Fibrinolysis Use Among Patients Requiring Interhospital Transfer for ST-Segment Elevation Myocardial Infarction Care

Abstract

IMPORTANCE Guidelines for patients with ST-segment elevation myocardial infarction (STEMI) recommend timely reperfusion with primary percutaneous coronary intervention (pPCI) or fibrinolysis. Among patients with STEMI who require interhospital transfer, it is unclear how reperfusion strategy selection and outcomes vary with interhospital drive times. OBJECTIVE To assess the association of estimated interhospital drive times with reperfusion strategy selection among transferred patients with STEMI in the United States. DESIGN, SETTING, AND PARTICIPANTS We identified 22 481 patients eligible for pPCI or fibrinolysis who were transferred from 1771 STEMI referring centers to 366 STEMI receiving centers in the Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With the Guidelines database between July 1, 2008, and March 31, 2012. MAIN OUTCOMES AND MEASURESIn-hospital mortality and major bleeding. RESULTSThe median estimated interhospital drive time was 57 minutes (interquartile range [IQR], 36-88 minutes). When the estimated drive time exceeded 30 minutes, only 42.6% of transfer patients treated with pPCI achieved the first door-to-balloon time within 120 minutes. Only 52.7% of eligible patients with a drive time exceeding 60 minutes received fibrinolysis. Among 15 437 patients with estimated drive times of 30 to 120 minutes who were eligible for fibrinolysis or pPCI, 5296 (34.3%) received pretransfer fibrinolysis, with a median door-to-needle time of 34 minutes (IQR, 23-53 minutes). After fibrinolysis, the median time to transfer to the STEMI receiving center was 49 minutes (IQR, 34-69 minutes), and 97.1% underwent follow-up angiography. Patients treated with fibrinolysis vs pPCI had no significant mortality difference (3.7% vs 3.9%; adjusted odds ratio, 1.13; 95% CI, 0.94-1.36) but had higher bleeding risk (10.7% vs 9.5%; adjusted odds ratio, 1.17; 95% CI, 1.02-1.33). CONCLUSIONS AND RELEVANCEIn the United States, neither fibrinolysis nor pPCI is being optimally used to achieve guideline-recommended reperfusion targets. For patients who are unlikely to receive timely pPCI, pretransfer fibrinolysis, followed by early transfer for angiography, may be a reperfusion option when potential benefits of timely reperfusion outweigh bleeding risk.

Neighborhood and Acute Myocardial Infarction Mortality as Related to the Driving Time to Percutaneous Coronary Intervention–Capable Hospital

“…Some of the examples of systems of care for heart attack are the Mission: Lifeline STEMI system of care promulgated by the American Heart Association (http://maps.heart.org/ml/#;); and the RACE (Regional Approach to Cardiovascular Emergencies (https://racecars.dcri.duke.edu/) project utilized by the Carolinas Healthcare System. Additionally, a recent report from the National Cardiovascular Data Registry showed that the median interhospital driving time was 57 minutes (IQR 36–88 minutes) in the United States 20. The interhospital driving times suggest that fibrinolytic therapy should be considered for some of these patients, as supported by the Mission: Lifeline and RACE protocols.…”

Pharmacoinvasive Strategy Versus Primary Percutaneous Coronary Intervention in Patients With ST-Segment–Elevation Myocardial Infarction

“…An observational study using the Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With the Guidelines database between 2008 and 2012 21 showed that only 51.3% of patients with STEMI (≤12 hours) transferred for PPCI achieved the FMCto-balloon time of ≤120 minutes and 34.3% of fibrinolysis-eligible patients received pretransfer fibrinolysis with only 43.8% achieving a door-to-needle time of ≤30 minutes. Similarly, in the present study, only 45.8% of patients (26.1% of transferred patients) in the PPCI group achieved the FMC-to-balloon time of ≤120 minutes, even though the median door-to-balloon time at STEMI-receiving hospitals (80 minutes) was within the recommended 90 minutes.…”

Nationwide Analysis of Patients With ST-Segment–Elevation Myocardial Infarction Transferred for Primary Percutaneous Intervention

“…24 An alternative interpretation is that focused improvement is required in use of prehospital activation and transfer to higher volume PCI centers to achieve guideline mandated primary PCI practice.…”