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Patient outcomes

STREAM and 1-year mortality

The STREAM (STrategic Reperfusion Early After Myocardial infarction) trial compared PPCI versus pharmaco-invasive strategy in STEMI patients who presented within three hours of symptom onset but who were unable to undergo PPCI within one hour.


Overall, the mortality rates at one year were low and no significant differences were seen between pharmaco-invasive strategy and PPCI groups.1

Table 1: Cause of death at one year by reperfusion therapy (pharmaco-invasive strategy vs. PPCI) in the STREAM study population 1

Table comparing cause of death by pharmaco-invasive strategy and PPCI in the STREAM study

 

Find out more about STREAM. 

FAST-MI and 5-year mortality

In the FAST-MI registry, 2 out of 3 patients received pre-hospital fibrinolysis and of these patients, 84% underwent subsequent PCI (pharmaco-invasive strategy).2

  • One-year follow-up data showed similar results with respect to mortality between PPCI and fibrinolysis with routine early coronary angiography (91.8% vs 93.6%, respectively).2

  • 5-year follow-up data showed a trend toward favouring the pharmaco-invasive strategy over PPCI, although the difference in outcomes between the two treatments is not significant (HR, 0.73; 95% CI, 0.50-1.06).2

The FAST-MI data show, “STEMI patients treated with a pre-hospital-initiated pharmaco-invasive strategy fare as good as those transported for primary PCI in the real-world…” Furthermore, patients who presented early and were treated with the pharmaco-invasive strategy had a greater chance of survival compared to those in whom PPCI was delayed by >90 minutes after the initial call to EMS.2


Find out more about FAST-MI.

KAMIR: time delays and clinical outcomes at one year

The Korea Acute Myocardial Infarction Registry (KAMIR) data was used to compare outcomes at one year in STEMI patients who received either pharmaco-invasive strategy reperfusion therapy (n=708) or PPCI (n=8878).3

  • In all patients, time delays (symptom-to-FMC, symptom-to-start-of-treatment, FMC-to-treatment) were all significantly shorter for the pharmaco-invasive strategy group compared to the PPCI group.

  • In the propensity-matched cohort, significantly shorter delays were still seen with respect to symptom onset to start of reperfusion therapy and for FMC-to-treatment in the pharmaco-invasive vs. PPCI groups.3

  • Before adjustment, data from all patients showed lower rates of in-hospital mortality (HR, 0.44; 95% CI, 0.26-0.74; p=0.002), death at 12 months (HR, 0.64; 95% CI, 0.44-0.92; p=0.015), and major adverse cardiac event (MACE) (HR, 0.69; 95% CI, 0.52-0.92; p=0.010) for pharmaco-invasive strategy vs. the PPCI.3

  • After adjustment, there were no significant differences between the two groups in in-hospital mortality (HR, 0.65; 95% CI, 0.21-2.01; p=0.456), death at 12 months (HR, 1.37; 95% CI, 0.59-3.16; p=0.468), or MACE (HR, 0.96; 95% CI, 0.65-1.41; p=0.831) in the propensity-matched cohort.3

Overall, the data show patients treated with a pharmaco-invasive strategy had significantly shorter symptom-to-reperfusion times and similar clinical outcomes at 12 months compared to patients who underwent PPCI.3

Safety and efficacy

Data from over 1,200 patients treated within the University of Ottawa Heart Institute’s tertiary care cardiac centre were analysed based on reperfusion strategy with respect to patient outcomes.4

  • Of the 1,216 consecutive STEMI patients, 980 underwent PPCI and 236 received pharmaco-invasive strategy.

  • There was no difference between the two reperfusion strategies in the primary efficacy outcome (composite of mortality, stroke, or re-infarction within index hospitalisation).4

  • In terms of safety, intracranial bleeding was significantly higher in the pharmaco-invasive strategy group. However, the authors note the increase in bleeding may be mitigated in the future through the use of half-dose TNK in patients 75 years or older.4

References: 

  1. Sinnaeve PR, et al. ST-segment-elevation myocardial infarction patients randomized to a pharmaco-invasive strategy or primary percutaneous coronary intervention: STrategic Reperfusion Early After Myocardial infarction (STREAM) 1-year mortality follow-up. Circulation 2014;130:1139-1145.

  2. Sinnaeve PR & Van de Werf F. Primary percutaneous coronary intervention not always the best reperfusion strategy? Circulation 2014;129(16):1623-1625.

  3. Sim DS, et al. Pharmcaoinvasive strategy versus primary percutaneous coronary intervention in patients with ST-segment-elevation myocardial infarction: A propensity score-matched analysis. Circ Cardiovasc Interv 2016;9:e003508.

  4. Rashid MK, et al. Safety and Efficacy of a Pharmacoinvasive Strategy in ST-Segment Elevation Myocardial Infarction: A Patient Population Study Comparing a Pharmacoinvasive Strategy With a Primary Percutaneous Coronary Intervention Strategy Within a Regional System. JACC Cardiovasc Intervent 2016;9(19):2014-2020.