Does time matter? A pooled analysis of randomized clinical trials comparing primary percutaneous coronary intervention and in-hospital fibrinolysis in acute myocardial infarction patients

Boersma, Eric

doi:10.1093/eurheartj/ehi810

Cited by 587 publications

(334 citation statements)

References 45 publications

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“…(1) According to the ESC guidelines, (1) it is a CLASS 1 A recommendation that STEMI patients presenting to a hospital with PCI capability should be treated with primary PCI within 90 minutes of first medical contact (FMC), while it is a CLASS 1 B recommendation that STEMI patients presenting to a hospital without PCI capability, and who cannot be transferred to a PCI center and Adriaan Snyders * and Rhena Delport # Autumn 2015 Volume 12 • Number 2 essary case fatalities. (3,4) Ideally patients should have access to a referral pathway to p-PCI that is managed by informed professionals and is free of delays and bottlenecks. Patient, system and other delays contribute to the inability to meet quality targets.…”

Section: These Objectives Accord With the European Society Ofmentioning

confidence: 99%

Referral pathways for reperfusion of STEMI – developing strategies for appropriate intervention

Snyders

Delport

2017

SAHJ

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undergo PCI within 90 minutes of FMC, should be treated with fibrinolytic therapy within 30 minutes of hospital presentation, unless such therapy is contraindicated.A recent study in STEMI patients found that while p-PCI was performed in 60%, the majority of the interventions occurred later than 120 minutes, and that only 36% received fibrinolysis.(2) This high percentage of patients receiving angiographyand an invasive treatment strategy may be explained by the location of the participating centers in urban areas, almost all of which were private healthcare facilities.Early and appropriate pre-hospital diagnosis, as well as immediate transport, are of vital importance to avoid unnec- ABSTRACT

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Section: These Objectives Accord With the European Society Ofmentioning

confidence: 99%

Referral pathways for reperfusion of STEMI – developing strategies for appropriate intervention

Snyders

Delport

2017

SAHJ

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“…The patient recall bias or unstable angina prior to AMI may modify the onset time information. The hemodynamic status of patient, severity of coronary artery disease, age, gender, presence of other comorbidities or socio-demographic factors affect the time from symptom onset to treatment and outcomes, hence may impose a selection bias [34][35][36] . For instance, patients with more severe disease and worse prognosis may present earlier, those presenting later are typically low-risk patients who have already survived the pre-hospital phase 36 .…”

Section: Timi-3 Flow As An Outcome Predictormentioning

confidence: 99%

Mortality in patients with TIMI 3 flow after PCI in relation to time delay to reperfusion

Vichova¹,

Malý²,

Ulman³

et al. 2016

Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub

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Background. Percutaneous coronary intervention (PCI) performed within 12 h from symptom onset enables complete blood flow restoration in infarct-related artery in 90% of patients. Nevertheless, even with complete restoration of epicardial blood flow in culprit vessel (postprocedural Thrombolysis in Myocardial Infarction (TIMI) flow grade 3), myocardial perfusion at tissue level may be insufficient. We hypothesized that the outcome of patients with STEMI/ bundle branch block (BBB)-myocardial infarction and post-PCI TIMI 3 flow is related to the time to reperfusion. Methods. Observational study based on a retrospective analysis of population of 635 consecutive patients with STEMI/ BBB-MI and post-PCI TIMI 3 flow from January 2009 to December 2011 (mean age 63 years, 69.6% males). Mortality of patients was evaluated in relation to the time from symptom onset to reperfusion. Results. A total of 83 patients (13.07%) with postprocedural TIMI 3 flow after PCI had died at 1-year follow-up. Median TD in patients who survived was 3.92 h (iqr 5.43), in patients who died 6.0 h (iqr 11.42), P = 0.004. Multiple logistic regression analysis identified time delay ≥ 9 h as significantly related to 1-year mortality of patients with STEMI/BBB-MI and post-PCI TIMI 3 flow (OR 1.958, P = 0.026). Other significant variables associated with mortality in multivariate regression analysis were: left ventricle ejection fraction < 30% (P = 0.006), age > 65 years (P < 0.001), Killip class >2 (P <0.001), female gender (P = 0.019), and creatinine clearance < 30 mL/min (P < 0.001). Conclusion. Time delay to reperfusion is significantly related to 1-year mortality of patients with STEMI/BBB-MI and complete restoration of epicardial blood flow in culprit vessel after PCI.

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“…Any delay to reperfusion is associated with an increase in mortality [12][13][14] . In the real world patients may experience considerable delays that may negate the benefit of PPCI over immediate fibrinolysis [15,16] .…”

Section: Ppci When Available or Immediate Fibrinolysis?mentioning

confidence: 99%

Risk stratification for ST segment elevation myocardial infarction in the era of primary percutaneous coronary intervention

Brogan

Malkin

Batin

et al. 2014

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Acute coronary syndromes presenting with ST elevation are usually treated with emergency reperfusion/ revascularisation therapy. In contrast current evidence and national guidelines recommend risk stratification for non ST segment elevation myocardial infarction (NSTEMI) with the decision on revascularisation dependent on perceived clinical risk. Risk stratification for STEMI has no recommendation. Statistical risk scoring techniques in NSTEMI have been demonstrated to improve outcomes however their uptake has been poor perhaps due to questions over their discrimination and concern for application to individuals who may not have been adequately represented in clinical trials. STEMI is perceived to carry sufficient risk to warrant emergency coronary intervention [by primary percutaneous coronary intervention (PPCI)] even if this results in a delay to reperfusion with immediate thrombolysis. Immediate thrombolysis may be as effective in patients presenting early, or at low risk, but physicians are poor at assessing clinical and procedural risks and currently are not required to consider this. Inadequate data on risk stratification in STEMI inhibits the option of immediate fibrinolysis, which may be cost-effective. Currently the mode of reperfusion for STEMI defaults to emergency angiography and percutaneous coronary intervention ignoring alternative strategies. This review article examines the current risk scores and evidence base for risk stratification for STEMI patients. The requirements for an ideal STEMI risk score are discussed. Key words: ST segment elevation myocardial infarction; Risk stratification; Primary percutaneous coronary intervention; Harm; Risk scores Core tip: Risk stratification is recommended in non ST segment elevation myocardial infarction (NSTEMI) by multiple international cardiology agencies however there is no such recommendation for STEMI. The short term risk of STEMI is perceived to be high and warrant emergency percutaneous coronary intervention rather than pharmacological fibrinolysis. The risk spectrum is wide therefore consideration should be given to developing an optimal reperfusion strategy based on risk of adverse outcome and probability of reperfusion regard- MINIREVIEWSSubmit a

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Does time matter? A pooled analysis of randomized clinical trials comparing primary percutaneous coronary intervention and in-hospital fibrinolysis in acute myocardial infarction patients

Cited by 587 publications

References 45 publications

Referral pathways for reperfusion of STEMI – developing strategies for appropriate intervention

Referral pathways for reperfusion of STEMI – developing strategies for appropriate intervention

Mortality in patients with TIMI 3 flow after PCI in relation to time delay to reperfusion

Risk stratification for ST segment elevation myocardial infarction in the era of primary percutaneous coronary intervention

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