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Benefit of Facilitated Percutaneous Coronary Intervention in High-Risk ST-Segment Elevation Myocardial Infarction Patients Presenting to Nonpercutaneous Coronary Intervention Hospitals

Howard C. Herrmann, MD^_*,_*, Jiandong Lu, MD, Bruce R. Brodie, MD, Paul W. Armstrong, MD, Gilles Montalescot, MD, PhD^||, Amadeo Betriu, MD^¶, Franz-Joseph Neuman, MD^#, Mark B. Effron, MD^_**, Elliot S. Barnathan, MD, Eric J. Topol, MD, Stephen G. Ellis, MD for the FINESSE Investigators

^_* Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
Centocor Research & Development, Inc., Malvern, Pennsylvania
LeBauer Cardiovascular Research, Greensboro, North Carolina
University of Alberta Hospital, Edmonton, Alberta, Canada
^|| Hôpital Pitiè-Salpétrière, Paris, France
^¶ Hospital Clinic i Provincial, Barcelona, Spain
^# Herz-Zentrum bad Krozingen, Bad Krozingen, Germany
^_** Eli Lilly and Company, Indianapolis, Indiana
The Scripps Research Institute and Scripps Clinic, La Jolla, California
Cleveland Clinic Foundation, Cleveland, Ohio

^_* Reprint requests and correspondence: Dr. Howard C. Herrmann, 9038 West Gates Building, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, Pennsylvania 19104 (Email: howard.herrmann{at}uphs.upenn.edu).

Objectives: We hypothesized that patients most likely to benefit would be those at high risk with a shorter duration of acute ischemia and who required transfer for percutaneous coronary intervention (PCI).

Background: The FINESSE (Facilitated Intervention with Enhanced Reperfusion Speed to Stop Events) study failed to demonstrate an improvement in the 90-day composite clinical end point of early treatment with abciximab plus half-dose reteplase (combination-facilitated PCI) or abciximab alone.

Methods: We performed a retrospective analysis of 2,452 patients in this double-blind, placebo-controlled study. Patients were stratified by Thrombolysis In Myocardial Infarction (TIMI) risk score for ST-segment elevation myocardial infarction (STEMI), presentation to a spoke (no PCI available) or hub site, and symptom-to-randomization time. Outcomes included the primary composite end point of death, ventricular fibrillation after 48 h, cardiogenic shock, and congestive heart failure through day 90 as well as 1-year mortality.

Results: Mortality for all patients at 1 year was directly related to TIMI risk score (23 of 1,223 = 1.9% in patients with score <3 and 145 of 1,229 = 11.8% with score 3, p < 0.001). Patients with TIMI risk score 3 and presentation to a spoke site with a symptom-to-randomization time 4 h had significantly better 1-year survival if treated with combination-facilitated PCI (hazard ratio [HR]: 0.351, p = 0.01) as well as 90-day composite outcome (HR: 0.45, p = 0.009). A trend for improved survival was also observed in patients with TIMI score 3 and spoke site alone (HR: 0.549, p = 0.06).

Conclusions: Facilitation of PCI with a combination of abciximab and half-dose reteplase improved survival at 1 year in high-risk patients presenting to a spoke hospital with symptom-to-randomization time 4 h. Further prospective study of facilitated PCI in this subgroup of patients is warranted.

Key Words: percutaneous coronary intervention • STEMI facilitation

Abbreviations and Acronyms   HR = hazard ratio   MI = myocardial infarction   PCI = percutaneous coronary intervention   STEMI = ST-segment elevation myocardial infarction   TIMI = Thrombolysis In Myocardial Infarction

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