Coronary Revascularization Benefits Even Latecomer STEMI: FAST-MI Registry

Patients with ST-segment elevation myocardial infarction who present late to the hospital—beyond 12 hours—fare significantly better in short- and long-term follow-up if they are treated with coronary revascularization, according to results from a French registry.

For lead investigator Frédéric Bouisset, MD (Toulouse Rangueil University Hospital, France), and colleagues, these new data “strengthen the current European guidelines that recommend performing a PCI on STEMI patients up to 48 hours after symptom onset.”

That conclusion is echoed by Adnan Kastrati, MD, J.J. Coughlan, MBBCh, and Gjin Ndrepepa, MD (Deutsches Herzzentrum, Munich, Germany), in an editorial accompanying this analysis of the FAST-MI registry. “Existing evidence and large observational studies such as the study of Bouisset et al strengthen the conviction that primary PCI should be offered to all patients with STEMI presenting 12 to 48 hours from symptom onset,” write the editorialists.

Ajay Kirtane, MD (NewYork-Presbyterian/Columbia University Irving Medical Center, NY), on the other hand, challenged the assertion that “all” STEMI patients presenting late should be revascularized. Instead, the decision ultimately depends on the clinical picture, he said.

“How sick is the patient? Are they having ongoing symptoms? What does the angiogram look like? Is the wall truly akinetic and not moving?” said Kirtane. “This is an area where clinical judgement is paramount.”

Moreover, he is circumspect about the large reduction in all-cause mortality observed with invasive management in this new study. The analysis, he said, is inherently limited by its observational nature, noting that it’s impossible to control for all the variables that factor into clinical decision-making.

“For the patients selected for revascularization, the treating physicians, understanding that there is negative clinical trial data in these late-presenters, made a decision to treat them,” he told TCTMD, referring to the OAT trial. “There has to be some reason for that, and I think that manifests in the difference in clinical outcomes. If you look at the order of magnitude, the relative difference of one strategy versus the other dwarves the revascularization benefit of primary PCI in a normal-presenter. There’s clearly something at else at play than just the benefit of revascularization.”

French Observational Database: FAST-MI

How best to manage the STEMI patient presenting late to the hospital is a topic of debate, with the US and European guidelines differing in their recommendations.

The 2017 European Society of Cardiology guidelines for the management of acute MI recommend physicians consider routine primary PCI in patients presenting within 12 to 48 hours (class IIa, level of evidence B). The recommendation is stronger for late-presenting patients who have ongoing symptoms, hemodynamic instability, or arrhythmias (class I, level of evidence B). In contrast, the American College of Cardiology/American Heart Association guidelines state that patients who present 12 to 24 hours after symptom onset while having ongoing symptoms or signs of ischemia should undergo primary PCI (class IIa, level of evidence B).

In the absence of consensus, the French researchers aimed to assess long-term outcomes in latecomer STEMI patients who underwent revascularization and those who did not. In their study, which was published in the September 28, 2021, issue of the Journal of the American College of Cardiology, the group identified 6,273 STEMI patients from three pooled FAST-MI registries (2005, 2010, and 2015). Of these, 1,169 patients presented to the hospital more than 12 hours after symptom onset.

Compared with those who arrived within 12 hours, latecomer patients were more likely to be women (30.8% versus 25.2%) and were significantly older (mean age 65.2 vs 62.6 years; P < 0.001 for both). Latecomers were also more likely to have diabetes, hypertension, and a prior history of heart failure, but were less likely to have had a prior MI or undergone PCI. Patients presenting later were less likely to report typical chest pain symptoms. In terms of management, the later patients were less frequently referred for coronary angiography (91.9% vs 96.5%) and were less likely to be treated with PCI (76.8% vs 86.5%; P < 0.001 for both) compared with those who presented within 12 hours.

After excluding patients treated with thrombolysis and those who died within 2 days of hospital admission, the researchers identified 729 latecomer patients treated with revascularization within 48 hours and 348 latecomers who were not revascularized.

At 30 days, all-cause mortality among revascularized latecomers was 2.1% versus 7.2% in latecomers who were not revascularized (P < 0.001). Recurrent MI was lower in the revascularized group, but the difference wasn’t statistically significant. During a median follow-up of 58 months, there were 30.4 deaths per 1,000 person-years in the revascularized latecomers compared with 78.7 deaths per 1,000 person-years in latecomers not treated with PCI (P < 0.001). Rates of recurrent MI were also significantly lower in those who underwent revascularization.

In a multivariate-adjusted model, revascularization within 48 hours after hospital admission was associated with a significantly lower risk of all-cause mortality (HR 0.65; 95% CI 0.50-0.84). In a propensity-matched analysis of 267 pairs, the risk of all-cause mortality was significantly lower in the latecomers treated with PCI.

Some Will Benefit, Some Won’t

In their editorial, Kastrati, Coughlan, and Ndrepepa point out the analysis includes patients who would be good candidates for invasive management, such as those with cardiogenic shock or out-of-hospital cardiac arrest, as well as those in whom there’d be some degree of skepticism of PCI’s benefit, such as patients without persistent typical chest pain.   

To TCTMD, Kirtane said that the potential of a clinical trial testing coronary revascularization in late-presenting STEMI is unlikely given the challenges of randomizing such a heterogeneous patient population. In the OAT trial, PCI was not shown to be of any benefit in patients who presented 3 to 28 days after acute MI with a persistent total occlusion of the infarct-related artery, but not every late-presenting STEMI case is an OAT-type patient, he said. Some latecomers might have clinical characteristics, such as ST-segment resolution, hypokinetic wall motion, and TIMI 2 flow on angiography, that would suggest a benefit from PCI, said Kirtane. 

FAST-MI, which suggests such a dramatic benefit from revascularization, “supports the fact that physicians likely selected the best” candidates for PCI, he said.

The editorialists point to some reassuring data in the FAST-MI registry, namely that there was a decrease in the proportion of late-presenting STEMI patients from 22.7% in 2005 to 16.1% in 2015. Still, “it is striking that approximately one in six patients presented beyond 12 hours from the onset of symptoms,” they write. “This finding is even more conspicuous when we consider that this data comes from a country that has implemented one of the best regional systems of STEMI care worldwide.”