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NORDISTEMI

The NORwegian study on DIstrict treatment of ST-Elevation Myocardial Infarction (NORDISTEMI) compared immediate transfer for percutaneous coronary intervention (PCI) with an ischaemia-guided approach after thrombolysis for patients in rural areas that had very long transfer distances to PCI centres.

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In a remote area of Norway, a total of 266 patients with ST-elevation myocardial infarction (STEMI) of less than 6 h duration and more than 90 min expected time delay to PCI received thrombolysis (full-dose tenecteplase), aspirin, enoxaparin and clopidogrel, and were then randomised to either an early invasive strategy or a conservative strategy:

  • Early invasive strategy: Immediate coronary angiography/PCI of the infarct-related artery if indicated (≥50% diameter stenosis).
  • Conservative strategy: Admitted to hospital for continued care, with urgent transfer only for a rescue indication or with clinical deterioration.

The primary endpoint was a 12-month composite of death, re-infarction, stroke, or new myocardial ischaemia.


Secondary endpoints included a 12-month composite of death, re-infarction or stroke, transport-related complications, bleeding at 30 days, and infarct size (by SPECT and troponin T levels).

NORDISTEMI: Study design

NORDISTEMI Study design: STEMI patients with less than 6 hours duration and more than 90 min delay to PCI were given thrombolytic therapy and randomised to either an early invasive strategy or a conservative strategy.

 

The results support an early invasive strategy after thrombolysis, even for patients with long transfer distances.


At 30 days, the early invasive strategy was associated with a significant reduction in the primary endpoint (relative risk 0.49; 95% CI 0.27 to 0.89; p=0.03) and a non-significant reduction in the secondary composite endpoint (relative risk 0.45; 95% CI 0.18 to 1.16; p=0.14).


At 12 months, the early invasive strategy was associated with a non-significant reduction in the primary endpoint (HR 0.72; 95% CI 0.44 to 1.18; p=0.19) and a significant reduction in the secondary composite endpoint of death, re-infarction or stroke (HR 0.36; 95% CI 0.16 to 0.81; p=0.01).

NORDISTEMI: Primary endpoint (n=266)

NORDISTEMI Study design

 

NORDISTEMI: Death, reinfarction or stroke

Invasive procedures in the 2 randomisation groups: Angiography and PCI was performed in majority of the patients in both the early invasive and conservative groups.

It is important to note that angiography was performed in the majority of patients in both the early invasive (99%) and conservative groups (95%), at an average time of 130 min and 5.5 days post-lysis respectively. PCI was also performed in the majority of patients in both groups, at an average time of 163 min and 3 days post-lysis respectively.

NORDISTEMI: Invasive procedures in the 2 randomisation groups

NORDISTEMI Invasive procedures in the 2 randomisation groups: Angiography and PCI was performed in majority of the patients in both the early invasive and conservative groups.

 

  • The significant reduction in the composite of death, re-infarction or stroke suggests that an early invasive strategy after thrombolytic therapy may be preferable, even for patients in areas with long transfer distances.

References:

  1. Bøhmer E, et al. The NORwegian study on DIstrict treatment of ST-Elevation Myocardial Infarction (NORDISTEMI). Scand Cardiovasc J 2007;41:32-38.

  2. Bøhmer E et al. Efficacy and safety of immediate angioplasty versus ischaemia-guided management after thrombolysis in acute myocardial infarction in areas with very long transfer distances: Results of the NORDISTEMI (NORwegian study on DIstrict treatment of ST-elevation myocardial infarction). J Am Coll Cardiol 2010;55:102-110.