Department of Cardiology, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Européen Georges Pompidou, France (N.D., E.P.).Université Paris-Descartes, France (N.D., E.P.).INSERM U-970, Paris, France (N.D., E.P.).Department of Cardiology, Centre Hospitalier Universitaire de Nîmes, Université de Montpellier, France (G.C.).Department of Cardiology, Centre Hospitalier Universitaire du Bocage, Dijon, France (Y.C.).Department of Cardiology, Hôpital Cardiologique du Haut-Lévêque, CHU de Bordeaux, Pessac, France (P.C.).Département de Cardiologie CHU La Cavale Blanche, Brest, France (M.G.).Société Française de Cardiologie, Paris, France (M.G.).Emergency Department, Lille Regional University Hospital, France (P.G.).Emergency Department, Centre Hospitalier Régional, Hôpital Mercy, Metz, France (F.B.).SAMU-Urgences de France, Paris (F.B.).Department of Cardiology, Centre Hospitalier Annecy Genevois, Epagny Metz-Tessy, France (L.B.).Collège National des Cardiologues des Hôpitaux, Paris, France (L.B.).Institut de Cardiologie, Centre Hospitalier Pitié-Salpêtrière, Paris, France (G.M.).Department of Cardiology, Toulouse Rangueil University Hospital, France (J.F.).UMR1027, INSERM, Toulouse, France (J.F.).Department of Cardiology, University Hospital Jean Minjoz, Besançon, France (F.S.).Department of Clinical Pharmacology and Unité de Recherche Clinique (URCEST), AP-HP, Hôpital Saint Antoine, Paris, France (T.S.).Université Pierre et Marie Curie (UPMC-Paris 06), France (T.S.).INSERM U-698, Paris, France (T.S.).
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BackgroundThe optimal timing of administration of dual antiplatelet therapy (DAPT) in acute ST-segment–elevation myocardial infarction patients is debated. Clinical trials have failed to demonstrate the superiority of pretreatment with P2Y12 inhibitors in ST-segment–elevation myocardial infarction, but they were not designed to assess hard clinical end points. We used data from the FAST-MI (French Registry on Acute ST-Segment–Elevation or Non-ST-Segment–Elevation Myocardial Infarction) cohorts to determine 1-year survival and in-hospital outcomes in patients receiving DAPT, comparing prehospital versus in-hospital administration.Methods and ResultsThe FAST-MI program collects extensive data on patients admitted in France for acute myocardial infarction over a 1-month period every 5 years since 2005. For the present analysis, 3548 patients with ST-segment–elevation myocardial infarction ≤12 hours from symptom onset, transported by physician-staffed emergency medical system ambulances, not treated with intravenous fibrinolysis, and receiving DAPT were included, of whom 44% received DAPT in the ambulance. The primary end point was 1-year survival as assessed by multivariate Cox analysis and propensity score analysis. In-hospital bleeding and ischemic complications were also analyzed. Adjusted in-hospital mortality was numerically but not significantly lower in patients with prehospital DAPT. There were no differences in in-hospital bleeding complications. Fully-adjusted hazard ratio for 1-year death in patients with prehospital versus in-hospital DAPT was 0.69 (95% CI, 0.51–0.92; P=0.011), and propensity score–adjusted hazard ratio was 0.55 (95% CI, 0.41–0.73; P=0.001) in the whole population. In the propensity score–matched cohorts (360 patients each), 1-year survival was 93.9% in patients with prehospital versus 90.3% in those with in-hospital DAPT (hazard ratio, 0.62; 95% CI, 0.36–1.05; P=0.077). Results were consistent in subgroups, including by year of survey, age, presence of out-of-hospital cardiac arrest, morphine use, and type of P2Y12 inhibitor used.ConclusionsIn these cohorts of ST-segment–elevation myocardial infarction patients considered for primary percutaneous coronary intervention, prehospital administration of DAPT was associated with higher 1-year survival and no increase in in-hospital bleeding complications. The magnitude of the decrease in 1-year mortality, however, may suggest the persistence of some degree of residual confounding.Clinical Trial Registration:URL: https://www.clinicaltrials.gov. Unique identifiers: NCT00673036, NCT01237418, and NCT02566200.