Benefit of Transferring ST-Segment-Elevation Myocardial Infarction Patients for Percutaneous Coronary Intervention Compared With Administration of Onsite Fibrinolytic Declines as Delays Increase

Although randomized trials suggest that transfer for primary percutaneous coronary intervention (X-PCI) in ST-segment-elevation myocardial infarction is superior to onsite fibrinolytic therapy (O-FT), the generalizability of these findings to routine clinical practice is unclear because door-to-ball...

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Bibliographic Details
Published in:Circulation (New York, N.Y.) N.Y.), 2011-12, Vol.124 (23), p.2512-2521
Main Authors: PINTO, Duane S, FREDERICK, Paul D, CHAKRABARTI, Anjan K, KIRTANE, Ajay J, ULLMAN, Edward, DEJAM, Andre, MILLER, Dave P, HENRY, Timothy D, MICHAEL GIBSON, C
Format: Article
Language:English
Subjects:
Aged
Angioplasty, Balloon, Coronary - statistics & numerical data
Biological and medical sciences
Blood and lymphatic vessels
Cardiology. Vascular system
Coronary heart disease
Diseases of the peripheral vessels. Diseases of the vena cava. Miscellaneous
Electrocardiography
Emergency Medical Services - statistics & numerical data
Fibrinolytic Agents - administration & dosage
Heart
Humans
Logistic Models
Medical sciences
Middle Aged
Myocardial Infarction - diagnosis
Myocardial Infarction - mortality
Myocardial Infarction - therapy
Registries - statistics & numerical data
Risk Factors
Survival Analysis
Time Factors
Transportation of Patients - statistics & numerical data
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Summary:Although randomized trials suggest that transfer for primary percutaneous coronary intervention (X-PCI) in ST-segment-elevation myocardial infarction is superior to onsite fibrinolytic therapy (O-FT), the generalizability of these findings to routine clinical practice is unclear because door-to-balloon (XDB) times are rapid in randomized trials but are frequently prolonged in practice. We hypothesized that delays resulting from transfer would reduce the survival advantage of X-PCI compared with O-FT. ST-segment-elevation myocardial infarction patients enrolled in the National Registry of Myocardial Infarction (NRMI) within 12 hours of pain onset were identified. Propensity matching of patients treated with X-PCI and O-FT was performed, and the effect of PCI-related delay on in-hospital mortality was assessed. PCI-related delay was calculated by subtracting the XDB from the door-to-needle time in each matched pair. Conditional logistic regression adjusted for patient and hospital variables identified the XDB door-to-needle time at which no mortality advantage for X-PCI over O-FT was present. Eighty-one percent of X-PCI patients were matched (n=9506) to O-FT patients (n=9506). In the matched cohort, X-PCI was performed with delays >90 minutes in 68%. Multivariable analysis found no mortality advantage for X-PCI over O-FT when XDB door-to-needle time exceeded ≈120 minutes. PCI-related delays are extensive among patients transferred for X-PCI and are associated with poorer outcomes. No differential excess in mortality was seen with X-PCI compared with O-FT even with long PCI-related delays, but as XDB door-to-needle time times increase, the mortality advantage for X-PCI over O-FT declines.
ISSN:0009-7322
1524-4539
DOI:10.1161/CIRCULATIONAHA.111.018549