Deferred or Immediate Stent Implantation Based on Microvascular Function in STEMI
- Conditions
- Microcirculatory PerfusionST Elevation Myocardial Infarction
- Interventions
- Procedure: Deferred or Immediate Stent Implantation
- Registration Number
- NCT03581513
- Lead Sponsor
- Harbin Medical University
- Brief Summary
Timely percutaneous coronary intervention (PCI) with stenting implantation is the current standard treatment for patients with ST-segment elevation myocardial infarction (STEMI). However, stenting in thrombus-laden artery is associated with higher risk of embolization and no-or slow-reflow, leading to larger infarct size and poor prognosis. The SALVAGE study is a prospective, multicenter, randomized, controlled study aimed to optimize the therapeutic strategies (deferred vs. immediate stenting) to protect microvascular function and eventually improve clinical outcomes at 12-months in STEMI.
- Detailed Description
Methodology:
A multicenter, prospective, randomized, controlled clinical study enroll patients with ST-segment elevation myocardial infarction (STEMI) intended for PCI with stenting implantation. Eligible patients are randomly assigned to the immediate stenting group or delayed stenting group in a 1:1 ratio when residual stenosis \>70% and TIMI grade 3 with angiography guidance.
The index of microcirculation resistance (IMR) is quantitative analysis by an invasive approach for evaluating post-infarct myocardial microcirculatory perfusion. IMR correlates with the infarct size of patients with acute myocardial infarction and predicts the improvement in left ventricular ejection fraction. Studies have shown that acute myocardial infarction patients with IMR \>40 after primary PCI predict adverse long-term clinical outcomes with higher mortality and heart failure rehospitalization rates.
According to therapeutic strategies and microvascular function detected by IMR, participants are classified into four groups: immediate stenting with IMR ≥ 40, immediate stenting with IMR \< 40, deferred stenting with IMR ≥ 40 and deferred stenting with IMR \< 40. All randomized patients will be followed by phone call or clinical visit at 12 months.
Patient enrollment and procedure overview:
Patients aged from 18 to 80 with STEMI\<12h in whom PCI is planned will be screened. Thrombectomy and balloon dilatation will be performed at the operator's discretion to restore an effective antegrade blood flow with TIMI flow grade 3. Patients with residual diameter stenosis \>70% visually and TIMI blood flow grade 3 are eligible for including in the study. All patients must provide written informed consent and patients will be randomized to immediate stenting group or deferred stenting group in a 1:1 ratio. All participants in immediate stenting group will be treated with stent implantation immediately. Those assigned to the deferred arm will undergo stenting after an interval of 7±2 days. This interval will be bridged with anti-coagulant and anti-platelet therapy to reduce thrombus burden. All patients in both groups are required to take dual antiplatelet treatment while the application of low molecular weight heparin and glycoprotein IIb/IIIa inhibitor are determined by the operators. All participants are required to perform IMR pre-stenting and post-stenting to evaluate microcirculation function. All randomized patients will be followed up to 12 months to evaluate the prevalence of heart failure, all-cause mortality, recurrent infarction or targeted vessel revascularization.
Study follow-up:
Clinical follow-up:
Participants will be followed by phone calls or clinical visits by study coordinators at 1 month (+/-7 days), 3 months (+/-15 days), 6 months (+/-15 days), 9 months (+/-15 days) and 12 months (+/-30 days) after randomization. Major adverse cardiovascular events (MACEs) will be recorded throughout the study period until last patient has been followed for 12 months.
Recruitment & Eligibility
- Status
- TERMINATED
- Sex
- All
- Target Recruitment
- 629
- 18 years old ≤ age ≤ 80 years old;
- STEMI and the onset time <12h;
- The culprit lesions are de novo lesion;
- Sign written informed consent.
- Patients are hemodynamically unstable;
- Infract-related artery diameter stenosis ≤ 70%;
- Left main disease;
- AMI caused by surgery, trauma, gastrointestinal bleeding or PCI and complications;
- AMI occurs in patients who have been hospitalized for other reasons;
- The investigator judges that the patient has poor compliance and cannot complete the study as required;
- Life expectancy ≤ 12 months;
- Heart transplant patients;
- Definite diagnosis of patients with tumors;
- Participate in other clinical studies (excluding other trials of this project) and haven't reach the primary endpoints.
Study & Design
- Study Type
- INTERVENTIONAL
- Study Design
- PARALLEL
- Arm && Interventions
Group Intervention Description IMR<40 and immediately PCI Deferred or Immediate Stent Implantation Patients whose IMR\<40 undergo immediately stent implantation. IMR≥40 and defer PCI Deferred or Immediate Stent Implantation Patients whose IMR≥40 undergo stent implantation after an interval of 7±2 days. IMR<40 and defer PCI Deferred or Immediate Stent Implantation Patients whose IMR\<40 undergo stent implantation after an interval of 7±2 days. IMR≥40 and immediately PCI Deferred or Immediate Stent Implantation Patients whose IMR≥40 undergo immediately stent implantation.
- Primary Outcome Measures
Name Time Method Prevalence of heart failure, all-cause death, reinfarction and targeted vessel revascularization within 1 year of STEMI 1 year MACE including the prevalence of heart failure, all-cause death, reinfarction and targeted vessel revascularization will be collected as the primary outcome.
- Secondary Outcome Measures
Name Time Method Peaks of CK, CK-MB, cTnI and area under CK curve through hospitalization, an average of 7 days We will compare the peaks of CK, CK-MB, cTnI and area under CK curve while in hospital.
Peri-procedural myocardial reperfusion reinjury through hospitalization, an average of 7 days Prevalence of in-hospital heart failure, all-cause death, re-myocardial infarction or targeted vessel revascularization.
Procedural success and clinical success postprocedure and through hospitalization, an average of 7 days Culprit lesion stenosis\<30% in the presence of TIMI 3 grade flow after PCI are regarded as procedural success.
Clinical success is determined as procedural success in the absence of in-hospital cardiac death, target vessel myocardial infarction and clinically-driven target lesion revascularization.ECG ST-segment resolution at 90 minutes after primary PCI 90 minutes postprocedure We will compare the differences of the ST-segment resolution at 90 minutes among groups after primary PCI.
LVEF detected by echocardiographic indices at 7 days after stenting, 1 month and 12 months after discharge 7 days, 1 month and 12months LVEF will be detected by echocardiographic indices at 7 days after stenting, 1 month and 12 months after discharge
Hospitalization due to heart failure 1 year Prevalence of hospitalization for heart failure will be compared among groups.
Contrast score index and myocardial blood flow detected by myocardial contrast echocardiography 7 days after stenting and 1 month after discharge 7 days and 1 month Contrast score index and myocardial blood flow detected by myocardial contrast echocardiography 7 days after stenting and 1 month after discharge
Trial Locations
- Locations (8)
Beijing An Zhen Hospital, Capital Medical University
🇨🇳Beijing, Beijing, China
Second hospital of hebei medical university
🇨🇳Shijiazhuang, Hebei, China
The 2nd Affiliated Hospital of Harbin Medical University
🇨🇳Harbin, Heilongjiang, China
Daqing Longnan Hospital
🇨🇳Daqing, Heilongjiang, China
Jiamusi City Central Hospital
🇨🇳Jiamusi, Heilongjiang, China
The First Affiliated Hospital of Jiamusi University
🇨🇳Jiamusi, Heilongjiang, China
Shuangyashan Mining Hospital
🇨🇳Shuangyashan, Heilongjiang, China
Mudanjiang Cardiovascular Hospital
🇨🇳Mudanjiang, Heilongjiang, China