Impact of Time to Treatment on Mortality After Prehospital Fibrinolysis or Primary Angioplasty

Abstract

MD; for the Comparison of Angioplasty and Prehospital Thrombolysis In acute Myocardial infarction (CAPTIM) Investigators*Background-CAPTIM was a randomized trial comparing prehospital thrombolysis with transfer to an interventional facility (and, if needed, percutaneous intervention) with primary percutaneous coronary intervention (PCI) in patients with ST-segment-elevation myocardial infarction (STEMI). Because the benefit of thrombolysis is maximal during the first 2 hours after symptom onset, and because prehospital thrombolysis can be implemented earlier than PCI, this analysis studied the relationship between the effect of assigned treatment and the time elapsed from symptom onset. Methods and Results-Randomization within 2 hours (nϭ460) or Ն2 hours (nϭ374) after symptom onset had no impact on the effect of treatment on the 30-day combined primary end point of death, nonfatal reinfarction, and disabling stroke. However, patients randomized Ͻ2 hours after symptom onset had a strong trend toward lower 30-day mortality with prehospital thrombolysis compared with those randomized to primary PCI (2.2% versus 5.7%, Pϭ0.058), whereas mortality was similar in patients randomized Ն2 hours (5.9% versus 3.7%, Pϭ0.47). There was a significant interaction between treatment effect and delay with respect to 30-day mortality (hazard ratio 4.19, 95% CI 1.033 to 17.004, Pϭ0.045). Among patients randomized in the first 2 hours, cardiogenic shock was less frequent with lytic therapy than with primary PCI (1.3% versus 5.3%, Pϭ0.032), whereas rates were similar in patients randomized later. Conclusions-Time from symptom onset should be considered when one selects reperfusion therapy in STEMI.Prehospital thrombolysis may be preferable to primary PCI for patients treated within the first 2 hours after symptom onset.

Selecting the Best Reperfusion Strategy in ST-Elevation Myocardial Infarction

“…There was no difference at 30 days in the primary composite of death, non-fatal reinfarction, and non-fatal stroke (8.2% for fibrinolysis versus 6.2% for PCI, Pϭ0.29) or in mortality alone (3.8% versus 4.8%, Pϭ0.61). Furthermore, as described in a provocative analysis by Steg et al 6 in the current issue of Circulation, there was a strong trend toward lower mortality (2.2% versus 5.7%, Pϭ0.058) and a reduction of cardiogenic shock (1.3% versus 5.3%, Pϭ0.032), but no difference in the primary triple endpoint (7.4% versus 6.6%, Pϭ0.86) in patients treated with prehospital fibrinolysis within 2 hours of symptom onset. Thus, the abovedescribed superiority of PCI over fibrinolysis appears not always to be present in a small but important subgroup of patients, ie, those who can receive treatment in the first 2 hours after symptom onset.…”

Cardiogenic Shock

“…A randomized trial of early, in-ambulance thrombolysis versus primary PCI found no CS among patients assigned to prehospital thrombolysis. 7 Among PCI-assigned patients, just 0.5% developed CS in the group randomized Ͻ2 hours from symptom onset. A major focus of public health campaigns is the very early recognition and reperfusion of MI, which should reduce CS incidence.…”

Diretrizes

“…É importante ressaltar que a segurança da transferência para um hospital terciário habilitado para ICP de urgência já foi verificada por alguns estudos [323][324][325] .…”