Abstract 21182: Rescue Percutaneous Coronary Intervention for ST-segment Elevation Myocardial Infarction patients who Failed Fibrinolytic Therapy: A Population-Based Assessment
Background: Fibrinolytic therapy remains the first line reperfusion treatment for ST-segment elevation myocardial infarction (STEMI) patients in many regions and limited data are available regarding the use of rescue Percutaneous Coronary Intervention (PCI) in clinical practice. Our objective was to evaluate the pattern or use of rescue PCI, factors associated with its use, and the association between rescue PCI and long-term outcomes in a large population-based cohort.
Methods: Observational analysis of the Enhanced Feedback for Effective Cardiac Treatment (EFFECT) database, a population-based cohort that included 2,953 STEMI patients hospitalized from April 1, 2004 to March 31, 2005 in Ontario, Canada. Failed fibrinolysis was defined as < 50% ST-segment resolution on follow-up ECG at 60 to 90 minutes. The primary outcome was death or recurrent acute coronary syndrome at 4 years.
Results: Among the 1,517 patients who received fibrinolytic therapy, 611 patients (40.2%) failed to reperfuse after fibrinolysis. Rescue PCI was performed in 212 patients (34.7%), conservative management in 373 patients (61.1%), and repeat fibrinolytic in 26 patients (4.3%). The strongest predictor of rescue PCI was presentation to a PCI facility (OR 4.27; 95% CI 2.54 to 7.18). At 4-years follow-up, the primary endpoint occurred in 25% of patients who received rescue PCI as compared with 36.5% in patients who received conservative management (adjusted HR 0.70; 95% CI 0.50 to 0.97). This difference was attributed mainly to a reduced hazard of death favoring rescue PCI patients (11.8% vs. 25.5%, HR 0.60; 95% CI 0.38 to 0.94). No significantly increased incidence of stroke (1.4% vs. 1.9%, P = 0.68) or hemorrhage requiring interventions (3.8% vs. 2.7%, P = 0.46) was observed in the rescue PCI group vs. the conservative group.
Conclusions: Rescue PCI was associated with significantly improved long-term clinical outcomes for STEMI patients after failed fibrinolytic therapy. However, this strategy is substantially underused in clinical practice. An expeditious transfer system is needed in regions that utilize fibrinolysis as the predominant reperfusion treatment for STEMI patients.
- Myocardial infarction, STEMI
- Health services research
- Percutaneous coronary intervention
- Quality assessment
- © 2010 by American Heart Association, Inc.