Multicentre randomized trial comparing transport to primary angioplasty vs immediate thrombolysis vs combined strategy for patients with acute myocardial infarction presenting to a community hospital without a catheterization laboratory. The PRAGUE Study

S everal studies have shown that primary percutaneous coronary intervention (PCI) performed by experienced operators immediately after patients are admitted to high-volume tertiary care centres with ST elevation myocardial infarction (STEMI) results in decreased mortality, reinfarction and stroke (1-9). Furthermore, for community hospitals without onsite PCI services, transport of STEMI patients to a PCI centre is superior to thrombolysis under specific circumstances, which are described below (10-14).Thrombolysis is preferred for patients who have STEMI for less than 3 h if the medical contact-to-balloon time is more than 90 min or if the delta time (ie, medical contact-to-balloon time minus medical contact-to-thrombolysis time) is more than 60 min.Alternatively, PCI is preferred if the medical contact-to-balloon time is less than 90 min and the delta time is less than 60 min, or if there are other reasons (eg, contraindications to thrombolysis, symptom onset of more than 3 h or high-risk STEMI [cardiogenic shock, or Killip class 3 or greater]).Chilliwack General Hospital (CGH, Chilliwack, British Columbia), a community hospital without onsite PCI services, is unique because the travel time to the nearest coronary intervention centre (Royal Columbian Hospital [RCH], New Westminster, British Columbia), which is 83 km away, has been anecdotally estimated to be 60 min to 120 min. Currently, there is a paucity of data on the average medical contact-to-thrombolysis time, average medical contact-to-balloon time, and delta time on STEMI patients presenting to CGH. Because CGH emergency physicians were debating on transferring all eligible STEMI patients for PCI therapy, we sought to acquire the average medical contact-to-thrombolysis time, average medical contact-to-balloon time, and delta time to make an informed decision. MethodsA retrospective chart review was conducted on all patients presenting to the emergency department at CGH with STEMIs between January 1, 2004, and December 31, 2005. These dates were chosen because 24 h PCI service at RCH had only been available since January 1, 2004. The inclusion criteria included chest pain for at least 30 min, presentation to the CGH emergency department, ST segment elevation of at least 1 mm in two or more concordant leads, and the administration of thrombolytics or transfer to RCH for PCI. The exclusion criteria included contraindications to thrombolytics and not being transferred for PCI. A total of 67 patients with STEMIs were identified within this time period. Forty patients were then included in the study and 27 patients were excluded. CliniCal STudieS©2009 Pulsus Group Inc. All rights reserved BaCkGrouNd: Studies have shown that primary percutaneous coronary intervention (PCI), when performed by an experienced operator immediately after admission in a high-volume tertiary care centre, results in lower in-hospital mortality, and decreased risk of reinfarction and stroke. Furthermore, for those communities without a PCI centre, transport of patients to a PCI centre...

Section: Discussioncontrasting

confidence: 38%

Section: Discussionmentioning

confidence: 99%

Thrombolysis versus primary percutaneous coronary intervention for ST elevation myocardial infarctions at Chilliwack General Hospital

Janda

Tan

2009

“…Patients in cardiogenic shock were excluded or poorly represented in most trials. The fibrinolytic agent used was streptokinase in two trials (8,9), alteplase (rt-PA) in two trials (10,11) and tenecteplase (TNK) in three trials (12)(13)(14). In the ASSENT-4 and WEST studies (study acronyms are spelled out in Appendix 1), 20% and 40% of patients were enrolled in the prehospital setting, respectively.…”

Section: Pci Facilitated By Fibrinolytic Therapy Alonementioning

confidence: 99%

Systematic review of fibrinolytic-facilitated percutaneous coronary intervention: Potential benefits and future challenges

Afilalo

Roy

Eisenberg

2009

P rimary percutaneous coronary intervention (PCI) has been shown to be superior to fibrinolytic therapy for the treatment of ST segment elevation myocardial infarction (STEMI) (1). However, primary PCI is suboptimal when there are prolonged delays for interhospital transfer or resource mobilization. Facilitated PCI is defined as the administration of fibrinolytic therapy and/or glycoprotein (GP) IIb/IIIa inhibitors while waiting for PCI. The rationale is to open infarctrelated arteries (IRAs) as soon as possible, minimize myocardial ischemia time and, thus, salvage at-risk myocardium. Despite the theoretical benefits, randomized controlled trials have failed to support the clinical benefits of this strategy. These trials varied substantially in terms of facilitating regimens, timing of fibrinolysis, timing of PCI, and coadministered antiplatelet or antithrombin therapies. A recent metaanalysis (2) showed that facilitated PCI was associated with increased short-term mortality, reinfarction, major bleeding and stroke. Although the results of this meta-analysis were unequivocally negative, a systematic review may be better suited to address these heterogeneous and complex trials. Our objective was to systematically review trials of fibrinolytic-facilitated versus nonfacilitated PCI, and determine when this strategy may be beneficial and deserving of further research. BACKGROUND: Facilitated percutaneous coronary intervention (PCI) is defined as the administration of fibrinolytic therapy and/or glycoprotein (GP) IIb/IIIa inhibitors to minimize myocardial ischemia time while waiting for PCI. A pooled meta-analysis suggested that facilitated PCI was associated with higher rates of mortality and morbidity compared with nonfacilitated PCI. OBJECTIVE: The heterogeneous and complex trials of facilitated PCI were systematically reviewed to identify where this strategy may be beneficial and deserving of further research. METHODS: MEDLINE, EMBASE, the Cochrane database, the Internet and conference proceedings were searched to obtain relevant trials. Human studies that randomly assigned patients to fibrinolytic-facilitated PCI (administration of fibrinolytic therapy alone or in combination with GP IIb/IIIa inhibitors before angiography) versus nonfacilitated PCI were included. RESULTS: Nine trials encompassing 3836 patients were reviewed. The facilitated PCI strategy was fibrinolytic therapy alone in seven trials and half-dose fibrinolytic therapy plus GP IIb/IIIa inhibitors in two trials. In patients who had fibrinolysis less than 2 h after symptom onset (mainly in the prehospital setting) and/or slightly delayed PCI 3 h to 24 h after fibrinolysis, facilitated PCI was associated with the greatest Thrombolysis In Myocardial Infarction (TIMI) grade 3 flow and a trend toward reduced mortality. Overall, facilitated PCI was associated with increased intracranial hemorrhage and reinfarction. Combining half-dose fibrinolytic therapy and GP IIb/IIIa inhibitors reduced reinfarction but increased major bleeding. CONCLUSIONS: Facilitat...

“…All coronary angiograms from the PRimary Angioplasty in patients transferred from General community hospitals to specialized PTCA Units with or without Emergency thrombolysis-1 (PRAGUE-1) study (11) and the PRAGUE-2 study (12) (PRAGUE study angiograms, n=625) were retrospectively analyzed, along with coronary angiograms obtained during the last year of the PRAGUE-2 study (2002) at the Kralovske Vinohrady University Hospital, Prague, Czech Republic ('the hospital'), for this indication (PRAGUE ST-Elevation Myocardial Infarction [STEMI] registry angiograms, n=379). The inclusion criteria were acute myocardial infarction (ST elevations greater than 1 mm in at least two leads or a new bundle branch block on initial ECG), less than 12 h of symptoms and signed, informed consent.…”

Section: Patientsmentioning

confidence: 99%

Prevalence of normal coronary angiography in the acute phase of suspected ST-elevation myocardial infarction: Experience from the PRAGUE studies

Widimský

Stellova

Groch

et al. 2006

BACKGROUND: Acute ST-elevation myocardial infarction in patients with normal coronary arteries has previously been described, but coronary angiography in these patients was performed after the acute phase of the infarction. It is possible that these patients did not have normal angiograms during the acute phase (transient coronary thrombosis or spasm were usually suspected to be the cause). Information on the prevalence of truly normal coronary angiograms during the acute phase of a suspected ST-elevation myocardial infarction is lacking. PATIENTS AND METHODS:The PRimary Angioplasty in patients transferred from General community hospitals to specialized PTCA Units with or without Emergency thrombolysis-1 (PRAGUE-1) and PRAGUE-2 studies enrolled 1150 patients with ST-elevation acute myocardial infarction, in whom 625 coronary angiograms were performed within 2 h of the initial electrocardiogram. A simultaneous registry included an additional 379 coronary angiograms performed during the ST-elevation phase of a suspected myocardial infarction. Thus, a total of 1004 angiograms were retrospectively analyzed. A normal coronary angiogram was defined as one with the absence of any visible angiographic signs of atherosclerosis, thrombosis or spontaneous spasm. RESULTS: Normal coronary angiograms were obtained for 26 patients (2.6%). Among these, the diagnosis at discharge was a small myocardial infarction in seven patients (0.7%), acute (peri)myocarditis in five patients, dilated cardiomyopathy in four patients, hypertension with left ventricular hypertrophy in three patients, pulmonary embolism in two patients and misinterpretation of the electrocardiogram (ie, no cardiac disease) in five patients. Seven patients with small infarctions underwent angiography within 30 min to 90 min of complete relief of the signs of acute ischemia, and thus, angiograms during pain were not taken. None of the 898 patients catheterized during ongoing symptoms of ischemia had a normal coronary angiogram. Spontaneous coronary spasm as the only cause (without underlying coronary atherosclerosis) for the evolving infarction was not seen among these 898 patients. Thus, the causes of the seven small infarcts in patients with normal angiograms remain uncertain. CONCLUSIONS: The observed prevalence of normal coronary angiography in patients presenting with acute chest pain and ST elevations was 2.6%. Most of these cases were misdiagnoses, not infarctions. A normal angiogram during a biochemically confirmed infarction is extremely rare (0.7%) and was not seen during the ongoing symptoms of ischemia.