Is spontaneous pre-hospital coronary reperfusion in STEMI safe ?

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Abstract Background Complete spontaneous reopening of the culprit artery at admission in the catheterization laboratory was reported as associated with improved outcomes in ST- segment elevation myocardial infarction (STEMI). Purpose To evaluate incidence and prognostic of spontaneous coronary reperfusion in STEMI using a systematic pre-hospital P2Y12 inhibitor antithrombotic strategy. Methods This prospective bi-centric observational and prospective study included consecutive STEMI patients who referred in our catheterization laboratory for primary PCI from June 1, to November 1, 2022. Only patients admitted in the early phase of STEMI (pain onset < 12 hours) or with evolved STEMI (pain lasting between 12 and 48 hours were enrolled. All patients received as soon as possible and before hospital admission loading dose of aspirin, heparin and P2Y12 inhibitor. The primary outcome was the incidence of initial spontaneous coronary reperfusion (TIMI 3 flow) assessed by coronary angiography at admission before primary PCI. Major in-hospital outcomes and major events at 1- year follow-up were assessed as secondary outcomes. Results Within the study period, 263 patients were admitted with ongoing STEMI and 49 (18.6%) of them had spontaneous reperfusion of the culprit coronary artery at admission. Ticagrelor was used in main patients (n=185, 86.5%) without significant differences regarding the primary outcome comparing to clopidogrel therapy (p=0.42). Initial presentation with cardiac arrest was observed twice as often in the TIMI 3 flow group (16.33 vs 7.01% ; p=0.049) as TV/FV before admission (14.3 vs 7.5 %, p=0.15), possibly related to reperfusion arrhythmias. Regarding in-hospital evolution, we observed significantly lower peak of T-hs troponin and CRP in the spontaneous reperfusion group (respectively p<0.001 and p=0.031) but no significant difference regarding major in-hospital events in the 2 groups (table ) . At 1-year follow-up, LVEF was significantly higher in the TIMI 3 group (56 ±13 vs 54 ±10 ; p=0.032) but no significant difference in major events was highlighted (p=0.20). Conclusion Spontaneous reperfusion at admission is observed in about 1/5 of STEMI patients after pre-hospital loading dose of anti thrombotic therapy including P2Y12 inhibitors, and is associated with markers of decrease of infarct size. The significant increase of pre-admission cardiac arrests observed in the TIMI 3 group, has however to be further explored as it might be a concern regarding future pre-hospital reperfusion therapy strategies.

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