The Effect of Symptom Onset-to-needle time on Ischemic Outcomes in Patients Treated with Primary Angioplasty in the Era of Potent Antiplatelets

Abstract Purpose: Based on previous studies with clopidogrel, the time between onset of symptoms and primary PCI was proven as an important prognostic factor. Our aim was to assess the effect of symptoms onset to needle time (SNT) on procedural results and on the occurrence of ischemic endpoints in primary angioplasty patients treated with potent P2Y12 inhibitors. Methods: A total of 1,131 out of 1,230 patients randomized to the PRAGUE 18 study (prasugrel vs. ticagrelor in primary angioplasty) were divided into a high and a low-risk group. The effect of defined SNT on patients' ischemic endpoints and prognosis by their risk status at admission was tested.Results: The median SNT was 3.2 hours. Longer SNTs resulted in a more frequent incidence of TIMI flow < 3 post PCI (p = 0.015). There were significant differences in the occurrence of the combined ischemic endpoint among the compared SNT groups at 30 days (p=0.032), and 1 year (p=0.011), with the highest incidence in the ≤ 1 h SNT group of patients. "Latecomers" (SNT > 4 hs) in the high-risk group experienced more reMI within 1 year [OR (95% CI) 3.23 (1.09–9.62) p = 0.035]; no difference was found in the low-risk group. Conclusion: In the era of intense antithrombotic medication, stratification of STEMI patients undergoing primary angioplasty, based on initial ischemic risk assessment affected prognosis more than symptom onset to needle time. Longer time delay significantly increased the incidence of ischemic events and all-cause mortality only in patients with high ischemic risk.