Delays in fibrinolysis as primary reperfusion therapy for acute ST-segment elevation myocardial infarction.
BACKGROUND
In contemporary practice, the degree to which fibrinolytic therapy is administered in a timely fashion for ST-segment elevation myocardial infarction (STEMI) and its association with outcomes is not well-known. Our objective was to assess the performance of fibrinolytic therapy within the recommended 30-minute time frame for patients with STEMI.


METHODS
Patient characteristics associated with the timeliness of fibrinolytic therapy were evaluated. We also examined the association of timely fibrinolysis with key patient outcomes, including inpatient mortality, stroke, and cardiogenic shock. Logistic generalized estimating equations were used to account for baseline clinical factors and within-hospital clustering.


RESULTS
Between January 2007 and June 2008, 3,219 STEMI patients in 178 hospitals received primary fibrinolytic therapy. Median door-to-needle (DTN) time was 34.0 minutes (interquartile range 22.0-54.0 minutes). However, only 44.5% met the American College of Cardiology/American College of Cardiology guideline DTN time of < or =30 minutes. Patient characteristics associated with longer fibrinolysis times included female gender (+17.8% longer vs men, 95% CI 11.9-24.1) and age > or =75 (+12.0% longer vs age <55, 95% CI 1.8-23.2). Timely (vs delayed) fibrinolysis was associated with a decreased risk of a composite outcome of death, shock, or stroke (6.2% vs 8.8%, adjusted odds ratio 0.74, 95% CI 0.56-0.98).


CONCLUSIONS
Timely fibrinolytic therapy was associated with lower risk of a composite outcome of shock, death, or stroke, yet DTN times of < or =30 minutes were achieved in less than half of the patients studied. Thus, efforts to optimize regional systems of STEMI care should focus on shortening reperfusion times for patients who receive fibrinolysis, as well as those who receive primary percutaneous coronary intervention.
Glickman
Seth W
SW
Department of Emergency Medicine, University of North Carolina, Chapel Hill, NC 27599, USA. seth_glickman@med.unc.edu
Cairns
Charles B
CB
Chen
Anita Y
AY
Peterson
Eric D
ED
Roe
Matthew T
MT
D000368:Aged; D004562:Electrocardiography; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage*; D005500:Follow-Up Studies; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D007262:Infusions, Intravenous; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000150:complications / Q000188:drug therapy* / Q000401:mortality; D012189:Retrospective Studies; D012770:Shock, Cardiogenic / Q000209:etiology / Q000401:mortality / Q000517:prevention & control; D020521:Stroke / Q000209:etiology / Q000401:mortality / Q000517:prevention & control; D015996:Survival Rate / Q000639:trends; D015912:Thrombolytic Therapy / Q000379:methods*; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States
D005343:Fibrinolytic Agents