April 22nd, 2014

Large French Registry Lends Support To Pharmaco-Invasive Strategy For STEMI

It is generally agreed that the best treatment for STEMI patients is immediate reperfusion with PCI. But for many patients primary PCI is not available within the time frame leading to the greatest benefit. Previous studies have found good short-term outcomes in patients who receive a pharmaco-invasive strategy, in which patients first receive fibrinolytic therapy and then later undergo angiography. Now long-term results from a large real-world study show that this strategy may be an acceptable alternative for some patients when immediate primary PCI is not available.

In a paper published in Circulation, French researchers report the 5-year mortality findings from nearly 1,500 STEMI patients enrolled in the 2005 cohort of FAST-MI (The French Registry on Acute ST-Elevation and Non–ST-Elevation Myocardial Infarction).

30% of the patients received fibrinolysis. In two-thirds of these patients fibrinolysis was delivered prior to hospital arrival– a high rate made possible by the common presence of physicians in French ambulances. 97% of patients in the fibrinolysis group underwent subsequent angiography and 84% underwent PCI. For the rest of the patients in the study, 39% received primary PCI and 31% did not undergo reperfusion.

At 5 years the crude survival rate was 88% for patients in the fibrinolysis group, 83% for patients in the primary PCI group, and 59% for patients in the group that did not receive reperfusion. After adjusting for risk factors the hazard ratio was 0.73 (CI 0.50–1.06) in the fibrinolysis group when compared to the primary PCI group. For the subgroup of patients who received prehospital fibrinolysis the hazard ratio achieved statistical significance (0.57, CI 0.36–0.88). Prehospital fibrinolysis was also superior to primary PCI when the latter was delayed beyond 90 minutes in patients who called within 3 hours of the onset of symptoms (HR 0.63, CI 0.34–0.91). There were no significant differences between the two groups in propensity score-matched populations.

The French investigators concluded that “the pharmaco-invasive strategy yielded results that were at least as good as those of primary PCI.” Given the difficulty of implementing widespread, 24-hour emergency PCI services, “a pharmaco-invasive strategy seems to represent a safe alternative to primary PCI.”

In an accompanying editorial, Peter Sinnaeve and Frans Van de Werf point out that “it remains uncertain whether the high 5-year survival rates can be obtained” in other healthcare systems, especially those that don’t use physicians in the ambulance. Nevertheless, they conclude that “a contemporary pharmaco-invasive management appears to be at least as good as primary PCI in STEMI patients presenting early after symptom onset when a timely PCI is not an option.”

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