Objectives
To investigate the effects of early upstream antithrombotic therapy administration (ATTA) in ST‐segment elevation myocardial infarction (STEMI) patients with prolonged transport times to primary percutaneous intervention (PPCI) on major clinical outcomes.
Background
It remains unclear whether early upstream administration of aspirin, ticagrelor, and unfractionated heparin (UFH) confers additional benefits compared with in‐hospital administration.
Methods
Between 2015 and 2018, we performed PPCI in 709 included consecutive STEMI patients. We compared 482 STEMI patients who received aspirin, ticagrelor, and UFH loading in a non‐PCI capable spoke hospital before transfer (NPHT) versus 227 prehospital triage setting (PTS) STEMI patients who received in‐ambulance aspirin, followed by ticagrelor and UFH in the hub catheterization laboratory. The primary outcome was the presence of a pre‐PPCI TIMI flow 2–3 in the infarct related artery (IRA). The secondary outcomes included definite acute stent thrombosis and hemorrhagic complications.
Results
The median times from ticagrelor and heparin administration to angiography in the NPHT group and the PTS group were 80.5 min (Interquartile Range (IQR) 68.5–94) and 10 min (IQR 5–15) respectively (p < .0001). Using inverse probability of treatment weighting to minimize heterogeneity between groups, we showed significant differences for the primary outcome (44.6 versus 18.5%, p < .0001) and for definite acute stent thrombosis (0.6 versus 2.6%, p = .03), with no difference in the combined in‐hospital BARC 2–5 bleeding events (1.9 versus 3.5%, p = .18) in the NPHT versus the PTS group, respectively.
Conclusion
In this single‐center retrospective cohort study, after adjusting for baseline covariates, early upstream ATTA with aspirin, ticagrelor, and UFH was associated with greater pre‐PPCI TIMI flow and less definite acute stent thrombosis in STEMI patients, without increased bleeding risk.
Aims
Whether early combined antithrombotic therapy with aspirin, ticagrelor and unfractionated heparin (UFH) in STEMI patients can improve clinical outcomes is unknown. Data regarding the efficacy of UFH in this clinical setting is lacking. The objective of this novel study was to evaluate the effects of early pretreatment with aspirin, ticagrelor and UFH on pre-PCI TIMI flow in the IRA in acute STEMI patients.
Methods and results
Between January 2015 and June 2018, we retrospectively compared 488 STEMI patients receiving aspirin, ticagrelor and UFH pretreatment in a spoke peripheral hospital before transfer (PHT) versus 233 prehospital triage setting (PTS) STEMI patients receiving in-ambulance aspirin, followed by ticagrelor and UFH pretreatment in the hub catheterization laboratory before PCI. The primary outcome was the presence of a pre-PCI TIMI flow 2–3 in the IRA.
The median times from ticagrelor and UFH administration to angiography in the PHT group and in the PTS group were 80 minutes (95% CI: 68.5–93.9) and 10 minutes (95% CI: 5–15.5) respectively (p<0.0001). Inverse probability of treatment weighting was used to minimize differences between groups. Main results are shown in Table 1. Each 10-minute delay between ticagrelor and heparin administration and angiography was associated with a reduced pre-PCI TIMI flow (OR 0.89, 95% CI: 0.85–0.93).
Conclusion
STEMI patients receiving aspirin, ticagrelor and UFH before peripheral hospital transfer have a significantly greater pre-PCI TIMI flow 2–3 and a lower rate of definite in-hospital stent thrombosis compared to patients receiving in-ambulance aspirin in the prehospital setting followed by ticagrelor and heparin in the catheterization laboratory without greater bleeding risk. While prehospital triage with rapid primary PCI remains the preferred scenario for STEMI patients, a prompt UFH initiation may play a synergistic role with ticagrelor and aspirin in decreasing pre-PCI thrombus burden in the presence of organizational delays.
Figure 1. Study Design and Main Results
Funding Acknowledgement
Type of funding source: Public hospital(s). Main funding source(s): Université de Sherbrooke's Department of Medicine, Division of Cardiology
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