Prehospital Glucocorticoid and Infarct Size in STEMI

TOPLINE:

Prehospital pulse-dose glucocorticoid treatment in patients with ST-segment elevation myocardial infarction (STEMI) does not reduce the final infarct size at 3 months but may improve acute outcomes such as left ventricular ejection fraction (LVEF) and microvascular obstruction.

METHODOLOGY:

• A total of 530 adult patients (median age, 65 years; 78.9% men) with STEMI were included from Denmark in a blinded, placebo-controlled, randomized clinical trial.
• Patients were randomly assigned in the prehospital setting to receive either 250 mg of intravenous methylprednisolone or placebo.
• The primary outcome was the final infarct size on cardiac magnetic resonance (CMR) at the 3-month follow-up.
• The secondary outcomes included acute CMR parameters (the presence and extent of microvascular obstruction, LVEF, myocardial salvage index, area at risk, intramyocardial hemorrhage), peak cardiac biomarkers, all-cause mortality and hospitalization for heart failure at 3 months, and adverse events within 7 days of STEMI.

TAKEAWAY:

• The median final infarct size did not vary significantly between the glucocorticoid and placebo groups (P =.24).
• Patients treated with glucocorticoid had a higher acute LVEF (mean difference, 4.44%; 95% CI, 2.01%-6.87%), smaller acute infarct size (odds ratio, 0.78; 95% CI, 0.61-1.00), and less microvascular obstruction (relative risk ratio, 0.83; 95% CI, 0.71-0.99) than those who received the placebo.
• The secondary outcomes and incidence of serious adverse events on follow-up were comparable between the two groups.

IN PRACTICE:

“In patients with STEMI, treatment with prehospital pulse-dose glucocorticoid did not reduce final infarct size after 3 months. However, the trial was likely underpowered as the final infarct size was smaller than anticipated,” the authors wrote. “The glucocorticoid group had improved acute parameters compared with placebo,” they added.

SOURCE:

The study was led by Jasmine Melissa Madsen, MD, Department of Cardiology, Rigshospitalet, Copenhagen, Denmark. It was published online on August 30, 2024, in JAMA Cardiology.

LIMITATIONS:

The smaller-than-expected final infarct size in this STEMI cohort likely reduced the trial’s power, potentially masking a more significant effect of glucocorticoid treatment. Post-randomization exclusions increased the risk for selection bias. Patients who did not complete the acute scan were older and sicker than those who did, potentially affecting the results. The dropout rates from follow-up CMR scans presented a challenge in the evaluation of CMR outcomes.

DISCLOSURES:

The study was funded by the Research Foundation of Rigshospitalet and Novo Nordisk. Dr Madsen received grants from the Research Foundation of Rigshospitalet during the study. Some authors received grants, fees, or travel support from pharmaceutical and medical companies, outside the submitted work. Detailed disclosures are noted in the original article.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.