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US hospitals lack optimal reperfusion strategies for STEMI patients
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A new report from the US National Cardiovascular Data Registry suggests that fibrinolysis and primary PCI are not optimally used for patients with STEMI in the United States to achieve guideline-recommended reperfusion targets.
Researchers aimed to determine how the selection of reperfusion therapy and variability of drive time between hospitals affects outcomes for patients with STEMI.
The analysis included 22,481 candidates for primary PCI or fibrinolysis. Eligible participants had been 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 database. Accrual ran from July 2008 to March 2012. In-hospital mortality and major bleeding served as the primary outcome measures.
According to the results, the median estimated interhospital drive time was 57 minutes (interquartile range, 36-88).
Drive times longer than 30 minutes were associated with a door-to-balloon time of less than 20 minutes in 42.6% of cases. When estimated drive times were longer than 60 minutes, only 52.7% of patients received fibrinolysis. A total of 15,437 patients were eligible for fibrinolysis or primary PCI; among those with estimated drive times of 30 to 120 minutes, 34.3% received pre-transfer fibrinolysis and the median door-to-needle time was 34 minutes (interquartile range, 23-53).
The median transfer time after fibrinolysis to the STEMI-receiving center was 49 minutes (interquartile range, 34-69). Follow-up angiography was performed in 97.1% of those patients.
The researchers reported no significant difference in mortality between patients treated with fibrinolysis vs. primary PCI (3.7% vs. 3.9%; adjusted OR=1.13; 95% CI, 0.94-1.36). However, patients treated with fibrinolysis had a higher risk for bleeding (10.7% vs. 9.5%; adjusted OR=1.17; 95% CI, 1.02-1.33).
“This study represents the first evaluation of reperfusion strategy selection, timeliness and outcomes on a national scale for patients with STEM initially seen at a STEMI-referring center and subsequently transferred to a STEMI-receiving center. … [The data suggest that] for such patients who are unlikely to receive timely primary PCI, pre-transfer fibrinolytics, followed by early transfer for angiography, may be a contemporary reperfusion option when potential benefits of timely reperfusion outweigh bleeding risk,” the researchers wrote.
Disclosure: The research was supported by the American College of Cardiology Foundation’s National Cardiovascular Data Registry and by the American Heart Association’s Mission: Lifeline program.
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