Five-Year Survival in Patients With ST-Segment–Elevation Myocardial Infarction According to Modalities of Reperfusion Therapy

Danchin, Nicolás; Puymirat, Étienne; Steg, Philippe Gabriel; Goldstein, Patrick; Schiele, François; Belle, Loïc; Cottin, Yves; Fajadet, Jean; Khalife, Khalifé; Coste, Pierre; Ferrières, Jean; Simon, Tabassome

doi:10.1161/circulationaha.113.005874

Cited by 127 publications

(69 citation statements)

References 20 publications

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“…Despite a significantly longer door-to-balloon time, there were no significant differences in 30-day mortality, major bleeding or re-infarction/ischaemia between the pharmaco-invasive and primary PCI groups [7] . A recent large French analysis demonstrated similar five-year survival rates for STEMI patients managed by a pharmaco-invasive approach compared to primary PCI (88% versus 85%) [8] . However, local…”

Section: Discussionmentioning

confidence: 96%

Clinical Outcomes of Pharmaco-invasive ST-elevation Myocardial Infarction Management in a Large Australian Regional Centre

Nadurata

Avery

et al. 2015

Journal of Cardiology and Therapy

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Section: Discussionmentioning

confidence: 96%

Clinical Outcomes of Pharmaco-invasive ST-elevation Myocardial Infarction Management in a Large Australian Regional Centre

Nadurata

Avery

et al. 2015

Journal of Cardiology and Therapy

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“…3 We also recently reported no mortality difference for patients transferred for primary PCI in the United States whether or not they initially received fibrinolytic therapy, but bleeding risk was higher with fibrinolytic therapy.…”

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confidence: 86%

Response to Letter Regarding Article, “Evolution From Fibrinolytic Therapy to a Fibrinolytic Strategy for Patients With ST-Segment–Elevation Myocardial Infarction”

Bates

2015

Circulation

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I thank Drs Weiss and Gotsman for their interest in my editorial and respectfully acknowledge their pioneering work on prehospital fibrinolytic therapy. The potential benefit of prehospital compared with in-hospital fibrinolytic therapy was nicely demonstrated in a meta-analysis of 6 randomized, clinical trials including 6434 patients with ST-elevation-elevation myocardial infarction.1 Prehospital therapy produced a 17% relative risk reduction and 2% absolute risk reduction for in-hospital mortality (odds ratio, 0.83; 95% confidence interval, 0.70-0.98; P=0.03). Additionally, a retrospective substudy analysis including 596 patients from 2 randomized, clinical trials suggested a 1-year mortality advantage for prehospital fibrinolytic therapy compared with primary percutaneous coronary intervention (PCI) when patients were treated within 2 hours of symptom onset (hazard ratio, 0.43; 95% confidence interval, 0.21-0.91).2 However, a French national registry report comparing prehospital fibrinolytic therapy with primary PCI found equivalent 5-year mortality rates. 3 We also recently reported no mortality difference for patients transferred for primary PCI in the United States whether or not they initially received fibrinolytic therapy, but bleeding risk was higher with fibrinolytic therapy. 4Drs Weiss and Gotsman call for a randomized trial with prehospital fibrinolytic therapy administered within 2 hours of symptom onset to patients with a large volume of myocardium at risk and then transfer to a hospital with PCI capability. In fact, that was the Strategic Reperfusion Early After Myocardial Infarction (STREAM) trial, the trial about which I wrote the editorial.5 Patients had to have ≥2 mm of ST-segment elevation on their qualifying ECG, and the fibrinolytic patients were given prehospital tenecteplase. Median time from symptom onset to start of fibrinolytic therapy was only 100 minutes, so most of the patients in the prehospital fibrinolytic group were within the optimal 2-hour myocardial salvage window. Compared with primary PCI performed 178 minutes after symptom onset, the early administration of fibrinolytic therapy was associated with a trend toward lower rates of cardiogenic shock (4.4% versus 5.9%; P=0.13) and congestive heart failure (6.1% versus 7.6%; P=0.18), more aborted myocardial infarction (11.1% versus 6.9%; P<0.01), and higher patency rates (74% versus 30%; P<0.001) on the initial coronary angiogram, yet there were no differences in death and reinfarction rates. Bleeding and intracranial hemorrhage rates after a protocol amendment were still higher with fibrinolytic therapy but not statistically different from the rates with primary PCI.Whereas earlier time to treatment is an important reperfusion goal, prehospital fibrinolytic therapy is limited by lower reperfusion rates than primary PCI, increased bleeding risk, and the logistical, financial, and legal challenges of training, organizing, and indemnifying nonphysicians who would be delivering prehospital care in most countries. The best reperfusio...

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“…Accumulating contemporary evidence indicates that early fibrinolytic therapy followed by timely PCI, where appropriate, achieves clinical outcomes at least as good as PPCI in the common circumstance, where delay to PPCI is >60 to 90 minutes from first medical contact. 9,10 In this issue of Circulation, 11 the EARLY-MYO trial (Early Routine Catheterisation After Alteplase Fibrinolysis Versus Primary PCI in Acute ST-Elevation Myocardial Infarction) investigators provide another waypoint to help navigate the continuing reperfusion journey. Using a noninferiority design, they targeted a composite reperfusion end point of both thrombolysis in myocardial infarction flow and perfusion grade 3 combined with ST segment resolution ≥70% after PCI.…”

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confidence: 99%

Recalibrating Reperfusion Waypoints

Armstrong

Welsh

2017

Circulation

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T he realization that thrombus was the cause and not the consequence of acute myocardial infarction was a transformative pathophysiologic insight. 1 An even more stunning observation was the subsequent discovery that restoration of coronary patency could salvage ischemic myocardium and improve clinical outcomes in ST-elevation acute myocardial infarction (STEMI).2,3 Assertive clinical investigations of both the content and process of STEMI care over the subsequent 4 decades has demonstrated that the ultimate success of reperfusion is modulated by the timeliness, efficiency, and efficacy with which it is applied. Whereas contemporary guidelines indicate that primary percutaneous coronary intervention (PCI) is the preferred strategy for STEMI, most patients with STEMI do not present to a primary PCI (PPCI) center, and ≈50% are walk-ins who do not utilize emergency medical services.4-6 Accordingly, persisting delays-attributable to both patients and the healthcare system-in achieving timely PCI (ie, within 60 to 90 minutes of symptoms to first medical contact) are common and exact a price of excess morbidity and mortality. 7,8 Advances in fibrinolytic, anti-thrombotic, and antiplatelet therapies, coupled with improved pre-and in-hospital systems of care, have evolved dramatically pari passu with these clinical realities. Accumulating contemporary evidence indicates that early fibrinolytic therapy followed by timely PCI, where appropriate, achieves clinical outcomes at least as good as PPCI in the common circumstance, where delay to PPCI is >60 to 90 minutes from first medical contact. 9,10 In this issue of Circulation, 11 the EARLY-MYO trial (Early Routine Catheterisation After Alteplase Fibrinolysis Versus Primary PCI in Acute ST-Elevation Myocardial Infarction) investigators provide another waypoint to help navigate the continuing reperfusion journey. Using a noninferiority design, they targeted a composite reperfusion end point of both thrombolysis in myocardial infarction flow and perfusion grade 3 combined with ST segment resolution ≥70% after PCI.11 They randomized 344 low-risk East Asian patients with STEMI ≤6 hours of symptom onset to either a pharmaco-invasive (PhI) strategy with half-dose alteplase or PPCI and found the primary end point to be 34.2% versus 22.8% for PhI versus PPCI, respectively (P<0.05 for noninferiority and P=0.022 for superiority). Given that the angiographic end point was after PCI and the ST segment resolution assessment was ≈60 minutes after PCI in both treatment groups, it can be argued that this later assessment of reperfusion in the PhI group (≈7 hours after the PPCI group) Recalibrating Reperfusion Waypoints

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Five-Year Survival in Patients With ST-Segment–Elevation Myocardial Infarction According to Modalities of Reperfusion Therapy

Cited by 127 publications

References 20 publications

Clinical Outcomes of Pharmaco-invasive ST-elevation Myocardial Infarction Management in a Large Australian Regional Centre

Clinical Outcomes of Pharmaco-invasive ST-elevation Myocardial Infarction Management in a Large Australian Regional Centre

Response to Letter Regarding Article, “Evolution From Fibrinolytic Therapy to a Fibrinolytic Strategy for Patients With ST-Segment–Elevation Myocardial Infarction”

Recalibrating Reperfusion Waypoints

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