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.
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