CORRESPONDENCE: LETTER TO THE EDITOR
Interaction Among Risk-Time and Benefit of Primary Angioplasty
Giuseppe Tarantini, MD, PhD*,
Renato Razzolini, MD and
Sabino Iliceto, MD, FACC
* Division of Cardiology, Department of Cardiac, Thoracic, and Vascular Sciences, Policlinico Universitario, Via Giustiniani, 2, 35128 Padova, Italy (Email: giuseppe.tarantini.l{at}unipd.it).
We read with interest the study by Brodie et al. (1) showing that delays in door-to-balloon time have an impact on survival in high-risk patients with ST-segment elevation myocardial infarction (STEMI) treated by primary percutaneous coronary intervention (pPCI). We have the following concerns in relation to the reported results and conclusions in this single-center study.
In the current study, symptom-onset-to-balloon time was not included in the multivariate analyses. Considering that door-to-balloon time is significantly related to outcome only in patients with symptom onset less than 3 h when a striking benefit of reperfusion is present (1), it is very likely that the exclusion of total ischemic time from the multivariate analyses would have influenced the results. To this regard, in the single-center study conducted by De Luca et al. (2), door-to-balloon time was not related to outcome independently by the risk of the patients, but symptom-onset-to-balloon time and patent infarct-related artery remained independent predictors of 1-year survival in high-risk patients with STEMI. Indeed, Brodie et al. (1) did not take into account in their analyses the patency of the infarct-related artery at index angiography that was present in one-fifth of patients.
Finally, the results may be further biased by the fact that longer door-to-balloon times were observed in sicker patients treated by pPCI with a limited use of stents and abciximab (less than 30%) that are not representative of the actual worldwide standard.
Finally, although losing time appears to be prognostically less important in low-risk patients than in high-risk patients with STEMI treated by pPCI, when immediate thrombolysis is feasible, delaying PCI may be particularly disadvantageous in low-risk patients (3). On the contrary, a longer delay could be justified to choose pPCI for high-risk patients, despite the increased risk associated with delay according to the previously reported "risk-time-benefit" relationship (3).
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1. Brodie BR, Hansen C, Stuckey TD, et al. Door-to-balloon time with primary percutaneous coronary intervention for acute myocardial infarction impacts late cardiac mortality in high-risk patients and patients presenting early after the onset of symptoms J Am Coll Cardiol 2006;47:289-295.[Abstract/Free Full Text]2. De Luca G, Suryapranata H, Zijlstra F, et al. Symptom-onset-to-balloon time and mortality in patients with acute myocardial infarction treated by primary angioplasty J Am Coll Cardiol 2003;42:991-997.[Abstract/Free Full Text] 3. Tarantini G, Razzolini R, Ramondo A, Napodano M, Bilato C, Iliceto S. Explanation for the survival benefit of primary angioplasty over thrombolytic therapy in patients with ST-elevation acute myocardial infarction Am J Cardiol 2005;96:1503-1505.[CrossRef][Web of Science][Medline]
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Interaction Among Risk-Time and Benefit of Primary Angioplasty
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