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CORRESPONDENCE: LETTER TO THE EDITOR

Reperfusion Strategies in Acute ST-Segment Elevation Myocardial Infarction

Acute Angioplasty May Be Feasible for the Majority of U.S. Citizens

^_* Department of Cardiology B, Skejby University Hospital, Brendstrupgaardsvej 100, Aarhus N, Denmark DK-8200, Denmark (Email: christian_juhl_terkelsen{at}hotmail.com).

The idea of a 60-min maximal acceptable PCI-related delay is based on a previous meta-analysis by Nallamothu et al. (2), which included 23 randomized trials comparing fibrinolysis versus primary PCI. For each trial, they plotted the mortality benefit achieved by PPCI compared with fibrinolysis according to the observed PCI-related delay. Then, they performed a regression line and found that the intercept with the x-axis was approximately 60 min and concluded that fibrinolysis would be superior to PPCI if the extra delay used to perform PPCI exceeded 60 min.

However, Nallamothu et al. (2) plotted the PCI-related delay for the PRAGUE-1 (PRimary Angioplasty in patients transferred from General community hospitals to specialized PTCA Units with or without Emergency thrombolysis) study to be 10 min and for the PRAGUE-2 study to be 32 min (2). According to the original publications, the PCI-related delay was 70 and 85 min in the 2 trials, respectively (3,4) In addition, they plotted the PCI-related delay to be 7 min for a study by Ribicini et al. (5), 15 min for a study by García et al. (6), 25 min for a study by Gibbons et al. (7), and 15 min for a study by Vermeer et al. (8). According to the original articles, the correct PCI-related delays were 16, 47, 45, and 90 min, respectively (5–8).

Finally, the PCI-related delay for the DANAMI-2 trial was plotted as 55 min. The PCI-related delay, however, varies considerably between nontransfer and transfer patients, and DANAMI-2 data should be split accordingly (e.g., into a nontransfer and transfer group) (9). If one repeats the regression analysis, including the original tabulated data and splitting the DANAMI-2 data into a transfer and a nontransfer group, then the x-axis intercept becomes 120 min. A more proper meta-analysis, however, has already been performed by Boersma et al. (10), who included data at center-level. Accordingly, 153 values instead of 23 values for the association between PCI-related delay and mortality were implemented in the Boersma et al. (10) meta-analysis, and they found that, even at a PCI-related delay of 80 to 120 min, there was a benefit of PPCI in preference to fibrinolysis.

Regarding the optimal reperfusion therapy in the early incomers, Boden et al. (1) refer to a previous subanalysis of the CAPTIM (Comparison of Angioplasty and Prehospital Thrombolysis in Acute Myocardial Infarction) trial that demonstrated a greater mortality in PCI-treated patients compared with fibrinolytic-treated patients who received reperfusion therapy within 3 h of symptom duration (11). The CAPTIM data, however, should be interpreted cautiously because: 1) the trial was stopped before scheduled because of a lack of funding, thus hampering the power of the study; 2) there was no significant difference between the primary end point in the main study and thus no reason to perform subgroup analysis; and 3) the authors might as well have compared mortality in PCI patients treated early versus late and then found that mortality was greatest in the group treated early.

Again, Boersma et al. (10) have provided us with the best-available evidence, performing the only meta-analysis so far based on individual data from patients included in 22 studies comparing PPCI with fibrinolysis. The Boersma et al. (10) meta-analysis documents that fibrinolysis is not superior to PPCI in the early presenters and that lower mortality was observed in PPCI-treated patients compared with fibrinolysis-treated patients.

Regarding the "limited benefit of PPCI due to transport delays" and recommendation of pre-hospital fibrinolysis, a feasible logistic may be to implement pre-hospital diagnostic strategies combined with rerouting of patients directly to catheterization laboratories. This strategy reduces the delay in initiation of PPCI by up to 90 min (12) and would considerably increase the catchment areas to interventional hospitals. Given that 80% of American citizens live within 60 min of transport to a PPCI hospital and that the estimated median transportation time to the invasive hospital is 11 min, this strategy would enable PPCI to be the preferred reperfusion therapy in the majority of STEMI patients (13).

In conclusion, the maximal acceptable PCI-related may be at least 80 to 120 min, there is no evidence to support fibrinolysis in the early incomers, and a pre-hospital diagnostic strategy combined with rerouting of STEMI patients directly to catheterization laboratories would ensure that the majority of American citizens could be treated with PPCI in the case of STEMI.

	References

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