Temporal Trends in Care and Outcomes of Patients Receiving Fibrinolytic Therapy Compared to Primary Percutaneous Coronary Intervention: Insights From the Get With The Guidelines Coronary Artery Disease (GWTG‐CAD) Registry

Abstract

BackgroundTimely reperfusion after ST‐elevation myocardial infarction (STEMI) improves survival. Guidelines recommend primary percutaneous coronary intervention (PPCI) within 90 minutes of arrival at a PCI‐capable hospital. The alternative is fibrinolysis within 30 minutes for those in those for whom timely transfer to a PCI‐capable hospital is not feasible.Methods and ResultsWe identified STEMI patients receiving reperfusion therapy at 229 hospitals participating in the Get With the Guidelines—Coronary Artery Disease (GWTG‐CAD) database (January 1, 2003 through December 31, 2008). Temporal trends in the use of fibrinolysis and PPCI, its timeliness, and in‐hospital mortality outcomes were assessed. We also assessed predictors of fibrinolysis versus PPCI and compliance with performance measures. Defect‐free care was defined as 100% compliance with all performance measures. We identified 29 190 STEMI patients, of whom 2441 (8.4%) received fibrinolysis; 38.2% of these patients achieved door‐to‐needle times ≤30 minutes. Median door‐to‐needle times increased from 36 to 60 minutes (P=0.005) over the study period. Among PPCI patients, median door‐to‐balloon times decreased from 94 to 64 minutes (P<0.0001) over the same period. In‐hospital mortality was higher with fibrinolysis than with PPCI (4.6% vs 3.3%, P=0.001) and did not change significantly over time. Patients receiving fibrinolysis were less likely to receive defect‐free care compared with their PPCI counterparts.ConclusionsUse of fibrinolysis for STEMI has decreased over time with concomitant worsening of door‐to‐needle times. Over the same time period, use of PPCI increased with improvement in door‐to‐balloon times. In‐hospital mortality was higher with fibrinolysis than with PPCI. As reperfusion for STEMI continues to shift from fibrinolysis to PPCI, it will be critical to ensure that door‐to‐needle times and outcomes do not worsen.

Improved outcomes in patients with ST-elevation myocardial infarction during the last 20 years are related to implementation of evidence-based treatments: experiences from the SWEDEHEART registry 1995–2014

“…The two phases with a rapid increase of several evidence based treatments from 1999–2000 to 2007–08 and the subsequent plateau are also in keeping with trends seen in other countries, including the USA, UK, New Zealand, France, and Germany, although the exact timing may differ between regions. 10 , 21–25 The decline in the risk of recurrent MI has also been seen in other studies. 24 The steady decrease in short-term mortality in STEMI patients until 2007–08 has been shown in other studies, but not all.…”

In the search for an ideal registry: Does the cloud have a silver lining?

“…Two peaks in increase of evidence-based treatment have occurred, one between 1999–2000, and another one between 2007–2008. These peaks improved cardiovascular mortality and morbidity significantly, and coincide with guideline publications, 13–18 Interestingly enough, a subsequent plateau was observed, with no further reduction in mortality. 19,20 This plateau may be caused by the ageing of population, complex multivessel coronary anatomy and a high burden of co-morbidities.…”

Extending Time to Reperfusion with Mild Therapeutic Hypothermia: A New Paradigm for Providing Primary Percutaneous Coronary Intervention to Remote ST Segment Elevation Myocardial Infarction Patients

“…If such a timely transfer cannot be accomplished, then intravenous administration of a fibrinolytic is the recommended alternative (O'Gara et al, 2013). The administration of intravenous fibrinolytics for STEMI patients has been decreasing in recent years, in one report from 20.5% in 2003 to 3.7% in 2008, while in-hospital mortality remains higher in those receiving intravenous fibrinolytics versus PPCI (4.6% vs. 3.3%; p < 0.001) (Hira et al, 2016). Fibrinolysis is not as effective at restoring coronary flow as is PPCI.…”