FAST-MI

The 4 registries, in 1995, 2000, 2005 and 2010, included data from a total of 6,707 patients with ST-segment elevation myocardial infarction (STEMI) admitted to intensive care or coronary care units within 48 h of symptom onset during a specified month-long period.⁶ The characteristics, management and outcomes, including 30-day mortality, of patients were recorded.

• A total of 6707 patients were enrolled in four nationwide surveys and during the 15-year period, a 2.9% decline was observed in the mean age of patients with STEMI, declining from 66.2 years to 63.3 years.
• The age distribution also changed, with the proportion of STEMI patients that were <60 years old increasing for men (from 38.1% to 49.0%) and women (from 11.8% to 25.5%).

Age characteristics of STEMI patients in the 4 French national registries

• The duration of patient admission pathways decreased over the 15 years of the registries, with the median time from symptom onset to admission decreasing from 240 min in 1995 to 175 min in 2010. The mean time between symptom onset and first call also decreased.

Improvement in admission pathway times for STEMI patients in the 4 French national registries (1995-2010)

• The use of reperfusion therapy has increased over the past 20 years, with an increase in primary percutaneous coronary intervention (PPCI) from 11.9% to 76.0% of patients, but a decrease in fibrinolysis from 37.5% to 6.0%.

Management of STEMI patients in the 5 French national registries: reperfusion therapy

• Early use (within 48 h) of some adjunctive therapies, including statins, beta blockers, angiotensin-converting enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARB), anti-platelet agents, glycoprotein IIb/IIIa inhibitors and low-molecular-weight heparins, increased. In contrast, the use of unfractionated heparin decreased.
• Thirty-day mortality decreased from 13.7% in 1995 to 4.4% in 2010, with decreases unrelated to the use and type of reperfusion therapy.⁹

Improvements in 30-day mortality of STEMI patients in the 4 French national registries (1995-2010)

• FAST-MI data has shown that 6-month mortality in patients with STEMI has decreased considerably over the past 20 years.⁹

Improving treatments and STEMI care has had a huge impact on mortality over the years

FAST-MI 5-year survival analysis: real-life data supports a pharmaco-invasive strategy

The French Registry on Acute ST-Elevation and Non-ST-Elevation Myocardial Infarction (FAST-MI) investigators used a subpopulation of the FAST-MI 2005 cohort to investigate a prolonged follow-up window of 5 years based on reperfusion strategy in patients with STEMI.

Methods

• The study population included patients who had a symptom onset-to-call time of ≤12 hours with persisting ST-segment elevation or new left bundle-branch block on the initial ECG.

 STREAM-like population subset

• A 5-year all-cause mortality analysis was also done in a “STREAM-like” subgroup population, defined as, “the subgroup of patients with time from onset to call ≤180 minutes and treated with either fibrinolysis or primary PCI beyond 90 minutes of first call.”
• STREAM used a 60-minute threshold from diagnostic ECG to expected PPCI. However, time from diagnostic ECG to reperfusion was not recorded in the FAST-MI 2005 registry. Therefore, time from call to reperfusion was used with an adjusted time frame of >90 minutes. The additional allotted time compensates for emergency medical response time.

Results

• Given that the data is based on real-life setting, and not a randomised trial, the baseline characteristics of the overall study population were not uniform across all intervention therapies. However, the Global Registry of Acute Coronary Events (GRACE) scores were similar among patients who received fibrinolysis or intended PPCI.
• One difference that should be noted among the baseline characteristics is that patients who received fibrinolysis tended to call earlier after symptom onset than patients treated with PPCI.

Entire study population (N=1492) by reperfusion category

5-year cumulative survival curves

The real-life data from the FAST-MI 2005 registry favours pharmacoinvasive therapy, particularly pre-hospital, over PPCI for both the entire study population and the STREAM-like population.

FAST-MI update: 5-year cumulative survival in STEMI patients by reperfusion therapy

• Over the last 15 years, improvements in STEMI treatment (including increased use of reperfusion therapy, particularly PPCI, increased use of adjunctive therapies, and shorter patient admission pathways) as well as the changing demographics of the patient population (particularly the increase in the proportion of younger patients without a history of cardiovascular disease) has resulted in a decrease in 30-day mortality.
• When timely PPCI is unavailable within recommended timelines, FAST-MI data support the current recommendation of performing a coronary angiogram within 3–24 hours after successful fibrinolysis.⁸
• 5-year survival:
  ●  There is no significant difference in 5-year survival rates for STEMI patients as analysed by reperfusion strategy – fibrinolysis (both pre- and in-hospital combined) vs PPCI.
  ●  Pre-hospital fibrinolysis is associated with a significantly better 5-year survival rate for STEMI patients compared to PPCI.
  ●  Therefore, a pharmaco-invasive approach may be an effective and  safe alternative to PPCI.⁸

• Reperfusion strategies that are available vary from region to region and can be influenced by a number of factors such as access to PPCI facilities, facility hours, infrastructure, traffic/road conditions and weather.

• The emergency medical system is France is very well established and includes physicians, which undoubtedly contributed not only to the high prehospital fibrinolysis rate, but also to the early initiation of treatment.

• The 5-year survival analysis of the FAST-MI 2005 cohort data shows, in a real-life, country-wide setting, a pharmaco-invasive strategy seem to be an effective and safe alternative to PPCI for STEMI patients without contraindications to the components of pharmaco-invasive reperfusion strategy.

• PCI-related delay might have contributed to the favourable outcomes observed in the fibrinolysis group.

• It is difficult to emulate the high rate of pre-hospital fibrinolysis and set-up in many countries/regions.