Background:Recent clinical trial data support a pharmacoinvasive strategy as an alternative to primary percutaneous coronary intervention (pPCI) in ST-segment elevation myocardial infarction. We evaluated whether this is true in a real-world prehospital ST-segment elevation myocardial infarction network using ECG assessment of reperfusion coupled with clinical outcomes within 1 year.Methods:Of the 5583 ST-segment elevation myocardial infarction patients in the Alberta Vital Heart Response Program (Cohort 1 [2006–2011]: n=3593; Cohort 2 [2013–2016]: n=1990), we studied 3287 patients who received a pharmacoinvasive strategy with tenecteplase (April 2013: half-dose tenecteplase was employed in prehospital patients ≥75 years) or pPCI. ECGs were analyzed within a core laboratory; sum ST-segment deviation resolution ≥50% was defined as successful reperfusion. The primary composite was all-cause death, congestive heart failure, cardiogenic shock, and recurrent myocardial infarction within 1 year.Results:The pharmacoinvasive approach was administered in 1805 patients (54.9%), (493 [27.3%] underwent rescue/urgent percutaneous coronary intervention and 1312 [72.7%] had scheduled angiography); pPCI was performed in 1482 patients (45.1%). There was greater ST-segment resolution post-catheterization/percutaneous coronary intervention with a pharmacoinvasive strategy versus pPCI (75.8% versus 64.3%, IP-weighted odds ratio, 1.59; 95% CI, 1.33–1.90; P<0.001). The primary composite was significantly lower with a pharmacoinvasive approach (16.3% versus 23.1%, IP-weighted hazard ratio, 0.84; 95% CI, 0.72–0.99; P=0.033). Major bleeding and intracranial hemorrhage were similar between a pharmacoinvasive strategy and pPCI (7.6% versus 7.5%, P=0.867; 0.6% versus 0.6%; P=0.841, respectively). In the 82 patients ≥75 years with a prehospital pharmacoinvasive strategy, similar ST-segment resolution and rescue rates were observed with full-dose versus half-dose tenecteplase (75.8% versus 88.9%, P=0.259; 31.0% versus 29.2%, P=0.867) with no difference in the primary composite (31.0% versus 25.0%, P=0.585).Conclusions:In this large Canadian ST-segment elevation myocardial infarction registry, a pharmacoinvasive strategy was associated with improved ST-segment resolution and enhanced outcomes within 1 year compared with pPCI. Our findings support the application of a selective pharmacoinvasive reperfusion strategy when delay to pPCI exists.

中文翻译：

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在临床实践中，对ST抬高型心肌梗死的药物侵入策略与主要经皮冠状动脉介入治疗：生命心脏反应注册表的见解。

背景：最近的临床试验数据支持一种药物侵入性治疗策略，可替代ST段抬高型心肌梗死的原发性经皮冠状动脉介入治疗（pPCI）。我们使用ECG评估再灌注和1年内的临床结局评估了真实的院前ST段抬高型心肌梗死网络中这是否成立。方法：阿尔伯塔省5583例ST段抬高型心肌梗死患者的重要心脏反应程序（队列1 [2006–2011]：n = 3593；队列2 [2013–2016]：n = 1990），我们研究了3287例接受替奈普酶药物侵入性治疗的患者（2013年4月：半剂量替奈普酶用于院前治疗） ≥75岁的患者）或pPCI。心电图在一个核心实验室中进行了分析；ST段偏差总和≥50％定义为再灌注成功。主要复合物为1年内的全因死亡，充血性心力衰竭，心源性休克和复发性心肌梗死。结果：1805例患者（54.9％）进行了药物侵入性治疗，其中493例[27.3％]接受了经皮急救/紧急治疗冠状动脉介入治疗和1312例[72.7％]进行了定期血管造影）；在1482例患者中进行了pPCI（45.1％）。插管/经皮冠状动脉介入治疗后的ST段分辨率较之pPCI要高（75.8％比64.3％，IP加权比值比为1.59； 95％CI为1.33-1.90；1 805例患者（54.9％）采用了药物侵袭性方法（493例[27.3％]接受了急诊/急诊经皮冠状动脉介入治疗，而1312例[72.7％]接受了定期血管造影）；在1482例患者中进行了pPCI（45.1％）。插管/经皮冠状动脉介入治疗后的ST段分辨率较之pPCI要高（75.8％比64.3％，IP加权比值比为1.59； 95％CI为1.33-1.90；1 805例患者（54.9％）采用了药物侵袭性方法（493例[27.3％]接受了急诊/急诊经皮冠状动脉介入治疗，而1312例[72.7％]接受了定期血管造影）；在1482例患者中进行了pPCI（45.1％）。插管/经皮冠状动脉介入治疗后的ST段分辨率较之pPCI要高（75.8％比64.3％，IP加权比值比为1.59； 95％CI为1.33-1.90；P <0.001）。采用药物侵袭方法后，主要复合材料明显降低（IP加权危险比为0.84； IP加权风险比为16.3％，为23.1％； 0.72–0.99；P = 0.033）。药物侵入性策略和pPCI之间的大出血和颅内出血相似（分别为7.6％对7.5％，P = 0.867； 0.6％对0.6％；P = 0.841）。在82名≥75岁的院前药物侵入策略患者中，全剂量和半剂量替奈普酶组的ST段拆分和挽救率相似（75.8％对88.9％，P = 0.259； 31.0％对29.2％，P = 0.867），而主要复合材料没有差异（31.0％对25.0％，P= 0.585）。结论：在这个大型的加拿大ST段抬高型心肌梗死登记处，与pPCI相比，药物侵入策略与ST段分辨率的改善和1年内预后的改善相关。当存在pPCI延迟时，我们的发现支持选择性药物侵入性再灌注策略的应用。