CORRESPONDENCE: LETTER TO THE EDITOR
Reply
Bruce R. Brodie, MD, FACC*,
Charles Hansen, MA,
Thomas D. Stuckey, MD, FACC,
Scott Richter, PhD,
Debra S. VerSteeg, RN,
Navin Gupta, MD, FACC,
William E. Downey, MD, FACC and
Mark Pulsipher, MD, FACC
* 1126 North Church Street, Suite 300, Greensboro, North Carolina 27401 (Email: lebauerc{at}lebauercvresearch.org).
Our study (1) analyzed the relationship between door-to-balloon time and mortality rather than symptom-balloon time because door-to-balloon time is the strongest predictor of mortality and because we have influence over door-to-balloon time. We did not include symptom-balloon time in the multivariable analysis because symptom-balloon time is correlated with door-to-balloon time. Either is a significant predictor of mortality when included in the model alone. When both are included, symptom-balloon time is no longer a significant predictor of mortality.
We evaluated the relationship between door-to-balloon time and mortality 1) in patients who had Thrombolysis In Myocardial Infarction (TIMI) 0 to 1 flow in the infarct artery on initial angiography and 2) in patients treated since 1996 when stents and glycoprotein (GP) IIb/IIIa inhibitors were standard care. The results in these two groups were similar to the group as a whole. Therefore, we do not believe that inclusion of patients with TIMI 2 to 3 flow on initial angiography and patients treated before the availability of stents and GPIIb/IIIa inhibitors affected our results.
We disagree with Tarantini and colleagues that "delaying (percutaneous coronary intervention) PCI may be particularly disadvantageous in low-risk patients." We agree that primary PCI probably offers no mortality advantage over fibrinolytic therapy in low-risk patients, but our data and the data of others clearly show that time delays to primary PCI have little impact on mortality in low-risk patients. In low-risk patients presenting to noninterventional hospitals, transfer to an interventional facility for PCI avoids the risk of bleeding and intracranial hemorrhage from fibrinolytic therapy and results in fewer strokes and less reinfarction.
We agree with Tarantini et al. that the absolute mortality benefit of PCI over fibrinolytic therapy is considerable in high-risk patients, and this advantage may justify longer delays to PCI. However, our data show that these delays do have a major impact on mortality, especially in patients who present early. The hope has been that, in patients who present to noninterventional hospitals, with long delays to primary PCI, early pharmacologic reperfusion therapy followed by transfer for PCI (facilitated PCI) would establish earlier reperfusion and reduce mortality. Unfortunately, the recently published ASSENT-4 PCI (Assessment of the Safety and Efficacy of a New Treatment Strategy with Percutaneous Coronary Intervention) study showed worse, rather than better, outcomes with tenecteplase-facilitated PCI (2). There are several possible reasons for this, and it is possible that future trials with facilitated PCI using alternative pharmacologic therapies (such as FINESSE [Facilitated Intervention for Enhanced Reperfusion Speed to Stop Ischemic Events]) may prove beneficial, especially in high-risk patients presenting early after the onset of symptoms who have long delays to PCI. Until we have more data, the best strategy for high-risk patients who present early to noninterventional hospitals with very long delays to primary PCI may be local fibrinolytic therapy followed by transfer to an interventional facility for rescue PCI if needed. In high-risk patients who present later, the best strategy may be transfer for primary PCI without fibrinolytic therapy, even with longer delays to PCI.
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References
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- 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]
- ASSENT-4 PCI Investigators Primary versus tenecteplase-facilitated percutaneous coronary intervention in patients with ST-segment elevation acute myocardial infarction (ASSENT-4 PCI)randomized trial. Lancet 2006;367:569-578.[CrossRef][ISI][Medline]
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