A Comparison of Coronary Angioplasty with Fibrinolytic Therapy in Acute Myocardial Infarction

Andersen, Henning; Nielsen, Torsten T.; Rasmussen, Klaus; Thuesen, Leif; Kelbæk, Henning; Thayssen, Per; Abildgaard, Ulrik; Pedersen, Flemming; Madsen, Jan Kyst; Grande, Peer; Villadsen, Anton Boel; Krusell, Lars Romer; Haghfelt, Torben; Lomholt, P; Husted, Steen; Vigholt, Else; Kjærgård, Henrik K.; Mortensen, Leif Spange

doi:10.1056/nejmoa025142

Cited by 1,155 publications

(452 citation statements)

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“…This is also well within the 110 min to 114 min PCI-related delay at which primary PCI is expected to lose its mortality benefit over thrombolytic therapy (13,14). On the other hand, the 110 min estimated PCI-related delay for patients transferred from remote hospitals was longer than in previous randomized clinical trials (3,4). In the present study, DTB times were shorter for patients presenting during normal business hours than for patients presenting during weekends or outside normal duty hours.…”

Section: Discussionsupporting

confidence: 79%

“…Many studies have shown that transferring STEMI patients is safe, and that the benefits of primary PCI over thrombolytic therapy are conserved when transfer delays are reasonable (2)(3)(4)(5). Based on randomized, controlled trials, the current guidelines for STEMI recommend a door-to-balloon (DTB) time of less than 90 min when performing primary PCI, including transfer time (6)(7)(8).…”

mentioning

confidence: 99%

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Treatment delays in patients undergoing primary percutaneous coronary intervention for ST elevation myocardial infarction at the Quebec Heart and Lung Institute

Garceau

Déry

Lachance

et al. 2007

Canadian Journal of Cardiology

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P Garceau, J-P Déry, P Lachance, et al. Treatment delays in patients undergoing primary percutaneous coronary intervention for ST elevation myocardial infarction at the Quebec Heart and Lung Institute. Can J Cardiol 2007;23(Suppl B):53B-57B.BACKGROUND: Current guidelines for ST elevation myocardial infarction (STEMI) recommend performing primary percutaneous coronary intervention (PCI) within 90 min of hospital arrival. However, recent data suggest that in a real-world setting, median door-to-balloon (DTB) time is closer to 180 min for transfer patients, with less than 5% of patients being treated within 90 min. A retrospective observational study was conducted to assess time to treatment in patients undergoing primary PCI at the Quebec Heart and Lung Institute (QHLI). METHODS: Consecutive lytic-eligible patients undergoing primary PCI at the QHLI for STEMI between April 2004 and March 2005 were included in the present analysis. The primary evaluation was DTB time measured from arrival at the first hospital to first balloon inflation. Clinical outcomes were in-hospital death, reinfarction and bleeding. DTB times and hospital outcomes of patients transferred from referring hospitals were compared with those of patients presenting directly to the QHLI. RESULTS: During the study period, 203 lytic-eligible patients were treated with primary PCI. Sixty-nine patients presented directly to the QHLI and 134 were transferred from other hospitals. Six transfer patients were excluded because of missing time variables. The median DTB time was 114 min in transfer patients, compared with 87 min in patients presenting directly to the QHLI (P<0.001). DTB time was less than 90 min in 24% of the transfer population compared with 55% of patients presenting directly to the QHLI (P<0.001). In patients referred from hospitals within a radius of 30 km from the QHLI (n=100), median DTB time was 106 min with 30% receiving PCI within 90 min. In these patients, estimated PCI-related delay was 74 min. For patients presenting to hospitals beyond 30 km (n=28), median DTB time was 142 min with 4% receiving reperfusion within 90 min. In these patients, estimated PCI-related delay was 110 min. Median DTB time for patients presenting during off hours at the QHLI was 92 min compared with 79 min for patients presenting during regular business hours (P=0.02). In patients transferred from other hospitals, median DTB time was 118 min during off hours and 108 min during normal business hours (P=0.07). CONCLUSIONS: A DTB time of less than 90 min can be achieved in the majority of patients presenting directly to a primary PCI centre. However, for patients presenting to community hospitals, transfer for primary PCI is often associated with delayed revascularization. The present study highlights the need for careful patient selection when deciding between on-site thrombolytic therapy and transfer

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Section: Discussionsupporting

confidence: 79%

mentioning

confidence: 99%

Treatment delays in patients undergoing primary percutaneous coronary intervention for ST elevation myocardial infarction at the Quebec Heart and Lung Institute

Garceau

Déry

Lachance

et al. 2007

Canadian Journal of Cardiology

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“…There were delays in many parts of the PCI process. These include the longer catheter door-to-balloon inflation times recorded in our study compared with times achieved in published studies (40 min versus 26 min) (12,14). Another factor was the long average ambulance ride times of 51 min.…”

Section: Discussionmentioning

confidence: 39%

“…Second, ambulance ride time could potentially be improved, however minimally, and probably would not result in a significant decrease in the door-to-balloon time. Third, RCH catheter door-toballoon inflation time could be improved to match that of other studies (12,14), which would result in a 14 min reduction in the door-to-balloon time. Finally, the most significant improvement in the door to balloon time, perhaps by 60 min, could be possible if strategies were implemented to accelerate the assessment, investigation and transfer of STEMI patients in the CGH emergency department.…”

Section: Discussionmentioning

confidence: 99%

Thrombolysis versus primary percutaneous coronary intervention for ST elevation myocardial infarctions at Chilliwack General Hospital

Janda

Tan

2009

Canadian Journal of Cardiology

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S everal studies have shown that primary percutaneous coronary intervention (PCI) performed by experienced operators immediately after patients are admitted to high-volume tertiary care centres with ST elevation myocardial infarction (STEMI) results in decreased mortality, reinfarction and stroke (1-9). Furthermore, for community hospitals without onsite PCI services, transport of STEMI patients to a PCI centre is superior to thrombolysis under specific circumstances, which are described below (10-14).Thrombolysis is preferred for patients who have STEMI for less than 3 h if the medical contact-to-balloon time is more than 90 min or if the delta time (ie, medical contact-to-balloon time minus medical contact-to-thrombolysis time) is more than 60 min.Alternatively, PCI is preferred if the medical contact-to-balloon time is less than 90 min and the delta time is less than 60 min, or if there are other reasons (eg, contraindications to thrombolysis, symptom onset of more than 3 h or high-risk STEMI [cardiogenic shock, or Killip class 3 or greater]).Chilliwack General Hospital (CGH, Chilliwack, British Columbia), a community hospital without onsite PCI services, is unique because the travel time to the nearest coronary intervention centre (Royal Columbian Hospital [RCH], New Westminster, British Columbia), which is 83 km away, has been anecdotally estimated to be 60 min to 120 min. Currently, there is a paucity of data on the average medical contact-to-thrombolysis time, average medical contact-to-balloon time, and delta time on STEMI patients presenting to CGH. Because CGH emergency physicians were debating on transferring all eligible STEMI patients for PCI therapy, we sought to acquire the average medical contact-to-thrombolysis time, average medical contact-to-balloon time, and delta time to make an informed decision. MethodsA retrospective chart review was conducted on all patients presenting to the emergency department at CGH with STEMIs between January 1, 2004, and December 31, 2005. These dates were chosen because 24 h PCI service at RCH had only been available since January 1, 2004. The inclusion criteria included chest pain for at least 30 min, presentation to the CGH emergency department, ST segment elevation of at least 1 mm in two or more concordant leads, and the administration of thrombolytics or transfer to RCH for PCI. The exclusion criteria included contraindications to thrombolytics and not being transferred for PCI. A total of 67 patients with STEMIs were identified within this time period. Forty patients were then included in the study and 27 patients were excluded. CliniCal STudieS©2009 Pulsus Group Inc. All rights reserved BaCkGrouNd: Studies have shown that primary percutaneous coronary intervention (PCI), when performed by an experienced operator immediately after admission in a high-volume tertiary care centre, results in lower in-hospital mortality, and decreased risk of reinfarction and stroke. Furthermore, for those communities without a PCI centre, transport of patients to a PCI centre...

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“…In contrast, survivorship bias inherent in our study design may have been introduced because patients who died before arrival at the PCI centre were not included in the PCI databases, thereby falsely lowering mortality in the GEMS group, which had the longest transport times. However, a large Danish study comparing coronary angioplasty with fibrinolytic therapy found that no patients died during transportation to the hospital15, hence we do not consider these two potential sources of bias to be strong enough to have an impact on the overall conclusions.…”

Section: Discussionmentioning

confidence: 99%

Helicopter vs. ground transportation of patients bound for primary percutaneous coronary intervention

Funder

Rasmussen

Siersma

et al. 2018

Acta Anaesthesiol Scand

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BackgroundImplementation of the first Danish helicopter emergency medical service (HEMS) was associated with reduced time from first medical contact to treatment at a specialized centre for patients with suspected ST elevation myocardial infarction (STEMI). We aimed to investigate effects of HEMS on mortality and labour market affiliation in patients admitted for primary percutaneous coronary intervention (PCI).MethodsIn this prospective observational study, we included patients with suspected STEMI within the region covered by the HEMS from January 1, 2010, to April 30, 2013, transported by either HEMS or ground emergency medical services (GEMS) to the regional PCI centre. The primary outcome was 30‐day mortality.ResultsAmong the 384 HEMS and 1220 GEMS patients, time from diagnostic ECG to PCI centre arrival was lower with HEMS (median 71 min vs. 78 min with GEMS; P = 0.004). Thirty‐day mortality was 5.0% and 6.2%, respectively (adjusted OR = 0.82, 95% CI 0.44–1.51, P = 0.52. Involuntary early retirement rates were 0.62 (HEMS) and 0.94 (GEMS) per 100 PYR (adjusted IRR = 0.68, 0.15–3.23, P = 0.63). The proportion of patients on social transfer payments longer than half of the follow‐up time was 22.1% (HEMS) vs. 21.2% (adjusted OR = 1.10, 0.64–1.90, P = 0.73).ConclusionIn an observational study of patients with suspected STEMI in eastern Denmark, no significant beneficial effect of helicopter transport could be detected on mortality, premature labour market exit or work ability. Only a study with random allocation to one system vs. another, along with a large sample size, will allow determination of superiority of helicopter transport.

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A Comparison of Coronary Angioplasty with Fibrinolytic Therapy in Acute Myocardial Infarction

Abstract: A strategy for reperfusion involving the transfer of patients to an invasive-treatment center for primary angioplasty is superior to on-site fibrinolysis, provided that the transfer takes two hours or less.

Cited by 1,155 publications

References 19 publications

Treatment delays in patients undergoing primary percutaneous coronary intervention for ST elevation myocardial infarction at the Quebec Heart and Lung Institute

Treatment delays in patients undergoing primary percutaneous coronary intervention for ST elevation myocardial infarction at the Quebec Heart and Lung Institute

Thrombolysis versus primary percutaneous coronary intervention for ST elevation myocardial infarctions at Chilliwack General Hospital

Helicopter vs. ground transportation of patients bound for primary percutaneous coronary intervention

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