Transcript One-year clinical outcome of interventionalist

One-year clinical outcome of interventionalistversus patient- transfer strategies for primary
percutaneous coronary intervention in patients
with acute ST-elevation myocardial infarction:
Results from REVERSE-STEMI study
Wei Feng Shen, MD, PhD
RuiJin Hospital
Shanghai Jiaotong University School of Medicine
One Year Outcome of Interventionalist Transfer for STEMI
Background
• Primary percutaneous coronary intervention (PPCI), when
performed in a qualified center with a timely manner, has become
the first treatment option for STEMI patients presenting to a
hospital with PPCI capability.
• Currently, almost half of hospitals equipped with angiographic
facilities remain lack of interventionalists qualified for PPCI in China,
where the volume of PCI increases dramatically in recent years.
However, the strategy of transferring STEMI patients in large cities is
still not consummate.
• The RESVERSE-STEMI study investigated whether interventionalisttransfer strategy for PPCI could further shorten door-to-balloon
(D2B) time and improve one-year clinical outcome in patients with
acute STEMI.
One Year Outcome of Interventionalist Transfer for STEMI
Methods
• Study design: multicenter, prospective, randomized
• Hypothesis: STEMI patients presented to local hospitals
could be treated by interventionalist transfer strategy.
STEMI patients
presented to
referral hospitals
Patients
transfer
Interventionalist
transfer
Tertiary Hospital
Location of referral hospitals
and tertiary center
One Year Outcome of Interventionalist Transfer for STEMI
Methods
• Tertiary hospital:
Provided experienced interventionists to perform PCI in
the referral hospitals, or received referral patients and
then performed PPCI in the tertiary hospital.
• Referral hospitals:
(1) had coronary care unit
(2) had cardiac catheterization laboratories
(3) with cardiac interventional team, including operator,
nurses and technicians, qualified for elective PCI
(4) a formal training program of caring STEMI patients
for technicians and nurses before starting the study
One Year Outcome of Interventionalist Transfer for STEMI
Methods
• Study flow:
One Year Outcome of Interventionalist Transfer for STEMI
Endpoints
• Primary endpoint: D2B time (from patient’s arrival at
the local hospital to first balloon inflation).
• Secondary endpoints: left ventricular ejection
fraction (LVEF) and major adverse cardiac events
(MACE, including death, recurrence of non-fatal MI
[Re-MI], and target vessel revascularization [TVR] )at
one-year follow-up.
One Year Outcome of Interventionalist Transfer for STEMI
Results
• Baseline characteristics were not significantly
different between the interventionalist- and
patient-transfer groups, and medications at
the end of one-year follow-up were similar.
• Primary endpoint of D2B time was significantly
reduced (median: 92 min vs. 141 min, p<0.0001)
with the interventionalist-transfer strategy, and more
patients had first balloon angioplasty < 90 min
(21.2% vs. 7.7%, p<0.001).
One Year Outcome of Interventionalist Transfer for STEMI
Door-to-Balloon Time
(mean ± sd)
One Year Outcome of Interventionalist Transfer for STEMI
Results
• LVEF was significantly higher in the interventionalisttransfer group than in the patient-transfer group
during hospitalization and at 6-month and one-year
follow-up.
• The one-year MACE-free survival was significantly
improved with interventionalist-transfer strategy
(84.8% vs. 74.6%, p=0.019).
One Year Outcome of Interventionalist Transfer for STEMI
One-year Clinical Outcome
One Year Outcome of Interventionalist Transfer for STEMI
LVEF during hospitalization and at oneyear clinical follow-up
One Year Outcome of Interventionalist Transfer for STEMI
Results
• Multivariate Cox proportional hazards model
showed that D2B time (>90 min) continued to
predict MACE at one year (HR= 2.24, 95% CI 1.273.96, p=0.02)
• The interventionalist-transfer strategy was an
independent factor for reduced risk of MACE in
overall patients (HR=0.63, 95% CI 0.45~0.88,
p=0.003), and significantly improved one-year
clinical outcomes in those with Killip class III-IV,
multivessel disease, anterior infarction, female in
gender, and older than 65 years of age
One Year Outcome of Interventionalist Transfer for STEMI
The effect of different transfer strategies
on composite MACE in subgroups
One Year Outcome of Interventionalist Transfer for STEMI
Conclusions
• The interventionalist-transfer strategy resulted in significantly
reduced D2B time and subsequently improved one-year
clinical outcome.
• This novel transfer strategy for primary PCI may improve the
care of STEMI patients presenting to a non-PPCI-capable
hospital, particularly in a region where patient transfers could
be prolonged by congestion.
One Year Outcome of Interventionalist Transfer for STEMI
Limitations
• First, this study was powered on D2B time. Nevertheless, the
results demonstrated significant difference in clinical outcomes at
one-year follow-up between the two treatment strategies.
• Second, the interventionalist-transfer strategy required PCI facilities
or materials, and nurses or paramedics adequately trained to deal
with STEMI patients and their acute problems in the local hospitals.
• Third, compared with findings in contemporary studies, the
proportion of patients with a D2B time <90 min was still relatively
low in the interventionalist-transfer group.
• Finally, the current interventionalist-transfer strategy may be a
tentative option in shortening D2B time for STEMI patients and
physician training in a single city with hospitals located close to
each other. This model may not be applied to a rural geographic
setting with long transfer distance.
One Year Outcome of Interventionalist Transfer for STEMI
Funding Sources
• This work was supported by the grants from
Shanghai Science and Technology Foundation
(05DZ19503), and National Nature Science
Foundation of China (30900589)