BACKGROUND:Whereas reperfusion benefit in ST-elevation myocardial infarction (STEMI) is time-dependent, outcome data from very early primary percutaneous coronary intervention (PPCI) are limited. The STREAM-1 and -2 trials provided a unique opportunity to assess this issue. We evaluated electrocardiographic (ECG), angiographic, and clinical outcomes of early presenting STEMI patients undergoing PPCI, focusing on those treated <60 minutes of randomization. METHODS:We analyzed STEMI patients from STREAM-1 (n = 1,892) and STREAM-2 (n = 604) trials presenting <3 hours of symptom onset who underwent PPCI. Endpoints included ECG (ST segment resolution, Q waves), angiographic (TIMI flow grade), 30-day composite of all-cause death, shock, heart failure, reinfarction, safety outcomes, and 1-year mortality. RESULTS:Patients undergoing PPCI <60 minutes of randomization (29.2%) were younger, more frequently male, and had shorter total ischemic times than those undergoing PPCI >60 minutes. ST resolution and TIMI flow outcomes were similar, but significantly fewer patients in the rapid PPCI group had Q waves on discharge ECG (58.2 vs. 71.9%, P < .001). The 30-day composite outcome was lower in the <60 minutes group (10.1 vs 14.8%, risk ratio [RR] 0.68 [95% confidence interval 0.47-0.98], P = .04), associated with a significant 62% reduction in cardiogenic shock (P = .0008), and also had lower 1-year mortality (4.0 vs 7.2%; RR 0.56 [0.31-1.01], P(logrank) = .047). After inverse probability weighted adjustment, the 30-day composite outcome and cardiogenic shock were RR 0.74 (0.50-1.08), P = .116 and RR 0.45 (0.22-0.91), P = .027, respectively, and the 1-year mortality was RR 0.70 (0.39-1.26), P = .235. Safety endpoints were similar in both groups. CONCLUSIONS:Substantial opportunity exists to improve outcomes for early-presenting STEMI patients undergoing PPCI. Establishing a first medical contact-to-PPCI time of <60 minutes provides incremental benefit. CLINICAL TRIAL REGISTRATION:URL:https://clinicaltrials.gov/study/NCT00623623, https://clinicaltrials.gov/study/NCT02777580. Unique identifiers: NCT02777580, NCT00623623.

BACKGROUND:Previous studies indicate a safety risk with full-dose TNK in elderly patients. In a study of patients ≥60 years STREAM-2 (STrategic Reperfusion Early After Myocardial infarction-2), a pharmaco-invasive (PI) strategy with half-dose TNK was similar (in efficacy and safety) to primary percutaneous coronary intervention (PPCI) in ST-elevation myocardial infarction (STEMI) patients presenting <3 hours. While no treatment difference ± 75 years was observed, the role of this half-dose PI strategy in patients <75 years is unknown. In this comparison of STEAM-1 and -2, we analyzed PI strategies with full-dose (STREAM-1) versus half-dose TNK (STREAM-2) to evaluate their relative efficacy and safety in this younger STEMI cohort. METHODS:We evaluated patients 60 to <75 years from STREAM-1 and STREAM-2 receiving PI treatment versus PPCI for their resolution of ST-elevation after fibrinolysis and angiography, primary efficacy composite of 30-day all-cause death, myocardial infarction, heart failure, and shock, and safety events. RESULTS:Among 1103 patients, 327 received a full-dose PI strategy (STREAM-1), 289 a half-dose PI strategy (STREAM-2) and 487 PPCI (338 in STREAM-1; 149 in STREAM-2). Half- compared to full-dose TNK resulted in similar proportions of patients achieving ST resolution ≥50% (71.2% vs 68.7%, P = .519): their ICH risks were 2.1% vs 1.5%, P = .605 respectively). Following angiography, PI patients had nominally better ST resolution ≥50% compared to their PPCI counterpart (STREAM-1: 87.7% vs. 83.2%, P = .120; STREAM-2: 88.2% vs. 81.0%, P = .048) with similar primary composite outcome at 30 days (STREAM-1: 14.4% vs. 16.3%, 0.90 [0.62, 1.31]; STREAM-2: 9.0% vs 8.1%, 1.29 [0.64, 2.61]). Major (non-ICH) bleeding markedly declined in STREAM-2 compared to STREAM-1 in both treatment groups (STREAM-1: 7.1% vs. 6.0%; STREAM-2: 0.3% vs. 0.7%). CONCLUSIONS:In STEMI patients 60 to <75 years presenting within 3 hours of symptoms, half-dose PI treatment appears as efficacious as a full-dose PI strategy with a low systemic bleeding risk. Half-dose PI treatment deserves consideration when timely PPCI is not attainable in this important STEMI sub-group. CLINICALTRIALS: GOV REGISTRATION NUMBERS:NCT00623623, NCT02777580.

BACKGROUND:Contemporary guidelines support the use of a pharmaco-invasive (PI) strategy with immediate transfer to a percutaneous coronary intervention (PCI)-capable hospital for ST-elevation myocardial infarction (STEMI) when timely primary PCI (pPCI) is unattainable. However, when reperfusion with fibrinolysis fails to occur, rescue PCI is recommended. METHODS:In a pre-specified analysis from STREAM-2, we explored patients randomized to PI treatment and compared those receiving half-dose tenecteplase who required rescue intervention to those with successful fibrinolysis undergoing scheduled angiography. To provide context for those randomized pPCI, we also explored the relationship between site of randomization, i.e., community hospital (CH) versus ambulance on clinical outcomes. Resolution of ST-elevation following angiography and the composite of 30-day all-cause death, shock, heart failure and reinfarction, as well as safety, reflected by stroke and non-intracranial bleeding, were measured. RESULTS:Of the 583 patients in the current study, 168 patients required rescue intervention [43.5%], 218 patients had successful fibrinolysis scheduled for angiography and 197 were randomized to pPCI. Rescue PCI patients, compared to those undergoing scheduled angiography, had less ST resolution ≥50% (76.3% versus 92.5%, P<0.001) and worse clinical composite outcomes at 30 days (16.7% versus 6.0%, P<0.001) with a higher risk of intracranial hemorrhage (2.4% versus 0.5%). Intermediate outcomes were observed for patients undergoing pPCI (ST resolution ≥50%: 78.7%; 30-day composite outcome: 12.2%). Rescue intervention deployed in CH patients required 10 minutes longer compared to ambulance patients: however, there was similar ST resolution ≥50% (72.2% versus 80.5%, P=0.219) and comparable 30-day composite outcome (17.6% versus 15.7%, relative risk [RR] 0.97, 95% confidence interval [CI] 0.50 - 1.87), irrespective of location. pPCI required 48 minutes longer in CH patients, but resulted in similar outcomes to ambulance patients (ST resolution ≥50%: 77.0% versus 80.2%, P=0.595; 30-day composite outcome: 9.3% versus 15.6%, RR 1.57, 95% CI 0.72-3.41, respectively). CONCLUSION:Contemporary PI with half-dose tenecteplase in older patients requiring rescue intervention led to less ST resolution and worse 30-day outcomes compared to those with successful fibrinolysis receiving scheduled angiography. Notably, delays to deploying rescue PCI in CH patients were shortened over those previously achieved thereby resulting in similar outcomes to those randomized in the ambulance. Our results reinforce the benefits of functional hub and spoke models with rapid transfer to a PCI-capable facility.

Aims Contemporary guidelines support the use of a pharmaco-invasive (PI) strategy with immediate transfer to a percutaneous coronary intervention (PCI)-capable hospital for ST-elevation myocardial infarction when a timely primary PCI (pPCI) is unattainable. However, when reperfusion with fibrinolysis fails to occur, rescue PCI is recommended. Methods and results In a pre-specified analysis from STREAM-2, we explored patients randomized to PI treatment and compared those receiving half-dose tenecteplase and required rescue intervention to those with successful fibrinolysis undergoing scheduled angiography. To provide context for those randomized to pPCI, we also explored the relationship between sites of randomization, i.e. community hospital (CH) vs. ambulance on clinical outcomes. Resolution of ST-elevation following angiography and the composite of 30-day all-cause death, shock, heart failure, and reinfarction, as well as safety, reflected by stroke and non-intracranial bleeding, were measured. Of the 583 patients in the current study, 168 patients required rescue intervention (43.5%), 218 patients had successful fibrinolysis scheduled for angiography, and 197 were randomized to pPCI. Rescue PCI patients, compared with those undergoing scheduled angiography, had less ST resolution >= 50% (76.3 vs. 92.5%, P < 0.001) and worse clinical composite outcomes at 30 days (16.7 vs. 6.0%, P < 0.001) with a higher risk of intracranial haemorrhage (2.4 vs. 0.5%). Intermediate outcomes were observed for patients undergoing pPCI (ST resolution >= 50%: 78.7%; a 30-day composite outcome: 12.2%). Rescue intervention deployed in CH patients required 10 min longer compared with ambulance patients; however, there was a similar ST resolution of >= 50% (72.2 vs. 80.5%, P = 0.219) and comparable 30-day composite outcomes [17.6 vs. 15.7%, relative risk (RR) 0.97, 95% confidence interval (CI) 0.50-1.87], irrespective of location. Primary PCI required 48 min longer in CH patients, but resulted in similar outcomes to ambulance patients (ST resolution >= 50%: 77.0 vs. 80.2%, P = 0.595; 30-day composite outcome: 9.3 vs. 15.6%, RR 1.57, 95% CI 0.72-3.41, respectively). Conclusion Contemporary PI with half-dose tenecteplase in older patients requiring rescue intervention led to less ST resolution and worse 30-day outcomes compared with those with successful fibrinolysis receiving scheduled angiography. Notably, delays to deploying rescue PCI in CH patients were shortened over those previously achieved thereby resulting in similar outcomes to those randomized in the ambulance. Our results reinforce the benefits of functional hub and spoke models with rapid transfer to a PCI-capable facility.

BACKGROUND:In STREAM-1 (Strategic Reperfusion Early After Myocardial Infarction), excess intracranial hemorrhage occurred in patients aged ≥75 years receiving full-dose tenecteplase as part of a pharmaco-invasive strategy, whereas no further intracranial hemorrhage occurred after halving the tenecteplase dose. In STREAM-2 (Second Strategic Reperfusion Early After Myocardial Infarction), half-dose tenecteplase was an effective and safe pharmaco-invasive strategy in older patients with ST-segment-elevation myocardial infarction presenting within <3 hours, compared with primary percutaneous coronary intervention (PCI). We prespecified evaluating the efficacy and safety of a half-dose versus full-dose pharmaco-invasive strategy and compared the half-dose pharmaco-invasive strategy to primary PCI in patients aged ≥75 years. METHODS:We pooled data sets in patients aged ≥75 years from STREAM-1 and STREAM-2 receiving a pharmaco-invasive strategy versus primary PCI. Resolution of ST-segment-elevation after fibrinolysis and angiography was assessed, as was the relative risk of the primary composite of 30-day all-cause death, myocardial infarction, heart failure, and shock, along with bleeding. RESULTS:A total of 390 patients were included: 42 patients were randomized to full-dose pharmaco-invasive treatment, 205 patients to half-dose pharmaco-invasive treatment, and 143 patients to primary PCI. Half-dose versus full-dose pharmaco-invasive treatment resulted in similar proportions of patients achieving ≥50% ST-segment resolution posttenecteplase (63.2% versus 62.6%), with reduced intracranial hemorrhage (7.1% versus 0%, respectively). Half-dose pharmaco-invasive treatment and primary PCI also had similar proportions of patients with ≥50% ST-segment resolution postangiography (77.9% versus 72.4%; P=0.277) and comparable composite end points (23.4% versus 28.0%; relative risk, 0.90 [95% CI, 0.62-1.30]; P=0.567) without occurrence of intracranial hemorrhage. CONCLUSIONS:Comparable efficacy exists between half- and full-dose tenecteplase pharmaco-invasive treatments with improved safety in patients with ST-segment-elevation myocardial infarction aged ≥75 years. Half-dose pharmaco-invasive therapy is a legitimate therapeutic option for elderly patients with ST-segment-elevation myocardial infarction unable to access timely primary PCI. REGISTRATION:URL: https://www.clinicaltrials.gov; Unique identifier: NCT00623623. URL: https://www.clinicaltrials.gov; Unique identifier: NCT02777580.

Graphical Abstract In contrast to ST-elevation myocardial infarction (STEMI), the aetiology of acute ischaemic stroke (AIS) is more heterogeneous. Undetermined aetiology refers to the group of patients in whom no single cause is identified. More rare causes of AIS are categorized as AIS of other determined aetiologies (e.g. dissection, hypercoagulable state). Although both intravenous fibrinolysis and mechanical reperfusion strategies [primary percutaneous coronary intervention (PCI) for STEMI and thrombectomy for AIS] are available for treatment of both STEMI and AIS, differences in pathophysiology (in part) explain disease-specific management with a predominant role of primary PCI in STEMI, in contrast to the persisting relevance of fibrinolysis in the majority of AIS patients who are not eligible for mechanical thrombectomy. Topics for future research should focus on ways to increase the number of treatment-eligible patients, increase the success of reperfusion treatment, and reduce complications after reperfusion treatment. Acute ST-elevation myocardial infarction (STEMI) and acute ischaemic stroke (AIS) share a number of similarities. However, important differences in pathophysiology demand a disease-tailored approach. In both conditions, fast treatment plays a crucial role as ischaemia and eventually infarction develop rapidly. Furthermore, in both fields, the introduction of fibrinolytic treatments historically preceded the implementation of endovascular techniques. However, in contrast to STEMI, only a minority of AIS patients will eventually be considered eligible for reperfusion treatment. Non-invasive cerebral imaging always precedes cerebral angiography and thrombectomy, whereas coronary angiography is not routinely preceded by non-invasive cardiac imaging in patients with STEMI. In the late or unknown time window, the presence of specific patterns on brain imaging may help identify AIS patients who benefit most from reperfusion treatment. For STEMI, a uniform time window for reperfusion up to 12 h after symptom onset, based on old placebo-controlled trials, is still recommended in guidelines and generally applied. Bridging fibrinolysis preceding endovascular treatment still remains the mainstay of reperfusion treatment in AIS, while primary percutaneous coronary intervention is the strategy of choice in STEMI. Shortening ischaemic times by fine-tuning collaboration networks between ambulances, community hospitals, and tertiary care hospitals, optimizing bridging fibrinolysis, and reducing ischaemia-reperfusion injury are important topics for further research. The aim of this review is to provide insights into the common as well as diverging pathophysiology behind current reperfusion strategies and to explore new ways to enhance their clinical benefit.

HomeCirculationVol. 148, No. 1Circulation Editors and Editorial Board Free AccessAnnouncementPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessAnnouncementPDF/EPUBCirculation Editors and Editorial Board Originally published3 Jul 2023https://doi.org/10.1161/CIR.0000000000001169Circulation. 2023;148:1–3Download figureDownload PowerPointDownload figureDownload PowerPointDownload figureDownload PowerPoint eLetters(0)eLetters should relate to an article recently published in the journal and are not a forum for providing unpublished data. Comments are reviewed for appropriate use of tone and language. Comments are not peer-reviewed. Acceptable comments are posted to the journal website only. Comments are not published in an issue and are not indexed in PubMed. Comments should be no longer than 500 words and will only be posted online. References are limited to 10. Authors of the article cited in the comment will be invited to reply, as appropriate.Comments and feedback on AHA/ASA Scientific Statements and Guidelines should be directed to the AHA/ASA Manuscript Oversight Committee via its Correspondence page.Sign In to Submit a Response to This Article Previous Back to top Next FiguresReferencesRelatedDetails July 4, 2023Vol 148, Issue 1 Advertisement Article InformationMetrics © 2023 American Heart Association, Inc.https://doi.org/10.1161/CIR.0000000000001169PMID: 37399264 Originally publishedJuly 3, 2023 PDF download Advertisement

Objective We aimed to evaluate the applicability of the eligibility criteria of randomized controlled trials (RCTs) cited in guideline recommendations in a real-world cohort of patients receiving secondary prevention after acute myocardial infarction from the EPICOR registries. Methods Recommendations provided by American and European guidelines for acute myocardial infarction were classified into general (applying to all patients) and specific (applying to patients with left ventricular dysfunction or heart failure). Randomized controlled trials cited in these recommendations were selected, and their entry criteria were applied to our international cohort of 18,117 patients. Results There were 91.5% patients eligible for beta blockers (84.6% for general, and 5.9% for specific recommendations), 97.7% eligible for renin-angiotensin system inhibitor (angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers [ACEI/ARB]) recommendations (69.9% for general, 27.9% for specific) and 4.1% eligible for mineralocorticoid receptor antagonists (only specific recommendations). The percentages of patients with eligibility criteria who were discharged with a prescription of the recommended therapies were 80%-85% for beta blockers, 70%-75% for ACEI/ARB, and 29% for mineralocorticoid receptor antagonists. There were large regional variations in the percentage of eligible patients and in those receiving the medications (eg, 95% in Northern Europe and 57% in Southeast Asia for beta blockers). Conclusion Most real-world acute myocardial infarction patients are eligible for secondary prevention therapy in both general and specific guideline recommendations, and the percentage of those on beta blockers and ACEI/ARB at hospital discharge is high. There are large regional variations in the proportion of patients receiving recommended therapies. Local targeted interventions are needed for quality improvement.

Background Controversial findings have been reported in the literature regarding the impact of the absence of standard modifiable cardiovascular risk factors (SMuRFs) on long-term mortality risk in patients with acute coronary syndrome (ACS). While the prognostic additive value of SMuRFs has been well described, the prognostic role of prior cardiovascular disease (CVD) by sex is less well-known in patients with and without SMuRFs.Methods EPICOR and EPICOR Asia are prospective, observational registries conducted between 2010 and 2014, which enrolled ACS patients in 28 countries across Europe, Latin America, and Asia. Association between SMuRFs (diabetes, dyslipidaemia, hypertension, and smoking) and 2-year postdischarge mortality was evaluated using adjusted Cox models stratified by geographical region.Results Among 23,489 patients, the mean age was 60.9 & PLUSMN; 11.9 years, 24.3% were women, 4,582 (20.1%) presented without SMuRFs, and 16,055 (69.5%) without prior CVD. Patients with SMuRFs had a higher crude 2-year postdischarge mortality (HR 1.86; 95% CI, 1.56-2.22; P < .001), compared to those without SMuRFs. After adjustment for potential confounding, the association between SMuRFs and 2-year mortality risk was substantially attenuated (HR 1.17, 95% CI 0.98-1.41; P = .087), regardless of the type of ACS. The risk conferred by prior CVD was added to the underlying risk of SMuRFs to provide risk-specific phenotypes (eg, women with SMuRFs and with prior CVD were at higher risk of dying than women without SMuRFs and without CVD; HR 1.67, 95% CI 1.34-2.06).Conclusions In this large-scale international ACS cohort the absence of SMuRFs was not associated with a lower adjusted 2-year postdischarge mortality risk. Patients with both SMuRFs and prior CVD had a higher mortality irrespective of their sex. (Am Heart J 2023;264:20-30.)

BACKGROUND: ST-segment–elevation myocardial infarction (STEMI) guidelines recommend pharmaco-invasive treatment if timely primary percutaneous coronary intervention (PCI) is unavailable. Full-dose tenecteplase is associated with an increased risk of intracranial hemorrhage in older patients. Whether pharmaco-invasive treatment with half-dose tenecteplase is effective and safe in older patients with STEMI is unknown. METHODS: STREAM-2 (Strategic Reperfusion in Elderly Patients Early After Myocardial Infarction) was an investigator-initiated, open-label, randomized, multicenter study. Patients ≥60 years of age with ≥2 mm ST-segment elevation in 2 contiguous leads, unable to undergo primary PCI within 1 hour, were randomly assigned (2:1) to half-dose tenecteplase followed by coronary angiography and PCI (if indicated) 6 to 24 hours after randomization, or to primary PCI. Efficacy end points of primary interest were ST resolution and the 30-day composite of death, shock, heart failure, or reinfarction. Safety assessments included stroke and nonintracranial bleeding. RESULTS: Patients were assigned to pharmaco-invasive treatment (n=401) or primary PCI (n=203). Median times from randomization to tenecteplase or sheath insertion were 10 and 81 minutes, respectively. After last angiography, 85.2% of patients undergoing pharmaco-invasive treatment and 78.4% of patients undergoing primary PCI had ≥50% resolution of ST-segment elevation; their residual median sums of ST deviations were 4.5 versus 5.5 mm, respectively. Thrombolysis In Myocardial Infarction flow grade 3 at last angiography was ≈87% in both groups. The composite clinical end point occurred in 12.8% (51/400) of patients undergoing pharmaco-invasive treatment and 13.3% (27/203) of patients undergoing primary PCI (relative risk, 0.96 [95% CI, 0.62–1.48]). Six intracranial hemorrhages occurred in the pharmaco-invasive arm (1.5%): 3 were protocol violations (excess anticoagulation in 2 and uncontrolled hypertension in 1). No intracranial bleeding occurred in the primary PCI arm. The incidence of major nonintracranial bleeding was low in both groups (<1.5%). CONCLUSIONS: Halving the dose of tenecteplase in a pharmaco-invasive strategy in this early-presenting, older STEMI population was associated with electrocardiographic changes that were at least comparable to those after primary PCI. Similar clinical efficacy and angiographic end points occurred in both treatment groups. The risk of intracranial hemorrhage was higher with half-dose tenecteplase than with primary PCI. If timely PCI is unavailable, this pharmaco-invasive strategy is a reasonable alternative, provided that contraindications to fibrinolysis are observed and excess anticoagulation is avoided. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02777580.

Abstract Fibrinolytic therapy is still necessary to treat ST-elevation myocardial infarction patients in many centres worldwide because of limited access to catheterization facilities. In contemporary practice, fibrinolysis is given as a bolus combined with anticoagulation and antiplatelets, followed by an early catheterization in a strategy termed the ‘pharmacoinvasive approach’. In this strategy, ST-segment resolution is checked at 60–90 minutes after fibrinolysis. Patients without signs of reperfusion are immediately taken to the catheterization laboratory, while stable, successfully reperfused patients receive a ‘scheduled’ catheterization between 2 and 24 hours after thrombolysis. The advantage of this approach is that unnecessary percutaneous coronary intervention procedures can be avoided in the very early phase after lysis when the risk of prothrombotic and bleeding complications is higher. The optimal dose of bolus fibrinolysis in pharmacoinvasive strategies remains unclear and is currently being prospectively studied.

INTRODUCTION AND OBJECTIVES:Although several factors associated with sex differences in the management and outcomes after acute coronary syndrome (ACS) have been reported, little is known about the influence of socioeconomic factors on sex disparities. Our aim was to evaluate the influence of country wealth and income inequality on national sex differences in mortality after ACS.METHODS:Sex differences in 2-year postdischarge mortality were evaluated in 23 489 ACS patients from the EPICOR and EPICOR Asia registries. Adjusted Cox regression models by country-based terciles of gross national income per capita and income inequality were used.RESULTS:Women (24.3%) were older than men (65.5 vs 59.4 years, P <.001), had more comorbidities, were less often revascularized (63.6% vs 75.6%, P <.001) and received fewer guideline recommended therapies at discharge. Compared with men, a higher percentage of women died during follow-up (6.4% vs 4.9%, P <.001). The association between sex and mortality changed direction from hazard ratio (HR) 1.32 (95%CI, 1.17-1.49) in the univariate assessment to HR 0.76 (95%CI, 0.67-0.87) after adjustment for confounders. These differences were more evident with increasing country wealth (HRlow-incomecountries = 0.85; 95%CI, 0.72-1.00; HRmid-incomecountries = 0.66; 95%CI, 0.50-0.87; HRhigh-incomecountries = 0.60; 95%CI, 0.40-0.90; trend test P = .115) and with decreasing income inequality (HRlow-inequalityindex = 0.54; 95%CI, 0.36-0.81; HRintermediate-inequalityindex = 0.66; 95%CI, 0.50-0.88; HRhigh-inequalityindex = 0.87; 95%CI, 0.74-1.03; trend test P = .031).CONCLUSIONS:Women with ACS living in high socioeconomic countries showed a lower postdischarge mortality risk compared with men. This risk was attenuated in countries with poorer socioeconomic background, where adjusted mortality rates were similar between women and men.

Introducción y objetivosAunque se han comunicado varios factores asociados con las diferencias por sexo en el tratamiento y el pronóstico tras un síndrome coronario agudo (SCA), se sabe poco acerca de la influencia de factores socioeconómicos en las disparidades por sexo. Nuestro objetivo es evaluar el impacto de la riqueza nacional y la desigualdad de ingresos en las diferencias por sexo en la mortalidad tras un SCA.MétodosSe evaluaron las diferencias entre varones y mujeres en la mortalidad a los 2 años del alta hospitalaria de 23.489 pacientes con SCA de los registros EPICOR y EPICOR Asia. Se utilizaron modelos de regresión de Cox ajustados para evaluar los terciles del producto interior bruto y de desigualdad de ingresos.ResultadosLas mujeres (24,3%) eran de más edad que los varones (65,5 frente a 59,4 años; p <0,001), tenían más comorbilidades, se las revascularizó con menos frecuencia (el 63,6 frente al 75,6%; p <0,001) y recibieron al alta menos tratamientos recomendados por las guías de práctica clínica. Comparadas con los varones, la mortalidad de las mujeres en el seguimiento fue mayor (el 6,4 frente al 4,9%; p <0,001). La asociación entre sexo y mortalidad cambió su dirección desde una hazard ratio (HR)=1,32 (IC95%, 1,17-1,49) en el análisis univariado a HR=0,76 (IC95%, 0,67-0,87) después de ajustar por variables de confusión. Estas diferencias fueron más evidentes a medida que la riqueza de los países se incrementaba (HRpaíses con bajo nivel de riqueza=0,85; IC95%, 0,72-1,00; HRpaíses con nivel de riqueza intermedio=0,66; IC95%, 0,50-0,87; HRpaíses con elevado nivel de riqueza=0,60; IC95%, 0,40-0,90; p para test de tendencia=0,115) y a medida que se equilibraba la desigualdad de ingresos (HRbajo índice de desigualidad=0,54; IC95%, 0,36-0,81; HRíndice de desigualidad intermedio=0,66; IC95%, 0,50-0,88; HRalto índice de desigualidad=0,87; IC95%, 0,74-1,03; p para test de tendencia=0,031).ConclusionesLas mujeres con SCA que viven en países con altos estándares socioeconómicos tienen menos riesgo de mortalidad tras el alta en comparación con los varones. Este riesgo se atenúa en países con un contexto socioeconómico más bajo, donde la mortalidad ajustada es similar entre mujeres y varones.

0954-6928 Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/MCA.0000000000000939 Trends in reperfusion therapy for acute ST-segment elevation myocardial infarction in an academic percutaneous coronary intervention center in the metropolitan area of a developing country: insights from the Jakarta Acute Coronary Syndrome registry Surya Dharma, Iwan Dakota, Hananto Andriantoro, Isman Firdaus, Indra Gunawan Limadhy and Frans Van de Werf

AIMS Cardiogenic shock (CGS) occurs in 6-10% of patients with acute coronary syndromes (ACS). Mortality has fallen over time from 80% to approximately 50% consequent on acute revascularisation but has plateaued since the 1990s. Once established, patients with CGS develop adverse compensatory mechanisms that contribute to the downward spiral towards death, which becomes difficult to reverse. We aimed to test in a robust, prospective, randomised controlled trial whether early support with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) provides clinical benefit by improving mortality and morbidity. METHODS AND RESULTS The EURO SHOCK trial will test the benefit or otherwise of mechanical cardiac support using VA-ECMO, initiated early after acute percutaneous coronary intervention (PCI) for CGS. The trial sets out to randomise 428 patients with CGS complicating ACS, following primary PCI (P-PCI), to either very early ECMO plus standard pharmacotherapy, or standard pharmacotherapy alone. It will be conducted in 39 European centres. The primary endpoint is 30-day all-cause mortality with key secondary endpoints: 1) 12-month all-cause mortality or admission for heart failure, 2) 12-month all-cause mortality, 3) 12-month admission for heart failure. Cost-effectiveness analysis (including quality of life measures) will be embedded. Mechanistic and hypothesis-generating substudies will be undertaken. CONCLUSIONS The EURO SHOCK trial will determine whether early initiation of VA-ECMO in patients presenting with ACS-CGS persisting after PCI improves mortality and morbidity.

Information is lacking on long-term management of patients with acute coronary syndrome (ACS) and chronic kidney disease (CKD) (estimated glomerular filtration rate [eGFR] < 60 mL/min/1.73 m2). Our objectives were to describe antithrombotic management patterns and outcomes in patients with ACS with varying renal function from the EPICOR (long-tErm follow-uP of antithrombotic management patterns In acute CORonary syndrome patients; NCT01171404) and EPICOR Asia (NCT01361386) studies. EPICOR and EPICOR Asia were prospective observational studies of patients who survived hospitalization for ACS and were enrolled at discharge in 28 countries across Europe, Latin America, and Asia. The studies were conducted from 2010 to 2013 and from 2011 to 2014, respectively. This analysis evaluated patient characteristics and oral antithrombotic management patterns and outcomes up to 2 years post-discharge according to admission eGFR: ≥ 90, 60–89, 30–59, or < 30 mL/min/1.73 m2. Among 22,380 patients with available data, eGFR < 60 mL/min/1.73 m2 was observed in 16.7%. Patients with poorer renal function were older, were at greater cardiovascular risk, and had more prior cardiovascular disease and bleeding. Patients with CKD underwent fewer cardiovascular interventions and had more in-hospital cardiovascular and bleeding events. Dual antiplatelet therapy was less likely at discharge in patients with eGFR < 30 (82.3%) than in those with ≥ 90 (91.3%) mL/min/1.73 m2 and declined more sharply during follow-up in patients with low eGFR (p < 0.0001). An adjusted proportional hazards model showed that patients with lower eGFR levels had a higher risk of cardiovascular events and bleeding. The presence of CKD in patients with ACS was associated with less aggressive cardiovascular management and an increased risk of cardiovascular events.

Background Coronary stent type and risk of stent thrombosis remain important factors affecting recommended duration of dual antiplatelet therapy. We investigated the efficacy and safety of long‐term ticagrelor in patients with prior coronary stenting enrolled in the PEGASUS‐TIMI 54 (Prevention of Cardiovascular Events in Patients with Prior Heart Attack Using Ticagrelor Compared to Placebo on a Background of Aspirin–Thrombolysis in Myocardial Infarction 54) trial. Methods and Results Patients in PEGASUS‐TIMI 54 had a myocardial infarction 1 to 3 year prior and were randomized 1:1:1 to ticagrelor 60 or 90 mg BID or placebo. The primary end point was a composite of cardiovascular death, myocardial infarction, or stroke (major adverse cardiovascular events). Stent thrombosis was prospectively adjudicated (Academic Research Consortium definition). Baseline characteristics were compared by most recent stent type (bare metal versus drug‐eluting stent and first‐ versus later‐generation drug‐eluting stent). Treatment arms were compared using Cox proportional hazards models. Of 21 162 patients randomized, 80% (n=16 891) had prior coronary stenting. Following randomization, myocardial infarction was the most frequent ischemic event in patients with prior stenting in the placebo arm, occurring in 5.2% of patients (Type 1: 4.1%), followed by cardiovascular death (2.3%), stroke (1.7%), and stent thrombosis (0.9%). Ticagrelorpooled reduced major adverse cardiovascular events (7.0% versus 8.0%; hazard ratio [HR], 0.85; 95% CI, 0.75–96) regardless of stent type (bare metal stent versus drug‐eluting stent: pinteraction=0.767; first versus later generation: pinteraction=0.940). The rate of any stent thrombosis was numerically lower with ticagrelorpooled (0.7% versus 0.9%; HR, 0.73; 95% CI, 0.50–1.05) and Thrombolysis in Myocardial Infarction major bleeding was increased (HR, 2.65; 95% CI, 1.90–3.68). Conclusions Long‐term ticagrelor reduces major adverse cardiovascular events in patients with prior myocardial infarction and coronary stenting regardless of stent type, with the benefit driven predominantly by reduction in de novo events. Nonfatal major bleeding is increased with ticagrelor. Registration Information clinicaltrials.gov. Identifier: NCT01225562.

Antithrombotic drug use for acute coronary syndromes (ACS) varies considerably. The number of antithrombotic drugs (excluding oral anticoagulants) used pre- and in-hospital was recorded in ACS survivors enrolled at hospital discharge in the long-tErm follow-uP of antithrombotic management patterns In acute CORonary syndrome patients (EPICOR) registry ( NCT01171404 ), a prospective cohort study. Among 10,568 patients, the number of antithrombotic drugs used early/patient ranged from 0 to 8 (interquartile range = 3–4). Overall, 250 patients (2.4%) experienced ≥ 1 in-hospital ischemic event and 343 (3.2%) ≥ 1 non-fatal bleeding event. While there was no difference in the rate of ischemic events (p = 0.75 for-trend) according to the number of antithrombotic drugs, a significantly higher incidence of non-fatal bleeds was observed (p < 0.0001 for-trend), with OR = 1.68 (95%CI = 1.51–1.88) per additional antithrombotic drug, which remained after adjustment by patient characteristics. In conclusion, careful balancing of the short-term risks for ischemic and bleeding events should be considered when adding new antithrombotic drugs.