Provocative Strategies for Primary PCI in STEMI: Time to Rethink Guidelines

Abstract

Background: The primary percutaneous coronary intervention (PCI) is now the reference treatment for ST-segment elevation myocardial infarction (STEMI). Findings from randomized controlled trials suggest that PCI is superior to thrombolytic therapy in preventing death and recurrent myocardial infarction. However, longer delays for PCI implementation and variability in outcomes among different operators and centers may affect its efficacy. The European guidelines recommend fibrinolytic therapy if PCI cannot be performed within 120 minutes of the first medical contact.

Objective: The main objective of the study was to evaluate the efficacy of adjunctive provocative strategies in primary PCI for STEMI and their impact on procedural success and clinical outcomes.

Methods: This retrospective observational study was conducted at Luqman International Hospital, Mingora Swat, from December 2022 to June 2023. Data were collected from 230 STEMI patients, including demographic information, clinical characteristics, procedural details, and outcomes. The primary outcome measure was the occurrence of major adverse cardiac events (MACE) within 30 days and one year after primary PCI. Secondary outcomes included procedural success rate, myocardial blush grade, and left ventricular ejection fraction (LVEF) during follow-up assessments. Statistical analyses were performed using SPSS version 25, with continuous variables expressed as means and standard deviations and categorical variables as frequencies and percentages. Comparisons between groups were conducted using chi-square tests for categorical variables and Student’s t-tests or Mann-Whitney U tests for continuous variables, with a p-value of less than 0.05 considered statistically significant.

Results: Of the 230 patients, 120 (52%) received conventional strategies, while 110 (48%) received adjunctive provocative strategies. The provocative strategy group had higher rates of successful reperfusion (95.5% vs. 83.3%), improved myocardial blush grades (mean ± SD: 3.2 ± 0.6 vs. 2.7 ± 0.8), and lower rates of the no-reflow phenomenon (9.1% vs. 20.8%). At 30 days post-PCI, the incidence of MACE was lower in the provocative strategy group (9.1% vs. 12.5%). At one year, the provocative strategy group continued to show lower MACE rates (16.4% vs. 20.8%).

Conclusion: Adjunctive provocative strategies in primary PCI for STEMI show promise in enhancing reperfusion efficacy and preserving myocardial function. While trends towards improved procedural success and short-term outcomes were observed, larger prospective studies are needed to validate these findings. The exploration of provocative strategies represents an important avenue for advancing STEMI management and improving patient outcomes in interventional cardiology.