ST-Elevation Acute Myocardial Infarction Treated with Primary Percutaneous Coronary Intervention: The Importance of Local Data

ST Elevation Myocardial Infarction; Percutaneous Coronary Intervention; Myocardial Reperfusion; Fibrinolityc Therapy; Epidemiology; Mortality

Castro et al.¹ should be commended for providing the scientific community with a useful publication analyzing predictors of all-cause mortality in patients with ST-elevation acute myocardial infarction (STEMI) who are submitted to primary percutaneous coronary intervention (PPCI).

PPCI is the preferred method of reperfusion for patients with STEMI presenting within 12 hours of evolution from onset of symptoms.² To the best of my knowledge, the most recent meta-analysis comparing fibrinolytic therapy with PPCI found odds ratios of 0.73 (p = 0.002), 0.38 (p < 0.001), 0.38 (p < 0.001), and 1.03 (p = 0.86) for all-cause death, reinfarction, stroke, and major bleeding, respectively. However, absence of widespread availability of catheterization laboratories and logistical problems, mainly related to transportation, limit the access of patients with STEMI to this form of treatment.³ This is highlighted in the present publication, where only 0.26% of the analyzed population was from the vast North Region of Brazil, whereas the majority (58%) was from the Southeast Region. Maybe more importantly, the utilization of reperfusion therapies (fibrinolytics or PPCI) in general is far from ideal in Brazil, and important regional differences have been observed.⁴ , ⁵ Importantly, the previously cited meta-analysis by Fazel et al.³ found odds ratios of 0.79, 0.53, 0.70, and 1.19 for all-cause deaths, reinfarction, stroke, and major bleeding, respectively, when comparing the pharmacoinvasive approach with fibrinolytic treatment, which can be an option for issues related to access to PPCI.

The comparison between the paper by Castro et al.¹ and the literature summarized in Table 3 must be interpreted carefully. First, the Brazilian paper analyzed only the in-hospital phase, while the others analyzed follow-ups ranging from 30 days to 1 year. Second, not all studies

were related to patients submitted to PPCI. For example, the “DynTIMI”⁶ was derived from the ExTRACT study, which tested the role of enoxaparin versus non-fractioned heparin in patients with STEMI, and the GRACE⁷ was an international registry with a broad population of patients with acute coronary syndromes (with or without ST-elevation). It is noteworthy that all the studies included in Table 3 developed risk scores to facilitate understanding and to increase the utilization of the results in daily practice, which was not the case of the publication by Castro et al.¹ The authors missed an excellent opportunity to develop a risk score based on a Brazilian population, as did some previous publications from Brazil.⁸

In a somewhat simplistic manner, Castro et al.¹ stated that the only risk factor from the National Registry of Cardiovascular Interventions (CENIC, acronym in Portuguese) not in agreement with the other publications was female sex. The role of female sex as a prognostic risk factor in STEMI has been a matter of discussion for decades, with some studies, such as the present one, concluding that female sex is an independent risk factor for worse prognosis and others concluding that it is not.⁹ The best explanation was, perhaps, the one provided in the classical publication by Vacarinno et al.¹⁰ many years ago, namely, that there is an interaction between sex, age, and mortality in myocardial infarction with younger women, but not older women, having higher rates of in-hospital deaths than men of the same age;¹⁰ however, a more recent publication suggested that other interactions may be important as well.¹¹ In a more detailed analysis, we can note that there are many other differences between the Brazilian study and the others. For example, the CADILLAC risk score included 7 variables, including anemia and renal insufficiency,¹² and the ALPHA score had only 5 variables, including heart rate, need for life support, and arterial access, reaching an impressive c-statistic of 0.88 for all-cause mortality at 30 days.¹³

In summary, the study by Castro et al.¹ contributes to a better understanding of the epidemiology of STEMI in Brazil, with a robust number of approximately 27,000 patients analyzed. Its main limitation is likely a potential inclusion bias, since the contribution of the investigators was spontaneous, and, maybe more importantly, an opportunity to develop and validate a Brazilian score for patients with STEMI submitted to PPCI was missed.

Referências

• ¹
  Castro PPN, Castro MAN, Nascimento GA, Moura I, Pena JLB. Predictors of Hospital Mortality Based on Primary Angioplasty Treatment: A Multicenter Case-Control Study. Arq Bras Cardiol. 2022; 119(3):448-457.
• ²
  Avezum Jr A, Feldman A, Carvalho ACC, Sousa ACS, Mansur AP, Bozz AAZ, et al. Piegas LS, Timerman A, Feitosa GS et al. [V Guideline of the Brazilian Society of Cardiology on Acute Myocardial Infarction Treatment with ST Segment Elevation]. Arq Bras Cardiol. 2015;105(2Suppl 1):1-105. DOI: 10.5935/abc.20150107
  » https://doi.org/10.5935/abc.20150107
• ³
  Fazel R, Joseph TI, Sankardas MA, et al. Comparison of Reperfusion Strategies for ST-Segment-Elevation Myocardial Infarction: A Multivariate Network Meta-analysis. J Am Heart Assoc. 2020;9(12):e015186. DOI: 10.5935/abc.20150107
  » https://doi.org/10.5935/abc.20150107
• ⁴
  Nicolau JC, Franken M, Lotufo PA, Carvalho AC, Marin Neto JÁ, Lima FG, et al. Use of demonstrably effective therapies in the treatment of acute coronary syndromes: comparison between different Brazilian regions. Analysis of the Brazilian Registry on Acute Coronary Syndromes (BRACE). Arq Bras Cardiol. 2012;98(4):282-9. DOI: 10.1590/s0066-782x2012000400001
• ⁵
  Oliveira JC, Ferreira GJDS, Oliveira JC, Lima TM, Barreto IC, Oliveira LC, et al. Influence of Geographical Location on Access to Reperfusion Therapies and Mortality of Patients with IAMCSST in Sergipe: VICTIM Register. Arq Bras Cardiol. 2021;117(1):120-9. DOI: 10.36660/abc.20200015
• ⁶
  Amin ST, Morrow DA, Braunwald E, Sloan S, Contant C, Murphy S, et al. Dynamic TIMI risk score for IAMCSST. J Am Heart Assoc. 2013;2(1):e003269. DOI: 10.1161/JAHA.112.003269
• ⁷
  Granger CB, Goldberg RJ, Dabbous O, et al. Predictors of hospital mortality in the global registry of acute coronary events. Arch Intern Med. 2003;163(19):2345-53. DOI: 10.1001/archinte.163.19.2345
• ⁸
  Franken M, Giugliano RP, Goodman SG et al. Performance of acute coronary syndrome approaches in Brazil. A report from the BRACE (Brazilian Registry in Acute Coronary syndromEs). Eur Heart J Qual Care Clin Outcomes. 2020;6(4):284-92. DOI: 10.1093/ehjqcco/qcz045
• ⁹
  Nicolau JC, Auxiliadora FM, Nogueira PR, Coimbra Garzon SA, Serrano CV, Jr., Ramires JA. The role of gender in the long-term prognosis of patients with myocardial infarction submitted to fibrinolytic treatment. AnnEpidemiol. 2004;14(1):17-23. DOI: 10.1016/s1047-2797(03)00076-0
• ¹⁰
  Vaccarino V, Parsons L, Every NR, Barron HV, Krumholz HM. Sex-based differences in early mortality after myocardial infarction. National Registry of Myocardial Infarction 2 Participants. N Engl J Med. 1999;341(4):217-25. DOI: 10.1056/NEJM199907223410401
• ¹¹
  van Loo HM, van den Heuvel ER, Schoevers RA, Anselmino M, Carney R, Denollet J, et al. Sex dependent risk factors for mortality after myocardial infarction: individual patient data meta-analysis. BMC Med. 2014;12:242. DOI: 10.1186/s12916-014-0242-y
• ¹²
  Halkin A, Singh M, Nikolsky E, Grines CL, Tcheng JE, Garcia E, et al. Prediction of mortality after primary percutaneous coronary intervention for acute myocardial infarction: the CADILLAC risk score. J Am Coll Cardiol. 2005;45(9):1397-405. DOI: 10.1016/j.jacc.2005.01.041
• ¹³
  Hizoh I, Gulyas Z, Domokos D, Banhegyi G, Majoros Z, Major L, et al. A novel risk model including vascular access site for predicting 30-day mortality after primary PCI: The ALPHA score. Cardiovasc Revasc Med. 2017;18(1):33-9. DOI: 10.1016/j.carrev.2016.10.002

• Short Editorial related to the article: Predictors of Hospital Mortality Based on Primary Angioplasty Treatment: A Multicenter Case-Control Study

Publication Dates

• Publication in this collection
  05 Sept 2022
• Date of issue
  Sept 2022