Hospital Delays in Reperfusion for ST-Elevation Myocardial Infarction

Abstract

Background-It has been suggested that the survival benefit associated with primary percutaneous coronary intervention (PPCI) in ST-segment elevation myocardial infarction may be attenuated if door-to-balloon (DB) time is delayed by Ͼ1 hour beyond door-to-needle (DN) times for fibrinolytic therapy. Whereas DB times are rapid in randomized trials, they are often prolonged in routine practice. We hypothesized that in clinical practice, longer DB-DN times would be associated with higher mortality rates and reduced PPCI survival advantage. We also hypothesized that in addition to PPCI delays, patient risk factors would significantly modulate the relative survival advantage of PPCI over fibrinolysis. Methods and Results-DB-DN times were calculated by subtracting median DN time from median DB time at a hospital using data from 192 509 patients at 645 National Registry of Myocardial Infarction hospitals. Hierarchical models that adjusted simultaneously for both patient-level risk factors and hospital-level covariates were used to evaluate the relationship between PCI-related delay, patient risk factors, and in-hospital mortality. Longer DB-DN times were associated with increased mortality (PϽ0.0001). The DB-DN time at which mortality rates with PPCI were no better than that of fibrinolysis varied considerably depending on patient age, symptom duration, and infarct location. Conclusions-As DB-DN times increase, the mortality advantage of PPCI over fibrinolysis declines, and this advantage varies considerably depending on patient characteristics. As indicated in the American College of Cardiology/American Heart Association guidelines, both the hospital-based PPCI-related delay (DB-DN time) and patient characteristics should be considered when a reperfusion strategy is selected.

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

“…Also, although it was longer than current recommendations (ie, less than 60 min), the median 74 min estimated PCI-related delay for patients referred from nearby hospitals is similar to the average 73 min PCI-related delay observed in trials evaluating transfer for primary PCI (5). 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).…”

“…When total transfer time is expected to be longer than 30 min, physicians should assess whether thrombolytic therapy may be a better reperfusion strategy than primary PCI. In particular, young patients presenting early in the course of an STEMI may fare better with thrombolytic therapy when PCI is not readily available (14).…”

“…DTB times of less than 2 h in patients transferred for primary PCI are associated with improved survival, less recurrent ischemia and angina, less cardiogenic shock and a shorter hospital stay (11). Furthermore, recent analyses (12)(13)(14) suggest that the benefits of primary PCI over thrombolytic therapy vanish as PCI-related delays increase. For these reasons, treatment delays must be taken into account when deciding between thrombolytic therapy and transfer for primary PCI.…”

Das initiale Management des akuten Koronarsyndroms

“…Tab. Es ist weniger sicher, ob eine sofortige Fibrinolyse (prähospital oder im Krankenhaus) bzw. der Transfer zur PPCI bei jüngeren Patienten mit Vorderwandinfarkt und einer Symptomdauer von 2−4 h günstiger ist [133]. Die Verlegung von STEMI-Patienten, die nach mehr als 3 h und bis zu 12 h nach Symptombeginn gesehen werden, ist dagegen sinnvoll, sofern der Transport schnell möglich ist.…”

Pre-hospital treatment of STEMI patients. A scientific statement of the Working Group Acute Cardiac Care of the European Society of Cardiology

“…As shown from registry data, an increase in the PPCI-related delay (D2B minus D2N time) is associated with higher mortality rates. The time point at which PPCI loses its survival advantage over fibrinolysis varies considerably between subgroups, from <1 hour to 3 hours 9 . Registry data also show that field transfer is faster than inter-hospital transfer, resulting in more patients achieving a D2B time < 90mins.…”