Objectives:
To identify determinants of clinical outcomes following primary percutaneous coronary intervention (PPCI) for ST-segment elevation myocardial infarction (STEMI).
Background:
Although PPCI is currently the gold-standard guideline-indicated care for STEMI in the UK, factors associated with important clinical outcomes are still being explored and discovered. The purpose of this study and the analyses within this study, is to identify factors that were either previously unreported or variably reported.
Methods:
Baseline and procedural data of all consecutive patients undergoing PPCI between 01-01-2009 and 31-12-2011, and between 01-01-2013 and 31-12-2013 in Leeds General Infirmary UK were collected prospectively in the West Yorkshire Primary Percutaneous Coronary Intervention (WY-PPCI) research and audit databases. Patients were followed up to a minimum of 12-months following index-PPCI.
Five analyses were undertaken to assess the association between the following factors and clinical outcomes in PPCI: gender, ethnicity, P2Y12-receptor inhibitor, individual operator PPCI volume, glycoprotein IIb/IIIa inhibitor (GPI) use according to arterial access site. Multivariable analysis was undertaken to adjust for potential confounders. Clinical endpoints (depending on analyses) were: major adverse cardiovascular events (MACE; defined as all-cause mortality, myocardial infarction (MI), and repeat target and non-target vessel revascularisation), and HORIZONS-major bleeding.
Results:
Gender: Although women were older than men at presentation (median age 69 vs 60yr, p <0.01), mortality and MACE were not statistically significantly higher in women after stratification into age groups (<60, 60-79, and ≥80yr) alone, and also after multivariable analysis. Age was most strongly associated with adverse outcomes.
Ethnicity: Univariable and multivariable analysis both revealed no significant differences in MACE and mortality between South Asian and White patients, despite South Asian patients being significantly younger than White patients.
P2Y12-receptor inhibitor therapy: After multivariable analysis, both ticagrelor and prasugrel were associated with lower recurrent MI compared to clopidogrel. However, only prasugrel was associated with reduced mortality, both in comparison with clopidogrel and ticagrelor. There was no difference in bleeding between the three drugs.
Annual operator PPCI volume: Low annual operator-volume (<55 PPCI cases per year) was independently associated with 30-day mortality compared to high operator-volume (≥110 PPCI per year), suggesting a volume-outcome relationship at a significantly higher threshold than the AHA/ACC/SCAI recommendation of ≥11 PPCI cases per year.
GPI-use: In transfemoral PPCI, GPI use was independently associated with higher 30-day bleeding (particularly access-site bleeding) and mortality compared to no GPI-use. In transradial PPCI, GPI use was not associated with increased bleeding or mortality.
Conclusion
This study has identified important factors associated with outcomes following in the real-world, in a large, contemporary “all-comers” registry. Analyses from this study should lead to the interrogation of larger databases and possibly changes in guideline recommendations.
