title: Bridging the gap for nonmetropolitan STEMI patients through implementation of a pharmacoinvasive reperfusion strategy.
abstract: BACKGROUND
  Timely primary percutaneous coronary intervention (PCI) is the preferred reperfusion strategy in ST-elevation myocardial infarction (STEMI). However, universal access is limited outside metropolitan centres and portends worse outcomes for rural patients. This study evaluates the outcomes of STEMI patients treated in a metropolitan and nonmetroplitan setting within Vital Heart Response, an integrated reperfusion program developed to reduce reperfusion delay in Central and Northern Alberta.
  
  
  METHODS
  From October 2006 to March 2011, data on consecutive STEMI patients was prospectively recorded. Clinical characteristics, in-hospital management, and outcomes grouped by site of presentation are described.
  
  
  RESULTS
  There were 1990 metropolitan and 1602 nonmetropolitan STEMI patients. Metropolitan were older (62.7 vs 60.4 years; P < 0.001) and had more: angina (21.2% vs 16.5%; P < 0.001), dyslipidemia (45.3% vs 39.6%; P = 0.001), and hypertension (49.9% vs 46.6%; P = 0.047). The reperfusion strategy for metropolitan and nonmetropolitan: primary PCI (57.4% vs 22.9%; P < 0.001), fibrinolysis (26.3% vs 61.2%; P < 0.001), and no reperfusion (16.3% vs 15.9%; P = 0.855). First medical contact to reperfusion was delayed in nonmetropolitan with fibrinolysis and PCI, 8 and 125 minutes. A rescue PCI or coronary angiography within 24 hours was completed in 41.4% and 46.2%, respectively. Nonmetropolitan patients had fewer deaths (4.1% vs 6.8%; P = 0.001) with no difference in the composite outcome (death, reinfraction, congestive heart failure, cardiogenic shock) (16.8% vs 15.1%; P = 0.161) or major bleeding (7.9% vs 8.0%; P = 0.951).
  
  
  CONCLUSIONS
  Systematic application of a pharmacoinvasive strategy appears to be safe and effective for patients in whom a delay in mechanical reperfusion is anticipated.
authors: University of Alberta, Edmonton, Alberta, Canada.
authors: Jay
authors: J
authors: Shavadia
authors: Quazi
authors: Q
authors: Ibrahim
authors: Sunil
authors: S
authors: Sookram
authors: Neil
authors: N
authors: Brass
authors: Darren
authors: D
authors: Knapp
authors: Robert C
authors: RC
authors: Welsh
mesh_terms: D000368:Aged; D000416:Alberta; D002170:Canada; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000188:drug therapy / Q000401:mortality / Q000628:therapy*; D015425:Myocardial Reperfusion / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D011446:Prospective Studies; D015912:Thrombolytic Therapy / Q000009:adverse effects / Q000379:methods*; D013997:Time Factors; D016896:Treatment Outcome