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Pharmacoinvasive Approach Improves Outcomes for Cardiogenic Shock Patients with Prolonged Transport Times

27 Mar 2024

Amidst the complexities of managing patients with ST-segment–elevation myocardial infarction (STEMI) complicated by cardiogenic shock, primary percutaneous coronary intervention (pPCI) is the favored revascularization strategy. However, in scenarios where patients present to non-PCI hospitals with extended interhospital transport durations, the efficacy and safety of a pharmacoinvasive approach has been uncertain.

A retrospective analysis spanning from 2006 to 2021 delved into the data of a geographically expansive STEMI network. This analysis scrutinized 426 patients grappling with cardiogenic shock and STEMI who initially sought care at non-PCI-capable hospitals. Among them, reperfusion therapy was administered, with 53.8% undergoing a pharmacoinvasive approach and 46.2% opting for pPCI. The study’s primary endpoint encompassed a composite measure involving in-hospital mortality, renal failure necessitating dialysis, cardiac arrest, or mechanical circulatory support. Additionally, the investigation evaluated major bleeding events, defined as intracranial hemorrhage or bleeding necessitating transfusion, through an inverse probability weighted model. Electrocardiographic reperfusion outcomes, particularly the resolution of ST-segment elevation, also garnered attention.

Key Findings:

Patients subjected to pharmacoinvasive treatment experienced longer median interhospital transport durations (3 hours versus 1 hour) but shorter median symptom-onset-to-reperfusion times (125 minutes-to-needle versus 419 minutes-to-balloon). Notably, the postfibrinolysis electrocardiogram revealed a substantial ST-segment resolution of ≥50% in 56.6% of cases. Moreover, post-catheterization analysis disclosed a higher incidence of ST-segment resolution <1 mm in the pharmacoinvasive cohort compared to those who underwent pPCI (57.3% versus 46.3%; P=0.01). However, no significant differences emerged in the resolution of ST-segment elevation ≥50% between the two cohorts (77.4% versus 81.8%; P=0.57). Importantly, the primary clinical endpoint occurred less frequently in patients treated with a pharmacoinvasive approach (35.2% versus 57.0%; inverse probability weighted odds ratio, 0.44 [95% CI, 0.26–0.72]; P<0.01) than those who underwent pPCI. Furthermore, an interaction analysis unveiled a preference for the pharmacoinvasive strategy in cases with interhospital transfer times exceeding 60 minutes concerning all-cause mortality. Regarding safety, the incidence of major bleeding events was lower in the pharmacoinvasive arm (10.1%) compared to pPCI (18.7%), though this difference did not achieve statistical significance (adjusted odds ratio, 0.41 [95% CI, 0.14–1.09]; P=0.08).

In the context of STEMI patients presenting with cardiogenic shock and protracted interhospital transport times, a pharmacoinvasive approach emerged as a favorable strategy. This approach correlated with enhanced electrocardiographic reperfusion and a diminished risk of mortality, dialysis dependence, or mechanical circulatory support, all without a concomitant elevation in major bleeding events.

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Original article: Van Diepen S et al. Circulation: Cardiovascular Interventions. 2024;0:e013415.

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