Analysis of inter-hospital transfer on clinical outcomes after primary percutaneous coronary intervention for ST-segment elevation myocardial infarction: A secondary analysis of the BRIGHT-4 trial.
Previous studies evaluating the influence of inter-hospital transfer on mortality in ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI) reported conflicting results. The multicenter BRIGHT-4 trial demonstrated that bivalirudin plus a post-PCI high-dose infusion (1.75 mg/kg/h) reduced the 30-day primary endpoint of all-cause mortality or Bleeding Academic Research Consortium (BARC) types 3-5 bleeding compared with heparin monotherapy in STEMI patients. This study aimed to assess the impact of inter-hospital transfer on clinical outcomes and the effectiveness of bivalirudin versus heparin in STEMI patients undergoing PCI.
In BRIGHT-4, 2,121 (35.7%) patients were transferred to a tertiary hospital for primary PCI while 3,817 (64.3%) were directly admitted to an interventional facility. The primary outcome was the composite of all-cause death or BARC types 3-5 bleeding occurring within 30 days. The secondary outcomes included stent thrombosis. Adjustments were made for baseline covariates and randomized treatments. Transferred patients had a longer median time from symptom onset to wire crossing the infarct-related artery (6.00 versus 3.93 hrs, P < 0.0001). At 30 days, there were no significant between-group differences in the rates of the primary outcome (4.2% versus 3.4%, adjusted hazard ratio [HR] 0.99, 95% confidence intervals [CI] 0.73, 1.33, P = 0.94) or its components. Bivalirudin with a high-dose post-PCI infusion was associated with consistent reductions of the primary outcome in the transfer (3.5% versus 4.8%, adjusted HR 0.66, 95%CI 0.42, 1.05) and direct admission (2.8% versus 4.1%, adjusted HR 0.62, 95% CI 0.43, 0.89) group compared with heparin monotherapy (Pinteraction = 0.78), as well as individually for stent thrombosis. The main limitations of this study are that it is a post hoc analysis, and the long-term prognostic impact of transfer on STEMI patients requires further investigation.
In this post hoc analysis, 30-day clinical outcomes for STEMI patients transferred for PCI were not significantly worse than direct admission patients. Bivalirudin with a post-PCI high-dose infusion for 2-4 hrs was associated with lower rates of 30-day all-cause mortality, major bleeding and stent thrombosis, consistently observed in transfer and direct admission patients.
BRIGHT-4 trial NCT03822975 http://www.clinicaltrials.gov.
In BRIGHT-4, 2,121 (35.7%) patients were transferred to a tertiary hospital for primary PCI while 3,817 (64.3%) were directly admitted to an interventional facility. The primary outcome was the composite of all-cause death or BARC types 3-5 bleeding occurring within 30 days. The secondary outcomes included stent thrombosis. Adjustments were made for baseline covariates and randomized treatments. Transferred patients had a longer median time from symptom onset to wire crossing the infarct-related artery (6.00 versus 3.93 hrs, P < 0.0001). At 30 days, there were no significant between-group differences in the rates of the primary outcome (4.2% versus 3.4%, adjusted hazard ratio [HR] 0.99, 95% confidence intervals [CI] 0.73, 1.33, P = 0.94) or its components. Bivalirudin with a high-dose post-PCI infusion was associated with consistent reductions of the primary outcome in the transfer (3.5% versus 4.8%, adjusted HR 0.66, 95%CI 0.42, 1.05) and direct admission (2.8% versus 4.1%, adjusted HR 0.62, 95% CI 0.43, 0.89) group compared with heparin monotherapy (Pinteraction = 0.78), as well as individually for stent thrombosis. The main limitations of this study are that it is a post hoc analysis, and the long-term prognostic impact of transfer on STEMI patients requires further investigation.
In this post hoc analysis, 30-day clinical outcomes for STEMI patients transferred for PCI were not significantly worse than direct admission patients. Bivalirudin with a post-PCI high-dose infusion for 2-4 hrs was associated with lower rates of 30-day all-cause mortality, major bleeding and stent thrombosis, consistently observed in transfer and direct admission patients.
BRIGHT-4 trial NCT03822975 http://www.clinicaltrials.gov.
Authors
Su Su, Qiu Qiu, Gu Gu, Yang Yang, Liu Liu, Meng Meng, Ning Ning, Li Li, Zhong Zhong, Wang Wang, Shi Shi, Shang Shang, Liang Liang, Li Li, Han Han, Stone Stone
View on Pubmed