Optimal timing of pharmacoinvasive strategy and its impact on clinical and economic outcomes in patients with ST-elevation myocardial infarction: a real-world perspective

The pharmacoinvasive (PhI) strategy is the standard-of-care for ST-elevation myocardial infarction (STEMI) patients when primary percutaneous coronary intervention (pPCI) is unfeasible. Optimal timing for post-fibrinolytic PCI (lysis-PCI) remains elusive. Therefore, this study aimed to assess the clinical and economic impacts of early vs. delayed lysis-PCI in patients with STEMI. This retrospective cohort study included 1,043 STEMI patients classified by lysis-PCI timing. The primary outcome was in-hospital major adverse cardiovascular events (4p-MACE), with secondary outcomes such as 3p-MACE, in-hospital mortality, and costs. Multivariable logistic regression models were used to assess the association between lysis-PCI timing and outcomes. Cost analyses were conducted from the perspective of Brazilian public healthcare system, with values converted to international dollars (Int$) for broader applicability. Every 4-h delay in lysis-PCI was associated with a 44% reduction in in-hospital mortality [OR = 0.560 (95% CI: 0.381-0.775); = 0.001] and a 13% decrease in 4p-MACE [OR = 0.877 (95% CI: 0.811-0.948); = 0.001]. Additionally, 4-h delay in lysis-PCI was also associated with a significant reduction in in-hospital costs (Int$916.20 ± 99) and disease-induced years of productivity lost ( = -41.79 ± 151 years; = 0.001). These significant trends remained consistent even after adjusting for confounders and applying propensity score matching. Older adults (aged ≥80) experienced an increase in 3p-MACE with earlier lysis-PCI. Delaying lysis-PCI was found to be associated with reduced in-hospital cardiovascular adverse events and lower costs, particularly among older adults. Further research should develop evidence-based lysis-PCI protocols that optimize both clinical outcomes and cost-effectiveness.