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Dr. Rud Andersen
Prof. Steen Dalby Kristensen,
Transferral of patients with acute ST-elevation MI from community hospitals to centers with facilities for primary PCI is safe, and the short term outcome is better after primary PCI than after thrombolytic therapy given in the community hospital.
Primary PCI for the treatment of acute ST-elevation MI (STEMI) has been shown to be superior to treatment with thrombolytics, when patients are admitted to hospitals with an experienced interventional staff, that can provide immediate angioplasty therapy. A recent meta-analysis including 23 trials on thrombolytic therapy versus primary PCI showed a significant reduction in short term mortality from 9% to 7% (1).
Recently, trials have been evaluating, whether patients admitted to community hospitals may benefit from transfer to centers with primary PCI facilities. A multicenter trial performed in the Czech Republic (PRAGUE-2) randomized 850 patients with acute STEMI and onset of symptom < 12 h to streptokinase in the hospital of admission or transferral to a center with primary PCI facilities (2). The primary endpoint was mortality at 30 days and the maximal transport distance was 120 km. During transport 1.2% of the patients had complications (2 death and 3 ventricular fibrillation (successfully DC- converted)). Mortality rate at 30 days was 10.0% in the patients treated with streptokinase in the local hospital and 6.8% in the patients transferred to primary PCI (p=0.12, intention-to-treat analysis).
In the DANAMI-2 study (3) (a Danish multicenter trial) 1572 STEMI patients were randomized to accelerated treatment with intravenous alteplase or primary PCI; 1129 patients were enrolled at 24 referral hospitals and 443 patients at 5 invasive-treatment centers. The primary study end point was a composite of death, re-infarction or stroke at 30 days. During transport 8 patients (of the 559 patients that were transferred) developed ventricular fibrillation and were DC-converted. No patients died during transport. Among patients, who underwent randomization at referral hospitals, the primary endpoint was reached in 8.5 % of the patients in the angioplasty group, as compared to 14.2 % in the alteplase group (p=0.002). The results were similar among patients who were enrolled at invasive-treatment centers (6.7 % vs 12.3 %; p=0.05). Among all patients, the better outcome after angioplasty was driven primarily by a reduction in the rate of reinfarction (1.6 % vs 6.3 %; p<0.001). No significant differences were observed in the rate of death or stroke between the two groups. Ninety-six percent of the patients were transferred from referral hospitals to an invasive-treatment center within 2 hours. The study also includes an evaluation of the cost-effectiveness of the treatments – these results will be published later.
In a setting where transport time to hospitals with primary angioplasty facilities is short, a strategy of transferral of STEMI patients is attractive. Future focus areas for further improvement of the prognosis in patients transferred to primary angioplasty are: optimization of logistics of transportation and of adjunctive medical therapy.
The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.
1) Keeley EC, Boura JA, Grines CL. Primary angioplasty versus thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomized trials. Lancet 2003; 361: 13-20. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12517460&dopt=Abstract
2) Widimsky P, Budesinsky T, Vorac D et al. Long distance transport for primary angioplasty vs immediate thrombolysis in acute myocardial infarction. Eur H Journal 2003; 24: 94-104. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12559941&dopt=Abstract
3) Andersen HR, Nielsen TT, Rasmussen K et al. A comparison of coronary angioplasty with fibrinolytic therapy in acute myocardial infarction. N Engl J Med 2003; 349: 733-42. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12930925&dopt=Abstract
Steen Dalby Kristensen, MD, DMSc, FESC Vice-chairman of WG Thrombosis and Henning Rud Andersen, MD, DMSc Dept of Cardiology, Skejby Hospital, Aarhus University Hospital, Denmark.
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