Tabla 1. Demographic characteristics, risk factors, and medical history.

Tabla 2. Electrocardiographic characteristics.

Tabla 3. Complications

Tabla 4. Angiography and percutaneous coronary intervention.

Tabla 5. Echocardiography at discharge.

Introduction

Acute coronary syndrome (ACS) is a spectrum of clinical presentations (unstable angina [UA], non-ST-segment elevation myocardial infarction [NSTEMI], ST-segment elevation myocardial infarction [STEMI]) that are associated with a high risk of death from cardiovascular causes, non-fatal myocardial infarction, and recurrent hospitalizations due to refractory ischemia1.

The rupture or erosion of atheromatous plaque results in the formation of thrombi, either occlusive or subocclusive, which is the most common cause of ACS2, 3.

Current therapies are aimed at achieving rapid revascularization to reduce the ischemic area using antiplatelet agents, antithrombotic drugs combined with early revascularization of the culprit artery in appropriate patients4-7.

The treatment of ST-segment elevation acute coronary syndrome (STEACS) is based on the fast unblocking of the culprit artery, either through the use of fibrinolytic drugs or by means of primary percutaneous coronary intervention (pPCI)8. Both alternatives limit the extent of the infarction and improve prognosis. European Society of Cardiology clinical practice guidelines recommend the use of fibrinolysis or pPCI within the first 12 hours after symptom onset. Fibrinolytics have been shown to increase survival8, 9 but are more effective if administered within the first 3 hours after symptom onset. pPCI improves survival and reduces the incidence of recurrent infarction and stroke; therefore, it is considered the optimal therapy if performed in a timely manner8, 10, 11. Real-world registries suggest that fibrinolysis is an effective treatment when administered on time. It prevents delays related to primary angioplasty12.

Randomized clinical trials13, 14 and observational studies15 have shown that the use of fibrinolyic drugs has similar efficacy and safety to pPCI and is considered a reasonable alternative when pPCI cannot be conducted in a timely fashion12.

A pharmacoinvasive (PI) strategy is recommended if pPCI cannot be performed within 120 minutes after STEACS diagnosis and there are no contraindications. PI involves fibrinolysis followed by rescue PCI in case of failed fibrinolysis or routine early PCI (coronary angiography and PCI of the culprit artery, if indicated) in case of successful fibrinolysis16. Trials comparing pPCI and prehospital fibrinolysis followed by early strategic reperfusion after STEACS have reported similar mortality rates17, 18.

The reperfusion rate for STEMI in Argentina varies depending on the type of registry. The ARGEN-IAM-ST project19 is the STEMI registry; it includes 1759 patients from 247 centers in all provinces, covering 22% of all medical institutions in the country. In-hospital mortality was 8.8%. Of note, 83.5% of patients received reperfusion treatment, most (78.3%) by pPCI. Less than half had a door-to-balloon time ≤90 minutes. The study revealed that, among patients who received fibrinolytics (94% streptokinase), only 25% had a door-to-needle time ≤30 minutes20.

In our region, data on STEMI patients are scarce, and times and outcomes are unknown.

Centers with 24-hour cath labs are located in centralized regions; in Neuquén province, there are 3, all located in Neuquén City (Department of Confluencia). As for Río Negro province, there are 2 centers with cath labs in Cipolletti city, 2 in General Roca city, one in Viedma city, and one in San Carlos de Bariloche city21.

According to the 2022 National Census, these provinces together have around 1,461,582 inhabitants. Neuquén province has an area of 94,422 km2 and 710,814 inhabitants; the Department of Confluencia has the highest population density (65.1 inhabitants/km2). In Río Negro province, with an area of 202,168.6 km2 and 750,768 inhabitants, two departments stand out for their population density: Bariloche (29.9 inhabitants/km2) and General Roca (26.1 inhabitants/km2)22.

Our center (Leben Salud) mainly receives referrals from both provinces (Río Negro and Neuquén) pursuant to agreements signed with the main provincial and national medical insurance organizations, and private medical insurance companies, as well as public health patients from Río Negro. Consequently, it is a renowned institution in the region for the treatment of ACS.

The aim of this study was to observe the epidemiological, demographic, and clinical characteristics of STEACS patients who underwent pPCI vs. PI in the aforementioned region. The secondary aim was to record clinical and angiographic results and the interventional treatment with both strategies in STEACS patients admitted to this institution.

Materials and methods

An observational cross-sectional study was conducted involving patients who were admitted or referred to Leben Salud institutions and their surrounding areas (Río Negro and Neuquén) from January 9 to July 2, 2023, with a diagnosis of STEMI, who met the fourth universal definition of myocardial infarction23. The information was obtained from the clinical records of patients admitted during the aforementioned period.

Inclusion criteria:

1. All patients diagnosed with STEACS who consulted within the first 12 hours from symptom onset23.
2. Patients over 18 years of age.
3. Patients who consulted within the period from January 9 to July 2, 2023.

Exclusion criteria:

1. All patients diagnosed with STEACS who consulted after the first 12 hours from symptom onset.
2. Patients under 18 years of age.
3. Patients whose clinical records were incomplete regarding study variables, patients who did not receive reperfusion treatment within the first 12 hours of evolution, patients with unknown ischemia time, patients who did not undergo acute reperfusion, in-hospital STEMI patients, patients treated with fibrinolysis alone, and patients who did not undergo reperfusion at any time.

The included population was divided into two groups: (1) the pPCI group, which included STEACS patients who underwent coronary angiography, primary angioplasty, and intracoronary stenting as first reperfusion therapy within the first 12 hours of symptom onset; (2) the PI group, which included STEACS patients who received fibrinolysis as first reperfusion therapy within the first 12 hours of symptom onset, followed by routine coronary angiography and coronary angioplasty within 3 to 24 hours after administration of the fibrinolytic agent in case of successful fibrinolysis, and immediately in case of failed fibrinolysis.

Study variables

The variables studied were age, sex, medical history, and cardiovascular risk factors (arterial hypertension, diabetes mellitus, dyslipidemia, smoking, chronic kidney disease, prior myocardial infarction, prior coronary revascularization, and cerebrovascular disease, as defined in ARGENT-IAM-ST19). Additionally, we assessed Killip-Kimball classification on admission, time to first medical contact (FMC), time from symptom onset to reperfusion, and complications24; in-hospital mortality, cardiovascular mortality (due to cardiac arrest or cardiogenic shock), and post-infarction heart failure (symptoms and signs of heart failure and/or cardiac dysfunction on echocardiogram during hospitalization)25.

We also assessed the following complications during hospitalization: stroke (defined as the presence of new neurological deficits lasting more than 24 hours with evidence of ischemia or hemorrhage in computed tomography or magnetic resonance imaging)26; reinfarction, defined as recurrent cardiac ischemia symptoms occurring at rest lasting more than 30 minutes combined with new ST-segment elevation on electrocardiogram (ECG) and cardiac enzymes (twice the upper limit of normal) or angiographic evidence of reocclusion of the culprit artery26; major and minor bleeding, as defined according to TIMI classification24.

The primary endpoint was a composite of in-hospital death, reinfarction, cardiogenic shock, and post-infarction heart failure during hospitalization25.

The secondary endpoints were delay times until first medical consultation, until admission to the cath lab center, and from FMC to reperfusion; complications (stroke, reinfarction, major and minor bleeding); ejection fraction (measured by Simpson’s method using echocardiography)27; mechanical complications (mitral regurgitation, ventricular septal rupture, free wall rupture); success of reperfusion (TIMI 3 flow) in the culprit coronary artery after stenting in both strategies; length of hospital stay, in days.

Statistical analysis

Categorical variables are summarized as absolute frequency and percentage. Numerical variables are expressed as mean, standard deviation, and range when they follow a normal distribution, and as median and range when they do not. The Kolmogorov-Smirnov test was used to assess distribution normality for numerical variables.

To compare patients with and without pharmacological treatment, for numerical variables, Student’s t-test and Mann-Whitney’s test were used depending on whether or not they followed a normal distribution; for categorical variables, the comparison was made using Pearson’s chi-square test and Fisher’s exact test.

For time variables, in addition to parametric estimation of median and range, the mean, the 95% confidence interval (95% CI) of the mean, the median, and the 95% CI of the median were estimated through the Kaplan-Meier estimator. Comparisons of time-to-event functions estimated by this estimator were performed using the Log Rank test (Mantel-Cox).

The level of statistical significance used in hypothesis testing was p < 0.05.

The software used was SPSS version 25.0.

Results

A total of 64 patients were included during the aforementioned period; 43 (67.2%) belonged to the pPCI group and 21 (32.8%) to the PI strategy group.

The average age for the PI group was 60.3±10.6 years, while it was 62.3±11.4 years for the pPCI group, with no significant differences. Most subjects in both groups were men; their proportion was higher in the PI group (90.5% vs. 79.1%, respectively). Demographic characteristics, risk factors, and medical history are all listed in Table 1.

Regarding patient medical history and comorbidities, the percentage of former smokers was higher among patients without pharmacological treatment (34.9%, compared to 9.5% in patients in the PI group); in this case, the difference was statistically significant (p=0.031). For the rest of the variables considered, the differences were not statistically significant, although there were some noticeable trends: in patients in the pPCI group, there was a higher percentage of hypertension (58.1%), dyslipidemia (48.8%), and prior angioplasty (23.3%).

There were no significant differences in the primary endpoint between the pPCI and PI groups (p=0.97).

The comparison of hospitalization days showed that, on average, patients under PI treatment were hospitalized for 5.4 days (95% CI: 2.5–6.5) while pPCI patients were hospitalized for 4.5 days (95% CI: 2.3–8.4). There were no significant differences in hospitalization time between groups.

Regarding prior pharmacological treatment, there were no statistically significant differences between groups. Nonetheless, among subjects in the pPCI group, the percentage of patients receiving concomitant medication was somewhat higher (Table 2).

ECG results also showed no statistically significant differences between groups. Descriptively, one can note a higher percentage of inferior localization in patients from the pPCI group and of other locations in patients with PI treatment (Table 2).

The times elapsed between symptoms onset and FMC, between FMC and arrival at the hemodynamics center, and between FMC and reperfusion were compared.

The mean time between symptoms onset and FMC was 104.3 minutes (95% CI: 73.6–135.0 minutes) in patients with PI therapy and 101.7 minutes (95% CI: 70.2–133.3 minutes) in patients with pPCI; the difference is not statistically significant (p=0.781).

Comparing the time between FMC and reperfusion, in patients with PI, the mean was 138.1 minutes (95% CI: 49.4–226.8 minutes), while it was 214.7 minutes (95% CI: 168.2-261.2 minutes) in patients with pPCI; the difference is statistically significant (p=0.018).

In 100% of the PI group, streptokinase was used as the thrombolytic agent. Among these patients, 71.4% (n=15 patients) met positive reperfusion criteria, so 28.6% (n=6 patients) required rescue angioplasty. Regarding the time between FMC and arrival at the hemodynamics center and subsequent PCI, in patients with PI treatment, the mean was 1097.9 minutes (95% CI: 560.5–1635.2 minutes).

Only 44.2% of pPCI patients were treated within the recommended 120 minutes (timely angioplasty), 20.9% within 121–180 minutes (delayed angioplasty), and 34.9% after 181 minutes (late angioplasty).

Considering the cities, and their respective healthcare centers, where the first medical consultations took place, in the PI group, 14.28% (n=3) of patients were within a range of 0 to 100 km and 85.71% (n=18 patients) were more than 100 km away. In contrast, in the pPCI group, 88.38% (n=38) of patients were within 0 to 100 km and 11.62% (n = 5 patients) were more than 100 km away.

There were no significant differences in the severity of clinical presentation, according to the Killip–Kimball (KK) classification at admission. Patients in the PI group presented with KK A in 42.8%, KK B in 47.6%, KK C in 0%, and KK D in 9.5% of cases, whereas patients in the pPCI group had KK A in 69.7%, KK B 27.9%, KK C 0%, and KK D 2.3% of cases (p=0.40).

Complications were infrequent in both groups; there were no statistically significant differences between them (Table 3).

The data on angiography and percutaneous coronary intervention (Table 4) also show no statistically significant differences between groups. A descriptive reading of the data shows a slightly higher percentage of patients with multivessel disease in the group that received pharmacological treatment. There were no significant differences in TIMI either. There is a trend toward greater use of glycoprotein IIb-IIIa inhibitors and thromboaspiration in the pPCI group, though this was not statistically significant. PCI was unsuccessful in only two patients from the pPCI group, and they required myocardial revascularization surgery. Only one patient from the pPCI group had no significant epicardial artery lesions. In the rest of the patients, from both the PI and pPCI groups, drug-eluting stents were implanted.

There were no significant differences in echocardiographic results at discharge either (Table 5).

Discussion

This regional study assessed the outcomes of care for STEACS at private institution Leben Salud and its area of influence (Río Negro and Neuquén) over a 6-month period. It was a cross-sectional observational study based on information obtained from a review of medical records from patients admitted during the aforementioned period.

Among the patients who underwent PCI, only 44.2% of procedures were conducted in a timely manner (< 120 minutes). These times are similar to those reported in the ARGEN-IAM-ST registry19, 28.

In the PI group, 100% of patients received streptokinase as the thrombolytic agent. Of these subjects, 71.4% (n=15 patients) had positive reperfusion criteria. This percentage of positive reperfusion criteria is similar to that in the ARGEN-IAM-ST registry19, but differs from other Latin American registries, where it was 50%25; on the other hand, a study conducted in Mexico City reported a 59-% success rate (with tenecteplase as the most frequently used fibrinolytic agent [77%])29. This better outcome may possibly be attributed to shorter patient delay in seeking medical attention and the time elapsed from first medical contact (FMC) to reperfusion in the PI group.

Accordingly, the time from FMC to reperfusion shows a mean of 138.1 minutes for patients in the PI group and 214.7 minutes for those in the pPCI group, a statistically significant difference (p=0.018). The variation is due to delays in transportation to a center with a cath lab, since only 44.2% of patients underwent PCI within the recommended 120-minute window.

There were no significant differences in relation to the culprit artery. Additionally, 52.4% of the PI group and 39.5% of the pPCI group had multivessel disease, requiring the use of more stents per patient. These values are consistent with those from other registries25, 28.

While not statistically significant, there was a greater use of thromboaspiration devices (p=0.448) and glycoprotein IIb-IIIa inhibitors (p=0.085) in the pPCI group. These findings are consistent with studies conducted using streptokinase30.

PI and pPCI had similar rates for the composite endpoint of mortality, reinfarction, stroke, cardiogenic shock, and post-infarction heart failure during hospitalization. Compared to other national28 and international registries26, 29, 31, there were no major hemorrhagic complications in the PI group and bleeding events were consistent with a real-world meta-analysis32.

Conclusion

This retrospective observational study in our region showed that major adverse cardiovascular outcomes and major bleeding events did not differ between patients treated with PI or pPCI, and that there were no significant differences in clinical outcomes, angiographic characteristics, or interventional treatment between the groups. The study suggests that the PI strategy is a feasible, effective, and safe therapeutic option for patients with STEACS.

As for future perspectives, these results could warrant a broader data survey across all institutions in the region, in order to later develop infarction networks and improve both public and private care systems. In this way, the PI strategy could be implemented as the most effective and safe reperfusion option in remote areas.

Limitations

The limitations of this study were the sample size and its selection (which may involve type α and β errors), the fact that the follow-up period was restricted to the hospital stay (with no long-term follow-up), and the inherent biases of retrospective studies.

Acknowledgments

This study was conducted in collaboration with Dr. Pablo Olavegogeascoechea and Dr. Ricardo Ruggeri.

Summary of key points

• In the Northern Patagonian region, data on STEMI patients are scarce, and times and outcomes are unknown.
• There are long distances between the various institutions in the region and the centers with cath labs.
• The PI strategy is still the best option for the Northern Patagonian region.
• These results could warrant a broader data collection effort across all institutions in the region, leading to the development of infarction networks.

Glossary

• Acute coronary syndrome (ACS)
• First medical contact (FMC)
• Non-ST-segment elevation myocardial infarction (NSTEMI)
• Percutaneous coronary intervention (PCI)
• Pharmacoinvasive (PI)
• Primary PCI (pPCI)
• ST-segment elevation acute coronary syndrome (STEACS)
• ST-segment elevation myocardial infarction (STEMI)
• Unstable angina (UA)

1. Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, White HD. Third Universal Definition of Myocardial Infarction. Circulation. 2012 Oct 16;126(16):2020–35.

2. Virmani R, Kolodgie FD, Burke AP, Farb A, Schwartz SM. Lessons From Sudden Coronary Death. Arterioscler Thromb Vasc Biol. 2000 May;20(5):1262–75.

3. Falk E. Pathogenesis of Atherosclerosis. J Am Coll Cardiol. 2006 Apr;47(8):C7–12.

4. Held C, Tornvall P, Stenestrand U. Effects of revascularization within 14 days of hospital admission due to acute coronary syndrome on 1-year mortality in patients with previous coronary artery bypass graft surgery. Eur Heart J. 2007 Jan 11;28(3):316–25.

5. Mehta SR, Cannon CP, Fox KAA, et al. Routine vs Selective Invasive Strategies in Patients With Acute Coronary Syndromes. JAMA. 2005 Jun 15;293(23):2908.

6. Anderson JL, Adams CD, Antman EM, et al. ACC/AHA 2007 Guidelines for the Management of Patients with Unstable Angina/Non–ST-Elevation Myocardial Infarction—Executive Summary. J Am Coll Cardiol. 2007 Aug;50(7):652–726.

7. Bassand JP, Hamm CW, Ardissino D, et al. Guidelines for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes: The Task Force for the Diagnosis and Treatment of Non-ST-Segment Elevation Acute Coronary Syndromes of the European Society of Cardiology. Eur Heart J. 2007 May 5;28(13):1598–660.

8. Nieto Tolosa J, Cambronero F, A. Hurtado J, et al. Estrategia farmacoinvasiva como tratamiento de reperfusión en áreas sin disponibilidad de angioplastia primaria. REC: interventional cardiology. 2021;

9. Fibrinolytic Therapy Trialists’ (FTT) Collaborative Group. Indications for fibrinolytic therapy in suspected acute myocardial infarction: collaborative overview of early mortality and major morbidity results from all randomised trials of more than 1000 patients. The Lancet [Internet]. 1994 Feb 5 [cited 2023 Jul 22];343(8893):311–22.

10. Andersen HR, Nielsen TT, Rasmussen K, et al. A comparison of coronary angioplasty with fibrinolytic therapy in acute myocardial infarction. N Engl J Med [Internet]. 2003 Aug 21 [cited 2023 Jul 22];349(8):733–42.

11. Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials. Lancet [Internet]. 2003 Jan 4 [cited 2023 Jul 22];361(9351):13–20.

12. Bonnefoy E, Steg PG, Boutitie F, et al. Comparison of primary angioplasty and pre-hospital fibrinolysis in acute myocardial infarction (CAPTIM) trial: a 5-year follow-up. Eur Heart J. 2009;30(13):1598-606.

13. Armstrong PW, Gershlick AH, Goldstein P, et al. Fibrinolysis or Primary PCI in ST-Segment Elevation Myocardial Infarction. New England Journal of Medicine. 2013 Apr 11;368(15):1379–87.

14. Sinnaeve PR, Armstrong PW, Gershlick AH, et al. ST–Segment-Elevation Myocardial Infarction Patients Randomized to a Pharmaco-Invasive Strategy or Primary Percutaneous Coronary Intervention. Circulation. 2014 Sep 30;130(14):1139–45.

15. Sim DS, Jeong MH, Ahn Y, et al. Pharmacoinvasive Strategy Versus Primary Percutaneous Coronary Intervention in Patients With ST-Segment–Elevation Myocardial Infarction. Circ Cardiovasc Interv. 2016 Sep;9(9):e003508.

16. Ibanez B, James S, Agewall S, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J [Internet]. 2018 Jan 7 [cited 2023 Jul 22];39(2):119–77.

17. Bonnefoy E, Lapostolle F, Leizorovicz A, et al. Primary angioplasty versus prehospital fibrinolysis in acute myocardial infarction: a randomised study. Lancet [Internet]. 2002 Sep 14 [cited 2023 Jul 22];360(9336):825–9.

18. Jortveit J, Pripp AH, Halvorsen S. Outcomes after delayed primary percutaneous coronary intervention vs. pharmaco-invasive strategy in ST-segment elevation myocardial infarction in Norway. Eur Heart J Cardiovasc Pharmacother. 2022;8(5).

19. Gagliardi JA, Charask A, Perna E, et al. Encuesta nacional de infarto agudo de miocardio con elevación del ST en la República Argentina (ARGENT-IAM-ST). Rev Argent Cardiol. 2016;84(6).

20. Cardiología SA de. Consenso De Infarto Agudo De Miocardio Con Elevación Del Segmento St - Actualización focalizada 2020. Rev Argent Cardiol. 2020;88(3).

21. Salas acreditadas por CACI. Colegio Argentino de Cardioangiólogos Intervencionistas (CACI). Disponible en: https://www.caci.org.ar/acreditacion-de-salas/

22. Instituto Nacional de Estadística y Censos -INDEC. 1a ed. - Ciudad Autónoma de Buenos Aires : Instituto Nacional de Estadística y Censos -INDEC, 2023. Libro digital, PDF - (Censo nacional de población, hogares y viviendas 2022 ; 1). 2023 [cited 2024 Feb 9]. Censo Nacional de Población, Hogares y Viviendas 2022 : resultados definitivos : indicadores demográficos por sexo y edad . Disponible en: https://censo.gob.ar/index.php/datos_definitivos/

23. Kristian Thygesen, Joseph S. Alpert, Allan S. Jaffe, et al. Consenso ESC 2018 sobre la cuarta definición universal del infarto. Rev Esp Cardiol. 2019 Jan;72(1):72.e1-72.e27.

24. Chesebro JH, Knatterud G, Roberts R, et al. Thrombolysis in Myocardial Infarction (TIMI) Trial, Phase I: A comparison between intravenous tissue plasminogen activator and intravenous streptokinase. Clinical findings through hospital discharge. Circulation. 1987 Jul;76(1):142–54.

25. Chacón-Diaz M, Custodio-Sánchez P, Rojas De la Cuba P, et al. Outcomes in ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention or pharmacoinvasive strategy in a Latin American country. BMC Cardiovasc Disord. 2022 Dec 29;22(1):296.

26. Rashid MK, Guron N, Bernick J, et al. Safety and Efficacy of a Pharmacoinvasive Strategy in ST-Segment Elevation Myocardial Infarction. JACC Cardiovasc Interv. 2016 Oct;9(19):2014–20.

27. San Román JA, Candell-Riera J, Arnold R, et al. Quantitative Analysis of Left Ventricular Function as a Tool in Clinical Research. Theoretical Basis and Methodology. Revista Española de Cardiología (English Edition). 2009 May;62(5):535–51.

28. Arazi HC, Zapata G, Marturano MP, et al. Primary angioplasty in Argentina. Results from ARGEN-IAM-ST registry | Angioplastia primaria en Argentina. Registro ARGEN-IAM-ST (relevamiento nacional del infarto agudo de miocardio con elevación del segmento st). Medicina (Argentina). 2019;79(4).

29. Araiza-Garaygordobil D, Gopar-Nieto R, Cabello-López A, et al. Pharmacoinvasive Strategy vs Primary Percutaneous Coronary Intervention in Patients With ST-Elevation Myocardial Infarction: Results From a Study in Mexico City. CJC Open. 2021 Apr;3(4):409–18.

30. Sultan EZM, Elberry AA, Rabea H, Mahmoud HB. Safety and Efficacy of Pharmaco-invasive Approach Using Streptokinase Compared With Primary Percutaneous Coronary Angiography. Critical Pathways in Cardiology: A Journal of Evidence-Based Medicine. 2021 Sep 25;20(3):149–54.

31. De Marqui Moraes PI, Galhardo A, Barbosa AHP, et al. Metrics of care and cardiovascular outcomes in patients with ST-elevation myocardial infarction treated with pharmacoinvasive strategy: a decade-long network in a populous city in Brazil. BMC Cardiovasc Disord. 2023 Jun 15;23(1):300.

32. Li K, Zhang B, Zheng B, Zhang Y, Huo Y. Reperfusion Strategy of ST-Elevation Myocardial Infarction: A Meta-Analysis of Primary Percutaneous Coronary Intervention and Pharmaco-Invasive Therapy. Front Cardiovasc Med. 2022 Mar 17;9.

Para descargar el PDF del artículo
Pharmacoinvasive strategy versus primary percutaneous coronary intervention in ST-segment elevation myocardial infarction: the Northern Patagonian experience

Haga click aquí