Transfer for Primary Angioplasty
2005; Lippincott Williams & Wilkins; Volume: 111; Issue: 6 Linguagem: Inglês
10.1161/01.cir.0000156406.52178.c5
ISSN1524-4539
Autores Tópico(s)Cardiac Imaging and Diagnostics
ResumoHomeCirculationVol. 111, No. 6Transfer for Primary Angioplasty Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBTransfer for Primary AngioplastyThe Importance of Time Howard C. Herrmann Howard C. HerrmannHoward C. Herrmann From the Cardiovascular Division, Department of Medicine, University of Pennsylvania Medical Center, Philadelphia. Originally published15 Feb 2005https://doi.org/10.1161/01.CIR.0000156406.52178.C5Circulation. 2005;111:718–720Primary angioplasty offers benefits as compared with fibrinolysis for many patients with acute ST-elevation myocardial infarction (STEMI).1 This superiority of percutaneous coronary intervention (PCI) in trials has led to the investigation of transfer strategies that would make PCI more widely available. Such a strategy would regionalize care and divert patients with STEMI to centers with PCI capability. The clinical cost of such a strategy in terms of time requires investigation.See p 761Time to reperfusion after fibrinolysis is a critical determinant of outcome.2–4 In some reports of primary angioplasty, the time to reperfusion has had little effect on mortality.5 In most other studies, however, a longer door-to-balloon time worsened outcome as assessed by myocardial infarct size as well as mortality.6–9 In one recent analysis of 1791 patients with STEMI treated by primary angioplasty, each 30-minute delay in reperfusion was associated with a relative risk for 1-year mortality of 1.075.10 In a retrospective analysis of randomized trials that compared fibrinolysis to primary angioplasty, the mortality benefit associated with PCI was lost when the door-to-balloon time was delayed by >1 hour as compared with the door-to-needle time.11 Some of the difference in the comparison of fibrinolysis and primary angioplasty may reflect a relative decrease in the efficacy of fibrinolysis with time after symptom onset12,13 or the relatively good outcome that occurs in the lowest-risk STEMI patients.14 On the basis of the benefit associated with primary angioplasty over fibrinolysis in randomized trials, new trials were designed and carried out that involved transferring patients from hospitals without cardiac catheterization capability to PCI centers. The proper interpretation of the results of these trials requires a careful analysis of the importance of time.Trials of Transfer for PCIFive randomized trials compare fibrinolysis with transfer to another hospital for primary angioplasty.13,15–18 The results of these trials (shown in the Table) summarized in 2 meta-analyses12,19 have been interpreted to demonstrate that transfer for primary angioplasty is a better treatment than thrombolysis at the presenting hospital. Before the results of these trials can be generalized to routine practice, however, a number of caveats need to be considered. Results of Randomized Trials Comparing Fibrinolysis With Transfer to Another Hospital for Primary AngioplastyStudy/ReferenceNo./ArmTotal Symptom or Door-to-Lysis, min*Total Symptom or Door-to-PCI, min*Difference (Transfer Delay), minDoor-to-Balloon in Transfer Hospital, minAbsolute Risk Reduction Death, %, 30 dAbsolute Risk Reduction MI, %, 30 d*Symptom-to-therapy in Vermeer et al, PRAGUE-2, and DANAMI-2 trials; door-to-therapy in AIR-PAMI and DANAMI trials.†Data available in 82% of patients.‡Data provided by H. Krumholz, MD, written communication, 2004.Vermeer et al157513523095NA06PRAGUE-1131002295732879PRAGUE-21642518528095263.21.7AIR-PAMI176963174111383.7−1.4DANAMI-21878616621448261.24.7 Total (weighted average)1455155.2224.068.925.42.23.9Nallamothu et al22†4278…287‡12053……First, the overall door-to-balloon time in these 5 trials was short and minimized by protocols that involved calling ahead to the transfer hospital and bypassing the emergency department and coronary care unit in the transfer hospital on the way to the cardiac catheterization laboratory. Thus, the transfer time could be considered "parallel" rather than additive to the usual door-to-balloon time. As summarized in the Table, the delay in transfer resulted in a total door- (or symptom-) to-balloon time that was only 69 minutes longer than the corresponding door- (or symptom-) to-lysis time. This time was only ≈30 minutes longer than the door-to-balloon time in the randomized trials of primary angioplasty.11 Unfortunately, as shown by the Second National Registry of Myocardial Infarction database, <30% of US patients can actually achieve door-to-balloon times 3 hours after the onset of symptoms,16 consistent with the relatively greater benefit of fibrinolysis in early presenters.4,12What does the study by Nallamothu et al22 in this issue of Circulation add to our consideration of the importance of time in patients transferred for primary angioplasty? Their study demonstrates from a large registry of MI in the United States that the "total" door-to-balloon time in 4278 transfer patients was a median of 180 minutes, with only 4% of patients having a door-to-balloon time of <90 minutes and 15% ≤120 minutes.22 These values contrast with the current American College of Cardiology/American Heart Association guidelines, which recommend a goal of 2 hours in the transfer hospital. Furthermore, a longer door-to-door time for transfer was not associated with a shorter door-to-balloon time in the transfer hospital. This finding contrasts directly with the planning and execution of the randomized transfer trials described above and suggests a clear opportunity for improvement.Clinical ImplicationsCurrently, real-world hospital transfer greatly increases door-to-balloon time.6,22 Furthermore, the total door-to-balloon time is substantially (2-fold) longer than in the randomized trials of transfer for primary PCI. For this reason, we must exercise caution in applying the conclusions from the randomized trials to general practice.To make a transfer strategy successful, it is essential to reduce the door-to-balloon time by improving systems and processes of care. To minimize the effect of the transfer on the time to reperfusion, communication should be optimized to include early mobilization of the cardiac catheterization laboratory team in the transfer hospital. Efforts must be made to minimize delays on arrival at the transfer hospital on the way to the catheterization laboratory. The randomized trials, as well as treatment networks now established in Poland, the Czech Republic, and isolated networks in the United States, demonstrate that this can indeed be accomplished. This study demonstrates that in the United States many patients are being transferred for primary PCI, with remarkably long door-to-balloon times averaging ≈3 hours. For most patients in whom the total door-to-balloon time (including the transfer time) is expected to exceed 120 minutes and without contraindications, a fibrinolytic agent administered at the first hospital is the better treatment choice.23If organized systems can be implemented to optimize transfer for primary angioplasty, then there may be a synergistic benefit with technologically advanced therapies that may be available only in specialized centers. Several authors have called for the development of regional and national strategies to create such centers of excellence.24 Therapies that may be expensive but beneficial, including advanced support mechanisms for cardiogenic shock, for myocardial reperfusion, and potentially for myocardial preservation, could be centralized at such sites.25 In this regard, it would be important to identify those patients who benefit most from transfer.The long time to transfer also suggests that a strategy of treatment on the way to primary angioplasty may be necessary. This approach of "facilitated PCI" has the potential benefit of opening the artery on the way to the transfer hospital, thereby resulting in earlier reperfusion and a more successful intervention with more complete patency and better perfusion.26 This idea is being tested in the ongoing FINESSE (Facilitated Intervention With Enhanced Reperfusion Speed to Stop Events) and ASSENT-4 (Assessment of the Safety and Efficacy of a New Treatment Strategy for Acute Myocardial Infarction-4) trials. Finally, regardless of whether patients are transferred for primary PCI, undergo primary PCI at the presenting hospital, or have fibrinolysis with or without subsequent catheterization, it is imperative that clinicians not ignore postinfarction care to minimize adverse remodeling, the risk of sudden death, and to provide secondary prevention.ConclusionThe study by Nallamothu et al22 demonstrates that in a real-world US population, transfer for primary angioplasty markedly delays door-to-balloon time and must be carefully balanced against any potential benefit of primary PCI over fibrinolysis. For this reason, it is too early to recommend routine transfer for primary angioplasty for all patients with STEMI. It may be most appropriate for patients with large MIs, cardiogenic shock, Killip class ≥3, failed fibrinolysis, a long symptom-to-presentation time, or a short transfer delay. This study also suggests major areas for improvement that can result in better outcomes for patients that are in need of transfer therapy. In the debate of fibrinolysis versus primary PCI with or without transfer, we should not lose sight of the importance of time.The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.FootnotesCorrespondence to Howard C. Herrmann, MD, Professor of Medicine and Director, Interventional Cardiology and Cardiac Catheterization Laboratories, Hospital of the University of Pennsylvania, 9 Founders Pavilion, 3400 Spruce St, Philadelphia 19104. E-mail [email protected] References 1 Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomized trials. Lancet. 2003; 361: 13–20.CrossrefMedlineGoogle Scholar2 Morrow DA, Antman EM, Sayah A, Schuhwerk KC, Giugliano RP, deLemos JA, Waller M, Cohen SA, Rosenberg DG, Cutler SS, McCabe CH, Walls RM, Braunwald E. Evaluation of the time saved by prehospital initiation of reteplase for ST-elevation myocardial infarction. J Am Coll Cardiol. 2002; 40: 71–77.CrossrefMedlineGoogle Scholar3 Newby LK, Rutsch WR, Califf RM, Simoons ML, Aylward PE, Armstrong PW, Woodlief LH, Lee KL, Topol EJ, Van De Werf F. Time from symptom onset to treatment and outcomes after thrombolytic therapy. J Am Coll Cardiol. 1996; 27: 1646–1655.CrossrefMedlineGoogle Scholar4 Steg PG, Bonnefoy E, Chabaud S, Lapostolle F, Dubien PY, Cristofini P, Leizorovicz A, Touboul P. Impact of time to treatment on mortality after prehospital fibrinolysis or primary angioplasty. 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A randomized trial of transfer for primary angioplasty versus on-site thrombolysis in patients with high-risk myocardial infarction. J Am Coll Cardiol. 2002; 39: 1713–1719.CrossrefMedlineGoogle Scholar18 Andersen HR, Nielsen TT, Rasmussen K, Thuesen L, Kelbaek H, Thayssen P, Abidgaard U, Pedersen F, Madsen JK, Grande P, Villadsen AB, Krusell LR, Haghfelt T, Lomhjolt P, Husted SE, Vigholt E, Kjaergard HK, Mortensen LS; DANAMI-2 Investigators. A comparison of coronary angioplasty with fibrinolytic therapy in acute myocardial infarction. N Engl J Med. 2003; 349: 733–742.CrossrefMedlineGoogle Scholar19 Dalby M, Bouzamondo A. Lechat P, Montalescot G. Transfer for primary angioplasty versus immediate thrombolysis in acute myocardial infarction: a meta-analysis. Circulation. 2003; 108: 1809–1814.LinkGoogle Scholar20 American Heart Association. REACT trial results. 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Comments should be no longer than 500 words and will only be posted online. References are limited to 10. Authors of the article cited in the comment will be invited to reply, as appropriate.Comments and feedback on AHA/ASA Scientific Statements and Guidelines should be directed to the AHA/ASA Manuscript Oversight Committee via its Correspondence page.Sign In to Submit a Response to This Article Previous Back to top Next FiguresReferencesRelatedDetailsCited Byvan Diepen S, Widimský P, Lopes R, White K, Weaver W, Van de Werf F, Ardissino D, van't Hof A, Armstrong P and Granger C (2012) Transfer Times and Outcomes in Patients With ST-Segment–Elevation Myocardial Infarction Undergoing Interhospital Transfer for Primary Percutaneous Coronary Intervention, Circulation: Cardiovascular Quality and Outcomes, 5:4, (437-444), Online publication date: 1-Jul-2012. Herrmann H, Lu J, Brodie B, Armstrong P, Montalescot G, Betriu A, Neuman F, Effron M, Barnathan E, Topol E and Ellis S (2009) Benefit of Facilitated Percutaneous Coronary Intervention in High-Risk ST-Segment Elevation Myocardial Infarction Patients Presenting to Nonpercutaneous Coronary Intervention Hospitals, JACC: Cardiovascular Interventions, 10.1016/j.jcin.2009.06.018, 2:10, (917-924), Online publication date: 1-Oct-2009. Curós A, Ribas N, Antonio Baz J, Serra J, Fernández E, Rodríguez O and Valle V (2009) Estrategias para reducir el tiempo de reperfusión en el tratamiento con angioplastia primaria, Revista Española de Cardiología Suplementos, 10.1016/S1131-3587(09)72811-0, 9:3, (34-45), Online publication date: 1-Jan-2009. Wharton T and Sinclair N (2009) Primary Coronary Intervention in Community Hospitals with Off-Site Cardiac Surgery Backup: Rationale and Steps to Quality Primary Angioplasty in Acute Myocardial Infarction, 10.1007/978-1-60327-497-5_5, (65-83), . 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Loo A, Saurbier B, Kalbhenn J, Koberne F and Zehender M (2006) Primary percutaneous coronary intervention in acute myocardial infarction: Direct transportation to catheterization laboratory by emergency teams reduces door-to-balloon time, Clinical Cardiology, 10.1002/clc.4960290306, 29:3, (112-116), Online publication date: 1-Mar-2006. KHAN M (2006) Heart Attacks Encyclopedia of Heart Diseases, 10.1016/B978-012406061-6/50065-5, (397-431), . February 15, 2005Vol 111, Issue 6 Advertisement Article InformationMetrics https://doi.org/10.1161/01.CIR.0000156406.52178.C5PMID: 15710773 Originally publishedFebruary 15, 2005 Keywordsfibrinolysiscatheterizationangioplastymyocardial infarctionEditorialsPDF download Advertisement SubjectsMyocardial InfarctionStentThrombosis
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