CORRESPONDENCE: LETTER TO THE EDITOR
Reply
William E. Boden, MD, FACC*
* Buffalo General and Millard Fillmore Hospitals, Division of Cardiology, 100 High Street, Buffalo, New York 14203 (Email: wboden{at}kaleidahealth.org).
We appreciate the perspectives offered by Drs. Terkelsen and Nielsen regarding the optimal approach to achieving timely reperfusion for acute ST-segment elevation myocardial infarction (STEMI). In our review (1), we strongly favored the view that primary percutaneous coronary intervention (PCI) represents the best modality of reperfusion in STEMI patients and, in a perfect world with no resource limitations or cost restraints, would be the treatment of choice for all STEMI patients. However, we attempted to address the "real-world" challenges that exist within the U.S., where 1) fully one-third of all STEMI patients currently receive no reperfusion (fibrinolytic or mechanical) acutely; 2) the majority of STEMI patients (60% to 70%) present initially to non-PCI-capable hospitals, which creates inevitable transport delays to PCI-capable facilities that are frequently beyond the control of emergency medicine physicians and cardiologists; 3) the group of "transfer-in" STEMI patients to PCI-capable hospitals rarely achieve door-to-balloon (DTB) times of <90 min (only 8%, according to the Chakrabarti et al. [2] recent analysis of the National Registry of Myocardial Infarction); and 4) among STEMI patients who present within 3 h of initial STEMI symptom-onset, there is no clear advantage of a mechanical reperfusion strategy over a pharmacologic reperfusion strategy, which form the basis for the current American College of Cardiology/American Heart Association clinical practice guideline recommendations that, in such patients, either reperfusion approach is considered a Class IA recommendation (3).
Our goal in this review (1) was to address primarily the management issues confronting acute STEMI management in patients presenting to community hospitals without on-site PCI capability. In such settings, both emergency medicine physicians and cardiologists must quickly decide whether urgent transport to a PCI-capable hospital can likely achieve prompt reperfusion with a DTB <90 min or, alternatively, whether the use of a bolus fibrinolytic agent (in a patient without evident contraindications) would be a more appropriate reperfusion strategy. If, in fact, 92% of all such STEMI patients who require urgent transfer for primary PCI do not achieve DTB times <90 min, it seems reasonable to consider a pharmacologic reperfusion approach, because there is an almost a 40% relative increase in 30-day mortality among patients in whom reperfusion is delayed beyond 120 min.
Although both regional and national initiatives are presently underway within the U.S. to streamline and expedite STEMI management by using enhanced, field-based electrocardiogram diagnosis to bypass community hospitals without on-site PCI capability and instead direct such patients de novo to PCI-capable hospitals, these efforts are not yet widely developed in many communities and inherently conflict with existing Emergency Medical Service infrastructure nationwide, which continues to espouse the transport of myocardial infarction patients to the closest hospital. Accordingly, unlike most of European countries, where there is more highly coordinated and expedited STEMI transport to PCI-capable facilities, the logistical limitations that continue to exist within the U.S. regarding triage and transport of STEMI patients represent formidable barriers to expanding and achieving a more broad-based system of primary PCI for all STEMI patients.
Therefore, we believe our review highlights the need for both mechanical and pharmacologic reperfusion, as dictated by local resource availability, as the best overall approach to expediting timely reperfusion in patients who present with STEMI to either rural or urban hospitals where differential systems and processes of care may influence clinical decision-making.
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1. Boden WE, Eagle K, Granger CB. Reperfusion strategies in acute ST-segment elevation myocardial infarction: a comprehensive review of contemporary management options J Am Coll Cardiol 2007;50:917-929.[Abstract/Free Full Text]2. National Cardiovascular Data RegistryChakrabarti A, Krumholz HM, Wang Y, Rumsfeld JS, Nallamothu BK. Time-to-reperfusion in patients undergoing interhospital transfer for primary percutaneous coronary intervention in the U.S.: an analysis of 2005 and 2006 data from the National Cardiovascular Data Registry J Am Coll Cardiol 2008;51:2442-2445.[Free Full Text] 3. Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction—executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction) J Am Coll Cardiol 2004;44:671-719.[Free Full Text]
Related Article
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Reperfusion Strategies in Acute ST-Segment Elevation Myocardial Infarction: Acute Angioplasty May Be Feasible for the Majority of U.S. Citizens
- Christian Juhl Terkelsen and Torsten Toftegaard Nielsen
J. Am. Coll. Cardiol. 2008 52: 966-967.
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