Initial Fibrinolysis versus Primary Percutaneous Coronary Intervention for ST-Segment-Elevation Myocardial Infarction-Cardiogenic-Shock
Presenter
Dhiran Verghese, MD, NAPLES HEART INSTITUTE, Naples, FL
Dhiran Verghese, MD, NAPLES HEART INSTITUTE, Naples, FL and Saraschandra Vallabhajosyula, MD MSc, FSCAI, Warren Alpert Medical School of Brown University, Providence, RI
Keywords: Acute Coronary Syndromes (ACS), Cardiogenic shock, Complications and Coronary
Background
Cardiogenic shock (CS) complicates 10% of all ST-segment-elevation myocardial infarction (STEMI). Fibrinolysis with subsequent percutaneous coronary intervention (PCI) is used in >25% of the contemporary STEMI. Very few studies of fibrinolysis included patients with CS
Methods
Using the National Inpatient Sample adult STEMI-CS admissions receiving initial fibrinolysis were compared to those receiving primary PCI (PPCI). Multivariable regression and propensity matching were used to adjust for confounders
Results
During 2009-2017, 5,297 and 110,452 admissions received initial fibrinolysis and PPCI respectively. Compared to those receiving PPCI, the initial fibrinolysis group were more often non-white, with lower comorbidity, admitted on weekends and to rural hospitals (all p<0.001). In the fibrinolysis group, 95.3%, 77.4% and 15.7% received angiography, PCI and CABG. The fibrinolysis group had higher rates of hemorrhagic complications (13.5% vs. 9.9%; p<0.001), comparable rates of acute organ failure, length of stay (7.7% vs 7.6%, p=0.44), palliative referral (7.4% vs 7.6%, p=0.53), do-not-resuscitate status (9.9% vs 10.1%, p=0.66) and lower hospitalization costs. The fibrinolysis group had comparable all-cause in-hospital mortality (logistic regression analysis: 28.8% vs. 28.5%; propensity matched analysis: 30.8% vs. 30.3%; adjusted odds ratio 0.97 [95% CI 0.90-1.05]; p=0.50)
Conclusions
Initial fibrinolysis had comparable in-hospital mortality to PPCI in STEMI-CS in the contemporary era. There should be a strong consideration for development of a pharmaco-invasive network into the hub-and-spoke model for STEMI-CS care
