Facilitated percutaneous coronary intervention in patients with acute myocardial infarction transferred from remote hospitals

Abstract

Primary percutaneous coronary intervention (PCI) is the preferred therapy for myocardial infarction (MI) in centers that have access to immediate invasive treatment because it confers higher patency rates, lower mortality, and lower intracranial hemorrhage rates than fibrinolysis alone. 1 Grines C.L. Browne K.F. Marco J. Rothbaum D. Stone G.W. O’Keefe J. Overlie P. Donohue B. Chelliah N. Timmis G.C. A comparison of immediate angioplasty with thrombolytic therapy for acute myocardial infarction. The Primary Angioplasty in Myocardial Infarction Study Group. N Engl J Med. 1993; 328: 673-679 Crossref PubMed Scopus (1878) Google Scholar , 2 Zijlstra F. Hoorntje J.C. de Boer M.J. Reiffers S. Miedema K. Ottervanger J.P. van’T Hof A.W. Suryapranata H. Long-term benefit of primary angioplasty as compared with thrombolytic therapy for acute myocardial infarction. N Engl J Med. 1999; 341: 1413-1419 Crossref PubMed Scopus (601) Google Scholar , 3 Widimsky P. Groch L. Zelizko M. Aschermann M. Bednar F. Suryapranata H. Multicentre randomized trial comparing transport to primary angioplasty vs immediate thrombolysis vs combined strategy for patients with acute myocardial infarction presenting to a community hospital without a catheterization laboratory. The PRAGUE study. Eur Heart J. 2000; 21: 823-831 Crossref PubMed Scopus (493) Google Scholar Current guidelines suggest that primary PCI could be offered as an alternative to thrombolytic therapy if performed by experienced operators within 90 ± 30 minutes after admission. 4 Ryan TJ, Antman EM, Brooks NH, Califf RM, Hillis LD, Hiratzka LF, Rapaport E, Riegel B, Russell RO, Smith EE III, et al. Update: ACC/AHA guidelines for the management of patients with acute myocardial infarction: executive summary and recommendations: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Acute Myocardial Infarction). Circulation 1999;100:1016–1030 Google Scholar Recent studies have suggested that PCI for MI is superior to thrombolysis even if treatment is delayed by >120 minutes by transferring the patient to an interventional center. 5 Grines C.L. Westerhausen D.R. Grines L.L. Hanlon J.T. Logemann T.L. Niemela M. Weaver W.D. Graham M. Boura J. O’Neill W.W. Balestrini C. A randomized trial of transfer for primary angioplasty versus on-site thrombolysis in patients with high-risk myocardial infarction. The Air Primary Angioplasty in Myocardial Infarction Study. J Am Coll Cardiol. 2002; 39: 1713-1719 Crossref PubMed Scopus (330) Google Scholar , 6 Andersen HR. DANish Study in Acute Myocardial Infarction (DANAMI-II). Available at: http://www.clinicaltrialresults.org Google Scholar However, delay in restoring myocardial blood flow is known to adversely impact long-term outcome. 7 Cannon C.P. Gibson C.M. Lambrew C.T. Shoultz D.A. Levy D. French W.J. Gore J.M. Weaver W.D. Rogers W.J. Tiefenbrunn A.J. Relationship of symptom-onset-to-balloon time and door-to-balloon time with mortality in patients undergoing angioplasty for acute myocardial infarction. JAMA. 2000; 283: 2941-2947 Crossref PubMed Scopus (1033) Google Scholar If safe and feasible, restoration of myocardial blood flow by thrombolytic therapy during transfer would make longer transfer times to primary PCI acceptable without compromising myocardial salvage. In the present study we tested a combined therapy of a reduced dose of fibrinolytic drug and glycoprotein IIb/IIIa inhibitor during transfer of patients with acute MI from remote community hospitals to a routine emergency angiographic center and possible invasive treatment of MI.