Predictors of infarct artery patency after prehospital thrombolysis: the multicentre, prospective, observational OPTIMAL study
- V Bongard1,
- J Puel2,
- D Savary3,
- L Belle4,
- S Charpentier5,
- Y Cottin6,
- L Soulat7,
- M Elbaz2,
- D Miljkovic8,
- Ph G Steg9,
- for the OPTIMAL Investigators
- 1Department of Epidemiology, Centre Hospitalier Universitaire de Toulouse, Université de Toulouse, Toulouse, France
- 2Pôle Cardiovasculaire et Métabolique, Department of Cardiology, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
- 3SAMU 74, Centre Hospitalier d’Annecy, Annecy, France
- 4Department of Cardiology, Centre Hospitalier d’Annecy, Annecy, France
- 5Department of Emergency, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
- 6Department of Cardiology, Centre Hospitalier Universitaire de Dijon, Dijon, France
- 7Centre 15 SAMU SMUR, Centre Hospitalier de Châteauroux, Châteauroux, France
- 8Boehringer Ingelheim, Reims, France
- 9INSERM U-698, Department of Cardiology, AP-HP, Université Paris 7, Paris, France
- Dr V Bongard, Department of Epidemiology, Faculté de Médecine, 37 allées Jules Guesde, 31073 Toulouse Cedex, France;
- Accepted 18 November 2008
- Published Online First 15 December 2008
Objective: To identify predictors of early TIMI 3 flow patency of the infarct-related artery after prehospital thrombolysis in patients with ST-segment elevation myocardial infarction (STEMI) using data from a “real-world” population, and to develop a nomogram for triaging patients to emergency angiography.
Design: Multicentre, observational, prospective, cohort study.
Setting: 79 Hospitals in France with a prehospital mobile intensive care unit and a coronary care unit with 24 h access to coronary angiography.
Patients: 997 Patients with STEMI.
Interventions: All patients received prehospital thrombolysis within 6 h of symptom onset and angiography was performed within 6 h of thrombolysis.
Main outcome measures: Coronary patency (TIMI flow).
Results: The median age of the population was 59 years and the sample comprised 18% women. After multivariable logistic regression analysis, predictors of TIMI 3 flow in the infarct-related artery were current/previous smoking (odds ratio (OR) = 1.60, 95% confidence interval 1.15 to 2.22), ⩽5 leads with ST-segment elevation before thrombolysis (OR = 1.59, 1.12 to 2.25), Killip class I (OR = 1.96, 1.05 to 3.67), chest pain relief (OR = 1.62, 1.17 to 2.25) and ST-segment resolution ⩾70% (OR = 1.76, 1.29 to 2.38). A nomogram was developed to assess the probability of TIMI 3 flow, according to smoking status, number of leads with ST elevation before thrombolysis, Killip class, chest pain relief and ST-segment resolution.
Conclusions: This study provides quantitative data for predicting success of prehospital thrombolysis. The nomogram is a simple tool for predicting likelihood of coronary patency, based on clinical and electrocardiographic data. It may help to identify patients who require emergency angiography and rescue percutaneous coronary intervention.
An appendix is published online only at http://heart.bmj.com/content/vol95/issue10
Funding: Funding and sponsorship for the OPTIMAL study are provided by Boehringer-Ingelheim France. The sponsor had no involvement in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication.
Competing interests: VB: none declared; JP is on the speakers’ bureau for Boehringer-Ingelheim, BMS, MSD, Novartis, Sanofi-Aventis, Servier, Pfizer; is on consulting or advisory boards for AstraZeneca, Abbott, Pfizer, Sanofi-Aventis; and has no stockholding. DS, LB, SC, YC, LS, ME: none declared. DM is an employee of Boehringer-Ingelheim. PGS has received research grants from Sanofi-Aventis; is on the speakers’ bureau for Boehringer-Ingelheim, Bristol-Myers Squibb, GlaxoSmithKline, Merck Sharp & Dohme, Novartis, Nycomed, Sanofi-Aventis, Sankyo, Servier, ZLB-Behring; is on consulting or advisory boards for AstraZeneca, Bristol-Myers Squibb, GlaxoSmithKline, Merck Sharp & Dohme, Pfizer, Sanofi-Aventis, Servier, Takeda; and has no stockholding.
Ethics approval: Patients received an information leaflet outlining their right to access, correct or withhold their data. The study protocol was reviewed by the French Society of Cardiology and was performed in accordance with French law and the Declaration of Helsinki. A written consent form was not required according to the French law since the study was an observational study without randomisation.
Contributions: VB analysed the data and wrote the report in collaboration with JP, PGS and SRS. JP conceived the study, designed the protocol and wrote the report in collaboration with VB, PGS and SRS. DS, LB, SC, LS, ME participated in the design, data management and the analysis. YC actively helped with the conception of the study and the design of the protocol. DM oversaw the study. PGS supervised the analysis, oversaw the study and wrote the report in collaboration with JP, VB and SRS.
A complete list of participating sites and SAMU/SMUR can be found in the Appendix.
OPTIMAL scientific advisory committee:
Emergency clinicians: F Berthier (Nantes), JL Bordonado (Bastia), S Charpentier (Toulouse), P Goldstein (Lille), Y Lambert (Le Chenay), F Lapostolle (Bobigny), A Ricard-Hibon (Clichy), D Savary (Annecy), JL Sebbah (Gonesse), L Soulat (Châteauroux), K Tazarourte (Melun).
Cardiologists: L Belle (Annecy), P Coste (Bordeaux), Y Cottin (Dijon), N Danchin (Paris), K Khalifé (Metz), C Loubeyre (Paris), J Puel (Toulouse), F Schiele (Besançon), PG Steg (Paris), P Virot (Limoges).