Fibrinolysis Use Among Patients Requiring Interhospital Transfer for ST-Segment Elevation Myocardial Infarction Care: A Report From the US National Cardiovascular Data Registry | Journal Scan

Study Questions:

What is the association of estimated interhospital drive times with reperfusion strategy selection among transferred patients with ST-segment elevation myocardial infarction (STEMI) in the United States?

Methods:

The investigators identified 22,481 patients eligible for primary percutaneous coronary intervention (pPCI) or fibrinolysis, who were transferred from 1,771 STEMI referring centers to 366 STEMI receiving centers in the Acute Coronary Treatment and Intervention Outcomes Network Registry–Get With the Guidelines (ACTION Registry-GWTG) database between July 1, 2008, and March 31, 2012. The main outcomes and measures were 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 30-120 minutes who were eligible for fibrinolysis or pPCI, 5,296 (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 versus pPCI had no significant mortality difference (3.7% vs. 3.9%; adjusted odds ratio, 1.13; 95% confidence interval [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:

The authors concluded that for patients who are unlikely to receive timely pPCI, pretransfer fibrinolysis, followed by early transfer for angiography, may be a useful reperfusion option.

Perspective:

This study reports that less than half of patients with STEMI achieved pPCI within the guideline-recommended time frame if they required transfer to a STEMI receiving center more than 30 minutes away. These findings suggest consideration of estimated interhospital drive times when making reperfusion decisions. For patients who are unlikely to receive timely pPCI, pretransfer fibrinolytics, followed by early transfer for angiography, may be a contemporary reperfusion option when potential benefits of timely reperfusion outweigh bleeding risk.

Clinical Topics: Invasive Cardiovascular Angiography and Intervention, Interventions and Imaging, Angiography, Nuclear Imaging

Keywords: Angiography, Fibrinolysis, Hospital Mortality, Myocardial Infarction, Hemorrhage, Percutaneous Coronary Intervention, Registries, Thrombolytic Therapy, United States


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