Long-term clinical outcome of acute myocardial infarction according to the early revascularization method: a comparison of primary percutaneous coronary interventions and fibrinolysis followed by routine invasive treatment원문보기
Min, Hyang Ki
(Division of Cardiology, Department of Internal Medicine, Eulji General Hospital)
,
Park, Ji Young
(Division of Cardiology, Department of Internal Medicine, Eulji General Hospital)
,
Choi, Jae Woong
(Division of Cardiology, Department of Internal Medicine, Eulji General Hospital)
,
Ryu, Sung Kee
(Division of Cardiology, Department of Internal Medicine, Eulji General Hospital)
,
Kim, Seunghwan
(Division of Cardiology, Department of Internal Medicine, Eulji General Hospital)
,
Song, Chang Sup
(Division of Cardiology, Department of Internal Medicine, Eulji General Hospital)
,
Kim, Dong Shin
(Division of Cardiology, Department of Internal Medicine, Eulji General Hospital)
,
Song, Chi Woo
(Division of Cardiology, Department of Internal Medicine, Eulji General Hospital)
,
Kim, Se Jong
(Division of Cardiology, Department of Internal Medicine, Eulji General Hospital)
,
Kim, Young Bin
(Division of Cardiology, Department of Internal Medicine, Eulji General Hospital)
Background: This study was conducted to provide a comparison between the clinical outcomes of primary percutaneous coronary intervention (PCI) and that of fibrinolysis followed by routine invasive treatment in ST elevation myocardial infarction (STEMI). Methods: A total of 184 consecutive STEMI pati...
Background: This study was conducted to provide a comparison between the clinical outcomes of primary percutaneous coronary intervention (PCI) and that of fibrinolysis followed by routine invasive treatment in ST elevation myocardial infarction (STEMI). Methods: A total of 184 consecutive STEMI patients who underwent primary PCI or fibrinolysis followed by a routine invasive therapy were enrolled from 2004 to 2011, and their major adverse cardiovascular events (MACEs) were compared. Results: Among the 184 patients, 146 patients received primary PCI and 38 patients received fibrinolysis. The baseline clinical characteristics were similar between both groups, except for triglyceride level ($68.1{\pm}66.62$ vs. $141.6{\pm}154.3mg/dL$, p=0.007) and high density lipoprotein level ($44.6{\pm}10.3$ vs. $39.5{\pm}8.1mg/dL$, p=0.005). The initial creatine kinase-MB level was higher in the primary PCI group ($71.5{\pm}114.2$ vs. $35.9{\pm}59.9ng/mL$, p=0.010). The proportion of pre-thrombolysis in MI 0 to 2 flow lesions (92.9% vs. 73.0%, p<0.001) was higher and glycoprotein IIb/IIIa inhibitors were administered more frequently in the primary PCI group. There was no difference in the 12-month clinical outcomes, including all-cause mortality (9.9% vs. 8.8%, p=0.896), cardiac death (7.8% vs. 5.9%, p=0.845), non-fatal MI (1.4% vs. 2.9%, p=0.539), target lesion revascularization (5.7% vs. 2.9%, p=0.517), and stroke (0% vs. 0%). The MACEs free survival rate was similar for both groups (odds ratio, 0.792; 95% confidence interval, 0.317-1.980; p=0.618). The clinical outcome of thrombolysis was not inferior, even when compared with primary PCI performed within 90 minutes. Conclusion: Early fibrinolysis with optimal antiplatelet and antithrombotic therapy followed by appropriate invasive procedure would be a comparable alternative to treatment of MI, especially in cases of shorter-symptom-to-door time.
Background: This study was conducted to provide a comparison between the clinical outcomes of primary percutaneous coronary intervention (PCI) and that of fibrinolysis followed by routine invasive treatment in ST elevation myocardial infarction (STEMI). Methods: A total of 184 consecutive STEMI patients who underwent primary PCI or fibrinolysis followed by a routine invasive therapy were enrolled from 2004 to 2011, and their major adverse cardiovascular events (MACEs) were compared. Results: Among the 184 patients, 146 patients received primary PCI and 38 patients received fibrinolysis. The baseline clinical characteristics were similar between both groups, except for triglyceride level ($68.1{\pm}66.62$ vs. $141.6{\pm}154.3mg/dL$, p=0.007) and high density lipoprotein level ($44.6{\pm}10.3$ vs. $39.5{\pm}8.1mg/dL$, p=0.005). The initial creatine kinase-MB level was higher in the primary PCI group ($71.5{\pm}114.2$ vs. $35.9{\pm}59.9ng/mL$, p=0.010). The proportion of pre-thrombolysis in MI 0 to 2 flow lesions (92.9% vs. 73.0%, p<0.001) was higher and glycoprotein IIb/IIIa inhibitors were administered more frequently in the primary PCI group. There was no difference in the 12-month clinical outcomes, including all-cause mortality (9.9% vs. 8.8%, p=0.896), cardiac death (7.8% vs. 5.9%, p=0.845), non-fatal MI (1.4% vs. 2.9%, p=0.539), target lesion revascularization (5.7% vs. 2.9%, p=0.517), and stroke (0% vs. 0%). The MACEs free survival rate was similar for both groups (odds ratio, 0.792; 95% confidence interval, 0.317-1.980; p=0.618). The clinical outcome of thrombolysis was not inferior, even when compared with primary PCI performed within 90 minutes. Conclusion: Early fibrinolysis with optimal antiplatelet and antithrombotic therapy followed by appropriate invasive procedure would be a comparable alternative to treatment of MI, especially in cases of shorter-symptom-to-door time.
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문제 정의
To the best of our knowledge, this study is the first to report a comparable prognosis between fibrinolysis followed by a routine invasive therapy and primary PCI in a Korean population. We did not expect a comparable result between fibrinolysis and primary PCI, or a result that suggested the effectiveness of routine facilitated PCI.
제안 방법
The reason that the number of patients in each group is small considering the period as the limitation of study conducted in single center. Finally, the most important limitation of this study was that there were no data describing bleeding events and hemorrhagic stroke, which are major side effects of thrombolytic therapy.
To adjust for potential confounders, propensity score matching analysis was conducted using the logistic regression model, which tested the propensity to have facilitated PCI after fibrinolysis treatment in STEMI patients rather than primary PCI. We tested all available variables that could be of potential relevance; namely, age, sex, symptom to door time, peak troponin T, low density lipoprotein, diabetes mellitus, hypertension, smoking, and left ventricular ejection fraction.
We also analyzed the differences in clinical outcomes between primary PCI with a door to balloon time ≤90 minutes and fibrinolysis followed by coronary angiography.
To adjust for potential confounders, propensity score matching analysis was conducted using the logistic regression model, which tested the propensity to have facilitated PCI after fibrinolysis treatment in STEMI patients rather than primary PCI. We tested all available variables that could be of potential relevance; namely, age, sex, symptom to door time, peak troponin T, low density lipoprotein, diabetes mellitus, hypertension, smoking, and left ventricular ejection fraction. The logistic model by which the propensity score was estimated showed the predictive value well (C-static=0.
데이터처리
All statistical analyses were performed using SPSS 18.0 (SPSS Inc., Chicago, IL, USA) Continuous variables were expressed as the mean±standard deviation and compared using a Student’s t-test.
Categorical data were expressed as percentages and compared using chi-squared statistics or Fisher’s exact test.
이론/모형
, Chicago, IL, USA) Continuous variables were expressed as the mean±standard deviation and compared using a Student’s t-test. Cox proportion hazard regression analysis was used to evaluate the survival rate.
성능/효과
The curve comparing the MACE free survival between groups is shown in Fig. 1. The hazard ratio for fibrinolysis followed by PCI was 0.792 (95% CI, 0.317-1.980; p=0.618) after adjusting for age, sex, symptom-to-door time, peak troponin T, triglyceride, diabetes, hypertension, and smoking (Fig. 1). Comparison of MACE free survival between PCI (DBT ≤90 minutes) and fibrinolysis followed by CAG was shown in Fig.
Comparison of MACE free survival between PCI (DBT ≤90 minutes) and fibrinolysis followed by CAG was shown in Fig. 2. The hazard ratio for fibrinolysis followed by PCI was 0.729 (95% CI, 0.256-2.075; p=0.554) after adjusting for age, sex, symptom-to-door time, peak troponin T, triglycerides, diabetes, hypertension, and smoking (Fig. 2).
Based on our analysis, early fibrinolysis followed by routine invasive therapy was not inferior to primary PCI. Most of our recruited patients were collected prior to 2010, and the regulation for door-to-balloon time within 90 minutes was not strongly adapted.
The baseline clinical characteristics showed that age was similar in both groups (60.5±11.7 vs. 57.0±12.2 years, p=0.111), the initial levels of creatine kinase-MB (CK-MB) were higher in the primary PCI group (71.5±114.2 vs. 35.9±59.9 ng/mL, p=0.010), and triglyceride levels were higher in the fibrinolysis group (68.1±66.6 vs. 141.6±154.3 mg/dL, p=0.007).
There was no difference in the 12-month clinical outcome, including all-cause mortality (9.9% vs. 8.8%, p=0.896), cardiac death (7.8% vs. 5.9%, p=0.845), non-fatal MI (1.4% vs. 2.9%, p=0.539), target lesion revascularization (5.7% vs. 2.9% p=0.517), and stroke (0% vs. 0%) (Table 3).
In the real world, routine invasive methods such as coronary angiography and PCI are commonly performed on the same day after thrombolysis, even in patients whose symptoms have subsided. Therefore, the present study was conducted to evaluate whether the clinical outcome or lesion-related complications, such as stent thrombosis or restenosis, would be significantly higher in thrombolysis followed by a routine invasive strategy. Moreover, we analyzed particular clinical circumstances that induce thrombolytic therapies that are as effective as primary PCI.
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