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Benefits of interhospital transfer of STEMI patients for PCI maintained for 8 years

Reuters Health • The Doctor's Channel Daily Newscast

NEW YORK (Reuters Health) – The advantages of primary percutaneous coronary intervention (PCI) over fibrinolysis for patients with ST-segment elevation myocardial infarction (STEMI) are maintained for 8 years, even when patients require transfer to a hospital with a catheterization laboratory.

However, transport to the second hospital should be completed within 2 hours, according to long-term follow-up of the Danish Acute Myocardial Infarction 2 (DANAMI-2) cohort, published in the April 6th issue of Circulation.

In DANAMI-2, which compared onsite fibrinolysis with primary PCI, most patients had to be transported to hospitals with PCI facilities. Dr. Michael Maeng, from Aarhus University Hospital, Skejby, Denmark, and co-authors previously reported that the superiority of PCI persisted over 3 years. The current study extended the follow-up to a median of 7.8 years (until March 2008).

The study cohort included 790 patients randomized to PCI with bare metal stents and 782 to treatment with tissue plasminogen activator (alteplase). The median transfer time from randomization to arrival at the cath lab was 67 minutes, with 96% arriving within 120 minutes.

The 8-year incidence of the primary end point – a composite of death or reinfarction – was 34.8% in the PCI group and 41.3% in the fibrinolysis group (hazard ratio 0.78, p = 0.003). The difference was driven primarily by the reduction in reinfarction rates (11.7% vs 18.5%, HR 0.60, p < 0.001).

Thus, Dr. Maeng’s team advises, transport to a hospital with interventional facilities should be offered to STEMI patients when the move can be complete “within 2 hours after the diagnosis has been established.”

This recommendation differs from American and European guidelines, which in general recommend fibrinolytic treatment if primary PCI can’t be performed within 90 minutes of first medical contact.

The researchers point out that Denmark triages patients with prehospital 12-lead ECG, rerouting of ambulances directly to hospitals with around-the-clock interventional facilities, and immediate angiography/PCI.

They also note that that DANAMI-2 was launched in an earlier era, before the benefit of long-term clopidogrel treatment was recognized and when many hospitals were inexperienced at PCI. Therefore, they say, their analysis may underestimate the benefit of state-of-the-art PCI.

Circulation 2010;121:1484-1491.