Fibrinolysis vs. primary percutaneous coronary intervention for ST‐segment elevation myocardial infarction cardiogenic shock

Abstract

Aims There are limited contemporary data on the use of initial fibrinolysis in ST-segment elevation myocardial infarction cardiogenic shock (STEMI-CS). This study sought to compare the outcomes of STEMI-CS receiving initial fibrinolysis vs. primary percutaneous coronary intervention (PPCI). Methods Using the National (Nationwide) Inpatient Sample from 2009 to 2017, a comparative effectiveness study of adult (>18 years) STEMI-CS admissions receiving pre-hospital/in-hospital fibrinolysis were compared with those receiving PPCI. Admissions with alternate indications for fibrinolysis and STEMI-CS managed medically or with surgical revascularization (without fibrinolysis) were excluded. Outcomes of interest included in-hospital mortality, development of non-cardiac organ failure, complications, hospital length of stay, hospitalization costs, use of palliative care, and do-not-resuscitate status. Results During 2009-2017, 5297 and 110 452 admissions received initial fibrinolysis and PPCI, respectively. Compared with those receiving PPCI, the fibrinolysis group was more often non-White, with lower co-morbidity, and admitted on weekends and to small rural hospitals (all P < 0.001). In the fibrinolysis group, 95.3%, 77.4%, and 15.7% received angiography, PCI, and coronary artery bypass grafting, respectively. The fibrinolysis group had higher rates of haemorrhagic complications (13.5% vs. 9.9%; P < 0.001). The fibrinolysis group had comparable all-cause in-hospital mortality [logistic regression analysis: 28.8% vs. 28.5%; propensity-matched analysis: 30.8% vs. 30.3%; adjusted odds ratio 0.97 (95% confidence interval 0.90-1.05); P = 0.50]. The fibrinolysis group had comparable rates of acute organ failure, hospital length of stay, rates of palliative care referrals, do-not-resuscitate status use, and lesser hospitalization costs. Conclusions The use of initial fibrinolysis had comparable in-hospital mortality than those receiving PPCI in STEMI-CS in the contemporary era in this large national observational study.

Reperfusion in Patients With ST-Segment–Elevation Myocardial Infarction With Cardiogenic Shock and Prolonged Interhospital Transport Times

“…A prior nationwide inpatient sample study in the United States using STEMI-CS identified from administrative coding reported comparable all-cause mortality (30.8% versus 30.3%) but higher hemorrhagic complications (13.5% versus 9.9%) between fibrinolysis and pPCI-treated cohorts, though it should be acknowledged that this prior study lacks hemodynamic, time to treatment, transport, and angiographic information. 9 The present data build on previous studies with the inclusion of robust patient risk and time-to-treatment variables. We acknowledge that our results were attenuated with IPW and the study sample was likely underpowered to detect a mortality difference.…”

“…The 0.8% intracranial hemorrhage rate in the pharmacoinvasive cohort was low and similar to the 0.4% rates reported in other population-based analyses of STEMI-associated CS receiving fibrinolysis and the 0.5% to 1.0% risk reported in randomized trials of patients without CS. 9,30 In a seminal secondary analysis of the CULPRIT-SHOCK (PCI Strategies in Patients With Acute Myocardial Infarction and Cardiogenic Shock), Freund et al 31 reported the incidence of bleeding was 21.5% using the Bleeding Academic Research Consortium definition. Moreover, independent risk factors for bleeding identified by the authors included cardiac arrest/targeted temperature management, renal replacement therapy, MCS, and incomplete reperfusion.…”

“…2,5,6 In patients with CS with an anticipated prolonged interhospital transport time to a PCI-capable hospital, professional societies have suggested that fibrinolysis can be considered, but there is little high-quality evidence to guide its therapeutic use in this high-risk population. [7][8][9] A meta-analysis of randomized trials by the Fibrinolytic Therapy Trialists Collaborative Group reported a 6% lower risk of death at 35 days in the subset of patients with a systolic blood pressure <100 mm Hg, but the proportion of patients with hypoperfusion associated with hypotension was not reported. 10 In addition, the SHOCK (Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock) registry reported that patients receiving fibrinolysis had lower unadjusted rates of Thrombolysis in Myocardial Infarction 0/1 flow rates.…”

Outcomes in non-ST-segment elevation myocardial infarction complicated by in-hospital cardiac arrest based on management strategy

“…≥hospital day 1; (c) ‘PCI, if the admissions received PCI at any time during the hospitalization; and (d) ‘medical management’ or no CAG/PCI if they did not receive both CAG and PCI. 29 , 30 Acute non-cardiac organ failure was divided into neurological, hematologic, renal, hepatic and respiratory failures. 29 Non-cardiac multiorgan failure was defined as involvement of ≥2 organ systems other than cardiovascular system failure.…”

Prioritizing Rapid Reperfusion in ST-Segment–Elevation Myocardial Infarction Complicated by Cardiogenic Shock: Leveraging Regionalized Systems of Care

“…1,3 Scant data inform us about the use of fibrinolytic therapy in STEMI-CS. 1 In a contemporary analysis of the National Inpatient Sample, Vallabhajosyula et al 5 found that patients with STEMI-CS receiving fibrinolytics (n=5297) followed by angiography and either PCI (77.4%) or coronary artery bypass grafting (15.7%) had comparable in-hospital mortality to patients treated with PPCI (n=110 452) in both unmatched and propensity-matched (n=526 per arm) comparisons. However, being an analysis of a large administrative database, variables including time to reperfusion, angiographic findings, and hemodynamic data were not available and posed important study limitations.…”