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CLINICAL STUDY: INTERVENTIONAL CARDIOLOGY

Primary angioplasty and selection bias inpatients presenting late (>12 h) after onset of chest pain and ST elevation myocardial infarction

Yaron Elad, MD^*, William J. French, MD, FACC^*,*, David M. Shavelle, MD, Lori S. Parsons, BS, Mark J. Sada, MD, FACC^*, Nathan R. Every, MD, MPH, FACC Participants in the National Registry of Myocardial Infarction 2

^* Saint John’s Cardiovascular Research Center, Division of Cardiology, Harbor-UCLA Medical Center, Torrance, California, USA
Division of Cardiology, University of Washington, Puget Sound Veterans Affairs Medical Center, Seattle, Washington, USA
Ovation Research Group, Seattle, Washington, USA

Manuscript received June 26, 2001; revised manuscript received November 21, 2001, accepted December 11, 2001.

^* Reprint requests and correspondence: Dr. William J. French, Division of Cardiology, Box 405, Harbor-UCLA Medical Center, 1000 W. Carson Street, Torrance, California 90509 USA.
wjfrench{at}ucla.edu

OBJECTIVES: This study was designed to compare the in-hospital outcome of patients presenting with >12 h from onset of chest pain and acute ST elevation myocardial infarction (AMI) who received either immediate invasive or conservative therapy.

BACKGROUND: The benefits of fibrinolytic therapy diminish in patients presenting with AMI and onset of chest pain >12 h. Primary angioplasty has been suggested as a possible treatment for such patients, but they have been excluded from most trials of primary angioplasty. It remains unclear if an invasive treatment strategy is beneficial to these patients.

METHODS: Patients presenting with >12 h of chest pain and AMI were identified from the National Registry of Myocardial Infarction 2 database. Patients receiving invasive therapy <6 h after hospital admission were compared with those receiving conservative therapy. Short-term outcomes were compared on the basis of the initial therapy received. To help control for baseline differences in the groups, patients were matched with controls by propensity score methodology.

RESULTS: On preliminary analysis, in-hospital outcome was improved in terms of recurrent ischemia, angina, myocardial infarction and mortality in patients receiving initial invasive therapy (odds ratio [OR] = 0.67; 95% confidence interval [CI] 0.49 to 0.92 for mortality). After matching by propensity score, the mortality benefit persisted on bivariate analysis (3.5% vs. 5.0%, p = 0.036), though on multivariate analysis, only a non-significant but strong trend toward decreased mortality remained (OR = 0.73; 95% CI 0.53 to 1.01).

CONCLUSIONS: Patients receiving early invasive therapy had lower risk features on presentation. Selection bias may play an important role in choosing these patients’ course of treatment and their subsequent outcomes. Certain patients presenting with AMI and duration of chest pain >12 h may benefit from early invasive therapy. These patients could be characterized in a randomized trial.

Abbreviations and Acronyms   GUSTO   AMI   acute ST elevation myocardial infarction   CABG   coronary artery bypass grafting   CHF   congestive heart failure   CI   confidence interval   CK   creatine kinase   ECG   electrocardiogram   GUSTO   Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries   MI   myocardial infarction   NRMI   National Registry of Myocardial Infarction   OR   odds ratio   PAMI   Primary Angioplasty in Myocardial Infarction   PTCA   percutaneous transluminal coronary angioplasty   TIMI   Thrombolysis In Myocardial Infarction

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