title: Safety and efficacy of a pharmaco-invasive reperfusion strategy in rural ST-elevation myocardial infarction patients with expected delays due to long-distance transfers.
abstract: OBJECTIVE
  To determine the safety and efficacy of a pharmaco-invasive reperfusion strategy utilizing half-dose fibrinolysis combined with transfer for immediate percutaneous coronary intervention (PCI) in ST-elevation myocardial infarction (STEMI) patients presenting to remote rural hospitals. Primary PCI is preferred for STEMI if performed in a timely manner. However, <20% of STEMI patients transferred for PCI in the USA have door-to-balloon times <2 h.
  
  
  RESULTS
  Prospective data from the Level 1 MI programme were analysed. All STEMI patients presenting to the Minneapolis Heart Institute or 31 referral hospitals received aspirin, clopidogrel, and unfractionated heparin (UFH) at the presenting hospital and those presenting to hospitals ≥60 miles away also received half-dose fibrinolytic with transfer for immediate PCI. From April 2003 through December 2009, we enrolled 2634 consecutive STEMI patients in the Level 1 MI database including 660 transferred from remote hospitals utilizing pharmaco-invasive therapy and 600 patients who presented directly to the PCI centre. There were no significant differences in 30-day mortality (5.5 vs. 5.6%; P= 0.94), stroke (1.1 vs. 1.3%; P= 0.66) or major bleeding (1.5 vs. 1.8%; P= 0.65), or re-infarction/ischaemia (1.2 vs. 2.5%; P= 0.088) in patients receiving a pharmaco-invasive strategy compared with patients presenting directly to the PCI centre, despite a significantly longer door-to-balloon time.
  
  
  CONCLUSIONS
  Within a regional STEMI system of care, 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.
authors: Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, 920 East 28th Street, Minneapolis, MN 55407, USA. stephan.schirmer@uks.eu
authors: David M
authors: DM
authors: Larson
authors: Sue
authors: S
authors: Duval
authors: Scott W
authors: SW
authors: Sharkey
authors: Ross F
authors: RF
authors: Garberich
authors: James D
authors: JD
authors: Madison
authors: Peter J
authors: PJ
authors: Stokman
authors: Timothy G
authors: TG
authors: Dirks
authors: Robert K
authors: RK
authors: Westin
authors: James L
authors: JL
authors: Harris
authors: Timothy D
authors: TD
authors: Henry
mesh_terms: D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use; D000368:Aged; D015906:Angioplasty, Balloon, Coronary / Q000379:methods*; D001241:Aspirin / Q000627:therapeutic use; D000077144:Clopidogrel; D004638:Emergency Treatment; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000628:therapy*; D015425:Myocardial Reperfusion / Q000379:methods*; D010360:Patient Transfer; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use; D011446:Prospective Studies; D012008:Recurrence; D012423:Rural Health; D000077785:Tenecteplase; D013988:Ticlopidine / Q000031:analogs & derivatives / Q000627:therapeutic use; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use*; D016896:Treatment Outcome
chemical_list: D000319:Adrenergic beta-Antagonists; D005343:Fibrinolytic Agents; D010975:Platelet Aggregation Inhibitors; D000077144:Clopidogrel; D010959:Tissue Plasminogen Activator; D013988:Ticlopidine; D001241:Aspirin; D000077785:Tenecteplase