Reperfusion Strategies in Acute ST-Segment Elevation Myocardial InfarctionA Comprehensive Review of Contemporary Management Options
William E. Boden, MD, FACC*,1,*,
Kim Eagle, MD, FACC ,2 and
Christopher B. Granger, MD, FACC ,3
* School of Medicine and Biomedical Sciences, State University of New York, and Kaleida Health System, Buffalo, New York
University of Michigan Cardiovascular Center, Ann Arbor, Michigan
Division of Cardiology, Duke University Medical Center, Durham, North Carolina.
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Figure 1 Absolute 35-Day Mortality Versus Fibrinolytic Treatment Delay*
*Solid circles = information from trials included in Fibrinolytic Therapy Trialists’ Collaborative Group analysis; open circles = information from additional trials; small squares = data beyond scale of x/y cross. The linear and nonlinear regression lines are fitted within these data, weighted by inverse of the variance of the absolute benefit in each datapoint. Solid squares = average effects in 6 time-to-treatment groups (areas of squares inversely proportional to variance of absolute benefit described). Reproduced with permission from Boersma et al. (28).
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Figure 4 Influence of Patient Arrival Period on Time to Treatment
Regular hours include weekdays, 7 AM to 5 PM. Off hours include weekdays, 5 PM to 7 AM, and all weekend times. (A) Guideline adherence for fibrinolytic therapy and percutaneous coronary intervention (PCI) by patient arrival period. The American College of Cardiology/American Heart Association guidelines recommend that door-to-drug times be  30 min and door-to-balloon time 90 min. (B) Door-to-drug and door-to-balloon subintervals by patient arrival. Door to data is time from hospital arrival to electrocardiogram (ECG) completion. Data to drug is time from ECG completion to administration of fibrinolytic therapy. Data to catheter lab is time from ECG completion to arrival at catheterization laboratory. Catheter lab to balloon is time from arrival at cardiac catheterization laboratory to balloon inflation. Reprinted with permission from Magid et al. (42).
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Figure 5 Absolute RR in 4- to 6-Week Mortality Rates With Primary PCI as a Function of PCI-Related Time Delay
Circle size reflects the sample size of the individual study. The solid line represents the weighted meta-regression. Values >0 favor PCI and values <0 favor fibrinolysis. PCI = percutaneous coronary intervention; RR = risk reduction. Reprinted with permission from Nallamothu et al. (57).
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Figure 6 Mortality Benefit With Prehospital Fibrinolysis Versus Inhospital Fibrinolysis
Diagonal line represents equal rates; above line favors inhospital fibrinolysis and below line favors prehospital fibrinolysis. Reprinted with permission from Morrison et al. (61).
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This calculation implies that the estimated delay to the implementation of the invasive strategy is >1 h versus initiation of fibrinolytic therapy immediately with a fibrin-specific agent. Reprinted with permission from Antman et al. (2). ICH = intracerebral hemorrhage; PCI = percutaneous coronary intervention; STEMI = ST-segment elevation myocardial infarction.