Reperfusion strategies in acute myocardial infarction: comparison between primary percutaneous coronary intervention and a pharmacoinvasive strategy in a real-world Brazilian setting
A H P B Barbosa, H T Bianco, S R Borges Filho, M T Souza, P C D Ribeiro, B C Reis, J M A Sousa, D H Silva, P S Teixeira, P I Moraes, V A Moises, F A H Fonseca, W F Leite, W N Ribeiro, V A C NancassaAbstract
Background
Early reperfusion is the cornerstone of ST-segment elevation myocardial infarction (STEMI) management, with treatment delays directly influencing mortality and haemodynamic complications. Although primary percutaneous coronary intervention (PPCI) is the guideline-recommended strategy, access limitations remain a major challenge in middle-income countries. The pharmacoinvasive (PI) strategy has been proposed as a pragmatic alternative, yet real-world comparative data remain limited. We evaluated in-hospital mortality and cardiogenic shock in patients treated with PPCI versus PI strategy.
Methods
In this multicentre observational study, 5,941 consecutive STEMI patients were included: 3,240 underwent PPCI (2014–2020) and 2,701 received PI strategy (2010–2020). Clinical characteristics, angiographic findings, and system delays (symptom-to-reperfusion and door-to-reperfusion times) were analysed. Multivariable logistic regression adjusted for clinical and haemodynamic covariates was performed, with results expressed as adjusted prevalence ratios (aPR) and 95% confidence intervals.
Results
PPCI patients were older, whereas smoking was more prevalent in the PI group. Diabetes and hypertension were similarly distributed. Reperfusion times were significantly shorter with PPCI, which was also associated with higher rates of final TIMI 3 flow and myocardial blush grade 3(Table 1). In-hospital mortality was comparable between PPCI and PI strategy (5.8% vs 5.9%; p=0.94). However, cardiogenic shock occurred more frequently in the PI group (8.9% vs 2.6%; p<0.001). After adjustment, age and diabetes independently predicted mortality. The PI strategy was not associated with increased mortality but remained strongly associated with cardiogenic shock (Figure 1B).
Conclusion
In this large real-world cohort, the pharmacoinvasive strategy achieved similar in-hospital mortality compared with PPCI but was associated with a markedly higher risk of cardiogenic shock. These findings reinforce the priority of timely PPCI and highlight the need for optimised regional STEMI networks in resource-limited settings.Figure 1- Mortality and cardiogenic shock