title: Infarct Size, Shock, and Heart Failure: Does Reperfusion Strategy Matter in Early Presenting Patients With ST-Segment Elevation Myocardial Infarction?
abstract: BACKGROUND
  A pharmacoinvasive (PI) strategy for early presenting ST-segment elevation myocardial infarction nominally reduced 30-day cardiogenic shock and congestive heart failure compared with primary percutaneous coronary intervention (PPCI). We evaluated whether infarct size (IS) was related to this finding.
  
  
  RESULTS
  Using the peak cardiac biomarker in patients randomized to PI versus PPCI within the Strategic Reperfusion Early After Myocardial Infarction (STREAM) trial, IS was divided into 3 groups: small (≤2 times the upper limit normal [ULN]), medium (>2 to ≤5 times the upper limit normal) and large (>5 times the upper limit normal). The association between IS and 30-day shock and congestive heart failure was subsequently examined. Data on 1701 of 1892 (89.9%) patients randomized to PI (n=853, 50.1%) versus PPCI (n=848, 49.9%) within STREAM were evaluated. A higher proportion of PPCI patients had a large IS (PI versus PPCI: small, 49.8% versus 50.2%; medium, 56.9% versus 43.1%; large, 48.4% versus 51.6%; P=0.035), despite comparable intergroup ischemic times for each reperfusion strategy. As IS increased, a parallel increment in shock and congestive heart failure occurred in both treatment arms, except for the small IS group. The difference in shock and congestive heart failure in the small IS group (4.4% versus 11.6%, P=0.026) in favor of PI likely relates to higher rates of aborted myocardial infarction with the PI strategy (72.7% versus 54.3%, P=0.005). After adjustment, a trend favoring PI persisted in this subgroup (relative risk 0.40, 95% CI 0.15 to 1.06, P=0.064); no difference in treatment-related outcomes was evident in the other 2 groups.
  
  
  CONCLUSIONS
  A PI strategy appears to alter the pattern of IS after ST-segment elevation myocardial infarction, resulting in more medium and fewer large infarcts compared with PPCI. Despite a comparable number of small infarcts, PI patients in this group had more aborted myocardial infarctions and less 30-day shock and congestive heart failure.
  
  
  BACKGROUND
  URL: http://ClinicalTrials.gov. Unique identifier: NCT00623623.
authors: Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada (J.S., Y.Z., N.D.M., P.W.A.).
authors: Jay
authors: J
authors: Shavadia
authors: Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada (J.S., Y.Z., N.D.M., P.W.A.).
authors: Yinggan
authors: Y
authors: Zheng
authors: Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada (J.S., Y.Z., N.D.M., P.W.A.).
authors: Neda
authors: N
authors: Dianati Maleki
authors: Department of Cardiology, University of Vienna, Austria (K.H.).
authors: Kurt
authors: K
authors: Huber
authors: Department of Cardiology, Oslo University Hospital HF Ullevål, Oslo, Norway (S.H.).
authors: Sigrun
authors: S
authors: Halvorsen
authors: Centre Hospitalier Régional et Universitaire, Lille Cedex, France (P.G.).
authors: Patrick
authors: P
authors: Goldstein
authors: Department of Academic Cardiology, University Hospitals of Leicester, Leicester, United Kingdom (A.H.G.).
authors: Anthony H
authors: AH
authors: Gershlick
authors: Department Cardiovascular Medicine, University Hospital, Nottingham, United Kingdom (R.W.).
authors: Robert
authors: R
authors: Wilcox
authors: Department of Cardiology, University Hospital Gasthuisberg, Leuven, Belgium (F.V.W.).
authors: Frans
authors: F
authors: Van de Werf
authors: Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada (J.S., Y.Z., N.D.M., P.W.A.).
authors: Paul W
authors: PW
authors: Armstrong
mesh_terms: D000368:Aged; D015415:Biomarkers / Q000097:blood; D017023:Coronary Angiography; D052279:Creatine Kinase, MB Form / Q000097:blood; D004562:Electrocardiography; D005260:Female; D006333:Heart Failure / Q000175:diagnosis / Q000209:etiology / Q000517:prevention & control*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000150:complications / Q000175:diagnosis / Q000503:physiopathology / Q000628:therapy*; D015425:Myocardial Reperfusion / Q000009:adverse effects / Q000379:methods*; D009206:Myocardium / Q000378:metabolism / Q000473:pathology*; D062645:Percutaneous Coronary Intervention / Q000009:adverse effects; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use; D011446:Prospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D012770:Shock, Cardiogenic / Q000175:diagnosis / Q000209:etiology / Q000517:prevention & control*; D015912:Thrombolytic Therapy / Q000009:adverse effects; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D015415:Biomarkers; D010975:Platelet Aggregation Inhibitors; D052279:Creatine Kinase, MB Form
keywords: ST‐segment elevation myocardial infarction; infarct size; pharmacoinvasive; primary percutaneous coronary intervention