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. 2017 Aug;14(8):524-531.
doi: 10.11909/j.issn.1671-5411.2017.08.006.

Patients with ST-segment elevation of myocardial infarction miss out on early reperfusion: when to undergo delayed revascularization

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Patients with ST-segment elevation of myocardial infarction miss out on early reperfusion: when to undergo delayed revascularization

Wen Zheng et al. J Geriatr Cardiol. 2017 Aug.

Abstract

Objective: There are still a high proportion of patients with ST-segment elevation myocardial infarction (STEMI) missing out early reperfusion even in the primary percutaneous coronary intervention (PCI) era. Most of them are stable latecomers, but the optimal time to undergo delayed PCI for stable ones remains controversial.

Methods: We investigated all STEMI patients who underwent delayed PCI (2-28 days after STEMI) during 2007-2010 in Beijing and excluded patients with hemodynamic instability. The primary outcome was major adverse cardiovascular events (MACEs).

Results: This study finally enrolled 5,417 STEMI patients and assigned them into three groups according to individual delayed time (Early group, 55.9%; Medium group, 35.4%; Late group, 8.7%). During 1-year follow-up, MACEs occurred in 319 patients. The incidence of MACEs were respectively 7.1%, 5.6% and 6.7% among three groups. The Medium group had less recurrent myocardial infarction plus cardiac death (hazard ratio, 0.525; 95% confidence interval, 0.294-0.938, P = 0.030) than Late group and less repeat revascularization (hazard ratio, 0.640; 95% confidence interval, 0.463-0.883, P = 0.007) than Early group in pairwise comparisons. We depicted the incidence of major adverse cardiovascular event (MACE) by delayed time as a quadratic curve and found the bottom appeared at day 14.

Conclusions: The delayed PCI time varied in the real-world practice, but undergoing operations on the second week after STEMI had greater survival benefit and less adverse events for whom without early reperfusion and hemodynamic instability.

Keywords: Angioplasty; Epidemiology; Latecomer; Myocardial infarction; Stents.

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Figures

Figure 1.
Figure 1.. The flowchart of patients' selection.
CABG: coronary artery bypass grafting; MI: myocardial infarction; PCI: percutaneous coronary intervention; STMI: ST-segment elevation myocardial infarction.
Figure 2.
Figure 2.. The distribution of delayed PCI time.
(A): showed the relationship between operation time and the incidence of 1-year MACEs. The relationship between operation time and incidence of MACE adjusted by demographic and clinical characteristics was depicted as a ‘U’ shape. The bottom occurred on the second week from STEMI onset. Also, the distribution of operation time was left-skewed and the number of delayed PCI reached the top on the day 2 and day 7. (B–D): showed the distribution of operation time by different gender (male or female, B), ages (> 75 or ≤ 75, C) or hospital levels (tertiary hospital or secondary hospital, (D). MACE: major adverse cardiovascular event; PCI: percutaneous coronary intervention; STEMI: ST-segment elevation myocardial infarction.
Figure 3.
Figure 3.. Kaplan-Meier curves for primary and secondary endpoints.
(A): showed the Kaplan-Meier curves for 1-year MACE. There were significantly fewer MACEs in Medium group than other two groups at one year. Over time, the difference among three groups did not significantly changed. As most of events occurred within the first month, we further analyzed the primary endpoint with landmark analysis (B). Only patients free 28-day MACEs were enrolled in order to adjusting the impacts of early events. (C–F): showed the Kaplan-Meier curves for secondary endpoints including repeat revascularization (C), recurrent myocardial infarction (D), cardiac death (E) and recurrent myocardial infarction plus cardiac death (F). MACE: major adverse cardiovascular event; STEMI: ST-segment elevation myocardial infarction.

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