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Does Late Reperfusion After STEMI Improve Outcomes?

An invasive treatment strategy benefited some patients with ST-segment–elevation MI, but without ongoing pain, who presented more than 12 hours after symptom onset.

Conventional wisdom holds that an acute ST-segment–elevation MI (STEMI) is finished in 6 to 12 hours. Current guidelines do not recommend reperfusion treatment in STEMI patients who present more than 12 hours after symptom onset. In this randomized, multicenter European trial, 365 STEMI patients who presented from 12 to 48 hours after symptom onset were randomized to an invasive or a conservative treatment strategy. The mean time from pain onset to angiography was about 25 hours. Of the invasive group, 87% received stents and all received abciximab.

The final left-ventricular infarct size, assessed with single-photon emission computed tomography a median of 7 days after randomization, was significantly smaller with invasive than with conservative management (median, 8.0% vs. 13.0%), particularly among patients who presented 24 to 48 hours after symptom onset (6.5% vs. 15.0%). The only independent predictor of final infarct size was initial TIMI flow. Clinical outcomes at 30 and 90 days tended to favor invasively managed patients.

Comment: This is the first randomized trial to show a benefit of very late reperfusion after STEMI. The inclusion of more patients with initially patent infarct arteries than in previous trials, and the routine use of stents and abciximab, might help to explain the benefit. The editorialists suggest that "late presenters" may represent up to 30% of STEMI patients. They also note that residual antegrade or collateral flow (present in 73% of subjects) might have preserved myocardial viability until intervention and that absence of symptoms is a poor indicator of absence of viability. According to this study, late reperfusion benefits some STEMI patients without ongoing pain who present more than 12 hours after symptom onset. However, as the editorialists note, less is likely to be gained from late reperfusion in these patients than from improving reperfusion rates in early presenters and reducing the time from symptom onset to presentation.

— Howard C. Herrmann, MD

Published in Journal Watch Cardiology July 29, 2005

Citation(s):

Schömig A et al. for the Beyond 12 hours Reperfusion AlternatiVe Evaluation (BRAVE-2) Trial Investigators. Mechanical reperfusion in patients with acute myocardial infarction presenting more than 12 hours from symptom onset: A randomized controlled trial. JAMA 2005 Jun 15; 293:2865-72.

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• Medline abstract (Free)

Gibbons RJ and Grines CL. Acute PCI for ST-segment elevation myocardial infarction: Is later better than never? JAMA 2005 Jun 15; 293:2930-2.

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• Medline abstract (Free)