3layout original Article dr Anita suryo

A. S. Santoso, et al.
Heart Sci J 2022; 3(2): 10-17
3.2 Primary Clinical Outcome
 
The implication of PPCI in primary clinical outcome was 
demonstrated in figure 3.3. Incidence of all-cause mortality defined as 
in Hospital adverse event within early PCI category is significantly 
lower (7.5%) in comparison to both late PCI category (15%) and 
optimal medical therapy category (32.4%) with P value 0.000. Post hoc 
analysis between subgroups were also provided in table 3.3. 
13
3.3 Secondary Clinical Outcome
Several complications played important role towards the 
clinical outcome in STEMI patients. Therefore we analyze the most 
common complication occurred that were correlated to the primary 
clinical outcome. Further we also analyze the impact of each category 
towards the duration and cost during hospitalizations. The number of 
in hospital complications in each category was presented in table 3.3. 
Subsequent post-hoc analysis was presented in table 3.4. Also the 
impact of complications and in-hospital mortality was shown in table 
3.5
Table 3.2 Baseline characteristics of subjects in each category
Variable
ECG rhythm
Sinus
Atrial Fibrillation/atrial flutter
Junctional
Atrioventricular Block
Total Atrioventricular Block
Supraventricular Tachycardia
Ventricular Tachycardia
Drugs
ACE inhibitor
Beta Blocker
High Intensity Statin 
(Early PCI)
351 (90.6%)
7 (1.8%)
2 (0.5%)
10 (2.6%)
10 (2.6%)
1 (0.3%)
6 (1.6%)
374 (96.6%)
278 (71.8%)
384 (99.2%)
(Late PCI)
96 (89.7%)
3 (2.8%)
1 (0.9%)
3 (2.8%)
3 (2.8%)
0 (0.0%)
1 (0.9%)
105 (98.1%)
81 (75.7%)
107 (100%)
Note. PPCI = primary percutaneous coronary intervention; PCI = percutaneous coronary intervention; BPJS = social health insurance administrator; 
SKTM = poor mark certificate; CAD = coronary artery disease; COPD = chronic obstructive pulmonary disease; AMI = acute myocardial infarction; 
HF = heart failure; PAD = peripheral arterial disease; CVA = cerebrovascular accident; CABG = coronary artery bypass graft coronary syndrome; 
UAP = unstable angina pectoris.
Optimal Medical Therapy
67 (90.5%)
2 (2.7%)
0 (0.0%)
0 (0.0%)
4 (5.4%)
0 (0.0%)
1 (1.4%)
72 (97.3%)
57 (77%)
74 (100%)
P Value
0.937
0.717
0.532
0.494 
Figure 3.3 Mortality rate between treatment groups
Table 3.3 Post hoc analysis on impact of PPCI in between treatment 
groups
Category
Odd Ratio
95% CI
Early PPCI
Early PPCI
Late PPCI
Late PPCI
Optimal Medical Therapy
Optimal Medical Therapy
0.45
0.17
0.37
0.21 – 0.59
0.13 – 0.41
0.17 – 0.52 
Note. PPCI = primary percutaneous coronary intervention; 95% CI = 
95% confidence interval
Table 3.3 in-hospital complications in each category
Complication
Cardiogenic shock
Acute heart failure
Pneumonia
Stroke
Acute renal failure
Cardiac arrest
Arrhythmia
VT/VF
AF/SVT
TAVB/Junctional/AV Block grade II
Length of stay (days)
Cost
Early PPCI
140 (36.3%)
67 (17.5%)
27 (7%)
9 (2.4%)
24 (6.3%)
10 (2.6%)
15 (3.9%)
4 (1%)
14 (3.6%)
5.68±2.974
42.700.00 ± 14.270.000
Late PPCI
32 (29.9%)
19 (17.8%)
8 (7.5%)
0 (0%)
3 (2.8%)
16 (15%)
16 (15%)
1 (0.9%)
3 (2.8%)
5.96 ± 2.664
45.400.000 ± 14.700.000
Optimal Medical Therapy
24 (32.4%)
14 (19.2%)
5 (6.8%)
1 (1.4%)
6 (8.1%)
25 (33.8%)
25 (33.8%)
0 (0.0%)
0 (0%)
6.57±4.629
57.100.000 ± 55.690.000
P
0.011*
0.945
0.979
0.253
0.271
0.00*
0.00*
0.681
0.243
0.105
0.003* 

4. Discussion
In this study, we found that in between January 2018 – 
December 2021 early PCI comprised of 387 patients from the entire 
568 subjects. Within 4 years of observation, early PPCI was gradually 
declining from 73.8%, 77.7%, 57.1%, and 56.8% with the most signifi-
cant decline occurred in 2020 and 2021 (table 3.1). The decline in early 
PCI was followed by steady increase in the number of late PCI and non 
revascularized patients. Simultaneously mortality rate among STEMI 
patients were also gradually increased between 2020 and 2021 (figure 
4.1). This phenomenon arises in concurrence with the COVID 19 
pandemic. De Luca et al. compared the number of PCI in 2019 (non 
COVID) and 2020 (COVID) and found 18.9% decline of early PCI in 
2020. The study also found 34% increase in >12 hours ischemic time 
and 17% increase in >30 minutes door to balloon time19. Another 
multicenter study in Italy also reported 48.4% decline within patients 
presenting with AMI and three-fold increase in mortality rate compared 
to 201920. The spread of COVID-19 is directly related with substantial 
decrease in the number of AMI patients undergoing primary PCI, and 
increase in significant ischemic time, higher time delay, and increase in 
door to balloon time.
21-23
KILLIP Class, GRACE, and Troponin are significantly 
different variables within the baseline characteristics (table 3.2). Post 
infarct heart failure is correlated with higher in-hospital mortality, even 
can increase 4 fold compared with patients without heart failure. In this 
case, KILLIP Class is particularly useful for risk stratification. The risk of 
post infarct heart failure is the result of interaction between baseline 
characteristics and the medication prescribed. Thus the interaction is 
multifactorial in nature. 
14
Our study demonstrated significant different in the number 
of in-hospital mortality within treatment groups (P 0.000). The propor-
tion of in hospital mortality between early PCI, late PCI, and optimal 
medical therapy groups were 42%, 23.2%, and 34.8% respectively 
(table 3.3). Odds ratio were also substantially different among 
treatment groups, compared with optimal medical therapy group early 
PPCI had 83% mortality risk reduction (table 4.2). Based on current 
STEMI guideline, revascularization with PCI should be performed 
within 12 hours post onset24. However, in real setting, majority of 
patients presented to the hospital >12 h after the chest pain onset. 
Therefore, several studies tried to propose the benefit of late PCI.
25,26
Note. PPCI = primary percutaneous coronary intervention; VT = ventricular tachycardia; VF = ventricular fibrillation; TAVB = total atrioventricu-
lar block; AV bock = atrioventricular block
Table 3.4 Post hoc analysis of complications in each category

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