Primary Percutaneous Coronary Intervention vs Conservative Treatment for Acute ST Elevation Myocardial Infarction Short- and Long-Term Follow-up According to Disease Severity

Abstract

n recent years, primary percutaneous coronary intervention (PPCI) has gradually emerged as the preferred treatment strategy for ST-elevation myocardial infarction (STEMI). 1,2 In particular, the usefulness of PPCI for acute myocardial infarction (AMI) resulting in cardiogenic shock has been recognised. 3 In the treatment of STEMI, PPCI is associated with favourable vital prognosis, 4 and current therapeutic guidelines for STEMI recommend PPCI whenever feasible. 5,6 Numerous randomized studies and meta-analyses have demonstrated the superiority of PPCI over thrombolytic therapy for AMI. However, in recent randomized trials, investigators have demonstrated a lack of cost-effectiveness for PPCI in some cases, as compared with thrombolytic therapy. 7,8 To the best of our knowledge, no randomized comparative studies have assessed the useCirculation Journal Vol.72, September 2008 fulness of PPCI and conservative therapy in the treatment of AMI. Whether percutaneous coronary intervention (PCI) is essential in all AMI patients thus remains unclear.To elucidate the characteristics of AMI in the Japanese population, we conducted a prospective cohort study to investigate therapeutic modalities and prognosis of AMI at the Department of Cardiology of Tokyo Women's Medical University (The Heart Institute of Japan, Cardiology) and its 17 affiliated institutions, 9 and report our findings here. MethodsThe protocol was approved by the Ethics Committee of Tokyo Women's Medical University. Study PopulationThe study population was drawn from a registered prospective Japanese multicenter observational cohort, the Heart Institute of Japan Acute Myocardial Infarction (HIJAMI) registry. 9,10 Briefly, 3,021 consecutive patients with AMI admitted to 17 Japanese hospitals were registered from January 1999 to June 2001. Among these, eligible patients were those over 20 years old with chest pain or ECG changes typical of AMI accompanied by an increase in cardiac enzymes to at least twice the upper limit of the normal Background Because there is insufficient evidence to support primary percutaneous coronary intervention (PPCI) as the treatment of acute myocardial infarction (AMI), this study elucidated the efficacy of PPCI according to disease severity. Methods and ResultsBetween January 1999 and June 2001, 3,021 AMI patients were registered at Tokyo Women's Medical University and 17 affiliated institutions. Of these, 1,994 patients with ST-elevation AMI were admitted within 12 h of onset. PPCI was performed in 1,143 and 294 were treated conservatively. The 1,437 patients were grouped according to Thrombolysis In Myocardial Infarction-risk score: PPCI was performed in 59.5% of the low-risk group, 61.8% of the moderate-risk group, and 56.2% of the high-risk group. Cardiac death was the primary outcome. In the low-risk group, no significant differences were observed between PPCI and conservative therapy for 30-day and long-term cardiac mortality rates. In the moderate-risk group, the 30-day cardiac mortality rate for PPCI was significantly ...

An Asian Validation of the TIMI Risk Score for ST-Segment Elevation Myocardial Infarction

“…A recent pooled meta-analysis confirmed that absolute risk reduction for mortality using thrombolytics or primary PCI depended on the patient’s baseline risk [17]. Other studies have shown that in low risk patients, fibrinolysis [18] and even conservative therapy [19] performed as well as primary PCI for 30-day mortality. Therefore, the use of the TIMI risk score in Malaysia may help improve the use of limited resources through better targeted treatment for higher risk patients.…”

Relationship Between Hospital Volume and Outcomes Following Primary Percutaneous Coronary Intervention in Patients With Acute Myocardial Infarction

“…European randomized trials also support transferring patients from community hospitals to tertiary PCI centers for primary PCI. 23, 24 From a clinical perspective, 1 recent study reported that low-risk patients may not benefit from primary PCI, 25 suggesting that this therapy may not be indicated for all patients. The recent registry study also revealed an increased number of elderly patients with AMI 13 and suggested appropriate treatment for such patients.…”