiliation: Department and Service d'aide Medicale Urgente, Lille University Hospital, Lille Cedex, France.
authors.forename: Patrick
authors.initials: P
authors.lastname: Goldstein
authors.affiliation: Leicester Cardiovascular Biomedical Research Unit, University Hospital of Leicester, Leicester, United Kingdom.
authors.forename: Anthony H
authors.initials: AH
authors.lastname: Gershlick
authors.affiliation: Department of Cardiovascular Medicine, Nottingham University Hospital, Nottingham, United Kingdom.
authors.forename: Robert G
authors.initials: RG
authors.lastname: Wilcox
authors.affiliation: Boehringer Ingelheim, Reims, France.
authors.forename: Thierry
authors.initials: T
authors.lastname: Danays
authors.affiliation: Boehringer Ingelheim, Biberach, Germany.
authors.forename: Erich
authors.initials: E
authors.lastname: Bluhmki
authors.affiliation: Department of Medicine, Federal University of São Paulo, São Paulo, Brazil; Duke Clinical Research Institute, Durham, North Carolina.
authors.forename: Renato D
authors.initials: RD
authors.lastname: Lopes
authors.affiliation: Department of Cardiology, Hôpital Bichat, INSERM U698 and Université Paris-Diderot, Paris, France.
authors.forename: Philippe Gabriel
authors.initials: PG
authors.lastname: Steg
authors.affiliation: Department of Medicine, Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada. Electronic address: paul.armstrong@ualberta.ca.
authors.forename: Paul W
authors.initials: PW
authors.lastname: Armstrong
mesh_terms: D000368:Aged; D017023:Coronary Angiography; D004359:Drug Therapy, Combination; D004562:Electrocardiography; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000000981:diagnostic imaging / Q000628:therapy*; D062645:Percutaneous Coronary Intervention / Q000379:methods*; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use*; D015912:Thrombolytic Therapy / Q000379:methods*; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D005343:Fibrinolytic Agents; D010975:Platelet Aggregation Inhibitors