Initial Fibrinolysis versus Primary Percutaneous Coronary Intervention for ST-Segment-Elevation Myocardial Infarction-Cardiogenic-Shock
Presenter
Dhiran Verghese, MD, Massachusetts General Hospital/Harvard Medical School, Boston , MA
Dhiran Verghese, MD, Massachusetts General Hospital/Harvard Medical School, Boston , MA 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
