As time goes by? The fallacy of thrombolysis in STEMI networks

Abstract

Primary percutaneous coronary intervention (PPCI) is superior to thrombolysis (TL) as reperfusion therapy in ST-elevation myocardial infarction (STEMI). TL is a rapidly available, but semi-effective therapy (effective reperfusion in 50% of patients only), whereas PPCI is a potentially delayed, but highly effective therapy (effective reperfusion in >90%). Since TL loses its efficacy beyond 2-3 h after symptom onset, it is a significant reperfusion alternative to PPCI in early presenters only. The individual decision to treat an early presenter with PPCI or TL requires the evaluation of the time delay between potential start of TL or PPCI, the PCI-related delay (PRD). PRD is greatest, if TL is given in the prehospital setting. Until now, prehospital TL as the most rapidly available reperfusion strategy has failed to demonstrate any prognostic or even any other relevant benefit compared to PPCI in any subgroup of patients, even with time delays for PPCI of up to several hours. On average, a median PRD of at least 90-120 min can be considered a time corridor of prognostic superiority of PPCI over TL. This is already achieved in contemporary registries and myocardial infarction networks.Therefore, the efforts should not focus on the implementation of a dual reperfusion strategy (PPCI, and prehospital TL in selected cases) in established or upcoming myocardial infarction networks, but concentrate on the availability of PPCI in less than 2 h. TL, as rapid as possible, i.e. prehospital, is a vital treatment option in case of non-existing PPCI facilities within a median time limit of 2 h or even more, a scenario not existing or easily to eliminate in European countries by implementing well organized myocardial infarction networks. This is the mission to be accomplished.

Interhospital transfer due to failed prehospital diagnosis for primary percutaneous coronary intervention: an observational study on incidence, predictors, and clinical impact

“…In some of these patients, fibrinolysis may be an alternative reperfusion strategy. However, we and others 23 believe that, in the context of STEMI networks with short transfer distances, further improvements in STEMI care are likely to come from efforts to improve prehospital triage and, if needed, efficient interhospital transfer in order to provide timely primary PCI rather than accepting delays and resorting to fibrinolysis. An important aspect in this process is discussing lessons from analyses as these with all regional STEMI care participants.…”

Cost-Effectiveness of Introducing Point-of-Care Test for Detection of Level of Glycogen Phosphorylase in Early Diagnostic Algorithm of Acute Coronary Syndrome

“…The basic and transition probabilities were obtained from relevant published clinical and pharmacoeconomic studies (see Table 1) [2,14,[17][18][19][20][21][22][23][24][25][26][27][28][29][30]. The model was simulated by Monte-Carlo simulation, using specially written macros in Microsoft Visual Basic for this purpose.…”