Heart Sci J 2020; 1(3): 21-26
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Heart Science Journal
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Original Article

Percutaneous Coronary Intervention in ST-Segment
Elevation Myocardial Infarction: Late is Better Than Not
Done at All
Hendrawati Hendrawati1,2*, Mohammad Saifur Rohman2,3, Cholid Tri Tjahjono3, Sasmojo Widito 3,
Budi satrijo3, Yoga Waranugraha3, Muhammad Rizki Fadlan2, Iskandar Iskandar2
1

Department of Cardiology and Vascular Medicine, Dr. Haryoto General Hospital, Lumajang, Indonesia.

2 Brawijaya Cardiovascular Research Center, Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Brawijaya, Malang, Indonesia.
3

Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Brawijaya, Malang, Indonesia.

ART I C LE I NFO

AB STR A C T

Keywords:
Angiotensin-converting enzyme inhibitor;
Heart failure;
Optimal dose

Background : For ST-segment elevation myocardial infarction (STEMI) patients, reperfusion through primary
percutaneous coronary intervention (PCI) must be done to return the coronary arteries' blood flow. However, a
large proportion of patients received late PCI. This study aimed to assess the impact of late PCI on the clinical
outcomes of STEMI patients.
Methods : A retrospective cohort study was conducted in Saiful Anwar General Hospital from January 2017 to
April 2018. A total of 192 STEMI patients were divided into three groups: (1) on-time PCI; (2) late PCI; and (3)
no PCI. The outcome measured included six months and 12 months of cardiovascular mortality and hospital
readmission because of worsening heart failure and recurrent myocardial infarction (MI).
Results: At six-month follow-up period, we found that hospital readmission was higher in the no PCI group (9.2%
vs. 12.1% vs. 34.8%; p = 0.009). The recurrent MI (0% vs. 0% vs. 7.2%; p = 0.010) and worsening heart failure
(6.2% vs. 8.6% vs. 33.3%; p < 0.001) was also higher in the no PCI group. On 12 months follow up period, the
mortality (4.6% vs. 13.8% vs. 21.7%; p = 0.015) and hospital readmission (15.4% vs. 20.7% vs. 42%; p = 0.001)
rate was higher in no PCI group. Hospital readmission because of worsening heart failure was also higher in no
PCI group (9.2% vs. 17.2% vs. 37.7%; p = 0.015).
Conclusion: Not performing revascularization was correlated with higher mortality and hospital readmission rate
in STEMI patients. Late PCI was associated with better outcomes than not conducting revascularization.

1. Introduction

3.3 additional deaths per 100 patients treated with PCI.7

STEMI is the most severe manifestation of the acute coronary
syndrome (ACS). Generally, STEMI is caused by the rupture of atheromatous plaque, leading to thrombus generation, resulting in acute total
occlusion of the coronary artery.1 Following interrupted coronary blood
flow, myocardial damage begins. The more prolonged ischemia
occurred, the greater the amount of myocardial damage. Revascularization using primary PCI conducted within 12 hours following onset is
the best treatment strategy in STEMI patients.2,3 Several studies emphasized the strong correlation between the delay in revascularization and
mortality in STEMI patients accompanied with out-of-hospital cardiac
arrest (OHCA) or cardiogenic shock.4-6 In STEMI accompanied by
cardiogenic shock without OHCA, between 60-180 minutes from the
first medical contact, every 10 minutes of treatment delay will produce

Previous studies also have shown that STEMI patients
received more benefit by primary PCI conducted less than 12 hours
from the onset of STEMI symptoms.8 However, for STEMI patients with
onset of more than 12 hours, the evidence to support performing PCI is
not strong enough. Occluded Artery Trial (OAT) revealed no benefit of
late reperfusion for patients who arrive over three days after the
onset.9,10 However, several studies showed that conducting PCI is still
beneficial for myocardial saving, even though it was done late.11,12 This
study aimed to assess the impact of late PCI on the clinical outcomes of
STEMI patients.
2. Methods

*Corresponding author at: Brawijaya Cardiovascular Research Center, Department of Cardiology and Vascular Medicine, Faculty of Medicine,
Universitas Brawijaya, Malang, Indonesia
E-mail address: hendrawati.dr@gmail.com (Hendrawati).
https://doi.org/10.21776/ub.hsj.2020.001.03.5
Received 9 September 2020; Received in revised form 12 September 2020; Accepted 24 September 2020
Available online 21 October 2020

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Heart Sci J 2020; 1(3): 21-26

financial problems or not covered by insurance) were classified as no
PCI.

2.1. Study Design

It was a retrospective cohort study. We used a consecutive
sampling method. This study protocol was recognized and approved
by the ethical committee of Saiful Anwar General Hospital.

The outcome measured was six months and 12 months of
mortality and hospital readmission. Readmission data were obtained
from medical records or interview questionnaires on phone calls about
hospital readmission after discharge due to recurrent MI and worsening
heart failure. Mortality data were obtained from family member
information declared dead from phone call interviews or medical
records that showed mortality during hospitalization. The study
flowchart is summarized in Figure 1.

2.2. Study population
AAll patients admitted to Saiful Anwar General Hospital,
Malang, Indonesia, with confirmed STEMI from January 2017 to April
2018, according to the 2017 ESC Guideline for STEMI, were included
in this study. We excluded patients with: (1) congenital heart disease;
(2) valvular heart disease; (3) pulmonary hypertension; (4) idiopathic
cardiomyopathy; (5) severe liver or renal dysfunction; (6) malignancy,
(7) autoimmune disease; or (8) uncontrolled systemic diseases
(Figure1).

2.5. Statistical analysis
IBM SPSS version 22 software was used to conduct statistical
analysis. Number and percentages were used to show categorical data.
Mean and standard deviation were used to present numeric data.
Statistical analysis for numeric data with normal distribution was
performed using the analysis of variance (ANOVA). However, if the
data abnormally distributed, the Kruskal Wallis test was used to
conduct statistical analysis of numerical data. Statistical analysis for
categorical data was conducted using the Chi-square test. A p-value of
<0.005 is considered significant statistically.

2.3. Baseline Data Collection
All information about the patient, including demographic
data, payment status, Killip class, and risk stratification using Thrombolysis in Myocardial Infarction (TIMI) risk score and Global Registry of
Acute Coronary Events (GRACE) score were collected using a standard
case-report form. The TIMI score is classified into two categories, the
score <5 is classified as low risk, while the score> 5 is high risk.13 We
used the GRACE score to estimate mortality within six months in STEMI
patients. The GRACE score is classified into three groups: (1) GRACE
score of <109 (low risk); (2) GRACE score 109 to 140 (moderate risk);
and (3) GRACE score of >140 (high risk).2,14,15

3. Results
3.1. Patients basic characteristics
We collected the data from 256 STEMI patients. However,
about 64 STEMI patients were excluded because of incomplete data,
lost follow-up, and refused participation. Finally, a total of 192 patients
were involved in the analysis process. The patients' mean age was 57.7
± 10.2 years, and 81.3% of them were male. The one-year readmission
and mortality rates were 26.6% and 13.5%, respectively. The most
common cause of readmission is worsening heart failure (62%). Table
1 is summarizing patients' baseline characteristics.
Among the three groups of patients, from baseline characteristics, no significant differences in the proportion of age, sex, chest pain
onset, TIMI risk score, GRACE score, Killip class, and medication
adherence, except payment status, were found. Coronary angiographic
characteristics data in groups of STEMI patients receiving PCI treatment
were not significantly different in terms of the number of coronary
lesions, the infarct-related artery (IRA), and TIMI flow. A total of 123
(64%) patients were treated by PCI, while 69 (36%) received only
optimal medical therapy.
3.1. Clinical outcome
During the six-month follow-up period, we found that
hospital readmission was higher in the no PCI group (9.2% vs 12.1% vs
34.8%; p = 0.009). We also conducted a subgroup analysis of the cause
of hospital readmission. Higher percentage of recurrent MI was found
in the no PCI group (0% vs. 0% vs. 7.2%; p = 0.010). A higher percentage of worsening heart failure was also found in the no PCI group (6.2%
vs 8.6% vs 33.3%; p < 0.001). The mortality rate among the three
groups was not significantly different (3.1% vs 5.2% vs 10.1%; p =
0.221).

Figure 1. Study flowchart

2.4. Exposure and Outcome
The exposure was the reperfusion strategy. STEMI Patients
were divided into three separate groups based on the reperfusion
strategy: on-time PCI group, late PCI group, and no PCI group. On-time
PCI was defined as PCI that was performed within the time frames
according to the 2017 ESC Guidelines for STEMI management. PCI that
performed beyond the time frames determined by the 2017 ESC Guidelines for STEMI management was Late PCI.2 The late PCI criteria
included PCI performed beyond 12 hours from the onset of chest pain
symptoms in STEMI patients with stable hemodynamic or rescue PCI in
>90 minutes after failed fibrinolytic therapy. STEMI patients who
received optimal medical treatment but did not receive any reperfusion
or failed to undergo PCI (due to abnormal anatomical morphology of
coronary artery, passed away before PCI, and refused PCI because of

During the follow-up period of 30 days following hospital
discharge, three patients in suboptimal dose of ACEI group were passed
away. Two patients passed away because of cardiogenic shock, while
one patient passed away because of sudden cardiac death. Data analysis
During the 12 months follow up period, the mortality (4.6%
vs. 13.8% vs. 21.7%; p = 0.015). and hospital readmission (15.4% vs.
20.7% vs. 42%; p = 0.001) rate was higher in no PCI group

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Heart Sci J 2020; 1(3): 21-26

showing survival from hospital readmission and mortality during 12
months follow-up period is shown in figure 2.

From subgroup analysis, we found that worsening heart failure causing
hospital readmission was higher in no PCI group (9.2% vs 17.2% vs
37.7%; p = 0.015). However, recurrent MI among the three groups
(4.6% vs 1.7% vs 7.2%; p = 0.340) was not significantly different. The
clinical outcomes were summarized in table 2. Kaplan-Meier curve

Figure 2. Kaplan-Maier curves for hospital readmission (B) and mortality (B)
Table 1. Baseline charaterictic of the patients

Group
Variables

On-time PCI
(n=65)

Age

56 + 10.4

Sex

Late PCI
(n=58)
57 + 8.9

No PCI
(n=69)

p

59 + 11.17

0.450

Student

0.336

Male

52 (80.0)

Female

13(20.0)

51 (87.9)
7 (12.1)

54 (78.3)
15 (21.7)

Payment status

0.000

Insurance

64 (98.5)

Regular

1 (1.5)

50 (86.2)
8 (13.8)

41 (59.4)
28 (40.6)

Symptom onset

0.930

<12 hours

44 (67.7)

>12 hours

21 (32.2)

28 (48.3)
30 (51.7)

40 (58.0)
29 (42.0)

TIMI score

0.389

<5

55 (84.6)

>5

10 (15.4)

44 (24.1)
14 (24.1)

51 (73.9)
18 (26.1)

GRACE score
Low

0.518
23 (39.7)

31 (47.7)

Intermediate

20 (30.8)

High

14 (21.5)

18 (31.0)
17 (29.3)

23

28 (40.6)
17 (24.6)
24 (34.8)

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Heart Sci J 2020; 1(3): 21-26

Killip

0.556

I

48 (73.8)

II

2 (3.1)

III

0 (0.0)

IV

15 (23.1)

Medication adherence

51(82.3)

40 (69.0)
5 (8.6)
2 (3.4)
11 (19.0)
55 (94.8)

48 (69.6)
3 (4.3)
1(1.4)
17 (24.6)
61 (89.7)

Infarct related artery

0.080
0.155

Left main

0 (0.0)

Left anterior descending artery

28 (43.1)

Left circumflex artery

4 (6.2)

Right coronary artery

33 (50.8)

0 (0.0)
35 (60.3)
3 (5.2)
20 (34.5)

-

Number of lesions

0.520

1

8 (12.3)

2

14 (21.5)

3

43 (66.2)

7 (12.5)
17 (30.4)
32 (57.1)

-

TIMI flow

0.203

0-1

1 (1.5)

2

13 (20.0)

3 (5.2)
9 (15.5)
46 (79.3)

51 (78.5)

3

-

Note, data were presented in mean ± SD or n(%); GRACE = Global Registry of Acute Coronary Events; PCI = percutaneous coronary intervention; TIMI = Thrombolysis in Myocardial Infarction

Table 2. Outcomes

Group
Variables

On-time PCI
(n=65)

6 months of follow up

56 + 10.4

Mortality

Late PCI
(n=58)
57 + 8.9

No PCI
(n=69)

p

59 + 11.17

0.450

Student

0.336

Readmission

52 (80.0)

Cause of readmission

13(20.0)

51 (87.9)
7 (12.1)

54 (78.3)
15 (21.7)

Recurrent myocardial infarction

0.000

Heart failure

64 (98.5)

Angina

1 (1.5)

50 (86.2)
8 (13.8)

41 (59.4)
28 (40.6)

12 months of follow up
Mortality
Readmission

0.930
28 (48.3)

44 (67.7)

30 (51.7)

21 (32.2)

Cause of readmission

40 (58.0)
29 (42.0)
0.389

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Heart Sci J 2020; 1(3): 21-26

Recurrent myocardial infarction

3 (4.6)

Heart Failure

6 (9.2)

Angina

3 (4.6)

1 (1.7)
10 (17.2)
3 (5.2)

5 (7.2)

0.340

26 (37.7)

<0.001

9 (13)

0.128

Note, data were presented in mean ± SD or n(%); PCI = percutaneous coronary intervention.

followed on days 30 and 90 did not show differences between both
groups.12 Mortality rate was significantly lower in the invasive strategy
group (11.1%) than the conservative group (18.9%), at four years
follow up, reflecting the absolute risk difference of 7.8%.22

4. Discussion
The hospital readmission rate for six months and twelve
months follow-up was higher in no PCI group. From the subgroup
analysis, there were essential variations causes of hospital admission.
Recurrent MI contributed to hospital readmission for six months
follow-up period. However, worsening heart failure contributed to
hospital readmission for six months and twelve months follow-up
period. From the subgroup analysis, it was found that the most common
reason behind hospital readmission was the worsening of heart failure.
It was significantly different between the on-time PCI and no PCI
groups (p < 0.001) and between the late PCI and no PCI groups (p =
0.019).

Our study aimed to look for the impact of late PCI on the
clinical outcome of STEMI patients without seeing the delay based on
the division of time frames. Delay >72 hours are considered the same
for the period after, while the data obtained for the delay in PCI in
opening an IRA starts from 24 hours to 11 months. The research with
better design might be warranted. The relatively small number of
samples and the high exclusion rate of patients were also the drawbacks
of this study besides the limited follow-up period of up to 12 months.
Further research with a larger number of samples, a more extended
follow-up period, and a more accurate analysis is needed.

The meta-analysis study by Yang et al., which involved 11
studies reported the incidence of readmission related to myocardial
infarction, showed significantly different results (p = 0.008). There was
a tendency of decreasing rates of recurrent MI in late revascularization
groups in all patients. Subgroup analysis showing late reperfusion
beyond 12 hours was associated with a significant reduction of the
incidence of recurrent MI compared to groups with optimal medical
therapy (p <0.001), but this difference did not show significant results
in 2-60 days late reperfusion (p = 0.55). Whereas for readmission
related to worsening heart failure, the meta-analysis of Yang et al.
reported that late reperfusion of beyond 12 hours was significantly
correlated with a reduction in worsening heart failure (p = 0.004).16

5. Conclusion
Not performing revascularization was correlated with higher
mortality and hospital readmission rate in STEMI patients. Late PCI was
associated with better outcomes than not conducting revascularization.
However, conducting on-time PCI based on the guideline recommendation was the best approach for improving STEMI patients' outcomes.
6. Declarations
6.1. Ethics Approval and Consent to participate
This study was approved by local Institutional Review Board, and all
participants have provided written informed consent prior to involve in
the study.

According to the open artery hypothesis, time-dependent
myocardial rescue (early) and a time-independent process (late) are
involved in the extended paradigm of acute MI. Late coronary reperfusion seems to disturb the adverse remodelling process of the heart,
chamber enlargement, and systolic dysfunction. Late coronary reperfusion seems to disturb the adverse remodelling process of the heart,
chamber enlargement, and systolic dysfunction. In the late reperfusion
setting through the contraction band necrosis, cellular oedema, and
intramyocardial haemorrhage, favourable myocardial stiffening is also
believed to take place more readily.17,18 Moreover, persistent occlusion
of the IRA has been related to an increase in the rate of apoptosis in the
peri-infarct region markers of ischemia. Left ventricular dilatation,
progressive left ventricular systolic dysfunction through apoptosis,
gradual cells lost are thought to have a role in the terrible ventricular
remodelling.19,20 Patients with an open IRA significantly had lower
30-day mortality than a not opened IRA (p <0.001). This advantage
could not be explained by myocardial rescue alone, because it resided
following adjustment for left ventricular ejection fraction (LVEF). The
coronary artery's patency was also correlated with lower 30-day and
1-year mortality, but not after adjustment for other late mortality
variables. Having an open IRA at the first coronary angiography confers
a survival benefit that expands beyond the advantages of myocardial
rescue from thrombolytic treatment and is not related to LVEF.21

6.2. Consent for publication
Not applicable.
6.3. Availability of data and materials
Data used in our study were presented in the main text.
6.4. Competing interests
Not applicable.
6.5. Funding source
Not applicable.
6.6. Authors contributions
Idea/concept: H. Design: H. Control/supervision: MSR, CT, SW, BS,
YW. Data collection/processing: H, MRF, I. Extraction/Analysis/interpretation: H, MRF, I. Literature review: MSR, CT, SW, BS, YW. Writing
the article: H. Critical review: MSR, CT, BS, YW. All authors have
critically reviewed and approved the final draft and are responsible for
the content and similarity index of the manuscript.
6.7. Acknowledgements
We thank to Brawijaya Cardiovascular Research Center

Beyond 12 hours Reperfusion AlternatiVe Evaluation
(BRAVE-2) trial specifically included STEMI patients with the symptom
onset ranging from 12 to 48 hours. They were randomized to conservative strategy and invasive strategy. A total of 365 STEMI patients were
involved in the BRAVE-2 trial, revealed a statistically significant
decrease in the size of the final infarction in the group receiving
invasive strategy with single-photon emission computed tomography
(SPECT) imaging at a median of 7.1 days. Clinical outcome results

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