Abstract 15640: Risk Stratification at Admission to Identify ST-Segment Elevation Myocardial Infarction Patients Receiving Fibrinolysis Who May Benefit from Early Angioplasty: Insights from the Trial of Routine Angioplasty and Stenting After Fibrinolysis to Enhance Reperfusion in Acute Myocardial Infarction (TRANSFER-AMI)
Background: Recent randomized controlled trials have demonstrated the benefits of early routine percutaneous coronary intervention (PCI) post-fibrinolysis for ST-elevation myocardial infarction (STEMI). We sought to determine the effectiveness of this early invasive strategy in relation to baseline risk status.
Methods: 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 (GRACE risk score <155; n=889) versus high-risk (GRACE risk score ≥155; n=170) groups, based on the Global Registry of Acute Coronary Events (GRACE) risk score for in-hospital mortality (using the published cutpoint of ≥155 to define high risk STEMI). The primary endpoint of this study was death/re-MI at 30 days.
Results: The GRACE risk score demonstrated excellent and good discrimination for 30-day mortality and death/re-MI, respectively (c-statistic=0.89 and 0.70, respectively, both p<0.001). There was a significant interaction between treatment assignment and risk status for death and the composite endpoint of death/re-MI at 30 days (Table). We found similar heterogeneity in the treatment effects on death/re-MI at 1 year (p for interaction= 0.001), when GRACE risk score was analyzed as a continuous variable (p for interaction<0.001) and when patients were stratified by the 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 must be considered exploratory and require confirmation in other trials and meta-analyses.
- © 2010 by American Heart Association, Inc.