title: Fibrinolysis use among patients requiring interhospital transfer for ST-segment elevation myocardial infarction care: a report from the US National Cardiovascular Data Registry.
abstract: OBJECTIVE
  Guidelines for patients with ST-segment elevation myocardial infarction (STEMI) recommend timely reperfusion with primary percutaneous coronary intervention (pPCI) or fibrinolysis. Among patients with STEMI who require interhospital transfer, it is unclear how reperfusion strategy selection and outcomes vary with interhospital drive times.
  
  
  OBJECTIVE
  To assess the association of estimated interhospital drive times with reperfusion strategy selection among transferred patients with STEMI in the United States.
  
  
  METHODS
  We identified 22,481 patients eligible for pPCI or fibrinolysis who were transferred from 1771 STEMI referring centers to 366 STEMI receiving centers in the Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With the Guidelines database between July 1, 2008, and March 31, 2012.
  
  
  METHODS
  In-hospital mortality and major bleeding.
  
  
  RESULTS
  The median estimated interhospital drive time was 57 minutes (interquartile range [IQR], 36-88 minutes). When the estimated drive time exceeded 30 minutes, only 42.6% of transfer patients treated with pPCI achieved the first door-to-balloon time within 120 minutes. Only 52.7% of eligible patients with a drive time exceeding 60 minutes received fibrinolysis. Among 15,437 patients with estimated drive times of 30 to 120 minutes who were eligible for fibrinolysis or pPCI, 5296 (34.3%) received pretransfer fibrinolysis, with a median door-to-needle time of 34 minutes (IQR, 23-53 minutes). After fibrinolysis, the median time to transfer to the STEMI receiving center was 49 minutes (IQR, 34-69 minutes), and 97.1% underwent follow-up angiography. Patients treated with fibrinolysis vs pPCI had no significant mortality difference (3.7% vs 3.9%; adjusted odds ratio, 1.13; 95% CI, 0.94-1.36) but had higher bleeding risk (10.7% vs 9.5%; adjusted odds ratio, 1.17; 95% CI, 1.02-1.33).
  
  
  CONCLUSIONS
  In the United States, neither fibrinolysis nor pPCI is being optimally used to achieve guideline-recommended reperfusion targets. For patients who are unlikely to receive timely pPCI, pretransfer fibrinolysis, followed by early transfer for angiography, may be a reperfusion option when potential benefits of timely reperfusion outweigh bleeding risk.
authors.affiliation: Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina.
authors.forename: Amit N
authors.initials: AN
authors.lastname: Vora
authors.affiliation: Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina.
authors.forename: DaJuanicia N
authors.initials: DN
authors.lastname: Holmes
authors.affiliation: Department of Emergency Medicine, Olive View-University of California, Los Angeles, Medical Center, Sylmar.
authors.forename: Ivan
authors.initials: I
authors.lastname: Rokos
authors.affiliation: Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina.
authors.forename: Matthew T
authors.initials: MT
authors.lastname: Roe
authors.affiliation: Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina.
authors.forename: Christopher B
authors.initials: CB
authors.lastname: Granger
authors.affiliation: Division of Cardiology, Department of Medicine, Harbor-University of California, Los Angeles, Medical Center, Torrance.
authors.forename: William J
authors.initials: WJ
authors.lastname: French
authors.affiliation: Cardiovascular Division, TIMI Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: Elliott
authors.initials: E
authors.lastname: Antman
authors.affiliation: Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota.
authors.forename: Timothy D
authors.initials: TD
authors.lastname: Henry
authors.affiliation: Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina.
authors.forename: Laine
authors.initials: L
authors.lastname: Thomas
authors.affiliation: Division of Cardiovascular Diseases, Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor.
authors.forename: Eric R
authors.initials: ER
authors.lastname: Bates
authors.affiliation: Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina.
authors.forename: Tracy Y
authors.initials: TY
authors.lastname: Wang
mesh_terms: D000368:Aged; D002755:Choice Behavior; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000188:drug therapy*; D015425:Myocardial Reperfusion / Q000706:statistics & numerical data*; D010360:Patient Transfer / Q000706:statistics & numerical data*; D062645:Percutaneous Coronary Intervention / Q000706:statistics & numerical data*; D017410:Practice Guidelines as Topic; D012042:Registries; D013997:Time Factors; D014481:United States
chemical_list: D005343:Fibrinolytic Agents