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Benefit of Transferring STEMI Patients for PCI Compared With Administration of Onsite Fibrinolytic Declines as Delays Increase



Benefit of Transferring STEMI Patients for PCI Compared With Administration of Onsite Fibrinolytic Declines as Delays Increase

Duane S. Pinto, MD, MPH; Paul D. Frederick, MPH, MBA; Anjan K. Chakrabarti, MD; Ajay J. Kirtane, MD, SM; Edward Ullman, MD; Andre Dejam, MD, PhD; Dave P. Miller, MS; Timothy D. Henry, MD; C. Michael Gibson, MS, MD for the National Registry of Myocardial Infarction Investigators

Circulation,
124:23, November 07, 2011

Benefit of Transferring STEMI Patients for PCI Compared With Administration of Onsite Fibrinolytic Declines as Delays Increase

Background
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.


Methods and Results
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.


Conclusion
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.







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Prepared by: Dr. Houssam Al-Nahhas






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