The relationship between symptom onset-to-needle time and ischemic outcomes in patients with acute myocardial infarction treated with primary PCI: Observations from Prague-18 Study. Issue 5 (May 2022)

• Record Type: Journal Article
• Authors: Hromadka, Milan; Motovska, Zuzana; Hlinomaz, Ota; Kala, Petr; Varvarovsky, Ivo; Dusek, Jaroslav; Svoboda, Michal; Jarkovsky, Jiri; Tousek, Frantisek; Jansky, Pavel; Simek, Stanislav; Branny, Marian; Mrozek, Jan; Miklik, Roman; Rokyta, Richard; Widimsky, Petr
• Is Part Of: Journal of cardiology. Volume 79:Issue 5(2022)
• Page Start: 626
• Page End: 633
• Publication Date: 2022-05
• Subjects: Acute myocardial infarction -- Symptoms onset to needle time -- Risk stratification -- P2Y12 inhibitors -- Ischemic endpoints; Cardiology -- Periodicals; 616.12
• DOI: 10.1016/j.jjcc.2021.11.015
• Languages: English
• ISSNs: 0914-5087

Abstract

Highlights: Initial ischemic risk in ST-segment elevation myocardial infarction patients affects prognosis more than ischemic time. Longer ischemic time increases ischemic events only in high-risk patients. Longer ischemic time increases all-cause mortality only in high-risk patients. Post-percutaneous coronary intervention suboptimal flow is more frequent in patients with longer ischemic time. Abstract: Objectives: Based on previous studies with clopidogrel, the time between acute myocardial infarction (AMI) symptoms onset and primary percutaneous coronary intervention (PCI) was proven as important prognostic factor. Our aim was to assess the relationship between symptoms onset to needle time (SNT) and procedural results and the occurrence of ischemic endpoints in primary angioplasty patients treated with potent P2Y12 inhibitors. Methods: A total of 1, 131 out of 1, 230 patients randomized to the Prague-18 study (prasugrel vs. ticagrelor in primary PCI) were divided into a high and a low-risk group. The effect of defined SNT on patients' ischemic endpoints and prognosis by their risk status at admission was tested. Results: The median SNT was 3.2 hours. Longer SNTs resulted in a more frequent incidence of TIMI flow <3 post PCI (p=0.015). There were significant differences in the occurrence of the combined ischemic endpoint among the compared SNT groups at 30 days (p=0.032), and 1 year (p=0.011), with the highest incidence in the ≤1 h SNT group of patients. "Latecomers" (SNT>4 hs) in the high-risk group experienced more reinfarction within 1 year [OR (95% CI) 3.23 (1.09–9.62) p=0.035]; no difference was found in the low-risk group. Conclusions: In the era of intense antithrombotic medication, stratification of MI patients undergoing primary angioplasty, based on initial ischemic risk assessment affected prognosis more than symptom onset to needle time. Longer time delay was significantly related to increased incidence of ischemic events and all-cause mortality only in patients with high ischemic risk. Graphical abstract: In STEMI patients referred to primary PCI and treated with prasugrel or ticagrelor, longer symptom-to-needle times (SNT) were associated with more frequent suboptimal PCI results. Stratification of patients based on their initial ischemic risk (per TIMI criteria) proved to have more prognostic power than SNT. Compared to low-risk patients, high-risk patients had a significantly higher incidence of both ischemic events and all-cause mortality when presenting with SNT > 4 hours. Concerning early comers (SNT < 4 hours), mortality rate but not the incidence of ischemic endpoints was significantly higher in the high-risk group of patients. Image, graphical abstract