Long distance transport for primary angioplasty vs immediate thrombolysis in acute myocardial infarction Final results of the randomized national multicentre trial—PRAGUE-2

Widimský, Petr; Buděšínský, Tomáš; Vorác, D; Groch, Ladislav; Želı́zko, Michael; Aschermann, Michael; Branny, M.; Šťásek, Josef; Formánek, Pavel

doi:10.1016/s0195-668x(02)00468-2

Cited by 690 publications

(372 citation statements)

References 24 publications

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“…This is also well within the 110 min to 114 min PCI-related delay at which primary PCI is expected to lose its mortality benefit over thrombolytic therapy (13,14). On the other hand, the 110 min estimated PCI-related delay for patients transferred from remote hospitals was longer than in previous randomized clinical trials (3,4). In the present study, DTB times were shorter for patients presenting during normal business hours than for patients presenting during weekends or outside normal duty hours.…”

Section: Discussionsupporting

confidence: 79%

“…Many studies have shown that transferring STEMI patients is safe, and that the benefits of primary PCI over thrombolytic therapy are conserved when transfer delays are reasonable (2)(3)(4)(5). Based on randomized, controlled trials, the current guidelines for STEMI recommend a door-to-balloon (DTB) time of less than 90 min when performing primary PCI, including transfer time (6)(7)(8).…”

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confidence: 99%

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

Garceau

Déry

Lachance

et al. 2007

Canadian Journal of Cardiology

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P Garceau, J-P Déry, P Lachance, et al. Treatment delays in patients undergoing primary percutaneous coronary intervention for ST elevation myocardial infarction at the Quebec Heart and Lung Institute. Can J Cardiol 2007;23(Suppl B):53B-57B.BACKGROUND: 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). METHODS: 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. RESULTS: 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). CONCLUSIONS: 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

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Section: Discussionsupporting

confidence: 79%

mentioning

confidence: 99%

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

Garceau

Déry

Lachance

et al. 2007

Canadian Journal of Cardiology

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“…Although the authors propose that emergency hospital transfer is both feasible and safe, a 1.2% complication rate amongst transported patients was recently reported in the Primary Angioplasty in patients transferred from General community hospitals to specialized PTCA Units with or without Emergency thrombolysis 2 (PRAGUE 2) study, in which 2 patients died and 3 developed ventricular fibrillation. 22 In our view, this analysis is Figure 1. The evolution of timing and location for administration of fibrinolytic therapy.…”

Section: Choice Of Reperfusion Strategymentioning

confidence: 95%

Fibrinolysis for Acute Myocardial Infarction

2003

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“…1,[15][16][17] The present findings of a different outcome of the comparison between thrombolysis and primary PCI as a function of time from onset of symptoms are consistent with results from the PRAGUE II trial, in which in-hospital thrombolysis achieved identical 30-day mortality compared with primary PCI within the first 3 hours after symptom onset (7.4% versus 7.3%, respectively), whereas mortality was lower with PCI among patients randomized later. 18 In the Zwolle randomized trial of thrombolysis versus primary PCI, the latter was associated with lower adverse event rates regardless of Values are number of patients (%) or median (interquartile range; 25th and 75th percentiles). *P for heterogeneity.…”

Section: Steg Et Al Prehospital Rtpa Vs Primary Pcimentioning

confidence: 99%

Impact of Time to Treatment on Mortality After Prehospital Fibrinolysis or Primary Angioplasty

et al. 2003

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MD; for the Comparison of Angioplasty and Prehospital Thrombolysis In acute Myocardial infarction (CAPTIM) Investigators*Background-CAPTIM was a randomized trial comparing prehospital thrombolysis with transfer to an interventional facility (and, if needed, percutaneous intervention) with primary percutaneous coronary intervention (PCI) in patients with ST-segment-elevation myocardial infarction (STEMI). Because the benefit of thrombolysis is maximal during the first 2 hours after symptom onset, and because prehospital thrombolysis can be implemented earlier than PCI, this analysis studied the relationship between the effect of assigned treatment and the time elapsed from symptom onset. Methods and Results-Randomization within 2 hours (nϭ460) or Ն2 hours (nϭ374) after symptom onset had no impact on the effect of treatment on the 30-day combined primary end point of death, nonfatal reinfarction, and disabling stroke. However, patients randomized Ͻ2 hours after symptom onset had a strong trend toward lower 30-day mortality with prehospital thrombolysis compared with those randomized to primary PCI (2.2% versus 5.7%, Pϭ0.058), whereas mortality was similar in patients randomized Ն2 hours (5.9% versus 3.7%, Pϭ0.47). There was a significant interaction between treatment effect and delay with respect to 30-day mortality (hazard ratio 4.19, 95% CI 1.033 to 17.004, Pϭ0.045). Among patients randomized in the first 2 hours, cardiogenic shock was less frequent with lytic therapy than with primary PCI (1.3% versus 5.3%, Pϭ0.032), whereas rates were similar in patients randomized later. Conclusions-Time from symptom onset should be considered when one selects reperfusion therapy in STEMI.Prehospital thrombolysis may be preferable to primary PCI for patients treated within the first 2 hours after symptom onset.

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Long distance transport for primary angioplasty vs immediate thrombolysis in acute myocardial infarction Final results of the randomized national multicentre trial—PRAGUE-2

Cited by 690 publications

References 24 publications

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

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

Fibrinolysis for Acute Myocardial Infarction

Impact of Time to Treatment on Mortality After Prehospital Fibrinolysis or Primary Angioplasty

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