https://doi.org/10.1007/s00392-025-02625-4
1Herzzentrum der Universität zu Köln Klinik für Kardiologie, Angiologie, Pneumologie und Internistische Intensivmedizin Köln, Deutschland; 2Herzzentrum der Universität zu Köln Klinik III für Innere Medizin Köln, Deutschland; 3Universitätsmedizin der Johannes Gutenberg-Universität Mainz Zentrum für Kardiologie Mainz, Deutschland; 4Universitätsklinikum Köln Herzzentrum - Kardiologie Köln, Deutschland; 5Krankenhaus der Augustinerinnen, Akademisches Lehrkrankenhaus Klinik für Kardiologie und internistische Intensivmedizin Köln, Deutschland; 6St. Antonius Krankenhaus Medizinische Klinik & Kardio-Diabetes-Zentrum Köln Köln, Deutschland; 7Ev. Krankenhaus Köln-Kalk Kardiologie & Internistische Intensivmedizin Köln, Deutschland; 8Krankenhaus Porz am Rhein gGmbH Klinik für Kardiologie, Elektrophysiologie u. Rhythmologie Köln, Deutschland; 9Cellitinnen Krankenhaus St. Vinzenz Köln Innere Medizin III - Kardiologie Köln, Deutschland; 10Kliniken der Stadt Köln gGmbH, Krankenhaus Merheim Medizinische Klinik II Köln, Deutschland; 11Klinikum Leverkusen Klinik für Akut- und Notfallmedizin Leverkusen, Deutschland; 12Universitätsklinikum Köln Klinik III für Kardiologie, Angiologie, Pneumologie und Internistische Intensivmedizin Köln, Deutschland
Background: The current European guideline on diagnosis and treatment of ST-segment elevation myocardial infarction (STEMI) explicitly recommends primary percutaneous coronary intervention (PPCI) in patients with ischemic symptoms and on-set within 12h. There is robust evidence that PPCI is superior to fibrinolysis or conservative treatment in these patients. On the contrary, there is uncertainty whether PPCI is equally advantageous in patients with a symptom on-set >12 and ≤48h. Currently, PPCI should be considered in these LATECOMERS (IIa B recommendation). Further evaluation of this understudied STEMI subgroup is required to optimize triage.
Objective: This study examined the treatment trends of LATECOMERS with STEMI. Efficacy and safety data were analyzed, these were compared to patients with early presentation.
Methods: The multicentric, metropolitan registry included STEMI patients treated between January 2005 and December 2020. Patients were stratified by the symptom-to-contact (S2C) time: LATECOMERS (>12h and ≤48h S2C time) were separated from those with EARLY presentation (≤12h S2C time). Patients with S2C time >48h were excluded. Data were analyzed using Student’s t test or Mann Whitney U test, and Chi square test. A two-sided p-value < 0.05 was defined as statistically significant.
Results: 4768 patients were registered in the infarction network. Of these, 4157 were eligible, 406 (9.8%) were classified as LATECOMERS and 3751 (90.2%) as EARLY group. The total ischemic interval was prolonged in LATECOMERS, but even in LATECOMERS system-related delay was within the recommended time frame: 92% of invasively managed LATECOMERS underwent coronary angiography within 2 hours after first medical contact.
In direct comparison, LATECOMERS were more often female, had a lower rate of culprit lesion, and were less frequently treated with stent implantation (see Table). LATECOMERS had a worse angiographic outcome: slow flow or no-reflow in the infarct-related artery following PPCI was more prevalent compared to EARLY group (TIMI 0-2: 17.8 vs. 12.7%, p<0.01). Enzymatic infarct size measured by peak creatine kinase was comparable between LATECOMERS and EARLY group (see Table). LATECOMERS showed a trend towards a worse echocardiographic outcome at discharge, 55% had impaired left ventricular ejection fraction (LVEF), while the corresponding rate was 47.3% in EARLY group (p=0.089). In-hospital mortality was similar between LATECOMERS and EARLY group (9.4 vs. 8.6%, p=0.619).
LATECOMERS with a culprit lesion (n=323) were a subgroup of interest as they are predisposed to benefit from PPCI. That subgroup had an in-hospital mortality of 7.7%. Notably, these patients had an even worse echocardiographic outcome: 42.4% had preserved, 57.5% had impaired LVEF (36.6% mildly reduced and 20.9% reduced LVEF).
Conclusions: Every tenth STEMI was a LATECOMER. These were frequently triaged to PPCI, and 92% underwent timely coronary angiography (≤2h) after first medical contact. A culprit lesion was a frequent finding in LATECOMERS. LATECOMERS with an identified culprit lesion had a similar short-term survival compared to EARLY group.
These findings are hypothesis-generating, but they support routine and immediate coronary angiography in LATECOMERS. Whether the worse angiographic and echocardiographic outcome at discharge have a specific impact on long-term prognosis of LATECOMERS requires further prospective evaluation.