Variations in the use of emergency PCI for the treatment of re-infarction following intravenous fibrinolytic therapy: Impact on outcomes in HERO-2

J. J. Edmond, J. K. French, P. E G Aylward, C. K. Wong, R. A H Stewart, B. F. Williams, C. G. De Pasquale, R. L. O'Connell, K. Van Den Berg, F. J. Van De Werf, R. J. Simes, H. D. White

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Abstract

Background: Patients who suffer re-infarction during initial hospitalization for ST-elevation myocardial infarction (STEMI) have decreased survival compared to patients without re-infarction, so treatment of re-infarction may influence survival. Methods and results: To determine whether the utilization of reperfusion therapies varied within 12 h of re-infarction and was associated with 30-day mortality, we studied 552 patients with re-infarction of 17 073 patients with STEMI enrolled in HERO-2 in five regions (Russia, Eastern Europe, Western Countries, Asia, and Latin America). Patients presenting within 6 h of symptom-onset were randomized to receive either bivalirudin or unfractionated heparin intravenously just prior to streptokinase. Re-infarction occurred in 2.8 and 3.6% of bivalirudin and heparin treated patients, respectively (P = 0.004), but treatment assignment did not influence mortality after re-infarction. Patients with re-infarction had a higher 30-day mortality than those without re-infarction (24 vs. 10%; P < 0.001 by Cox model). Within 12 h of re-infarction, fibrinolytic therapy was administered to 12.0 and 8.2% underwent percutaneous coronary intervention (PCI); these two treatments were more frequently utilized in patients from Western countries (n = 112), compared to patients from other countries (n = 440) (34.8 and 16.1% compared to 6.1 and 6.1%, respectively, P < 0.001). Mortality was 15% in patients receiving reperfusion therapy for re-infarction and 27% for those with conservative management, hazard ratio (HR) 0.53 (95% CI 0.32-0.88), P = 0.01. In multiple Cox regression analysis which included adjustment for clinical variables and randomized treatment assignment, 30-day mortality after re-infarction varied by region (highest Latin America 29%, lowest Western countries 15%; P = 0.01). Other independent prognostic factors included age, time from randomization to re-infarction, and Killip class at randomization. The HR for PCI treatment of re-infarction was 0.18 [(95% CI 0.04-0.76), P = 0.02] in analyses which excluded deaths within 12 h. Conclusion: Treatment of re-infarction with reperfusion therapies was markedly under-utilized, especially in non-western countries. PCI for re-infarction, in particular, was associated with a lower 30-day mortality, which may reflect both patient selection and effects of treatment.

LanguageEnglish
Pages1418-1424
Number of pages7
JournalEuropean Heart Journal
Volume28
Issue number12
DOIs
Publication statusPublished - 1 Jun 2007

Keywords

  • Clinical endpoints committee
  • Mortality
  • Percutaneous coronary intervention
  • Re-infarction

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine

Cite this

Edmond, J. J., French, J. K., Aylward, P. E. G., Wong, C. K., Stewart, R. A. H., Williams, B. F., ... White, H. D. (2007). Variations in the use of emergency PCI for the treatment of re-infarction following intravenous fibrinolytic therapy: Impact on outcomes in HERO-2. European Heart Journal, 28(12), 1418-1424. https://doi.org/10.1093/eurheartj/ehm087