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Impact of a pharmacoinvasive strategy when delays to primary PCI are prolonged
  1. Anthony H Gershlick1,
  2. Cynthia M Westerhout2,
  3. Paul W Armstrong2,
  4. Kurt Huber3,
  5. Sigrun Halvorsen4,
  6. Philippe Gabriel Steg5,
  7. Miodrag Ostojic,
  8. Patrick Goldstein6,7,
  9. Antonio C Carvalho8,
  10. Frans Van de Werf9,
  11. Robert G Wilcox10
  1. 1University of Leicester, University Hospitals of Leicester Glenfield Hospital, Leicester, UK
  2. 2Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
  3. 33rd Department of Medicine, Cardiology and Emergency Medicine, Wilhelminen hospital, Vienna, Austria
  4. 4Department of Cardiology, Oslo University Hospital Ulleval, Oslo, Norway
  5. 5Faculté de Médecine Xavier Bichat, Université de Paris XII, Paris, France
  6. 6Medical School, University of Belgrade, Belgrade, Serbia
  7. 7the Emergency Department and Service d'aide Medicale Urgente (SAMU), Lille University Hospital, Lille, France
  8. 8Cardiology Division, Department of Medicine, Universidade Federal de São Paulo, São Paulo, Brazil
  9. 9University Hospital Gasthuisberg, Leuven, Belgium
  10. 10Department of Cardiovascular Medicine, University of Nottingham, Nottingham, UK
  1. Correspondence to Professor Anthony H Gershlick, Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Cardiovascular Biomedical Research Unit, University Hospitals of Leicester Glenfield Hospital, Groby Road, Leicester LE3 9QP, UK; agershlick{at}


Objectives Primary percutaneous coronary intervention (P-PCI) is the preferred reperfusion option in ST-elevation myocardial infarction, but its benefits become attenuated as time to its potential delivery becomes prolonged. Based on the STrategic Reperfusion Early After Myocardial Infarction trial, we assessed the impact of increasing time delay on outcomes in patients randomised to a pharmacoinvasive strategy (PI) or P-PCI.

Methods Thirty-day clinical outcomes were examined according to PCI-related delay (P-RD). Data from hospitals that enrolled >10 randomised patients were used and P-RD categorised as ≤55 min, >55–97 min and >97 min.

Results Composite of death/congestive heart failure/cardiogenic shock/myocardial infarction in PI and P-PCI arms occurred in 10.6% versus 10.3% (≤55 min, p=0.910); 13.9% versus 17.9% (>55–97 min, p=0.148) and 13.5% versus 16.2% (>97 min, p=0.470), respectively. While there was no worsening of outcomes for PI across the P-RD spectrum, this occurred in the P-PCI arm (p(trend)=0.038). For P-RD ≤55 min, fewer events tended to occur with P-PCI than PI. Conversely, as P-RD increased to >55 min, PI-assigned patients had better outcomes than P-PCI, suggesting an event-free advantage with PI as P-RD increased (p(interaction)=0.094). Analysing P-RD continuously showed that for every 10-min increment there was an increasing trend towards benefit among PI-assigned patients (p(interaction)=0.073).

Conclusions As P-RD increased, PI outcomes became superior to P-PCI when P-RD is prolonged and exceeds guideline-mandated times. In such circumstances, a PI strategy may provide an alternative reperfusion option. Adverse time delays for delivery of P-PCI should be considered when evaluating reperfusion strategies.

Trial registration number NCT00623623.

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