Vol 26, No 4 (2019)
Original articles — Interventional cardiology
Published online: 2018-03-29

open access

Page views 4903
Article views/downloads 1661
Get Citation

Connect on Social Media

Connect on Social Media

Invasive reperfusion after 12 hours of the symptom onset remains beneficial in patients with ST-segment elevation myocardial infarction: Evidence from a meta-analysis of published data

Hai-Tao Yang1, Wen-Juan Xiu1, Ying-Ying Zheng1, Fen Liu2, Ying Gao3, Xiang Ma1, Yi-Ning Yang1, Xiao-Mei Li1, Yi-Tong Ma1, Xiang Xie1
Pubmed: 29611165
Cardiol J 2019;26(4):333-342.


Background: Early myocardial reperfusion therapy (< 12 h) in patients with acute myocardial infarc­tion (AMI) can significantly improve their prognosis. However, the effect of late reperfusion (> 12 h) remains controversial. In this study, the effects of late reperfusion versus standard drug therapy on the outcomes of patients with AMI were evaluated by systematic review and meta-analysis.

Methods: PubMed, Embase, Medline, Cochrane, Wanfang, and CNKI databases were searched for eligible studies for the present study. Meta-analysis was performed using RevMan 5.3.3 software. Rela­tive risk (RR) and the 95% confidence interval (CI) were used to compare the outcomes between the two groups. The main outcome measures were major adverse cardiac events (MACEs), all-cause mortality, recurrent myocardial infarction (MI), and heart failure.

Results: Eighteen studies were identified including 14,677 patients, of whom 5157 received late reperfusion with percutaneous coronary intervention (PCI) and 9520 received medication therapy (MT). Compared to MT, late PCI was associated with decreased all-cause mortality (RR 0.60, 95% CI 0.44–0.83; p = 0.002), MACEs (RR 0.67; 95% CI 0.50–0.89; p < 0.001), and heart failure (RR 0.76; 95% CI 0.60–0.97; p = 0.03), while there was also a trend toward decreased recurrent MI (RR 0.70; 95% CI 0.47–1.05; p = 0.08). However, subgroup analysis according to time to PCI showed that the clinical benefit was only from PCI after 12 h but not from 2 to 60 days of the onset of symptoms.

Conclusions: The present meta-analysis suggested that PCI performed > 12 h but not 2–60 days after AMI is associated with significant improvement in clinical outcomes. However, these results need further rigorously designed large sample size clinical trials to be validated.

Article available in PDF format

View PDF Download PDF file


  1. Kawaji T, Shiomi H, Morimoto T, et al. CREDO-Kyoto AMI investigators. Long-term clinical outcomes in patients with ST-segment elevation acute myocardial infarction complicated by cardiogenic shock due to acute pump failure. Eur Heart J Acute Cardiovasc Care. 2016 [Epub ahead of print].
  2. Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction). J Am Coll Cardiol. 2004; 44: e1–211.
  3. Choi IkJ, Koh YS, Lim S, et al. Impact of Percutaneous Coronary Intervention for Chronic Total Occlusion in Non-Infarct-Related Arteries in Patients With Acute Myocardial Infarction (from the COREA-AMI Registry). Am J Cardiol. 2016; 117(7): 1039–1046.
  4. Claessen BE, Dangas GD, Weisz G, et al. Prognostic impact of a chronic total occlusion in a non-infarct-related artery in patients with ST-segment elevation myocardial infarction: 3-year results from the HORIZONS-AMI trial. Eur Heart J. 2012; 33(6): 768–775.
  5. Welsh RC, Granger CB, Westerhout CM, et al. APEX AMI Investigators. Prior coronary artery bypass graft patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention. JACC Cardiovasc Interv. 2010; 3(3): 343–351.
  6. Appleton DL, Abbate A, Biondi-Zoccai GGL. Late percutaneous coronary intervention for the totally occluded infarct-related artery: a meta-analysis of the effects on cardiac function and remodeling. Catheter Cardiovasc Interv. 2008; 71(6): 772–781.
  7. Abbate A, Biondi-Zoccai GGL, Appleton DL, et al. Survival and cardiac remodeling benefits in patients undergoing late percutaneous coronary intervention of the infarct-related artery: evidence from a meta-analysis of randomized controlled trials. J Am Coll Cardiol. 2008; 51(9): 956–964.
  8. Horie H, Takahashi M, Minai K, et al. Long-term beneficial effect of late reperfusion for acute anterior myocardial infarction with percutaneous transluminal coronary angioplasty. Circulation. 1998; 98(22): 2377–2382.
  9. Hochman JS, Lamas GA, Buller CE, et al. Occluded Artery Trial Investigators. Coronary intervention for persistent occlusion after myocardial infarction. N Engl J Med. 2006; 355(23): 2395–2407.
  10. Dzavík V, Buller CE, Lamas GA, et al. TOSCA-2 Investigators. Randomized trial of percutaneous coronary intervention for subacute infarct-related coronary artery occlusion to achieve long-term patency and improve ventricular function: the Total Occlusion Study of Canada (TOSCA)-2 trial. Circulation. 2006; 114(23): 2449–2457.
  11. Yousef ZR, Redwood SR, Bucknall CA, et al. Late intervention after anterior myocardial infarction: effects on left ventricular size, function, quality of life, and exercise tolerance: results of the Open Artery Trial (TOAT Study). J Am Coll Cardiol. 2002; 40(5): 869–876.
  12. Gierlotka M, Gasior M, Wilczek K, et al. Reperfusion by primary percutaneous coronary intervention in patients with ST-segment elevation myocardial infarction within 12 to 24 hours of the onset of symptoms (from a prospective national observational study [PL-ACS]). Am J Cardiol. 2011; 107(4): 501–508.
  13. Freixa X, Džavík V, Forman SA, et al. Long-term outcomes after a strategy of percutaneous coronary intervention of the infarct-related artery with drug-eluting stents or bare metal stents vs medical therapy alone in the Occluded Artery Trial (OAT). Am Heart J. 2012; 163(6): 1011–1018.
  14. Wu Xl, Zhu R, Jiang H, et al. Different treatment interventions affect plasma NT-ProBNP levels and early exercise tolerance in patients with acute ST-segment elevation myocardial infarction. Postgrad Med. 2012; 124(2): 58–63.
  15. Zeymer U, Uebis R, Vogt A, et al. ALKK-Study Group. Randomized comparison of percutaneous transluminal coronary angioplasty and medical therapy in stable survivors of acute myocardial infarction with single vessel disease: a study of the Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte. Circulation. 2003; 108(11): 1324–1328.
  16. Steg PG, Thuaire C, Himbert D, et al. DECOPI Investigators. DECOPI (DEsobstruction COronaire en Post-Infarctus): a randomized multi-centre trial of occluded artery angioplasty after acute myocardial infarction. Eur Heart J. 2004; 25(24): 2187–2194.
  17. Erne P, Schoenenberger AW, Burckhardt D, et al. Effects of percutaneous coronary interventions in silent ischemia after myocardial infarction: the SWISSI II randomized controlled trial. JAMA. 2007; 297(18): 1985–1991.
  18. Schömig A, Mehilli J, Antoniucci D, et al. 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; 293(23): 2865–2872.
  19. Silva JC, Rochitte CE, Júnior JS, et al. Late coronary artery recanalization effects on left ventricular remodelling and contractility by magnetic resonance imaging. Eur Heart J. 2005; 26(1): 36–43.
  20. Dzavik V, Beanlands DS, Davies RF, et al. Effects of late percutaneous transluminal coronary angioplasty of an occluded infarct-related coronary artery on left ventricular function in patients with a recent (< 6 weeks) Q-wave acute myocardial infarction (Total Occlusion Post-Myocardial Infarction Intervention Study [TOMIIS]--a pilot study). Am J Cardiol. 1994; 73(12): 856–861.
  21. Ellis SG, Mooney MR, George BS, et al. Randomized trial of late elective angioplasty versus conservative management for patients with residual stenoses after thrombolytic treatment of myocardial infarction. Treatment of Post-Thrombolytic Stenoses (TOPS) Study Group. Circulation. 1992; 86(5): 1400–1406.
  22. Khan JN, Razvi N, Nazir SA, et al. Prevalence and extent of infarct and microvascular obstruction following different reperfusion therapies in ST-elevation myocardial infarction. J Cardiovasc Magn Reson. 2014; 16: 38.
  23. Qi BQ, Yang XJ. Short-term and long-term therapeutics effects of varying treatment methods in patients with acute myocardial infarction: a comparison study. Suzhou University. 2006; 1: 1.
  24. He J, Ni J, Zheng JL, et al. Comparison of outcome in patients with non-ST-segment elevation myocardial infarction treated with selective percutaneous coronary intervention and drug respectively. Chongqi Yi Xue. 2010; 39: 2334–2337.
  25. Elad Y, French WJ, Shavelle DM, et al. Primary angioplasty and selection bias inpatients presenting late (>12 h) after onset of chest pain and ST elevation myocardial infarction. J Am Coll Cardiol. 2002; 39(5): 826–833.
  26. Nishino S, Watanabe N, Kimura T, et al. The course of ischemic mitral regurgitation in acute myocardial infarction after primary percutaneous coronary intervention: from emergency room to long-term follow-up. Circ Cardiovasc Imaging. 2016; 9(8): e004841.
  27. Brunetti ND, Correale M, Pellegrino PL, et al. Early inflammatory cytokine response: a direct comparison between spontaneous coronary plaque destabilization vs angioplasty induced. Atherosclerosis. 2014; 236(2): 456–460.
  28. Robbers LF, Delewi R, Nijveldt R, et al. Myocardial infarct heterogeneity assessment by late gadolinium enhancement cardiovascular magnetic resonance imaging shows predictive value for ventricular arrhythmia development after acute myocardial infarction. Eur Heart J Cardiovasc Imaging. 2013; 14(12): 1150–1158.
  29. Dangas GD, Claessen BE, Mehran R, et al. Clinical outcomes following stent thrombosis occurring in-hospital versus out-of-hospital: results from the HORIZONS-AMI (Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction) trial. J Am Coll Cardiol. 2012; 59(20): 1752–1759.
  30. Levine GN, Bates ER, Blankenship JC, et al. 2015 ACC/AHA/SCAI Focused Update on Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial Infarction: An Update of the 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention and the 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction. J Am Coll Cardiol. 2016; 67(10): 1235–1250.
  31. Abbate A, Bussani R, Biondi-Zoccai GGL, et al. Persistent infarct-related artery occlusion is associated with an increased myocardial apoptosis at postmortem examination in humans late after an acute myocardial infarction. Circulation. 2002; 106(9): 1051–1054.
  32. Abbate A, Bussani R, Biondi-Zoccai GGL, et al. Infarct-related artery occlusion, tissue markers of ischaemia, and increased apoptosis in the peri-infarct viable myocardium. Eur Heart J. 2005; 26(19): 2039–2045.
  33. Sabia PJ, Powers ER, Ragosta M, et al. An association between collateral blood flow and myocardial viability in patients with recent myocardial infarction. N Engl J Med. 1992; 327(26): 1825–1831.
  34. Busk M, Kaltoft A, Nielsen SS, et al. Infarct size and myocardial salvage after primary angioplasty in patients presenting with symptoms for <12 h vs. 12-72 h. Eur Heart J. 2009; 30(11): 1322–1330.