Selection matters: clinical indication, not timing, determines angiographic success in late-presenting STEMI
A Zambrano Zambrano, A Arias Mendoza, H Gonzalez Pacheco, P Ramirez-Rangel, A Ezquerra Osorio, M Torres Padilla, F Bonilla Bonilla, W Valle Uitzil, S Favila Lira, C Sanchez Rodriguez, J Jardon Magallan, A Martinez Jimenez, R Del Angel Galvez, J Cortes Arroyo, A Priego RaneroAbstract
Background
In ST-segment elevation myocardial infarction (STEMI), primary percutaneous coronary intervention (PCI) is standard when performed early; however, many patients present ≥12 hours after symptom onset, and the role of PCI in this late-presenting setting remains controversial. Randomized trials in stable patients with persistently occluded infarct-related arteries failed to show clinical benefit, leading guidelines to recommend late PCI only in selected scenarios. Most prior studies have focused on clinical outcomes, with limited evaluation of angiographic reperfusion success—the mechanistic link between PCI and myocardial recovery. Whether angiographic success in late-presenting STEMI is driven by intrahospital timing or by clinical indication–based patient selection remains unclear.
Purpose
To evaluate the association between clinical indications for late PCI and angiographic reperfusion success in late-presenting STEMI, and to determine whether successful reperfusion is more strongly influenced by clinical selection than by intrahospital timing.
Methods
We conducted a retrospective cohort study of consecutive STEMI patients presenting 12–72 hours after symptom onset who underwent PCI within 7 days of hospital arrival. Patients were classified according to the primary indication for late PCI: persistent angina, clinical deterioration, or myocardial viability/ischemia. The primary endpoint was angiographic success, defined as final Thrombolysis in Myocardial Infarction (TIMI) 3 flow with TMP ≥2. Secondary endpoints included epicardial failure (TIMI <3), microvascular failure (TIMI 3 with TMP ≤1), and 30-day mortality. Multivariable logistic regression adjusted for baseline TIMI flow and clinical covariates.
Results
Among 397 patients, 199 underwent PCI for persistent angina, 133 for clinical deterioration, and 65 based on viability or ischemia. Symptom-onset–to-presentation intervals differed across groups (p=0.044). Arrival-to-PCI time varied markedly (median 6 h, 17 h, and 132 h, respectively; p<0.001). Baseline TIMI flow differed significantly. Angiographic success occurred in 90.8% of viability/ischemia patients, 75.9% of clinical deterioration patients, and 68.3% of persistent angina patients (p=0.001), despite the longest intrahospital delays in the viability/ischemia group. Thirty-day mortality was 1.5%, 23.3%, and 6.0%, respectively (p<0.001). After adjustment for baseline TIMI flow and arrival-to-PCI time, clinical indication remained independently associated with angiographic success, whereas intrahospital timing was not significantly associated with effective reperfusion.
Conclusion
In late-presenting STEMI, angiographic reperfusion success is more strongly associated with clinical indication than with intrahospital timing. A selection-based strategy, particularly guided by viability or ischemia, identifies patients with the highest likelihood of effective reperfusion.