STEMI Latecomers Still Benefit From Coronary Revascularization

Megan Brooks

September 22, 2021

Patients with ST-segment elevation myocardial infarction (STEMI) who delay seeking care for more than 12 hours still derive significant benefit from coronary revascularization of the infarct artery, new research shows.

A large analysis of data from the French FAST-MI registry found that primary percutaneous coronary intervention (PCI) was associated with improved short- and long-term outcomes in patients presenting up to 48 hours after their symptoms started.

The study was published online September 22 in the Journal of the American College of Cardiology.

Lifesaving Even 2 Days Out

"To the best of our knowledge, this report is the first documenting long-term clinical outcomes of latecomers according to their revascularization status in a large nationwide registry," write authors Jean Ferrières, MD, PhD, of Toulouse Rangueil University Hospital in Toulouse, France, and colleagues.

"Latecomers who had angioplasty clearly did better and that confirms a gut feeling and the practice pattern at present of many people," Samin Sharma, MD, director of clinical and interventional cardiology at Mount Sinai Hospital, New York City, told theheart.org | Medscape Cardiology.

"For somebody who comes to Mount Sinai at 24 hours or 30 hours after MI, unless there is some contraindication, we do the PCI on those patients. Doing the PCI saves lives; that's the simple message here," said Sharma, who wasn't involved in the study.

Ferrières and colleagues analyzed data from three nationwide observational studies, conducted as part of the FAST-MI program over a 1-month period in 2005, 2010, and 2015. 

Among 6273 STEMI patients, 1169 (18.6%) were latecomers, presenting more than 12 hours after symptom onset.

After excluding patients treated with fibrinolysis and patients who died within 2 days after admission, 1077 patients were analyzed. Of these, 729 (67.7%) were revascularized within 48 hours after hospital admission and the remaining 348 were not.

The mortality rate at 30 days was significantly lower among revascularized than nonrevascularized latecomers (2.1% vs 7.2%; P < .001), the authors report.

After a median follow-up of 58 months, the rate of death as a result of any cause (per 1000 patient-years) was 30.4 (95% CI, 25.7 - 35.9) in the revascularized latecomers vs 78.7 (95% CI, 67.2 - 92.3) in the nonrevascularized latecomers (P < .001).

In multivariate analysis, revascularization of latecomer STEMI patients was independently associated with a significant 35% reduction in dying during follow-up (hazard ratio, 0.65; 95% CI, 0.50 - 0.84; P < .001).

Existing evidence and large observational studies including this one "strengthen the conviction that primary PCI should be offered to all patients with STEMI presenting 12 to 48 hours from symptom onset," write Adnan Kastrati, MD, with the German Heart Center Munich, and co-authors in an accompanying editorial.

Fewer Latecomers Over the Years

Encouragingly, the data show a substantial drop-off in the prevalence of STEMI latecomers, from 22.7% in 2005 to 16.1% in 2015, Ferrières and colleagues report.

The finding that fewer patients are delaying coming to the hospital and "more and more are coming to the hospital within 12 hours is good news," Sharma told theheart.org | Medscape Cardiology.

However, the editorialists say it is "striking" that even in the most contemporary group of STEMI patients in this study, roughly 1 in 6 patients presented beyond 12 hours from the onset of symptoms.

"This finding is even more conspicuous when we consider that this data comes from a country that has implemented one of the best regional systems of STEMI care worldwide," they add.

Although there is hope for further declines in the latecomer STEMI population going forward, given that a relevant number of patients have no or only mild symptoms, "it is likely that a certain proportion of patients will continue to present late with STEMI, no matter how effective the system of care," they point out.

The French Society of Cardiology received grants for supporting the FAST-MI program from Amgen, AstraZeneca, Bayer, Bristol-Myers Squibb, Boehringer Ingelheim, Daiichi Sankyo, Eli Lilly, Merck Sharp and Dohme, Pfizer, and Sanofi. None of the companies had any role in the current study. Ferrières has received grants and personal fees from Akcea, Amarin, Amgen, Merck Sharp and Dohme, Sanofi, and Servier. The editorial writers and Sharma have disclosed no relevant financial relationships.

J Am Coll Cardiol. Published online September 21, 2021. Abstract, Editorial

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