title: Management Strategies and Outcomes of ST-Segment Elevation Myocardial Infarction Patients Transferred After Receiving Fibrinolytic Therapy in the United States.
abstract: Fibrinolytic therapy is still used in patients with ST-segment elevation myocardial infarction (STEMI) when the primary percutaneous coronary intervention cannot be provided in a timely fashion. Management strategies and outcomes in transferred fibrinolytic-treated STEMI patients have not been well assessed in real-world settings. Using the Nationwide Inpatient Sample from 2008 to 2012, we identified 18 814 patients with STEMI who received fibrinolytic therapy and were transferred to a different facility within 24 hours. The primary outcome was in-hospital mortality. Secondary outcomes included gastrointestinal bleeding, bleeding requiring transfusion, intracranial hemorrhage (ICH), length of stay, and cost. The patients were divided into 3 groups: those who received medical therapy alone (n = 853; 4.5%), those who underwent coronary artery angiography without revascularization (n = 2573; 13.7%), and those who underwent coronary artery angiography with revascularization (n = 15 388; 81.8%). Rates of in-hospital mortality among the groups were 20% vs 6.6% vs 2.1%, respectively (P < 0.001); ICH was 8.5% vs 1.1% vs 0.6%, respectively (P < 0.001); and gastrointestinal bleeding was 1.1% vs 0.4% vs 0.4%, respectively (P = 0.011). Multivariate analysis identified increasing age, higher Charlson Comorbidity Index score, cardiogenic shock, cardiac arrest, and ICH as the independent predictors of not performing coronary artery angiography and/or revascularization in patients with STEMI initially treated with fibrinolytic therapy. The majority of STEMI patients transferred after receiving fibrinolytic therapy undergo coronary angiography. However, notable numbers of patients do not receive revascularization, especially patients with cardiogenic shock and following a cardiac arrest.
authors.affiliation: Department of Cardiology, University of Miami Miller School of Medicine, Miami, Florida.
authors.forename: Nish
authors.initials: N
authors.lastname: Patel
authors.affiliation: Department of Cardiology, University of Miami Miller School of Medicine, Miami, Florida.
authors.forename: Nileshkumar J
authors.initials: NJ
authors.lastname: Patel
authors.affiliation: Department of Internal Medicine, Tulane School of Public Health and Tropical Medicine, New Orleans, Louisiana.
authors.forename: Badal
authors.initials: B
authors.lastname: Thakkar
authors.affiliation: Department of Cardiovascular Medicine, University of Miami Miller School of Medicine, Miami, Florida.
authors.forename: Vikas
authors.initials: V
authors.lastname: Singh
authors.affiliation: Department of Internal Medicine, Mount Sinai St. Luke's Roosevelt Hospital, New York, New York.
authors.forename: Shilpkumar
authors.initials: S
authors.lastname: Arora
authors.affiliation: Department of Internal Medicine, Saint Peter's University Hospital, New Brunswick, New Jersey.
authors.forename: Nilay
authors.initials: N
authors.lastname: Patel
authors.affiliation: Department of Internal Medicine, New York Medical College, Valhalla, New York.
authors.forename: Chirag
authors.initials: C
authors.lastname: Savani
authors.affiliation: Department of Cardiology, Mayo Clinic, Rochester, Minnesota.
authors.forename: Abhishek
authors.initials: A
authors.lastname: Deshmukh
authors.affiliation: Cardiovascular Section/Internal Medicine, VA Medical Center, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma.
authors.forename: Udho
authors.initials: U
authors.lastname: Thadani
authors.affiliation: Department of Cardiology, Heart and Vascular Center, Everett Clinic, Everett, Washington.
authors.forename: Apurva O
authors.initials: AO
authors.lastname: Badheka
authors.affiliation: Department of Cardiovascular Medicine, University of Miami Miller School of Medicine, Miami, Florida.
authors.forename: Carlos
authors.initials: C
authors.lastname: Alfonso
authors.affiliation: Department of Cardiology, Ahmanson-UCLA Cardiomyopathy Center, University of California, Los Angeles, California.
authors.forename: Gregg C
authors.initials: GC
authors.lastname: Fonarow
authors.affiliation: Department of Cardiovascular Medicine, University of Miami Miller School of Medicine, Miami, Florida.
authors.forename: Mauricio G
authors.initials: MG
authors.lastname: Cohen
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001803:Blood Transfusion; D016009:Chi-Square Distribution; D017023:Coronary Angiography; D003362:Cost-Benefit Analysis; D016208:Databases, Factual; D016527:Drug Costs; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage* / Q000009:adverse effects / Q000191:economics; D006471:Gastrointestinal Hemorrhage / Q000139:chemically induced / Q000628:therapy; D054625:Healthcare Disparities; D006323:Heart Arrest / Q000628:therapy; D017721:Hospital Costs; D017052:Hospital Mortality; D006801:Humans; D020300:Intracranial Hemorrhages / Q000139:chemically induced / Q000628:therapy; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009203:Myocardial Infarction / Q000175:diagnosis / Q000188:drug therapy / Q000191:economics / Q000401:mortality / Q000628:therapy*; D009204:Myocardial Revascularization; D010360:Patient Transfer; D012307:Risk Factors; D012770:Shock, Cardiogenic / Q000628:therapy; D015912:Thrombolytic Therapy / Q000009:adverse effects / Q000191:economics / Q000401:mortality; D013997:Time Factors; D061665:Time-to-Treatment; D016896:Treatment Outcome; D014481:United States; D055815:Young Adult
chemical_list: D005343:Fibrinolytic Agents