title: Impact of a pharmacoinvasive strategy when delays to primary PCI are prolonged.
abstract: OBJECTIVE
  Primary percutaneous coronary intervention (P-PCI) is the preferred reperfusion option in ST-elevation myocardial infarction, but its benefits become attenuated as time to its potential delivery becomes prolonged. Based on the STrategic Reperfusion Early After Myocardial Infarction trial, we assessed the impact of increasing time delay on outcomes in patients randomised to a pharmacoinvasive strategy (PI) or P-PCI.
  
  
  METHODS
  Thirty-day clinical outcomes were examined according to PCI-related delay (P-RD). Data from hospitals that enrolled >10 randomised patients were used and P-RD categorised as ≤55 min, >55-97 min and >97 min.
  
  
  RESULTS
  Composite of death/congestive heart failure/cardiogenic shock/myocardial infarction in PI and P-PCI arms occurred in 10.6% versus 10.3% (≤55 min, p=0.910); 13.9% versus 17.9% (>55-97 min, p=0.148) and 13.5% versus 16.2% (>97 min, p=0.470), respectively. While there was no worsening of outcomes for PI across the P-RD spectrum, this occurred in the P-PCI arm (p(trend)=0.038). For P-RD ≤55 min, fewer events tended to occur with P-PCI than PI. Conversely, as P-RD increased to >55 min, PI-assigned patients had better outcomes than P-PCI, suggesting an event-free advantage with PI as P-RD increased (p(interaction)=0.094). Analysing P-RD continuously showed that for every 10-min increment there was an increasing trend towards benefit among PI-assigned patients (p(interaction)=0.073).
  
  
  CONCLUSIONS
  As P-RD increased, PI outcomes became superior to P-PCI when P-RD is prolonged and exceeds guideline-mandated times. In such circumstances, a PI strategy may provide an alternative reperfusion option. Adverse time delays for delivery of P-PCI should be considered when evaluating reperfusion strategies.
  
  
  BACKGROUND
  NCT00623623.
authors.affiliation: University of Leicester, University Hospitals of Leicester Glenfield Hospital, Leicester, UK.
authors.forename: Anthony H
authors.initials: AH
authors.lastname: Gershlick
authors.affiliation: Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada.
authors.forename: Cynthia M
authors.initials: CM
authors.lastname: Westerhout
authors.affiliation: Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada.
authors.forename: Paul W
authors.initials: PW
authors.lastname: Armstrong
authors.affiliation: 3rd Department of Medicine, Cardiology and Emergency Medicine, Wilhelminen hospital, Vienna, Austria.
authors.forename: Kurt
authors.initials: K
authors.lastname: Huber
authors.affiliation: Department of Cardiology, Oslo University Hospital Ulleval, Oslo, Norway.
authors.forename: Sigrun
authors.initials: S
authors.lastname: Halvorsen
authors.affiliation: Faculté de Médecine Xavier Bichat, Université de Paris XII, Paris, France.
authors.forename: Philippe Gabriel
authors.initials: PG
authors.lastname: Steg
authors.affiliation: University of Leicester, University Hospitals of Leicester Glenfield Hospital, Leicester, UK Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada 3rd Department of Medicine, Cardiology and Emergency Medicine, Wilhelminen hospital, Vienna, Austria Department of Cardiology, Oslo University Hospital Ulleval, Oslo, Norway Faculté de Médecine Xavier Bichat, Université de Paris XII, Paris, France Medical School, University of Belgrade, Belgrade, Serbia the Emergency Department and Service d'aide Medicale Urgente (SAMU), Lille University Hospital, Lille, France Cardiology Division, Department of Medicine, Universidade Federal de São Paulo, São Paulo, Brazil University Hospital Gasthuisberg, Leuven, Belgium Department of Cardiovascular Medicine, University of Nottingham, Nottingham, UK.
authors.forename: Miodrag
authors.initials: M
authors.lastname: Ostojic
authors.affiliation: Medical School, University of Belgrade, Belgrade, Serbia the Emergency Department and Service d'aide Medicale Urgente (SAMU), Lille University Hospital, Lille, France.
authors.forename: Patrick
authors.initials: P
authors.lastname: Goldstein
authors.affiliation: Cardiology Division, Department of Medicine, Universidade Federal de São Paulo, São Paulo, Brazil.
authors.forename: Antonio C
authors.initials: AC
authors.lastname: Carvalho
authors.affiliation: University Hospital Gasthuisberg, Leuven, Belgium.
authors.forename: Frans
authors.initials: F
authors.lastname: Van de Werf
authors.affiliation: Department of Cardiovascular Medicine, University of Nottingham, Nottingham, UK.
authors.forename: Robert G
authors.initials: RG
authors.lastname: Wilcox
mesh_terms: D000368:Aged; 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; D062645:Percutaneous Coronary Intervention / Q000379:methods*; D011446:Prospective Studies; D012008:Recurrence; D061665:Time-to-Treatment; D016896:Treatment Outcome
chemical_list: D005343:Fibrinolytic Agents