title: Temporal Trends in Care and Outcomes of Patients Receiving Fibrinolytic Therapy Compared to Primary Percutaneous Coronary Intervention: Insights From the Get With The Guidelines Coronary Artery Disease (GWTG-CAD) Registry.
abstract: Timely reperfusion after ST-elevation myocardial infarction (STEMI) improves survival. Guidelines recommend primary percutaneous coronary intervention (PPCI) within 90 minutes of arrival at a PCI-capable hospital. The alternative is fibrinolysis within 30 minutes for those in those for whom timely transfer to a PCI-capable hospital is not feasible.
  
  
  
  We identified STEMI patients receiving reperfusion therapy at 229 hospitals participating in the Get With the Guidelines-Coronary Artery Disease (GWTG-CAD) database (January 1, 2003 through December 31, 2008). Temporal trends in the use of fibrinolysis and PPCI, its timeliness, and in-hospital mortality outcomes were assessed. We also assessed predictors of fibrinolysis versus PPCI and compliance with performance measures. Defect-free care was defined as 100% compliance with all performance measures. We identified 29 190 STEMI patients, of whom 2441 (8.4%) received fibrinolysis; 38.2% of these patients achieved door-to-needle times ≤30 minutes. Median door-to-needle times increased from 36 to 60 minutes (P=0.005) over the study period. Among PPCI patients, median door-to-balloon times decreased from 94 to 64 minutes (P<0.0001) over the same period. In-hospital mortality was higher with fibrinolysis than with PPCI (4.6% vs 3.3%, P=0.001) and did not change significantly over time. Patients receiving fibrinolysis were less likely to receive defect-free care compared with their PPCI counterparts.
  
  
  
  Use of fibrinolysis for STEMI has decreased over time with concomitant worsening of door-to-needle times. Over the same time period, use of PPCI increased with improvement in door-to-balloon times. In-hospital mortality was higher with fibrinolysis than with PPCI. As reperfusion for STEMI continues to shift from fibrinolysis to PPCI, it will be critical to ensure that door-to-needle times and outcomes do not worsen.
authors: Division of Cardiology, University of Washington, Seattle, WA hira@uw.edu.
authors: Ravi S
authors: RS
authors: Hira
authors: Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA.
authors: Deepak L
authors: DL
authors: Bhatt
authors: University of California Los Angeles, Los Angeles, CA.
authors: Gregg C
authors: GC
authors: Fonarow
authors: Veterans Administration Palo Alto Healthcare System, Palo Alto, CA Stanford University School of Medicine, Stanford, CA.
authors: Paul A
authors: PA
authors: Heidenreich
authors: Duke Clinical Research Institute, Duke University Medical Center, Durham, NC.
authors: Christine
authors: C
authors: Ju
authors: Michael E. DeBakey VA Medical Center, Houston, TX Division of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX Michael E. DeBakey Veterans Affairs Medical Center Health Services Research and Development Center for Innovations, Houston, TX.
authors: Salim S
authors: SS
authors: Virani
authors: Michael E. DeBakey VA Medical Center, Houston, TX Division of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX.
authors: Biykem
authors: B
authors: Bozkurt
authors: Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX Michael E. DeBakey Veterans Affairs Medical Center Health Services Research and Development Center for Innovations, Houston, TX.
authors: Laura A
authors: LA
authors: Petersen
authors: Duke Clinical Research Institute, Duke University Medical Center, Durham, NC.
authors: Adrian F
authors: AF
authors: Hernandez
authors: Department of Neurology, TeleStroke and Acute Stroke Services, Boston, MA Institute for Heart, Vascular, and Stroke Care, Massachusetts General Hospital, Boston, MA Department of Neurology, Harvard Medical School, Boston, MA.
authors: Lee H
authors: LH
authors: Schwamm
authors: Duke Clinical Research Institute, Duke University Medical Center, Durham, NC.
authors: Zubin J
authors: ZJ
authors: Eapen
authors: Division of Cardiology, University of California at San Francisco, San Francisco, CA.
authors: Michelle A
authors: MA
authors: Albert
authors: Duke Clinical Research Institute, Duke University Medical Center, Durham, NC.
authors: Li
authors: L
authors: Liang
authors: Duke Clinical Research Institute, Duke University Medical Center, Durham, NC.
authors: Roland A
authors: RA
authors: Matsouaka
authors: Duke Clinical Research Institute, Duke University Medical Center, Durham, NC.
authors: Eric D
authors: ED
authors: Peterson
authors: Michael E. DeBakey VA Medical Center, Houston, TX Division of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX.
authors: Hani
authors: H
authors: Jneid
mesh_terms: D000368:Aged; D015331:Cohort Studies; D016208:Databases, Factual; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D019983:Guideline Adherence; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care; D062645:Percutaneous Coronary Intervention / Q000639:trends*; D017410:Practice Guidelines as Topic; D012042:Registries; D000072657:ST Elevation Myocardial Infarction / Q000628:therapy*; D015912:Thrombolytic Therapy / Q000639:trends*; D061665:Time-to-Treatment / Q000639:trends*
chemical_list: D005343:Fibrinolytic Agents
keywords: fibrinolysis; myocardial infarction; outcome and process assessment; primary percutaneous coronary intervention