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Pharmacoinvasive Strategy Versus Primary Percutaneous Coronary Intervention in ST-Elevation Myocardial Infarction in Clinical Practice: Insights From the Vital Heart Response Registry.
Circ Cardiovasc Interv 2019; 12(10):e008059CC

Abstract

BACKGROUND

Recent clinical trial data support a pharmacoinvasive strategy as an alternative to primary percutaneous coronary intervention (pPCI) in ST-segment elevation myocardial infarction. We evaluated whether this is true in a real-world prehospital ST-segment elevation myocardial infarction network using ECG assessment of reperfusion coupled with clinical outcomes within 1 year.

METHODS

Of the 5583 ST-segment elevation myocardial infarction patients in the Alberta Vital Heart Response Program (Cohort 1 [2006-2011]: n=3593; Cohort 2 [2013-2016]: n=1990), we studied 3287 patients who received a pharmacoinvasive strategy with tenecteplase (April 2013: half-dose tenecteplase was employed in prehospital patients ≥75 years) or pPCI. ECGs were analyzed within a core laboratory; sum ST-segment deviation resolution ≥50% was defined as successful reperfusion. The primary composite was all-cause death, congestive heart failure, cardiogenic shock, and recurrent myocardial infarction within 1 year.

RESULTS

The pharmacoinvasive approach was administered in 1805 patients (54.9%), (493 [27.3%] underwent rescue/urgent percutaneous coronary intervention and 1312 [72.7%] had scheduled angiography); pPCI was performed in 1482 patients (45.1%). There was greater ST-segment resolution post-catheterization/percutaneous coronary intervention with a pharmacoinvasive strategy versus pPCI (75.8% versus 64.3%, IP-weighted odds ratio, 1.59; 95% CI, 1.33-1.90; P<0.001). The primary composite was significantly lower with a pharmacoinvasive approach (16.3% versus 23.1%, IP-weighted hazard ratio, 0.84; 95% CI, 0.72-0.99; P=0.033). Major bleeding and intracranial hemorrhage were similar between a pharmacoinvasive strategy and pPCI (7.6% versus 7.5%, P=0.867; 0.6% versus 0.6%; P=0.841, respectively). In the 82 patients ≥75 years with a prehospital pharmacoinvasive strategy, similar ST-segment resolution and rescue rates were observed with full-dose versus half-dose tenecteplase (75.8% versus 88.9%, P=0.259; 31.0% versus 29.2%, P=0.867) with no difference in the primary composite (31.0% versus 25.0%, P=0.585).

CONCLUSIONS

In this large Canadian ST-segment elevation myocardial infarction registry, a pharmacoinvasive strategy was associated with improved ST-segment resolution and enhanced outcomes within 1 year compared with pPCI. Our findings support the application of a selective pharmacoinvasive reperfusion strategy when delay to pPCI exists.

Authors+Show Affiliations

Canadian VIGOUR Centre (K.R.B., P.W.A., Y.Z., C.M.W., R.C.W.), University of Alberta, Edmonton, Canada. Division of Cardiology, Department of Medicine (K.R.B., P.W.A., N.B., B.D.T., R.L., R.C.W.), University of Alberta, Edmonton, Canada. Mazankowski Alberta Heart Institute, Edmonton, Canada (K.R.B., R.C.W.).Canadian VIGOUR Centre (K.R.B., P.W.A., Y.Z., C.M.W., R.C.W.), University of Alberta, Edmonton, Canada. Division of Cardiology, Department of Medicine (K.R.B., P.W.A., N.B., B.D.T., R.L., R.C.W.), University of Alberta, Edmonton, Canada.Canadian VIGOUR Centre (K.R.B., P.W.A., Y.Z., C.M.W., R.C.W.), University of Alberta, Edmonton, Canada.Division of Cardiology, Department of Medicine (K.R.B., P.W.A., N.B., B.D.T., R.L., R.C.W.), University of Alberta, Edmonton, Canada. CK Hui Heart Centre, Edmonton, Alberta, Canada (N.B., B.D.T., R.L.).Division of Cardiology, Department of Medicine (K.R.B., P.W.A., N.B., B.D.T., R.L., R.C.W.), University of Alberta, Edmonton, Canada. CK Hui Heart Centre, Edmonton, Alberta, Canada (N.B., B.D.T., R.L.).Division of Cardiology, Department of Medicine (K.R.B., P.W.A., N.B., B.D.T., R.L., R.C.W.), University of Alberta, Edmonton, Canada. CK Hui Heart Centre, Edmonton, Alberta, Canada (N.B., B.D.T., R.L.).Canadian VIGOUR Centre (K.R.B., P.W.A., Y.Z., C.M.W., R.C.W.), University of Alberta, Edmonton, Canada.Canadian VIGOUR Centre (K.R.B., P.W.A., Y.Z., C.M.W., R.C.W.), University of Alberta, Edmonton, Canada. Division of Cardiology, Department of Medicine (K.R.B., P.W.A., N.B., B.D.T., R.L., R.C.W.), University of Alberta, Edmonton, Canada. Mazankowski Alberta Heart Institute, Edmonton, Canada (K.R.B., R.C.W.).

Pub Type(s)

Journal Article

Language

eng

PubMed ID

31607152

Citation

Bainey, Kevin R., et al. "Pharmacoinvasive Strategy Versus Primary Percutaneous Coronary Intervention in ST-Elevation Myocardial Infarction in Clinical Practice: Insights From the Vital Heart Response Registry." Circulation. Cardiovascular Interventions, vol. 12, no. 10, 2019, pp. e008059.
Bainey KR, Armstrong PW, Zheng Y, et al. Pharmacoinvasive Strategy Versus Primary Percutaneous Coronary Intervention in ST-Elevation Myocardial Infarction in Clinical Practice: Insights From the Vital Heart Response Registry. Circ Cardiovasc Interv. 2019;12(10):e008059.
Bainey, K. R., Armstrong, P. W., Zheng, Y., Brass, N., Tyrrell, B. D., Leung, R., ... Welsh, R. C. (2019). Pharmacoinvasive Strategy Versus Primary Percutaneous Coronary Intervention in ST-Elevation Myocardial Infarction in Clinical Practice: Insights From the Vital Heart Response Registry. Circulation. Cardiovascular Interventions, 12(10), pp. e008059. doi:10.1161/CIRCINTERVENTIONS.119.008059.
Bainey KR, et al. Pharmacoinvasive Strategy Versus Primary Percutaneous Coronary Intervention in ST-Elevation Myocardial Infarction in Clinical Practice: Insights From the Vital Heart Response Registry. Circ Cardiovasc Interv. 2019;12(10):e008059. PubMed PMID: 31607152.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Pharmacoinvasive Strategy Versus Primary Percutaneous Coronary Intervention in ST-Elevation Myocardial Infarction in Clinical Practice: Insights From the Vital Heart Response Registry. AU - Bainey,Kevin R, AU - Armstrong,Paul W, AU - Zheng,Yinggan, AU - Brass,Neil, AU - Tyrrell,Benjamin D, AU - Leung,Raymond, AU - Westerhout,Cynthia M, AU - Welsh,Robert C, Y1 - 2019/10/14/ PY - 2019/10/15/entrez PY - 2019/10/15/pubmed PY - 2019/10/15/medline KW - Alberta KW - fibrinolysis KW - heart failure KW - percutaneous coronary intervention KW - tenecteplase SP - e008059 EP - e008059 JF - Circulation. Cardiovascular interventions JO - Circ Cardiovasc Interv VL - 12 IS - 10 N2 - BACKGROUND: Recent clinical trial data support a pharmacoinvasive strategy as an alternative to primary percutaneous coronary intervention (pPCI) in ST-segment elevation myocardial infarction. We evaluated whether this is true in a real-world prehospital ST-segment elevation myocardial infarction network using ECG assessment of reperfusion coupled with clinical outcomes within 1 year. METHODS: Of the 5583 ST-segment elevation myocardial infarction patients in the Alberta Vital Heart Response Program (Cohort 1 [2006-2011]: n=3593; Cohort 2 [2013-2016]: n=1990), we studied 3287 patients who received a pharmacoinvasive strategy with tenecteplase (April 2013: half-dose tenecteplase was employed in prehospital patients ≥75 years) or pPCI. ECGs were analyzed within a core laboratory; sum ST-segment deviation resolution ≥50% was defined as successful reperfusion. The primary composite was all-cause death, congestive heart failure, cardiogenic shock, and recurrent myocardial infarction within 1 year. RESULTS: The pharmacoinvasive approach was administered in 1805 patients (54.9%), (493 [27.3%] underwent rescue/urgent percutaneous coronary intervention and 1312 [72.7%] had scheduled angiography); pPCI was performed in 1482 patients (45.1%). There was greater ST-segment resolution post-catheterization/percutaneous coronary intervention with a pharmacoinvasive strategy versus pPCI (75.8% versus 64.3%, IP-weighted odds ratio, 1.59; 95% CI, 1.33-1.90; P<0.001). The primary composite was significantly lower with a pharmacoinvasive approach (16.3% versus 23.1%, IP-weighted hazard ratio, 0.84; 95% CI, 0.72-0.99; P=0.033). Major bleeding and intracranial hemorrhage were similar between a pharmacoinvasive strategy and pPCI (7.6% versus 7.5%, P=0.867; 0.6% versus 0.6%; P=0.841, respectively). In the 82 patients ≥75 years with a prehospital pharmacoinvasive strategy, similar ST-segment resolution and rescue rates were observed with full-dose versus half-dose tenecteplase (75.8% versus 88.9%, P=0.259; 31.0% versus 29.2%, P=0.867) with no difference in the primary composite (31.0% versus 25.0%, P=0.585). CONCLUSIONS: In this large Canadian ST-segment elevation myocardial infarction registry, a pharmacoinvasive strategy was associated with improved ST-segment resolution and enhanced outcomes within 1 year compared with pPCI. Our findings support the application of a selective pharmacoinvasive reperfusion strategy when delay to pPCI exists. SN - 1941-7632 UR - https://www.unboundmedicine.com/medline/citation/31607152/Pharmacoinvasive_Strategy_Versus_Primary_Percutaneous_Coronary_Intervention_in_ST-Elevation_Myocardial_Infarction_in_Clinical_Practice:_Insights_From_the_Vital_Heart_Response_Registry L2 - http://www.ahajournals.org/doi/full/10.1161/CIRCINTERVENTIONS.119.008059?url_ver=Z39.88-2003&amp;rfr_id=ori:rid:crossref.org&amp;rfr_dat=cr_pub=pubmed DB - PRIME DP - Unbound Medicine ER -