Primary Percutaneous Coronary Intervention Facilities Research Articles

Reperfusion therapy for ST elevation acute myocardial infarction 2010/2011: current status in 37 ESC countries

Primary percutaneous coronary intervention (PPCI) is the preferred reperfusion therapy in ST-elevation myocardial infarction (STEMI). We conducted this study to evaluate the contemporary status on the use and type of reperfusion therapy in patients admitted with STEMI in the European Society of Cardiology (ESC) member countries. A cross-sectional descriptive study based on aggregated country-level data on the use of reperfusion therapy in patients admitted with STEMI during 2010 or 2011. Thirty-seven ESC countries were able to provide data from existing national or regional registries. In countries where no such registries exist, data were based on best expert estimates. Data were collected on the use of STEMI reperfusion treatment and mortality, the numbers of cardiologists, and the availability of PPCI facilities in each country. Our survey provides a brief data summary of the degree of variation in reperfusion therapy across Europe. The number of PPCI procedures varied between countries, ranging from 23 to 884 per million inhabitants. Primary percutaneous coronary intervention and thrombolysis were the dominant reperfusion strategy in 33 and 4 countries, respectively. The mean population served by a single PPCI centre with a 24-h service 7 days a week ranged from 31 300 inhabitants per centre to 6 533 000 inhabitants per centre. Twenty-seven of the total 37 countries participated in a former survey from 2007, and major increases in PPCI utilization were observed in 13 of these countries. Large variations in reperfusion treatment are still present across Europe. Countries in Eastern and Southern Europe reported that a substantial number of STEMI patients are not receiving any reperfusion therapy. Implementation of the best reperfusion therapy as recommended in the guidelines should be encouraged.

Symptom-to-needle times in ST-segment elevation myocardial infarction: Shortest route to a primary coronary intervention facility

Primary percutaneous coronary intervention (PCI) is the preferred management for patients with acute ST-segment elevation myocardial infarction (STEMI) if performed in a timely manner by experienced providers. Patients can access a PCI facility by three routes: prehospital STEMI diagnosis by emergency medical services (EMS) and direct transport by EMS to a PCI facility (EMS-PCI); visit to a hospital emergency department (ED) followed by referral to an on-site PCI facility (ED-PCI); or transfer from the ED to a PCI facility in another hospital (ED-transfer-PCI). To assess the implementation rate in France of the guidelines recommending that STEMI patients be transported by EMS to a PCI facility and to compare the times between symptom onset and PCI for these three routes. We used the results of the pilot testing of a national quality indicator programme on STEMI in 64 hospitals, providing data on patient characteristics, referral route and symptom-onset-to-needle time. We compared delays for each route in a Cox proportional-hazard model. In a population of 1217 patients, median symptom-onset-to-needle time was 186minutes (Q1133; Q3 292) for the EMS-PCI route, 237minutes (Q1165; Q3 368) for the ED-PCI route and 305minutes (Q1230; Q3 570) for the ED-transfer-PCI route. A total of 70.8% of patients were transported by EMS as recommended. After adjustment for age, symptom onset period (weekends/nights) and history of cardiovascular disease, the EMS-PCI route was associated with the shortest symptom-onset-to-needle times. The hazard ratio was 0.71 [0.59-0.86] for the ED-PCI route and 0.67 [0.52-0.86] for the ED-transfer-PCI route. STEMI patients receive prompter care after prehospital diagnosis and direct transport to a PCI facility by EMS than by visiting a hospital ED. Use of this referral route should be further encouraged in France as approximately one-third of STEMI patients are still presenting directly to the ED.

Facilitated/Pharmaco-invasive Approaches in STEMI

Primary percutaneous coronary intervention (PCI) is the preferred reperfusion method in patients with ST-elevation myocardial infarction (STEMI), when performed in a timely manner and by skilled operators. However, this strategy has shown to be limited in environments with lack of PCI facilities and delay in the first medical contact-to-balloon time for logistic reasons. Pretreatment with fibrinolysis and/or glycoprotein IIb/IIIa inhibitors before PCI has the potential to provide early pharmacologic reperfusion before definitive PCI in STEMI patients. However, current data suggest that facilitated PCI does not offer any advantage over primary PCI. Conversely, a role for pharmacoinvasive recanalization, defined as pharmacological reperfusion followed by rapid transfer for routine delayed coronary angiography and PCI may still be considered in centers without on-site PCI capability.

Abstract 237: Retrospective Validation of Pre-Hospital Electrocardiogram with Zoll E-Series Monitoring System for Field Identification of ST Elevation Myocardial Infarction Patients

Background: Rapid reperfusion of ST elevation myocardial infarction (STEMI) patients with primary percutaneous coronary intervention (PCI) improves outcomes. Systems have been developed in many areas to identify STEMI patients in the field using pre-hospital electrocardiograms (ECGs). The Zoll E-Series (ES) is a defibrillator/monitoring system that utilizes the GE Medical Systems 12SL interpretive algorithm to assist with identification of STEMIs. There is a lack of significant data measuring the accuracy of the Zoll ES and its algorithm, especially in the setting of a large urban population. Methods: We retrospectively looked at 307 consecutive ECGs transmitted by one emergency medical service (EMS) provider to an urban primary PCI facility from October 2009 to January 2011. All transmissions were from Zoll ES monitors. Multiple ECG computer interpretations were screened and filtered out to those labeled ***ACUTE MI***. A retrospective chart review was performed to determine the clinical outcome for each transmission in order to determine the performance of the interpretive algorithm in this population. Results: Overall, 307 ECGs were analyzed. A total of 7% (20 of 307) were confirmed STEMIs (Table 1). The computer reading shows a sensitivity of 95% (20 of 21) and specificity of 94% (268 of 286). There is a positive predictive value (PPV) of 53% (20 of 38). Conclusions: The initial data from this study shows that the Zoll ES has a remarkably high sensitivity of 95% but a poor PPV of 53%. This may be due to multiple confounders that result in STEMI “mimics.” The Zoll ES helps provide a pre-hospital ECG that serves as a powerful and life saving tool in the field. However, due to the low PPV, these findings reinforce that the pre-hospital ECG needs to be combined with an appropriate clinical history and additional human interpretation. Further studies analyzing a larger population of patients should be conducted to further assess the value of using this tool.

As time goes by? The fallacy of thrombolysis in STEMI networks

Primary percutaneous coronary intervention (PPCI) is superior to thrombolysis (TL) as reperfusion therapy in ST-elevation myocardial infarction (STEMI). TL is a rapidly available, but semi-effective therapy (effective reperfusion in 50% of patients only), whereas PPCI is a potentially delayed, but highly effective therapy (effective reperfusion in >90%). Since TL loses its efficacy beyond 2-3h after symptom onset, it is a significant reperfusion alternative to PPCI in early presenters only. The individual decision to treat an early presenter with PPCI or TL requires the evaluation of the time delay between potential start of TL or PPCI, the PCI-related delay (PRD). PRD is greatest, if TL is given in the prehospital setting. Until now, prehospital TL as the most rapidly available reperfusion strategy has failed to demonstrate any prognostic or even any other relevant benefit compared to PPCI in any subgroup of patients, even with time delays for PPCI of up to several hours. On average, a median PRD of at least 90-120min can be considered a time corridor of prognostic superiority of PPCI over TL. This is already achieved in contemporary registries and myocardial infarction networks.Therefore, the efforts should not focus on the implementation of a dual reperfusion strategy (PPCI, and prehospital TL in selected cases) in established or upcoming myocardial infarction networks, but concentrate on the availability of PPCI in less than 2h. TL, as rapid as possible, i.e. prehospital, is a vital treatment option in case of non-existing PPCI facilities within a median time limit of 2h or even more, a scenario not existing or easily to eliminate in European countries by implementing well organized myocardial infarction networks. This is the mission to be accomplished.

Reduction of Delays in Primary Percutaneous Coronary Intervention

Background Acute myocardial infarction is a major health issue. Primary percutaneous coronary intervention (PPCI) for ST-elevation myocardial infarction was proved to be superior to fibrinolytic therapy in many randomized trials when done in a timely manner. However, PPCI is associated with delays. Studies have shown that greater delay is associated with increased mortality rate. We applied simple interventions to reduce door-to-balloon time. Our study goal was to evaluate the reduction of delays after our interventions and to monitor 30-day mortality. Methods A prospective registry was created to evaluate delays and mortality associated with PPCI. Measures such as annual feedback with suggestions were taken to minimize the delays. Door-to-balloon delays before and after the interventions were compared. Results A total of 1361 primary PCIs were performed from 2005 to 2008. Of these cases, 1071 patients were transferred from community hospitals. The median door-to-balloon time for transferred patients was 142 minutes for 2005, 138 minutes for 2006, 125 minutes for 2007, and 121 minutes for 2008 ( P < 0.001 for 2005 vs. 2008). Door-to-balloon time for patients admitted directly to our centre was 87 minutes in 2005, 74.5 minutes in 2006, 73.5 minutes in 2007, and 74.0 minutes in 2008 ( P < 0.001 for 2005 vs. 2008). Thirty-day mortality of these consecutive patients is low (5.2% for 2005 and 3.8% for 2008; P = not significant). Conclusions Inexpensive and simple interventions may significantly reduce primary PCI-related delays for transferred cases and patients admitted directly to a centre with PPCI facilities. We also observed a low mortality rate for those consecutive patients.

Recombinant tissue-type plasminogen activators: "time matters"

Although acute ST elevation myocardial infarction (STEMI) was described nearly a century ago, it remains a major health problem not only in the U.S. but also worldwide with more than three million people suffering STEMI every year. Primary percutaneous coronary intervention (PPCI) is now the treatment of choice for the management of patients with STEMI. In the 20th century, fibrinolytics were the agents of choice for the management of patients with acute STEMI and they continue to be utilized in centers where PPCI facilities are not readily available. Large-scale trials were performed comparing streptokinase and new agents such as the recombinant tissue-type plasminogen activators. This article discusses the use of recombinant tissue plasminogen activators for the management of patients with acute STEMI and the importance of restoring optimal timely reperfusion of the myocardium.

Combined reperfusion strategies in ST-segment elevation MI: Rationale and current role

Primary percutaneous coronary intervention (PCI) is the preferred reperfusion strategy for ST-elevation myocardial infarction (MI), but most patients do not arrive at a PCI facility within the recommended 90 minutes of first medical contact. If delay is expected, timely thrombolysis is recommended, followed by early transfer for PCI. The authors review the rationale behind three combined reperfusion strategies-facilitated PCI, pharmacoinvasive therapy, and rescue PCI-and data on their effectiveness.

Comparative Effectiveness of ST-Segment–Elevation Myocardial Infarction Regionalization Strategies

Primary percutaneous coronary intervention (PCI) is more effective on average than fibrinolytic therapy in the treatment of ST-segment-elevation myocardial infarction. Yet, most US hospitals are not equipped for PCI, and fibrinolytic therapy is still widely used. This study evaluated the comparative effectiveness of ST-segment-elevation myocardial infarction regionalization strategies to increase the use of PCI against standard emergency transport and care. We estimated incremental treatment costs and quality-adjusted life expectancies of 2000 patients with ST-segment-elevation myocardial infarction who received PCI or fibrinolytic therapy in simulations of emergency care in a regional hospital system. To increase access to PCI across the system, we compared a base case strategy with 12 hospital-based strategies of building new PCI laboratories or extending the hours of existing laboratories and 1 emergency medical services-based strategy of transporting all patients with ST-segment-elevation myocardial infarction to existing PCI-capable hospitals. The base case resulted in 609 (95% CI, 569-647) patients getting PCI. Hospital-based strategies increased the number of patients receiving PCI, the costs of care, and quality-adjusted life years saved and were cost-effective under a variety of conditions. An emergency medical services-based strategy of transporting every patient to an existing PCI facility was less costly and more effective than all hospital expansion options. Our results suggest that new construction and staffing of PCI laboratories may not be warranted if an emergency medical services strategy is both available and feasible.

Shortening the door-to-balloon time for transferring primary percutaneous coronary intervention: physician transfer may be a better way in China

Shortening the door-to-balloon time for transferring primary percutaneous coronary intervention: physician transfer may be a better way in China

Prospective multicenter randomized trial comparing physician versus patient transfer for primary percutaneous coronary intervention in acute ST-segment elevation myocardial infarction

Primary percutaneous coronary intervention (PCI) has been identified as the first therapeutic option for patients with acute ST-segment elevation myocardial infarction (STEMI). The strategy of transferring patient to a PCI center was recently recommended for those with acute STEMI who were present to PCI incapable hospitals, which include lack of facilities or experienced operators. In China, some local hospitals have been equipped with PCI facilities, but they have no interventional physicians qualified for performing primary PCI. This study was conducted to assess the feasibility, safety and efficacy of the strategy of transferring physician to a PCI-equipped hospital to perform primary PCI for patients with acute STEMI. Three hundred and thirty-four consecutive STEMI patients with symptom presentation = 12 hours in five local hospitals from November 2005 to November 2007 were randomized to receive primary PCI by either physician transfer (physician transfer group, n=165) or patient transfer (patient transfer group, n=169) strategy. Door-to-balloon time, in-hospital and 30-day major adverse cardiac events (MACE, including death, non-fatal re-infarction, and target vessel revascularization) were compared between the two groups. Baseline characteristics between the two groups were comparable. Thrombolysis in myocardial infarction (TIMI) 3 flow was revealed in more patients in the physician transfer group at initial angiography (17.6% vs 10.1%, P<0.05). The success rate of primary PCI (96.3% vs 95.4%, P>0.05) and length of hospital stay were similar between the two groups ((15+/-4) days vs (14+/-3) days, P>0.05). In the physician transfer group, door-to-balloon time was significantly shortened ((95+/-20) minutes vs (147+/-29) minutes, P<0.0001) and more patients received primary PCI with door-to-balloon time less than 90 minutes (21.2% vs 7.7%, P<0.001). During hospitalization, MACE occurred in 6.7% and 11.2% of patients in the physician and patient transfer groups, respectively (P=0.14). At 30-day clinical follow-up, the occurrence rates of death, non-fatal re-infarction, and target vessel revascularization (TVR) were 3.6% vs 5.9%, 4.2% vs 8.9%, and 1.2% vs 2.4% in the physician and patient transfer groups, respectively (all P>0.05). The cumulative composite of MACE was significantly reduced (8.9% vs 17.2%, P=0.03) and MACE free survival (91.0% vs 82.9%, P<0.05) was significantly improved in the physician transfer group at 30 days. The strategy of transferring physician to local hospital to perform primary PCI for patients with acute STEMI is feasible, safe and efficient in reducing the door-to-balloon time and 30-day MACE rate.

Outcome in transferred and nontransferred patients after primary percutaneous coronary intervention for ischaemic out‐of‐hospital cardiac arrest

To evaluate the impact of transfer from a referral hospital to a center with primary percutaneous coronary intervention (PCI) facilities of ST-segment elevation myocardial infarction (STEMI) patients after successful cardiopulmonary resuscitation (CPR). We studied all STEMI patients with successful CPR admitted to two centers after out-of-hospital cardiac arrest and CPR from January 2004 to December 2005. Subjects were divided in a transferred (PCI performed after referral from center without PCI facility) and nontransferred (PCI performed in hospital of admission, i.e. center with PCI facility) group. A total of 44 patients were included. Mean age was 61 +/- 13 year and 35 (80%) patients were male. Of all patients 16 (36%) were transferred for treatment. After treatment, the left ventricular function was preserved in 4 (25%) patients of the transferred group are compared with 17 (61%) of the nontransferred group (P = 0.024). In-hospital mortality after follow-up did not differ with 7 (44%) survivors in the transferred group versus 15 (54%) survivors in the nontransferred group (P = 0.76). Patients who did not survive were more often treated with endotracheal intubation (100% versus 71%, P= 0.019), had more often an occlusion of the proximal right coronary artery (37% versus 10%, P= 0.02), and higher glucose levels at admission (15.2 mmol/l +/- 4.4 versus 11.5 mmol/l +/- 4.2, P= 0.009). In conclusion, no difference in outcome was observed between nontransferred and transferred patients. Therefore, we suggest that transfer for primary PCI for STEMI patients after successful CPR should be considered.

Time to treatment and ST-segment resolution in high-risk patients with acute myocardial infarction transferred from community hospitals for coronary angioplasty after pharmacological treatment

To evaluate the impact of symptom-onset-to-balloon delay on ST-segment resolution (STR) in patients with acute myocardial infarction transferred from community hospitals for angioplasty after pharmacological treatment. The study design was prospective, single centre registry. Between October 2000 and December 2003, 330 consecutive patients aged < or =75 years with high-risk myocardial infarction were considered; 193 patients underwent primary percutaneous coronary intervention (PCI) (group P), whereas 137 patients were given pharmacological therapy and were immediately transferred to the hospital with PCI facilities (group F). Compared with group P, group F showed a longer time to treatment (253 +/- 136 vs. 195 +/- 141 min; P < 0.0001) and a higher percentage of Thrombolysis In Myocardial Infarction flow grade 2-3 at pre-PCI angiography (107 [78.1%] vs. 48 [24.8%]; P < 0.0001). The rate of STR > or =70% was similar in groups P and F (121 [62.7%] vs. 94 [68.6%]; P = 0.41). Even after accounting for baseline variables, STR <70% was not significantly related to the transfer strategy (adjusted hazard ratio 0.94, 95% confidence interval 0.94-1.77; P = 0.8). Patients with incomplete STR showed a higher six-month mortality compared with patients with complete STR (10 [8.85%] vs. 6 [2.76%]; P = 0.027). The STR index predicts survival in patients with ST-elevation myocardial infarction treated with angioplasty either directly or after pharmacological treatment and hospital transfer. Pharmacological facilitation seems to be able to counterbalance the negative consequences of the transfer-related time delay on myocardial reperfusion as evaluated by the STR index.

Treatment delays in patients undergoing primary percutaneous coronary intervention for ST elevation myocardial infarction at the Quebec Heart and Lung Institute

Current guidelines for ST elevation myocardial infarction (STEMI) recommend performing primary percutaneous coronary intervention (PCI) within 90 min of hospital arrival. However, recent data suggest that in a real-world setting, median door-to-balloon (DTB) time is closer to 180 min for transfer patients, with less than 5% of patients being treated within 90 min. A retrospective observational study was conducted to assess time to treatment in patients undergoing primary PCI at the Quebec Heart and Lung Institute (QHLI). Consecutive lytic-eligible patients undergoing primary PCI at the QHLI for STEMI between April 2004 and March 2005 were included in the present analysis. The primary evaluation was DTB time measured from arrival at the first hospital to first balloon inflation. Clinical outcomes were in-hospital death, reinfarction and bleeding. DTB times and hospital outcomes of patients transferred from referring hospitals were compared with those of patients presenting directly to the QHLI. During the study period, 203 lytic-eligible patients were treated with primary PCI. Sixty-nine patients presented directly to the QHLI and 134 were transferred from other hospitals. Six transfer patients were excluded because of missing time variables. The median DTB time was 114 min in transfer patients, compared with 87 min in patients presenting directly to the QHLI (P<0.001). DTB time was less than 90 min in 24% of the transfer population compared with 55% of patients presenting directly to the QHLI (P<0.001). In patients referred from hospitals within a radius of 30 km from the QHLI (n=100), median DTB time was 106 min with 30% receiving PCI within 90 min. In these patients, estimated PCI-related delay was 74 min. For patients presenting to hospitals beyond 30 km (n=28), median DTB time was 142 min with 4% receiving reperfusion within 90 min. In these patients, estimated PCI-related delay was 110 min. Median DTB time for patients presenting during off hours at the QHLI was 92 min compared with 79 min for patients presenting during regular business hours (P=0.02). In patients transferred from other hospitals, median DTB time was 118 min during off hours and 108 min during normal business hours (P=0.07). A DTB time of less than 90 min can be achieved in the majority of patients presenting directly to a primary PCI centre. However, for patients presenting to community hospitals, transfer for primary PCI is often associated with delayed revascularization. The present study highlights the need for careful patient selection when deciding between on-site thrombolytic therapy and transfer for primary PCI for STEMI patients presenting to hospitals without PCI facilities.

Appropriate invasive and conservative treatment strategies for patients with ST elevation myocardial infarction

The goal of treatment strategies for patients with ST elevation myocardial infarction is to reperfuse the occluded coronary artery, as rapidly and safely as possible. This review discusses evidence regarding the appropriate treatment strategy for patients with ST elevation myocardial infarction taking into consideration geographical and logistical barriers. Primary percutaneous coronary intervention is considered the gold standard of myocardial reperfusion. As therapy is time dependent, logistical barriers limit its use to no more than 29% of ST elevation myocardial infarction patients worldwide. Most patients with ST elevation myocardial infarction who undergo primary angioplasty achieve mechanical reopening of the infarct-related artery beyond the established time limit from which left ventricular preservation and clinical benefit are less probable. In contrast, early administration of newer fibrin-specific thrombolytics is at least as effective as primary angioplasty, and can abort infarction and dramatically reduce mortality when given during the first 1-2 hours of onset. Consequently, key elements from the current guidelines recommend that patients with ST elevation myocardial infarction should be reperfused either by primary percutaneous coronary intervention performed 90 minutes after the first medical contact or by thrombolysis within 30 minutes of presentation to hospital. These advantages and disadvantages should generate distinct viewpoints on reperfusion strategies for patients with infarction. For patients admitted in a hospital with primary percutaneous coronary intervention facilities, this should be considered the reperfusion strategy. Options for patients admitted to community hospitals without percutaneous coronary intervention facilities include administration of fibrinolysis or transfer to a tertiary care center for primary percutaneous coronary intervention. Implementation of reperfusion strategies should vary based on the mode of transportation of the patient and capabilities at the receiving hospital.

The use of GP IIb/IIIa inhibitors into new perspectives: pre-catheterization laboratory administration

There is a general consensus that primary percutaneous coronary intervention (PCI) is the most adequate approach to reperfusion therapy in ST-elevation acute myocardial infarction (STEMI), associated with more efficient reperfusion and less mortality, recurrent ischaemia, stroke, and major bleeding complications compared with fibrinolysis. The systematic use of intravenous GP IIb/IIIa inhibitors, especially abciximab as an adjunctive therapy to primary PCI, is associated with a further reduction of mortality and ischaemic events in this setting. Nevertheless, the need for transfer from centres without round-the-clock PCI facility, may delay myocardial reperfusion and reduce the benefit of primary PCI. In order to accelerate the flow restoration in the infarct-related artery, during the gap between presentation and primary PCI, several pharmacological approaches have been proposed. The facilitation of primary PCI by full or half-dose fibrinolytics alone or in association with GP IIb/IIIa inhibitors has raised some unresolved safety and efficacy issues. Recent trials of the early administration of GP IIb/IIIa inhibitors prior to primary PCI have shown improved flow restoration and myocardial perfusion compared with in-catheterization laboratory administration of such treatments. Although such trials have been underpowered to detect differences regarding clinical outcomes among patient groups, the administration of intravenous abciximab is recommended as soon as possible in STEMI patients who are candidates to direct primary PCI. Further, large trials are needed to assess the efficacy, safety, and cost-effectiveness of facilitation strategies and to eventually identify subgroups of patients in whom such strategies would be most beneficial.

Guideline-conforming interventional treatment of acute ST-segment elevation myocardial infarction in rural areas using network collaboration

Therapy of acute myocardial infarction demands rapid and complete myocardial reperfusion. Primary percutaneous coronary intervention (PCI) performed is superior to thrombolytic therapy in reducing mortality, non-fatal reinfarction and stroke, but is not available in rural Germany. : From 8/2001 to 12/2002 322 patients with STEMI were treated by PCI with standardized therapeutic guidelines within a regional infarction-network comprising one interventional centre and 7 community hospitals without PCI facilities. 160 patients were relocated (transferred) from a community hospital without PCI facilities (transfer group, 63.4 yrs., 71.8 % men); 162 patients were admitted directly to the interventional centre (centre group, 61.7 yrs., 73.8 % men). The interval from onset of symptoms to first medical contact was 205 minutes in the transfer group, and 195 minutes in the centre group. 7.8 % of the centre group and 7.2 % of the transfer group patients were in cardiogenic shock. 95 % of patients have completed a 6-month's follow-up. In the transfer group median transportation time to PCI was 54 minutes. PCI of the infarct-related artery (IRA) was performed in 95.1 % of transferred patients after transfer and in 94.1 % of patients with direct admission. In addition 96 % of all patients received a GP IIb/IIIa receptor inhibitor. In case of pre-interventional application of the GP IIb/IIIa receptor inhibitor 22.3 % of patients revealed normal (TIMI-3) flow of the IRA before PCI, compared to 14.9 % TIMI-3 flow with 5000 IE Heparin/500 mg aspirin alone (p < 0.05). After PCI normalized flow in the IRA was documented in 87.5 % after direct admission and 86.3 % after transfer. No differences between groups were shown with respect to infarct size (transfer vs. centre: CK 2482 vs. 2481 U/I; CKMB 302 vs. 264 U/I), mortality (30 days: 5.3 vs. 5.2 %, 6 months: 7.3 vs. 7.1 %); NYHA (1.41 vs. 1.43) and left ventricular ejection fraction (0.41 vs. 0.43). The organization of a regional infarction-network with logistic alliance of community hospitals with one experienced interventional centre ensures timely PCI for patients with STEMI according to present guidelines even in rural areas.

Transport and centralization of acute coronary syndrome care.

Primary percutaneous coronary intervention (PCI) is the optimal treatment for patients presenting with ST-elevation myocardial infarction (STEMI). But PCI facilities are not widely available, and the majority of patients who receive reperfusion therapy are treated with thrombolytic therapy. However, with significant improvements in the procedural success of PCI, there has been a concomitant reduction in the need for emergency bypass surgery and there is evidence to support primary PCI without on-site cardiac surgical facilities. Others have proposed immediate transfer to a suitable hospital for immediate primary PCI. An alternative treatment strategy is facilitated PCI, which might combine the early benefits of thrombolysis with the higher patency rates and superior clinical outcomes of primary PCI, although this remains unproven. Finally, rescue PCI remains a reasonable treatment option for patients with failed thrombolysis, but there is insufficient evidence to support this option as a preferred treatment strategy for patients with STEMI.

Current perspectives on reperfusion therapy for acute ST-segment elevation myocardial infarction: integrating pharmacologic and mechanical reperfusion strategies

The therapeutic approach to patients with acute ST-segment elevation myocardial infarction (STEMI) has advanced rapidly over the past decade. Intravenous fibrinolytic therapy remains the most common form of reperfusion therapy worldwide, since fibrinolytics are associated with a dramatic reduction in mortality rates. However, primary percutaneous coronary intervention (PCI) is associated with improved outcomes and less bleeding complications compared with fibrinolytic therapy, but it is not widely available. Adjunctive therapies with intracoronary stents, glycoprotein (GP) IIb/IIIa inhibitors, and more potent antithrombin agents have shown great promise for the initial treatment of STEMI and have stimulated further investigation of combined pharmacological/mechanical reperfusion strategies that may be synergistic. Although the optimal combination of fibrinolytics, antiplatelet agents, antithrombins, and mechanical reperfusion at hospitals with and without primary PCI facilities remains elusive, results from recent studies suggest that such a combined approach may facilitate transfer of patients with STEMI from a referral hospital to an invasive hospital for definitive primary PCI after administration of a potent pharmacologic regimen designed to enhance early infarct-related artery reperfusion. Thus, as the reperfusion era continues to evolve, the ideal treatment strategy for patients with STEMI is being redefined to integrate pharmacologic and mechanical approaches to reperfusion.