Treatment delayed is treatment denied.

Abstract

You may delay, but time will not. — —Benjamin Franklin In 1977, Reimer and coworkers published in this journal the results of an experiment that established the basis of reperfusion therapy for patients with ST-elevation myocardial infarction (STEMI).1 These investigators identified a relationship between the duration of acute coronary occlusion and the magnitude of subsequent myocardial necrosis. In other words, the extent of infarct size that resulted from sustained occlusion could be reduced if the occlusion were interrupted and flow restored. Furthermore, reductions in the duration of occlusion were associated with incremental decreases in infarct size. See Circulation . 2004;109:1223–1225 Such relationships were confirmed in early investigations of thrombolytic therapy for STEMI.2,3 Consequences of earlier treatment were improvements in indices of left ventricular systolic function and reductions in mortality rate. Although there was, in general, a linear relationship between time to treatment and outcome, the very best results were obtained when thrombolysis was initiated within the first hour.4,5 To this point, such a tight relationship between time to treatment and outcome has been less apparent when primary angioplasty is selected as the method for achieving reperfusion. Reports on this subject describe conflicting findings. With these considerations in mind, De Luca and colleagues performed a single-center database analysis and reported their results in the March 16, 2004, issue of Circulation .6 They reviewed the baseline and angiographic characteristics and clinical outcomes of 1791 patients with STEMI who were treated by primary angioplasty. Time to treatment was defined as the elapsed time between symptom onset and the initial balloon inflation. One key finding of their analysis was that time to treatment was influenced by several factors, including advanced age, female gender, and history of diabetes or prior revascularization. Presence of these factors prolonged time to treatment. An explanation …