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Canadian Journal of Cardiology 28 (2012) 40 – 47

Clinical Research

Reperfusion Strategies and Outcomes of ST-Segment
Elevation Myocardial Infarction Patients in Canada:
Observations From the Global Registry of Acute
Coronary Events (GRACE) and the Canadian Registry of
Acute Coronary Events (CANRACE)
Andrew Czarnecki, MD,a Robert C. Welsh, MD,b Raymond T. Yan, MD,c
J. Paul DeYoung, MD,d Richard Gallo, MD,e Barry Rose, MD,f Francois R. Grondin, MD,g
Jan M. Kornder, MD,h Graham C. Wong, MD,i Keith A. A. Fox, MB, ChB, FRCP,j
Joel M. Gore, MD,k Shaun G. Goodman, MD, MSc,a,c and Andrew T. Yan, MD;a,c on behalf of
the Global Registry of Acute Coronary Events (GRACE/GRACE2) and Canadian Registry of
Coronary Events (CANRACE) Investigators
a

Terrence Donnelly Heart Centre, Division of Cardiology, St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
b

Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada

e

c

Canadian Heart Research Centre, Toronto, Ontario, Canada

d

Cornwall Community Hospital, Cornwall, Ontario, Canada

Montréal Heart Institute, Université de Montréal, Montréal, Québec, Canada
f

Health Sciences Centre, St John’s, Newfoundland, Canada
g

h
i
j
k

Hôtel-Dieu de Lévis, Lévis, Québec, Canada

Surrey Memorial Hospital, Surrey, British Columbia, Canada

University of British Columbia, Vancouver, British Columbia, Canada

Cardiovascular Research, Division of Medical and Radiological Sciences, University of Edinburgh, Edinburgh, Scotland

Department of Medicine, Division of Cardiovascular Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA

ABSTRACT

RÉSUMÉ

Background: We examine the clinical characteristics and outcomes of
ST-elevation myocardial infarction (STEMI) patients receiving various
reperfusion therapies in 2 contemporary Canadian registries.
Methods: Of 4045 STEMI patients, 2024 received reperfusion therapy
and had complete data on invasive management. They were stratified
by reperfusion strategy used: primary percutaneous coronary interven-

Introduction : Nous avons examiné les caractéristiques et les résultats cliniques des patients ayant un infarctus du myocarde (IM) avec
sus-décalage du segment ST de 2 registres canadiens contemporains
et recevant divers traitements de reperfusion.
Méthodes : Des 4 045 patients ayant un IM avec sus-décalage du
segment ST, 2 024 ont reçu un traitement de reperfusion et ont eu des

The optimal therapeutic approach for ST-segment elevation
myocardial infarction (STEMI) has been long debated. Both

fibrinolysis and primary percutaneous coronary intervention
(PCI) are well-established reperfusion strategies with a wealth
of literature supporting their efficacy with respect to both morbidity and mortality.1 While the superiority of timely primary
PCI has been established and most Canadian interventional
centres have adopted primary PCI as the standard of care,2
many patients presenting to hospitals without on-site PCI facilities continue to receive fibrinolysis.

Received for publication May 31, 2011. Accepted September 15, 2011.
Corresponding author: Dr Andrew T. Yan or Dr Shaun G. Goodman, St Michael’s Hospital, Division of Cardiology, 30 Bond St., Room 6-030 Queen, Toronto,
Ontario M5B 1W8, Canada. Tel.: ⫹1-416-864-5465; fax: ⫹1-416-864-5159.
E-mail: yana@smh.ca
See page 45 for disclosure information.

0828-282X/$ – see front matter © 2012 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
doi:10.1016/j.cjca.2011.09.011

Local ethics board approval was obtained at each participating hospital. Methods The GRACE. and (4) fibrinolysis without PCI during index hospitalization. et 4. serial increases in serum biochemical markers of cardiac necrosis. and fibrinolysis without PCI (n ⫽921). la fibrinolyse avec ICP urgente ou élective (n ⫽ 210). and CANRACE projects have been previously described. respectively. no PCI during hospitalization was associated with death and reinfarction (adjusted odds ratio ⫽ 1.032). and medication utilization differed with respect to the reperfusion strategy. ␤-blockers and angiotensin-converting enzyme inhibitors.1 % (P ⫽ 0.009). 95% confidence interval. and 4. ces complications se sont présentées plus fréquemment chez ceux qui n’avaient pas subi d’ICP durant l’hospitalisation. Patients were excluded if they had an ACS precipitated by serious noncardiac comorbidities. pa- Patient stratification Of 14. Tandis que de faibles taux de récidive d’infarctus et de mortalité ont été observés. and study participants provided informed consent. Conclusions : Les caractéristiques cliniques.8 % par la fibrinolyse seule (P ⫽ 0. Standardized data collection forms were used and included patient demographics. 4.03-2. Ils ont été stratifiés selon la stratégie de reperfusion utilisée : l’intervention coronarienne percutanée (ICP) primaire (n ⫽ 716).7% of patients treated with primary PCI. 1.04). Il y a eu mortalité à l’hôpital chez 2. tients with acute coronary syndromes (ACS) were enrolled from 55 hospitals across Canada.70.009). Rates of heart failure or major bleeding were similar in the 4 groups. and clinical outcomes in STEMI patients receiving primary PCI or fibrinolysis in the Global Registry of Acute Coronary Events (GRACE) and Expanded GRACE (GRACE2) and the Canadian Registry of Acute Coronary Events (CANRACE). patients who did not receive acute reperfusion therapy (n ⫽ 1267) were excluded. had longer time to delivery of reperfusion therapy.04). The purpose of this observational study was to describe the “real world” patient characteristics and clinical outcomes of patients with STEMI in Canada treated with reperfusion therapy. In multivariable analysis. Rescue PCI was . P ⫽0. les taux de mortalité et de récidive d’infarctus ont été de 3.7 % par la fibrinolyse avec ICP urgente. 1. patients who did not receive reperfusion were excluded from our analysis. 4. 1. Of the 2778 patients who received reperfusion therapy. 1. Dans l’analyse multivariée.5 While these trials were not adequately powered to definitively guide routine clinical practice. 4. the rates of death/reinfarction were 3.9%. the use of currently available reperfusion treatment strategies and their associated clinical outcomes have not been well described in Canadian patients in the “real world.0 %. and 7. 4045 (28%) had a final diagnosis of STEMI. 1. and outcome data.7% fibrinolysis-rescue PCI. and they had a diagnosis of ACS with 1 of the following: electrocardiographic changes consistent with ACS. aucune ICP durant l’hospitalisation n’a été associée à la mortalité et à la récidive d’infarctus (ratio d’incidence approché ajusté ⫽ 1. et la fibrinolyse sans ICP (n ⫽ 921). fibrinolysis with urgent/elective PCI (n ⫽210). time to reperfusion.6 Furthermore. mais moins d’héparine.8% fibrinolysis-alone (P ⫽0. intervalle de confiance de 95 %.3%. Forms were completed by designated study coordinators or treating physicians. GRACE2. Résultats : Comparativement aux patients traités par fibrinolyse. Particularly important in the context of limited access to primary PCI in Canada. While low rates of re-infarction/death were observed. as compared with patients treated with tenecteplase followed by either usual care or early PCI.70. In addition. la fibrinolyse avec ICP urgente (n ⫽ 177).1% (P ⫽0. (2) fibrinolysis with rescue PCI. données complètes sur un traitement effractif.7 % des patients traités par l’ICP primaire. these complications occurred more frequently in those who did not undergo PCI during index hospitalization.Czarnecki et al.9 %. Conclusions: Clinical features. fibrinolysis with rescue PCI (n ⫽177).032). The CANRACE registry was initiated in 2008 after GRACE and GRACE2 ceased patient enrolment in 2007. primary PCI was associated with nonsignificantly lower rates of reinfarction but increased heart failure (HF) and cardiogenic shock.03-2.0% fibrinolysis-urgent/elective PCI. Reperfusion Strategies and Outcomes of STEMI 41 tion (PCI) (n ⫽716). We stratified the study population in accordance with the acute reperfusion strategy and in the fibrinolysis population by subsequent in-hospital PCI: (1) primary PCI. The rate of shock was highest in the primary PCI group. P ⫽ 0.432 patients enrolled. a number of studies have suggested that very early treatment with fibrinolytics may offer a benefit over primary PCI with respect to the incidence of cardiogenic shock and mortality. and utilized more antiplatelet therapy but less heparin.3 Although no difference was demonstrated in the composite endpoint in this pilot study. In-hospital death occurred in 2. Results: Compared with fibrinolytic-treated patients.0 % par la fibrinolyse avec ICP urgente ou élective.3 % et 7. 1. (3) fibrinolysis with urgent/elective PCI. de ␤-bloquants et d’inhibiteurs de l’enzyme de conversion de l’angiotensine. a subgroup analysis of the Comparison of Angioplasty and Prehospital Thrombolysis in Acute Myocardial Infarction (CAPTIM) trial suggested that early (⬍ 2 hours) treatment with fibrinolytics resulted in lower rates of cardiogenic shock when compared with primary PCI with enrollment in the prehospital environment.66. Les données ont été recueillies des découvertes cliniques et de laboratoire. Le taux de choc a été plus élevé dans le groupe d’ICP primaire. Patients were included if they were 18 years old or older. and/or documented history of coronary artery disease. avaient un délai d’attente plus long avant le traitement de reperfusion et utilisaient plus de traitements antiplaquettaires. Consecutive patient recruitment was encouraged at all sites. respectivement. reperfusion modalities. les patients traités par une ICP primaire étaient plus jeunes et avaient une classification de Killip plus élevée. treatment. the objective of this observational study was to describe the patient characteristics. 2024 had complete data on invasive management and were included in this analysis. Therefore. there is an ongoing randomized trial seeking to address this issue.0%.66. et des résultats.7–9 Between 1999 and 2008. clinical characteristics.4. and outcomes. Les taux d’insuffisance cardiaque ou de saignement majeur ont été similaires dans les 4 groupes. Data were collected on clinical and laboratory findings. The Which Early ST-Elevation (WEST) study randomized Canadian STEMI patients to primary PCI or fibrinolysis with or without mechanical cointervention. patients treated with primary PCI were younger and had higher Killip class.” Accordingly. 4. le délai d’attente avant la reperfusion et l’utilisation de la médication ont différé selon la stratégie de reperfusion.

069 Data are presented as percentages or mean ⫾ SD.4 3.6 43.001 0.3 2. Clinical outcomes in this study included reinfarction.27 0. Medication utilization in the first 24 hours was notable for significantly more use of clopidogrel and glycoprotein IIb/IIIa inhibitors in the primary PCI patients.0 73 ⫾ 20 142 ⫾ 28 84 ⫾ 17 63 ⫾ 13 27.3 17. Rates of major bleeding and sustained ventricular tachycardia are also presented.1 3.26 0.7 2.4 77 ⫾ 20 137 ⫾ 30 82 ⫾ 19 62 ⫾ 12 26. Bpm. reinfarction.002 0.31 0.5 19. and compared using the Kruskal-Wallis test (or Mann-Whitney U test). Chicago.3 8. Statistical analysis Baseline characteristics Data were analyzed with respect to therapeutic strategy.8 13.12 0.1 3.5 42.2 4.6 47.35 ⬍ 0. Adequate model discrimination and calibration were achieved. and HF.7 0.4 3. and nonemergent elective PCI of suspected culprit lesion. or fibrinolysis with no PCI).4 1. Baseline characteristics of the study patients Fibrinolysis Age Female gender Diabetes mellitus Smoker Hypertension Hyperlipidemia Peripheral artery disease TIA/stroke History of bleeding Angina History of heart failure Prior MI Prior PCI Prior coronary bypass surgery Heart rate (Bpm) Systolic BP (mm Hg) Diastolic BP (mm Hg) Killip Class Killip I Killip II Killip III/IV Cardiac arrest Creatinine (␮mol/L) GRACE risk score Primary PCI (n ⫽ 716) Overall (n ⫽ 1308) Rescue PCI (n ⫽ 177) Urgent/elective PCI (n ⫽ 210) No PCI (n ⫽ 921) 60 ⫾ 13 23.029 0. where appropriate).4 39. GRACE.05. no in-hospital PCI) were older. Continuous variables are reported as means with standard deviations or medians with interquartile ranges (where appropriate).3 13. beats per minute.027 0.42 Canadian Journal of Cardiology Volume 28 2012 defined as PCI after failed fibrinolysis which refers to ongoing/ recurrent ischemic discomfort and/or lack of ST-segment elevation resolution or recurrent ST elevation. However. TIA.2 7. HF.3 99 ⫾ 34 135 ⫾ 36 P* P† ⬍ 0.9 4.2 76 ⫾ 20 143 ⫾ 29 83 ⫾ 19 88.9 42.013 0. previous myocardial infarction. HF. and shock. Results Of the 2024 patients included in this study.3 1.1 2.3 4. of these patients 177 had fibrinolysis with rescue PCI.5 16.60 0.8 1.4 41.51 0. and in-hospital clinical events were described.3 2.002 0. 716 underwent primary PCI.6 93 ⫾ 23 130 ⫾ 36 92. BP. adjusted for the GRACE risk score.001 0.041 0.3 97 ⫾ 31 134 ⫾ 35 90. death. Table 1.3 1.6 7. The primary PCI and fibrinolysis-only groups tended to have higher GRACE risk scores.2 95 ⫾ 30 134 ⫾ 33 90.4 2. .29 0.3 41.024 0.4 2.7 3. Categorical variables are presented as percentages.50 0. and 921 had fibrinolysis without in-hospital PCI.9 40.15 0.2 9.9 5.23 0.7 75 ⫾ 20 142 ⫾ 29 83 ⫾ 19 58 ⫾ 11 26. which is a validated predictor of in-hospital mortality.7 41. facilitated PCI (immediate PCI following successful fibrinolysis.6 22.21 0. IL) statistical software was used for analysis.0 13.4 39. non-emergent adjunctive PCI of non-culprit lesion.8 8.003 0.11 0.15 0.6 19.5 17. PCI for post-acute myocardial infarction (AMI) ischemia. Multivariable models were developed for the combined endpoints including death and reinfarction.9 41.3 2. primary PCI vs fibrinolysis with rescue PCI.7 19. Statistical significance was established with a 2-sided P value of ⬍ 0. SPSS version 15. PCI for unstable angina.25 0. while fibrinolytic-treated patients more frequently received heparin. blood pressure.0 3.2 41.3 1.9 15.15 0.042 0.034 0. Baseline characteristics. surrogate markers of infarct size.36 0.1 11.9 3.6 1.4 1. or fibrinolysis with urgent/elective The baseline demographic and clinical characteristics of the patients in each group were generally similar (Tables 1 and 2).5 36. MI.0 5.2 17.4 15.8 2.42 0. cardiogenic shock.35 ⬍ 0. * Four-group (primary PCI and each individual fibrinolysis group) comparisons.8 3.3 73 ⫾ 20 139 ⫾ 31 85 ⫾ 20 60 ⫾ 12 23. The independent variable was the reperfusion strategy applied (primary PCI vs all patients treated with fibrinolysis. and 1308 received fibrinolysis.9 46. and compared using Pearson ␹2 (or Fisher’s exact test.1 3.3 45.10 –12 as well as diabetes and hypertension. † Primary PCI vs overall fibrinolysis. and in-hospital mortality.3 1.001 0. urgent/elective PCI included: early PCI for cardiogenic shock.1 4. patients treated with fibrinolytic only (ie. All PCI occurred during the index admission. In contrast. Global Registry of Acute Coronary Events.3 6.70 0.0 1.001 0.0 (SPSS Inc.6 1.7 12. and more likely had a history of heart disease including angina. PCI.1 2. PCI. ␤-blocker use was more common in the fibrinolytic-treated group compared with the primary PCI group. percutaneous coronary intervention.9 10.4 8.6 7. or in conjunction with fibrinolysis). transient ischemic attack. myocardial infarction.058 0. HF.98 0.001 0.36 0. and shock.6 1. 210 had fibrinolysis with urgent/elective PCI.11 0.001 0. as well as death.25 0.0 92 ⫾ 21 131 ⫾ 32 90.

1 4.1 55.3 24.2.12 0.3 62.0 8.0 80.001 ⬍ 0.7 145 (90-261) 15.001 0.001 ⬍ 0.1 85.3 4. 4.1 29.056 0.8 54.9 77. vs primary PCI).002 0.001 0.7% of rescue PCI.031 ⬍ 0.1 43.003 ⬍ 0.001 ⬍ 0.001 ⬍ 0.24 ⬍ 0.12 0.7 95.3 9. Medication use in the first 24 hours Fibrinolysis Aspirin Clopidogrel Unfractionated heparin Enoxaparin Any heparin Glycoprotein IIb/IIIa inhibitor ␤-Blockers Statin ACE inhibitor Calcium antagonist Inotrope use in first 24 h or after Inotrope use within first 24 h Inotrope use after first 24 h Primary PCI (n ⫽ 716) Overall (n ⫽ 1308) Rescue PCI (n ⫽ 177) Urgent/elective PCI (n ⫽ 210) No PCI (n ⫽ 921) P* P† 96.4 4.14 Data are presented as percentages.6 18. angiotensin-converting enzyme. higher GRACE risk score and diabetes independently predicted in-hospital death and reinfarction as well as the composite of death.04) (Table 5). electrocardiogram analysis. Primary PCI had a higher incidence of cardiogenic shock as compared with fibrinolysis overall.3 41.7% in fibrinolysis overall (P ⫽ 0.037 0.001 0.3 38.9 5.7 84. * Four-group (primary PCI and each individual fibrinolysis group) comparisons.8% of the fibrinolysis-alone cohort (P ⫽ 0.3 17.03). Death or reinfarction occurred less frequently with primary PCI.4 47.0 23. Analysis of the overall fibrinolysis group revealed that the reperfusion strategy (PCI vs Clinical outcomes Cardiovascular events and composite outcomes are listed in Table 4.2 ⬍ 0.3 48.009). The median time (25th-75th percentiles) from symptom onset to reperfusion with primary PCI (first balloon inflation) was 229 (161-370) minutes.1 47.0 36.66.5 96.9 80. creatine kinase.1 8. . HF.3 51.3 73.9% and 6.6 0. not undergoing PCI was independently associated with in-hospital death and reinfarction as compared with primary PCI (adjusted odds ratio ⫽ 1. Laboratory measurements of creatine kinase (CK).6 71.8 43.3 3.39 0. respectively (Table 3). respectively. † Primary PCI vs overall fibrinolysis.7 2.4 93. and 3.4 145 (81-225) 6. Time from symptom onset-toneedle was 143 (85-249) minutes in the fibrinolysis group. while the urgent/elective PCI and no PCI groups received fibrinolysis in 145 (81-225) and 145 (90-261) minutes from symptom onset.Czarnecki et al.3 97. and shock.8 6. or major bleeding were similar.2 81.8 65.067 0.6 Numerical values represent medians with interquartile range or %.7 6.075 0.8 53.5 2.68 0.2 74.046 229 (161-370) 16. percutaneous coronary intervention.0 60.3 8.049 0.6 10.7 15. PCI. * Four-group (primary PCI and each individual fibrinolysis group) comparisons.5 36. ACE. P ⫽ 0.3 5. with similar rates of HF and sustained ventricular tachycardia.7 83. In multivariable analysis.001 ⬍ 0.3 60. † Primary PCI vs overall fibrinolysis.5 8.3 2. as compared with Table 3. Rates of HF. 95% confidence interval.04 0.001 0.7 4.9 39.6 7.5 67.001 ⬍ 0.7 6.8 96. CKMB. 1. CK.5 52.5 22.022 0. A Cox regression analysis was also performed and showed similar results. inotrope use. PCI.5 23.2 14.38 ⬍ 0.0% of the urgent/elective PCI.7 39.001 ⬍ 0.9 10.4 95. 1.99 ⬍ 0. percutaneous coronary intervention.03-2. reinfarction.001 ⬍ 0.1 6. Infarct size and left ventricular function in relation to reperfusion strategies Fibrinolysis Max CK-MB (first 24 h) (n ⫽ 567) Max CK (first 24 h) (n ⫽ 1180) Time to reperfusion therapy (min) (n ⫽ 1726) New Q wave (n ⫽ 2024) New Q wave after index event (n ⫽ 1999) Left ventricular function (n ⫽ 1410) Normal Mild dysfunction Moderate dysfunction Severe dysfunction Primary PCI (n ⫽ 716) Overall (n ⫽ 1308) Rescue PCI (n ⫽ 177) Urgent/elective PCI (n ⫽ 210) No PCI (n ⫽ 921) P* P† 108 (34-265) 1446 (628-2778) 98 (37-203) 930 (436-2110) 152 (63-285) 1266 (667-2507) 137 (39-205) 1044 (420-2023) 82 (35-179) 802 (404-2047) 0.7 54. Reperfusion Strategies and Outcomes of STEMI 43 Table 2.005 0.1 44.7 97.6 52. P ⫽ 0.001 0.9 97. In addition.001 124 (80-200) 12.9 7. the patients who received fibrinolysis (3.8 56.7 7.1 5.001 ⬍ 0.4 96. ventricular tachycardia.3 29.3 57.1 35.2%. There was more major bleeding within the primary PCI group compared with the overall fibrinolysis group. with respect to the different fibrinolysis groups.001 0.6 143 (85-249) 13. and left ventricular function are shown in Table 3.7 4.039 0.3 54.1 2.2 77.7% of the primary PCI patients.5 3.6 13.001 ⬍ 0.9 1. The rescue PCI group received fibrinolytic therapy in 124 (80-200) minutes. Exclusion of patients who died within the first day from the analysis did not significantly change the results.1 72.70. Death occurred in 2. 1.

70-1.1.9 9.99 1.54 0.20 In our study.34 0.07 0. hypertension and diabetes mellitus.7 3.03-2.032 0. CI. heart failure. to admission and primary PCI.49 0.7 1. HF.75 Reference 0. Our data describe real-world therapeutic and outcome disparities seen in patients presenting with STEMI.2 2.19 in contrast. MI.14 However. Global Registry of Acute Coronary Events. but more heparin.33 0.8 7.30 0. Those treated with primary PCI had the lowest rates of death and reinfarction (driven primarily by less reinfarction). myocardial infarction.13 0.7 5 ⫾ 3.61-1.0 4.7 4.20 0. GRACE risk score.77-2. ␤-blockers and angiotensin-converting enzyme inhibitors.54-1.77 0.86 Reference 1.3 1. and hypertension were independently associated with HF.41-2.44 0.18 The Primary Angioplasty in Patients Transferred From General Community Hospitals to Specialized PTCA Units With or Without Emergency Thrombolysis (PRAGUE)-2 trial demonstrated a survival advantage with primary PCI when presentation was delayed by more than 3 hours.037 0.62-1. the French Unité de Soins Intensifs Coronaires (USIC) 2000 registry showed a clear survival benefit to prehospital fibrinolysis largely driven by timely delivery of therapy. Shock did not occur in patients treated with pre-hospital fibrinolysis. and markers of infarct size. HF. fibrinolysis) was not associated with HF.3 5 ⫾ 4.29 1.76-2.016 Data are percentages.12 Reference 0.97 0.70-1.30 0.4 13.03 0.29 0.058 0.8 6. * Represents 4-group (primary PCI and each individual fibrinolysis group) comparisons.0 2. Increased rates of cardiogenic shock in the CAPTIM trial were largely explained by the initiation of shock during the 1-hour delay from the time of randomization.70 0. while having more cardiogenic shock and bleeding episodes. there were similar survival rates for fibrinolytic-treated and primary PCI patients treated within 3 hours of symptom onset.0 9. patients presenting to hospitals with STEMI treated with primary PCI were younger. hospital admission was a predictor of higher mortality and reinfarction.25-1.3 1. PCI.10 ⬍ 0.031 0. and death/HF/shock (Table 5).66 0.8 4.72 0. there is considerable evidence that delays in establishing reperfusion are strongly associated with poor outcomes.91 0. MI.50-1.87 0.5 In addition.7 10.84 0. The lack of PCI during Table 5.62 0.33 0.7 1. heart failure.15 0.1 2.95 0.23 0. confidence interval.1 A number of studies have demonstrated a mortality benefit to primary PCI (if it can be performed in a timely manner in experienced centres) over fibrinolytic therapy13 and thus. First.9 5 ⫾ 4. this is the preferred strategy in the most recent American College of Cardiology and American Heart Association guidelines on the management of STEMI.001 0. with higher Killip class.3 This effect was previously seen in the CAPTIM study where patients treated with pre-hospital fibrinolysis less than 2 hours from symptom onset. percutaneous coronary intervention.52 0.5 11.001 0. Discussion In this observational study.4. In-hospital outcomes in relation to reperfusion strategies Fibrinolysis ‡ Length of stay In-hospital death In-hospital death/re-MI Cardiogenic shock HF/pulmonary edema Sustained ventricular tachycardia Major bleeding Primary PCI (n ⫽ 716) Overall (n ⫽ 1308) Rescue PCI (n ⫽ 177) Urgent/elective PCI (n ⫽ 210) No PCI (n ⫽ 921) P* P† 4 ⫾ 3.8 4 ⫾ 3.7 ⬍ 0.8 5.9 3. The increased rates of cardiogenic shock seen with primary PCI may be explained by 2 factors. myocardial infarction.009 0. patients had low rates of morbidity and mortality.9 4.28 0.70 0. The fibrinolytictreated group received less antiplatelet drugs and inotropes.37 1.34 0. death/reinfarction. Irrespective of the initial reperfusion strategy. Sec- . † Primary PCI vs overall fibrinolysis.72 0. the results of this study are consistent with previous registry data suggesting that the survival advantage of primary PCI is not necessarily reproducible in the real world.7 1.90-2.6 2.2 5. PCI. with no differences in the development of cardiogenic shock or HF. percutaneous coronary intervention. the presence of diabetes.7 4.039 Reference 1.28 Model adjusted for GRACE risk score. GRACE.8 3. Multivariable analysis In-hospital death/re-MI Primary PCI Fibrinolysis (overall) Rescue PCI Urgent/elective PCI No PCI In-hospital death/re-MI/HF/shock Primary PCI Rescue PCI Urgent/elective PCI No PCI HF/shock Primary PCI Rescue PCI Urgent/elective PCI No PCI In-hospital death/HF/shock Primary PCI Fibrinolysis (overall) HF Primary PCI Fibrinolysis (overall) Odds ratio 95% CI P Reference 1.2 6. ‡ Mean ⫾ SD.95 0.6 1. the difference in median time to delivery of reperfusion therapy was 86 minutes longer for patients treated with primary PCI.44 Canadian Journal of Cardiology Volume 28 2012 Table 4.0 3. Both fibrinolytic therapy and primary PCI are effective reperfusion strategies which reduce morbidity and mortality. had significantly lower rates of cardiogenic shock and a trend toward lower mortality.7 6.98 0.15 0.15–17 The WEST study revealed a tendency toward increased rates of HF and shock in patients randomized to primary PCI when compared with pre-hospital fibrinolysis.

coordinators. our observational data may support the use of routine angiography for patients with STEMI. routine early administration of clopidogrel has increased over time. J. which may not represent the practice patterns of all hospitals (especially rural). may have had particular research interests (evidenced by their participation) including those in quality improvement. Our study has certain limitations. the systems behind the administration of care have changed as well. Eli Lilly.Czarnecki et al. Dr Andrew Yan is supported by a New Investigator Award from the Heart and Stroke Foundation of Canada. Bristol-Myers Squibb. this study demonstrates that primary PCI and fibrinolysis with either rescue or urgent/elective PCI is associated with similar clinical outcomes in the real world. Goodman: speaker and consulting honoraria and research . Merck.23–25 A recent meta-analysis26 which includes Grupo de Análisis de la Cardiopatía Isquémica Aguda (GRACIA)-1. and patients who participated in the GRACE and CANRACE registries. Kornder: consulting honoraria and research grant support from sanofi-aventis and Bristol-Myers Squibb. as well as community hospitals. Acknowledgements The authors thank all the study investigators. This is an observational study. speaker and consulting honoraria from sanofi-aventis. GlaxoSmithKline. Our data may serve as a useful benchmark for future comparisons. Grondin: consulting honoraria and research grant support from sanofiaventis and Bristol-Myers Squibb. STEMI care has improved over the past decade and our data are likely reflective of that. early deaths might have been excluded. and Schering Plough. Hoffman LaRoche. and recurrent ischemia at 30 days. and no PCI during admission for STEMI was an independent predictor of death and reinfarction. These findings are consistent with our data. Fibrinolytic-treated patients were more likely to have previous myocardial infarction. Furthermore. were preferentially managed with early PCI. Furthermore.30 suggesting an association between angiography (with revascularization where appropriate) after fibrinolytic therapy and better outcomes in the real world. Keith A. Our observational data are also in accord with the findings previously reported in the French Registry of Acute ST-Elevation and Non-ST–Elevation Myocardial Infarction (FAST-MI) registry. Furthermore. Accordingly. while requiring more inotropic support and utilizing more antiplatelet therapy. Welsh: honoraria from Astra Zeneca. and CANRACE registries are not population-based. the CCORT study did show significant interregional variability in management and outcomes. A list of participating GRACE/GRACE2 investigators may be found in Goodman SG. Wong: consulting honoraria and research grant support from sanofi-aventis and Bristol-Myers Squibb.29 concluded that routine early PCI was beneficial for all STEMI patients. Patients in whom PCI was not performed during index hospitalization had the highest event rates. which are beyond the scope of this study. Disclosures Robert C. Boeringher Ingelheim. due to the need for informed consent.32 The GRACE. Mortality in STEMI is closely linked to reestablishment of Thrombolysis in Myocardial Infarction (TIMI) 3 flow. Over and above improvements in the medical management of STEMI care. In conclusion. routine PCI after fibrinolysis has shown significant benefits and has become the standard of care. it should be emphasized that the main purpose of 45 this study is to examine the clinical characteristics and in-hospital outcomes of patients treated with various reperfusion strategies in the “real world. and Bristol-Myers Squibb. Reperfusion Strategies and Outcomes of STEMI ondly.7 Funding Sources GRACE/GRACE2 and CANRACE were sponsored by Sanofi-Aventis and Bristol-Myers Squibb. Indeed. Patients treated with primary PCI trended toward having lower ejection fractions and higher biomarkers and Killip class.22 It is likely that patients with early high-risk features or those with early signs of shock. Jan M. and because of the non-randomized nature of our comparisons and potential unmeasured confounding variables. Johnson and Johnson. Gore. This is consistent with the trends toward lower ejection fractions and higher CK levels observed in our cohort. Furthermore. which may be reflected in our improved outcomes. High-risk patients and certainly those with cardiogenic shock have a significant survival advantage with primary PCI.28 and the Norwegian Study on District Treatment of ST-Elevation Myocardial Infarction (NORDISTEMI). reinfarction. Pfizer.3% in-hospital mortality for patients with AMI31 in the setting of similar rates of reperfusion. Previously published data by the Canadian Cardiovascular Outcomes Research Team (CCORT) group reported a 12. Our data addressed a much more specific cohort in a more contemporary therapeutic environment. causality cannot be inferred. Paul DeYoung. selection bias may have had a significant impact on our observational data. There have been significant temporal improvements in STEMI care. The hospitals in these registries were not chosen at random and they included many academic institutions. Francois R. Servier.15 Primary PCI has become the preferred strategy at most interventional centres in Canada. Graham C. for example. hospitals which chose to participate in these registries.27 Trial of Routine Angioplasty and Stenting After Fibrinolysis to Enhance Reperfusion in Acute Myocardial Infarction (TRANSFER-AMI). sanofi-aventis.21. Furthermore. Shaun G. suggesting that 1 of the key benefits of PCI is related to a reduction in reinfarction. The CCORT group also published data on all AMIs and their data reflect the years 1997 to 2000. which occurs in only 50%-60% of patients given fibrinolysis. GRACE2. ␤-blockers and angiotensin-converting enzyme inhibitors was more common. our outcomes may not be directly comparable with those found by the CCORT group. Fox: research grant support and honoraria from sanofi-aventis. Joel M. and Lilly. They demonstrated a clear reduction in death/reinfarction. while the utilization of heparin. However. et al. Barry Rose: speaker and consulting honoraria and research grant support from sanofi-aventis and Bristol-Myers Squibb.” Data collected in the GRACE/ GRACE2 and CANRACE were collected over time from 1999 to 2008. Richard Gallo: research grant support from sanofi-aventis and Bristol-Myers Squibb. research grant support from sanofi-aventis. A. and access to timely reperfusion via well-organized protocols has been the focus of quality improvement initiatives. the need for informed consent implies that patients who died shortly after presentation might not have been enrolled.

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