Expert Review: Heart Failure, Interventional / Cardiac Surgery

Safety and efficacy of a pharmaco-invasive reperfusion strategy in rural ST-elevation MI patients with expected delays due to long-distance transfers

This investigates the safety and efficacy of a pharmaco-invasive reperfusion strategy utilizing half-dose fibrinolysis combined with transfer for immediate PCI in STEMI patients presenting to remote rural hospitals. The authors found no significant differences in 30-day mortality, stroke, major bleeding, or re-infarction/ischaemia in patients receiving a pharmaco-invasive strategy compared with patients presenting directly to the PCI centre, despite a significantly longer door-to-balloon time.

Background 

The optimal reperfusion strategy for ST-segment elevation myocardial infarction (STEMI) is primary percutaneous coronary intervention (PCI) if it can be performed in a timely manner. To date, less than ideal treatment options exist for STEMI

patients residing in rural areas located long distances from primary PCI-capable hospitals. These options range from fibrinolysis alone, fibrinolysis followed by early rescue PCI or transfer to a PCI-capable hospital for primary PCI with significant delays of reperfusion.

Knowledge Gap

An alternative hybrid strategy, combining the advantage of fibrinolysis availability with the improved reperfusion with PCI is emerging as an appealing solution when dealing with STEMI patients in rural, remote hospitals.

Aim of the Study 

The aim of the present study was to determine the safety and efficacy of a pharmaco-invasive reperfusion strategy utilizing half-dose fibrinolysis combined with transfer for immediate PCI in STEMI patients presenting to remote, rural hospitals.

Methods

The present study was a prospective, non-placebo, controlled, two-parallel arms study including STEMI patients presenting to a tertiary hospital capable of primary PCI either for primary PCI (patients presenting directly to the tertiary centre or being referred by hospitals ≤60 miles) or for pharmaco-invasive therapy (patients being referred by hospitals >60 miles). A group of patients being referred for primary PCI without previous PCI by hospitals >60 miles with significant time delays in reperfusion formed an additional comparison group. A propensity-score method was used to identify comparable patients treated with the pharmaco-invasive approach and those receiving primary PCI.

Results

From April 2003 through December 2009, the study enrolled 2634 consecutive STEMI patients including 660 transferred from hospitals utilizing pharmaco-invasive therapy, 600 patients who presented directly to the PCI centre, 1163 patients transferred from hospitals ≤ 60miles for primary PCI (there were 32 additional patients from these hospitals that received hybrid reperfusion therapy) and 179 patients transferred from hospitals > 60miles for primary PCI without previous fibrinolysis. Median door-to-balloon times were 62 (44-83) minutes for those presenting directly to the PCI hospital, 94 (80-116) minutes for primary PCI patients transferred from hospitals ≤ 60 miles, 122 (100-147) minutes for pharmaco-invasive-treated patients transferred from hospitals > 60 miles and 131 (107-169) minutes for patients transferred from hospitals > 60 miles for primary PCI without previous PCI. Comparison of patients presenting directly to the PCI hospital, treated with primary PCI with patients transferred from hospitals ≥60 miles from the PCI hospital who received pharmaco-invasive PCI showed no significant differences with respect to 30-day mortality (5.5 vs. 5.6%; P = 0.94), stroke (1.3 vs. 1.1%; P = 0.66), recurrent ischaemia/ myocardial infarction (2.5 vs. 1.2%; P = 0.088), or TIMI major bleeding (1.8 vs. 1.5%; P = 0.65). In addition, comparing the total group of patients treated with primary PCI who presented to the PCI centre or were transferred from ≤ 60 miles with the total group treated with pharmaco-invasive PCI also showed no significant difference in 30-day mortality (5.6 vs. 5.8%; P = 0.87), stroke (0.9 vs. 1.2%; P = 0.48), recurrent ischaemia /myocardial infarction (1.5 vs. 1.3%; P = 0.67) or TIMI major bleeding (1.4 vs. 1.6%; P = 0.76). Patients not receiving fibrinolysis being transferred by hospitals >60miles for primary PCI had higher in-hospital (9.5 vs. 5.3%, P = 0.039) and 30-day mortality (10.6 vs. 5.6%, P ¼ 0.17) compared with patients transferred from these hospitals with pharmaco-invasive PCI.

Conclusion

Half-dose fibrinolysis combined with immediate transfer for PCI may be a safe and effective option for STEMI patients with expected delays due to long-distance transfer.

Perspective-Clinical Impact

Findings of the present study suggest that pharmaco-invasive therapy utilizing half-dose fibrinolysis, clopidogrel, and UFH, combined with emergent transfer for immediate PCI may be a safe and effective reperfusion strategy for STEMI patients with expected delays due to long distances to a PCI centre.

However, according to the authors these findings are inherent to certain limitations. First, these data were obtained within the context of an organized STEMI system of care requiring significant resources therefore may not be attainable in other regions that do not have such a system. Furthermore, it was a registry-based non-placebo controlled, randomized study. Thus certain biases may apply when interpreting the results.

Corresponding author from original paper

David Larson, 1Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, 920 East 28th Street, Suite 100, Minneapolis, MN 55407, USA Email: dlarsonmd@visi.com

Citation: Eur Heart J (2012) 33 (10): 1232-1240.

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