Pharmacoinvasive PCI may be prefered over late primary PCI when delays anticipated in STEMI patients

The study found that patients who underwent late primary percutaneous coronary intervention (pPCI) had higher mortality rates than those undergoing a pharmaco-invasive strategy.

For patients with STEMI (ST-elevation myocardial infarction) who cannot undergo timely primary PCI, pharmaco-invasive PCI is recommended. pPCI is often performed beyond recommended time targets in routine practice due to high failure rates of reperfusion with fibrinolytic therapy, and hence the need for rescue PCI in a third of patients with its perceived bleeding risks and unrealistic assessments of the possible times for performance of pPCI.

Javeria Jamal from the School of Medicine at Western Sydney University, Sydney, Australia, and colleagues assessed late outcome after PI-PCI (successful reperfusion followed by scheduled PCI or failed reperfusion and rescue PCI) versus timely and late pPCI.

The authors included all STEMI patients presenting within 12 h of symptom onset who underwent PCI during their initial hospitalization at Liverpool Hospital in Sydney from October 2003 to March 2014. From 2091 STEMI patients, 80% were male, 52% (n=1077) underwent pPCI (32% late and 68% timely), and 48% (n=1014) received PI-PCI (33% rescue, 67% scheduled).

The study led to the following findings:

• Mortality at three years was 11.1% after pPCI (6.7% timely, 20.2% late) and 6.2% after PI-PCI (9.4% rescue, 4.8% scheduled).
• After propensity matching, the adjusted mortality hazard ratio (HR) for timely pPCI compared with scheduled PCI was 0.9 and compared with rescue PCI; it was 0.5.
• The adjusted mortality HR for late pPCI, compared with scheduled PCI, was 2.2; compared with rescue PCI, it was 1.5.

Among unselected STEMI patients who underwent PCI, those who received PI-PCI and those who received pPCI at <120 min from first medical contact to first device time had similar late mortality rates. Among the one-third of patients undergoing late pPCI, the research team observed markedly higher late mortality. Rates of stroke and major bleeding were comparable in the two groups. The safety and efficacy of PI-PCI, including with half-dose fibrinolytic therapy, should be investigated further in large clinical trials among suitable patients.

"A pharmaco-invasive approach should be considered in cases where delays to PCI are anticipated as it achieves better outcomes than late primary PCI," the researchers concluded.

Reference:

Javeria Jamal, Hanan Idris, Amir Faour, Wesley Yang, Alison McLean, Sonya Burgess, Ibrahim Shugman, Kathryn Wales, Aiden O'LoughlinO'Loughlin, Dominic Leung, Christian Julian Mussap, Craig Phillip Juergens, Sidney Lo, John Kerswell French, Late outcomes of ST-elevation myocardial infarction treated by pharmaco-invasive or primary percutaneous coronary intervention, European Heart Journal, 2022;, ehac661, https://doi.org/10.1093/eurheartj/ehac661