Percutaneous coronary intervention for stable late ST-elevation myocardial infarction with symptoms onset between 12 and 72 h - A systematic review.

Background: There exists clinical equipoise regarding whether and when an invasive approach should be preferred over conservative treatment in the management of stable late ST-elevation myocardial infarction (STEMI) presenting within 12 to 72 h of symptom onset.

Objective: To perform a systematic review to identify the most effective treatment strategy between percutaneous coronary intervention (PCI) and medical therapy in stable late STEMI presenters by comparing their respective outcomes as well as determine the optimal timing of PCI by evaluating the outcomes of urgent versus non-urgent PCI approach in this patient population.

Methods: PubMed, Embase, and Cochrane databases were queried from inception until March 2024 for studies comparing the outcomes of PCI versus medical therapy, as well as urgent versus non-urgent PCI, in stable late STEMI patients presenting with symptom onset within 12-72 h. Quality of the studies and risk of bias were assessed using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) criteria and the Cochrane Risk of Bias (ROBINS-I 2016) tool, respectively.

Results: A total of 8 studies were included in this systematic review that met the inclusion criteria. Among these, 5 studies (1 randomized controlled trial (RCT), 1 post-hoc analysis, and 3 observational studies) with an aggregate of 3820 participants compared PCI and medical therapy in stable late STEMI presenters. They found that PCI was associated with statistically significant better short- and long-term outcomes by lowering all-cause mortality, recurrent myocardial infarction (MI), and infarct size, and by improving myocardial salvage index (P < 0.001). Similarly, a non-statistically significant improvement was seen in the events of cardiac death, heart failure, and revascularization as well as ejection fraction percentage with PCI (P > 0.05). The other 3 studies, involving 1270 participants, were observational and compared urgent versus non-urgent PCI and did not find any statistically significant difference in clinical outcomes between the two approaches (P > 0.05). The included studies were significantly heterogeneous in methodologies, follow-up intervals, and reporting of outcomes. Most of the studies provided moderate quality of evidence and had moderate to serious risk of bias.

Conclusions and relevance: Revascularization through PCI is associated with superior short- and long-term outcomes compared to medical therapy in stable late STEMI patients presenting within 12-72 h of symptom onset. However, the optimal timing of PCI needs further investigation.