Document Detail

Relationship between risk stratification at admission and treatment effects of early invasive management following fibrinolysis: insights from the Trial of Routine ANgioplasty and Stenting After Fibrinolysis to Enhance Reperfusion in Acute Myocardial Infarction (TRANSFER-AMI).
MedLine Citation:
PMID:  21307037     Owner:  NLM     Status:  MEDLINE    
AIMS: We sought to determine the effectiveness of early routine percutaneous coronary intervention (PCI) post-fibrinolysis for ST-elevation myocardial infarction (STEMI) in relation to baseline risk status.
METHODS AND RESULTS: In this post hoc subgroup analysis of Trial of Routine Angioplasty and Stenting after Fibrinolysis to Enhance Reperfusion in Acute Myocardial Infarction (TRANSFER-AMI), we stratified 1059 STEMI patients receiving tenecteplase into low-intermediate [Global Registry of Acute Coronary Events (GRACE) risk score<155; n=889] vs. high-risk (GRACE risk score ≥155; n=170) groups, based on the GRACE risk score for in-hospital mortality. There was a significant interaction between treatment assignment and risk status for the composite endpoint of death/re-MI at 30 days (P for interaction<0.001). Compared with the standard treatment, pharmacoinvasive therapy (early routine PCI) was associated with a lower rate of death/re-MI at 30 days in the low-intermediate risk stratum (8.1 vs. 2.9%, P<0.001), but a higher rate of death/re-MI in the high-risk group (13.8 vs. 27.8%, P=0.025). We found similar heterogeneity in the treatment effects on 30-day mortality and death/re-MI at 1 year (P for interaction=0.008 and 0.001, respectively), when the GRACE risk score was analysed as a continuous variable (P for interaction<0.001) and when patients were stratified by the Thrombolysis In Myocardial Infarction (TIMI) risk score (P for interaction=0.001).
CONCLUSION: We observed a strong heterogeneity in the treatment effects of a pharmacoinvasive strategy after fibrinolysis for STEMI, which is associated with improved outcomes only among patients with a low-intermediate GRACE risk score. Conversely, the early invasive strategy is associated with worse outcomes in high-risk patients. These novel findings should be considered exploratory only and require confirmation in other trials and meta-analyses.
Andrew T Yan; Raymond T Yan; Warren J Cantor; Bjug Borgundvaag; Eric A Cohen; David H Fitchett; Vladimir Dzavik; John Ducas; Mary Tan; Amparo Casanova; Shaun G Goodman;
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Publication Detail:
Type:  Journal Article; Multicenter Study; Randomized Controlled Trial; Research Support, Non-U.S. Gov't     Date:  2011-02-08
Journal Detail:
Title:  European heart journal     Volume:  32     ISSN:  1522-9645     ISO Abbreviation:  Eur. Heart J.     Publication Date:  2011 Aug 
Date Detail:
Created Date:  2011-08-15     Completed Date:  2011-12-07     Revised Date:  2014-07-30    
Medline Journal Info:
Nlm Unique ID:  8006263     Medline TA:  Eur Heart J     Country:  England    
Other Details:
Languages:  eng     Pagination:  1994-2002     Citation Subset:  IM    
Data Bank Information
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MeSH Terms
Angioplasty, Balloon, Coronary*
Fibrinolytic Agents / therapeutic use*
Middle Aged
Myocardial Infarction / therapy*
Myocardial Reperfusion / methods*
Risk Assessment
Tissue Plasminogen Activator / therapeutic use*
Treatment Outcome
Grant Support
//Canadian Institutes of Health Research
Reg. No./Substance:
0/Fibrinolytic Agents; 0/tenecteplase; EC Plasminogen Activator
Comment In:
Eur Heart J. 2011 Aug;32(16):1961-3   [PMID:  21447512 ]

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