ST-Segment–Elevation Myocardial Infarction Treatment and the Seductive Lure of Observational Analyses

Abstract

Randomized trials have demonstrated the clinical superiority of timely transfer for primary percutaneous coronary intervention (PCI) compared with onsite fibrinolytic therapy for reperfusion in the setting of ST-segment–elevation myocardial infarction (STEMI).1,2 On this point, there is relative clarity. What remains nebulous, however, is the degree to which these findings apply broadly across care systems that often have substantial transfer delays. Article see p 2512 Providers continue to face the challenging question posed by transfer delays: How long is too long to justify transfer of STEMI patients for primary PCI? The American College of Cardiology/American Heart Association guidelines have, until recently, called for transfer for primary PCI when reperfusion can be accomplished within 90 minutes of initial presentation to the non-PCI center or with a PCI-related delay (time interval from when fibrinolytic therapy can be given until when PCI can be performed) of <60 minutes.3 The latest ACCF/AHA/SCAI guidelines for PCI extend the acceptable first door-to-device time to 120 minutes for patients presenting to non-PCI-capable hospitals, an adjustment in line with current European guidelines.4,4a The Figure depicts the temporal anatomy of a transfer, the key time-based elements of the reperfusion delivery process. The guidelines acknowledge that the selection of reperfusion method also hinges on additional variables, such as time since symptom onset, risk of death, and relative or absolute contraindications to fibrinolysis.3 Moreover, the guidelines emphasize that the selected method of reperfusion may be less important than the use of some type of reperfusion for all eligible patients in a timely fashion. Regional systems of care (as supported by Mission: Lifeline5) have been identified as essential elements of optimal care provision. Figure. ST-segment–elevation myocardial infarction reperfusion pathways for non–percutaneous coronary intervention (PCI) centers. For the primary PCI pathway, both the latest American College …