Document Detail


Fibrinolysis Use Among Patients Requiring Interhospital Transfer for ST-Segment Elevation Myocardial Infarction Care: A Report From the US National Cardiovascular Data Registry.
MedLine Citation:
PMID:  25485876     Owner:  NLM     Status:  Publisher    
Abstract/OtherAbstract:
Importance: Guidelines for patients with ST-segment elevation myocardial infarction (STEMI) recommend timely reperfusion with primary percutaneous coronary intervention (pPCI) or fibrinolysis. Among patients with STEMI who require interhospital transfer, it is unclear how reperfusion strategy selection and outcomes vary with interhospital drive times.
Objective: To assess the association of estimated interhospital drive times with reperfusion strategy selection among transferred patients with STEMI in the United States.
Design, Setting, and Participants: We identified 22 481 patients eligible for pPCI or fibrinolysis who were transferred from 1771 STEMI referring centers to 366 STEMI receiving centers in the Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With the Guidelines database between July 1, 2008, and March 31, 2012.
Main Outcomes and Measures: In-hospital mortality and major bleeding.
Results: The median estimated interhospital drive time was 57 minutes (interquartile range [IQR], 36-88 minutes). When the estimated drive time exceeded 30 minutes, only 42.6% of transfer patients treated with pPCI achieved the first door-to-balloon time within 120 minutes. Only 52.7% of eligible patients with a drive time exceeding 60 minutes received fibrinolysis. Among 15 437 patients with estimated drive times of 30 to 120 minutes who were eligible for fibrinolysis or pPCI, 5296 (34.3%) received pretransfer fibrinolysis, with a median door-to-needle time of 34 minutes (IQR, 23-53 minutes). After fibrinolysis, the median time to transfer to the STEMI receiving center was 49 minutes (IQR, 34-69 minutes), and 97.1% underwent follow-up angiography. Patients treated with fibrinolysis vs pPCI had no significant mortality difference (3.7% vs 3.9%; adjusted odds ratio, 1.13; 95% CI, 0.94-1.36) but had higher bleeding risk (10.7% vs 9.5%; adjusted odds ratio, 1.17; 95% CI, 1.02-1.33).
Conclusions and Relevance: In the United States, neither fibrinolysis nor pPCI is being optimally used to achieve guideline-recommended reperfusion targets. For patients who are unlikely to receive timely pPCI, pretransfer fibrinolysis, followed by early transfer for angiography, may be a reperfusion option when potential benefits of timely reperfusion outweigh bleeding risk.
Authors:
Amit N Vora; DaJuanicia N Holmes; Ivan Rokos; Matthew T Roe; Christopher B Granger; William J French; Elliott Antman; Timothy D Henry; Laine Thomas; Eric R Bates; Tracy Y Wang
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Publication Detail:
Type:  JOURNAL ARTICLE     Date:  2014-12-8
Journal Detail:
Title:  JAMA internal medicine     Volume:  -     ISSN:  2168-6114     ISO Abbreviation:  JAMA Intern Med     Publication Date:  2014 Dec 
Date Detail:
Created Date:  2014-12-8     Completed Date:  -     Revised Date:  2014-12-9    
Medline Journal Info:
Nlm Unique ID:  101589534     Medline TA:  JAMA Intern Med     Country:  -    
Other Details:
Languages:  ENG     Pagination:  -     Citation Subset:  -    
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