Primary percutaneous coronary intervention within the first hour: Insights from early-treated patients with ST-elevation myocardial infarction.

BACKGROUND: Whereas reperfusion benefit in ST-elevation myocardial infarction (STEMI) is time-dependent, outcome data from very early primary percutaneous coronary intervention (PPCI) are limited. The STREAM-1 and -2 trials provided a unique opportunity to assess this issue. We evaluated electrocardiographic (ECG), angiographic, and clinical outcomes of early presenting STEMI patients undergoing PPCI, focusing on those treated <60 minutes of randomization. METHODS: We analyzed STEMI patients from STREAM-1 (n = 1,892) and STREAM-2 (n = 604) trials presenting <3 hours of symptom onset who underwent PPCI. Endpoints included ECG (ST segment resolution, Q waves), angiographic (TIMI flow grade), 30-day composite of all-cause death, shock, heart failure, reinfarction, safety outcomes, and 1-year mortality. RESULTS: Patients undergoing PPCI <60 minutes of randomization (29.2%) were younger, more frequently male, and had shorter total ischemic times than those undergoing PPCI >60 minutes. ST resolution and TIMI flow outcomes were similar, but significantly fewer patients in the rapid PPCI group had Q waves on discharge ECG (58.2 vs. 71.9%, P < .001). The 30-day composite outcome was lower in the <60 minutes group (10.1 vs 14.8%, risk ratio [RR] 0.68 [95% confidence interval 0.47-0.98], P = .04), associated with a significant 62% reduction in cardiogenic shock (P = .0008), and also had lower 1-year mortality (4.0 vs 7.2%; RR 0.56 [0.31-1.01], P(logrank) = .047). After inverse probability weighted adjustment, the 30-day composite outcome and cardiogenic shock were RR 0.74 (0.50-1.08), P = .116 and RR 0.45 (0.22-0.91), P = .027, respectively, and the 1-year mortality was RR 0.70 (0.39-1.26), P = .235. Safety endpoints were similar in both groups. CONCLUSIONS: Substantial opportunity exists to improve outcomes for early-presenting STEMI patients undergoing PPCI. Establishing a first medical contact-to-PPCI time of <60 minutes provides incremental benefit. CLINICAL TRIAL REGISTRATION: URL:https://clinicaltrials.gov/study/NCT00623623, https://clinicaltrials.gov/study/NCT02777580. Unique identifiers: NCT02777580, NCT00623623.

Duke Scholars

Author Paul Wayne Armstrong Medicine, Cardiology