title: Benefit of transferring ST-segment-elevation myocardial infarction patients for percutaneous coronary intervention compared with administration of onsite fibrinolytic declines as delays increase.
abstract: BACKGROUND
  Although randomized trials suggest that transfer for primary percutaneous coronary intervention (X-PCI) in ST-segment-elevation myocardial infarction is superior to onsite fibrinolytic therapy (O-FT), the generalizability of these findings to routine clinical practice is unclear because door-to-balloon (XDB) times are rapid in randomized trials but are frequently prolonged in practice. We hypothesized that delays resulting from transfer would reduce the survival advantage of X-PCI compared with O-FT.
  
  
  RESULTS
  ST-segment-elevation myocardial infarction patients enrolled in the National Registry of Myocardial Infarction (NRMI) within 12 hours of pain onset were identified. Propensity matching of patients treated with X-PCI and O-FT was performed, and the effect of PCI-related delay on in-hospital mortality was assessed. PCI-related delay was calculated by subtracting the XDB from the door-to-needle time in each matched pair. Conditional logistic regression adjusted for patient and hospital variables identified the XDB door-to-needle time at which no mortality advantage for X-PCI over O-FT was present. Eighty-one percent of X-PCI patients were matched (n=9506) to O-FT patients (n=9506). In the matched cohort, X-PCI was performed with delays >90 minutes in 68%. Multivariable analysis found no mortality advantage for X-PCI over O-FT when XDB door-to-needle time exceeded ≈120 minutes.
  
  
  CONCLUSIONS
  PCI-related delays are extensive among patients transferred for X-PCI and are associated with poorer outcomes. No differential excess in mortality was seen with X-PCI compared with O-FT even with long PCI-related delays, but as XDB door-to-needle time times increase, the mortality advantage for X-PCI over O-FT declines.
authors: Division of Cardiology, Interventional Section, Beth Israel Deaconess Medical Center, 185 Pilgrim Rd., Boston MA 02115, USA. mgibson@perfuse.org
authors: Duane S
authors: DS
authors: Pinto
authors: Paul D
authors: PD
authors: Frederick
authors: Anjan K
authors: AK
authors: Chakrabarti
authors: Ajay J
authors: AJ
authors: Kirtane
authors: Edward
authors: E
authors: Ullman
authors: Andre
authors: A
authors: Dejam
authors: Dave P
authors: DP
authors: Miller
authors: Timothy D
authors: TD
authors: Henry
authors: C Michael
authors: CM
authors: Gibson
mesh_terms: D000368:Aged; D015906:Angioplasty, Balloon, Coronary / Q000706:statistics & numerical data*; D004562:Electrocardiography; D004632:Emergency Medical Services / Q000706:statistics & numerical data*; D005343:Fibrinolytic Agents / Q000008:administration & dosage*; D006801:Humans; D016015:Logistic Models; D008875:Middle Aged; D009203:Myocardial Infarction / Q000175:diagnosis / Q000401:mortality* / Q000628:therapy*; D012042:Registries / Q000706:statistics & numerical data; D012307:Risk Factors; D016019:Survival Analysis; D013997:Time Factors; D014187:Transportation of Patients / Q000706:statistics & numerical data*
chemical_list: D005343:Fibrinolytic Agents