CORRESPONDENCE: LETTER TO THE EDITOR
Reply
Christian Juhl Terkelsen, MD, PhD*,
Jacob Thorsted Sørensen, MD and
Torsten Toftegaard Nielsen, MD, DmSc
* Department of Cardiology B, Aarhus University Hospital, DK-8200 Aarhus N, Denmark (Email: christian_juhl_terkelsen{at}hotmail.com).
We thank Drs. Vasaiwala and Vidovich for their interest in our recent viewpoint (1). Their observations from http://www.hospitalcompare.hhs.gov/ document that many patients are still given in-hospital fibrinolysis at unacceptable long door-to-needle (D2N) times. We agree that the wording in the 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of patients with ST-Segment Elevation Myocardial Infarction (STEMI) (2) may be prohibitive for a primary percutaneous coronary intervention (PCI) strategy and in some scenarios favors a fibrinolytic strategy. We still hope that the writing committee responsible for the updated STEMI guidelines for future revisions accepts that: 1) primary PCI is superior to fibrinolysis up to a PCI-related delay of 120 min; 2) the clock should start ticking at the same time when balancing primary PCI against fibrinolysis as the choice of reperfusion strategy; 3) pre-hospital diagnosis is important irrespective of reperfusion strategy to ensure either pre-hospital fibrinolysis or pre-hospital rerouting to high-volume PCI centers; and 4) in-hospital fibrinolysis should only be considered in self-presenters at rural hospitals without easy access to a PCI center. We would also recommend that the committee responsible for the ACC/AHA Performance Measures for Adults With STEMI/NSTEMI consider system delay as a future performance measure and recommend fibrinolysis only if the expected system delay when performing primary PCI is more than 120 min longer than expected system delay when giving fibrinolysis (3).
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1. Terkelsen CJ, Sørensen JT, Nielsen TT. Is there any time left for primary percutaneous coronary intervention according to the 2007 updated American College of Cardiology/American Heart Association ST-segment elevation myocardial infarction guidelines and the D2B alliance? J Am Coll Cardiol 2008;52:1211-1215.[Abstract/Free Full Text]2. Antman EM, Hand M, Armstrong PW, et al. 2007 focused update of the ACC/AHA 2004 guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines J Am Coll Cardiol 2008;51:210-247.[Free Full Text] 3. Masoudi FA, Bonow RO, Brindis RG, et al. ACC/AHA 2008 statement on performance measurement and reperfusion therapy: a report of the ACC/AHA Task Force on Performance Measures (Work Group to Address the Challenges of Performance Measurement and Reperfusion Therapy) J Am Coll Cardiol 2008;52:2100-2112.[Free Full Text]
Related Article
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Door-to-Balloon and Door-to-Needle Time for ST-Segment Elevation Myocardial Infarction in the U.S.
- Samip Vasaiwala and Mladen I. Vidovich
J. Am. Coll. Cardiol. 2009 53: 902.
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