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Heart attack patients showing up long after symptom onset still had better short- and long-term outcomes after revascularization of the infarct artery, according to data from a large French registry.

In the FAST-MI program, unselected ST-segment elevation MI (STEMI) patients presenting 12-48 hours after symptom onset had a lower incidence of 30-day mortality if they underwent revascularization, namely primary PCI (2.1% vs 7.2% if not revascularized, P<0.001).

Mortality rates over follow-up lasting a median 58 months also favored the revascularized group (30.4 vs 78.7 per 1,000 patient-years, P<0.001), and revascularization was independently associated with a significant reduction of long-term mortality (adjusted HR 0.65, 95% CI 0.50-0.84), reported Jean Ferrières, MD, PhD, of Toulouse Rangueil University Hospital in France, and colleagues in the .

As such, this analysis of 1,077 STEMI latecomers adds to "the conviction that primary PCI should be offered to all patients with STEMI presenting 12 to 48 hours from symptom onset," according to Adnan Kastrati, MD, of Deutsches Herzzentrum München in Germany, and colleagues in an .

This is particularly timely given that the COVID-19 pandemic has been associated with longer ischemia times and more latecomer STEMI patients, the investigators said.

"In the future, risk categories may be identified to help define the urgency of PCI in the setting of late presenting STEMI. However, current data suggest that the ability of PCI to salvage ischemic myocardium in this setting is less time-dependent than in patients presenting within 12 hours from the onset of symptoms," the editorialists concluded.

Ferrières' group reported that the prevalence of latecomers in the STEMI population dropped from 22.7% in 2005 to 16.1% in 2015 (P<0.001), perhaps the result of public policies, increased public awareness, and regional care networks in France.

The finding that one in six people in the study still presented beyond 12 hours in 2015 is "striking," Kastrati's group said. "This finding is even more conspicuous when we consider that this data comes from a country that has implemented one of the best regional systems of STEMI care worldwide."

Thus, given that some STEMI patients can have mild symptoms, "it is likely that a certain proportion of patients will continue to present late with STEMI, no matter how effective the system of care," the editorialists wrote.

Indeed, the French investigators reported atypical chest pain as one of the predictors of late arrival in STEMI patients.

"Interestingly, female sex was not related to late arrival in our cohort, whereas it was suggested in previous works. This difference we observed with older studies might be caused by an increasing awareness among physicians and the population of acute MI symptoms in female patients, because these are more likely to be atypical," Ferrières and colleagues suggested.

Their study covered the same 1-month period in 2005, 2010, and 2015 and included 6,273 consecutive STEMI patients admitted to cardiac ICUs within 48 hours of symptom onset. People treated with fibrinolysis and those who died within 2 days of admission were excluded.

For the 1,077 latecomers eligible for analysis in FAST-MI, median time from symptom onset to ICU admission was 20.2 hours. Revascularization was performed within 48 hours after hospital admission for 67.7% of this group and was by and large done with PCI (only three people got coronary artery bypass grafting).

Ferrières and colleagues highlighted increased use of invasive strategy and evidence-based medications in latecomer STEMI patients over the years.

However, their study was limited by an observational design that left room for potential confounding.

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