Abstract 17925: Impact of Rescue/Urgent Angiography on Outcomes of ST-Elevation Myocardial Infarction: Insights From STREAM
Background: Recently a pharmacoinvasive strategy including tenecteplase, urgent PCI for failed reperfusion and angiography 6- 24 hours in the remainder achieved comparable 30-day composite outcomes when compared to contemporary primary PCI (PPCI) in STEMI pts presenting <3 hours. We now report core-laboratory ECG metrics of reperfusion success and their relationship to clinical outcomes according to treatment received.
Methods: Among 1866 STEMI per-protocol-treated pts in STREAM, we compared 3 groups; i.e. fibrinolysis requiring rescue/urgent angiography (<50% ST-resolution at 90 min post-tenecteplase (TNK) or hemodynamic/electrical instability, n= 381), fibrinolysis with scheduled angiography (n=541), and PPCI (n=944).
Results: Rescue/urgent pts were more likely male, diabetic, have anterior MI and more baseline ST-deviation and Q waves within the distribution of ST-elevation(ST-E). Assessment of ST resolution from baseline i.e. ST shift ≥50% 90 min after TNK was 32.1% for rescue versus 79.7% for non-rescue TNK pts whereas it was 72.8% 30 min post-PPCI. Assessing the previously validated post-reperfusion worst lead ST-E residual (WLR) ≥2mm, revealed it occurred in 62.1%, 15.3%, and 24.7% of rescue, non-rescue and PPCI pts, respectively. Rescue/urgent pts had higher 30-day event rates compared to fibrinolysis pts with scheduled cath and PPCI (i.e. composite events: 20.0%, 7.6% and 14.3%; all-cause death: 5.5%, 4.3%, and 4.4%; shock: 7.4%, 2.6%, and 5.9%; HF: 11.4%, 2.6%, and 7.7% and re-MI: 3.7%, 1.7%, and 2.2%, respectively-appended table).
Conclusion: Whereas in STREAM, early STEMI pts randomized to a pharmacoinvasive strategy had overall similar outcomes to PPCI, those fibrinolytic-treated pts not requiring rescue had ECG evidence of superior reperfusion and reduced clinical events when compared to PPCI. By contrast the 41% of pts requiring rescue/urgent cath had higher risk with more baseline comorbidities and worse 30-day outcomes.
- © 2013 by American Heart Association, Inc.