CORRESPONDENCE: LETTERS TO THE EDITOR
Percutaneous Coronary Intervention Related Delay in ST-Segment Elevation Myocardial Infarction Patients
Christian Juhl Terkelsen, MD, PhD*,
Jacob Thorsted Sørensen, MD,
Torsten Toftegaard Nielsen, MD, DmSc and
Eric Boersma, MSc, PhD
* Department of Cardiology B, Skejby Hospital, Aarhus University Hospital, Cardiology, Brendstrupgaardsvej 100, Aarhus N, Denmark DK-8200, Denmark (Email: christian_juhl_terkelsen{at}hotmail.com).
We read with interest Antman's (1) editorial comment on the viewpoint taken by Terkelsen et al. (2).
Antman (1) highlights the following sentence from the 2007 updated ST-segment elevation myocardial infarction guidelines: "If EMS is not capable of administering pre-hospital fibrinolysis and the patient is transported to a non-PCI capable hospital, the door-to-needle time should be within 30 min for patients for whom fibrinolysis is indicated; If EMS is not capable of administering pre-hospital fibrinolysis, and the patient is transported to a PCI-capable hospital, the EMS arrival-to-balloon time should be within 90 min" (3). Antman (1) does not justify why the clock starts ticking at 2 different stages of the diagnostic process depending on whether in-hospital fibrinolysis or primary percutaneous coronary intervention (PCI) is performed.
Antman (1) states that "Terkelsen and colleagues argue without providing data that the typical pre-hospital delay includes 10 min at the scene and 10 min for transportation." In the ER–TIMI 19 (Early Retavase–Thrombolysis In Myocardial Infarction 19) trial by Morrow et al. (4), the pre-hospital delay was even longer, which only corroborates our point that the updated guidelines favor the use of fibrinolysis. In patients receiving in-hospital fibrinolysis, a substantial pre-hospital delay does not have any consequences, whereas any pre-hospital delay is devastating for implementing primary PCI as the preferred therapy.
The PCAT-2 (Primary Coronary Angioplasty vs. Thrombolysis-2) meta-analysis by Boersma et al. (5) is questioned and Antman (1) states that "a biologically implausible pattern was observed in those allocated to fibrinolysis." "Why should the efficiency with which a hospital can implement a primary PCI strategy have any bearing on the mortality rate when patients receive a fibrinolytic?" asks Antman (1), and obviously it has not. It is important to remember that the PCAT-2 meta-analysis (5) comprises data from 22 trials, and certainly PCI-related delay varies according to trial design (transfer or nontransfer for PCI) and from center to center. Also mortality in the fibrinolytic-treated patients varies according to the implemented selection criteria and trial design. This is the obvious explanation and the overall finding from the PCAT-2 meta-analysis (5) is still that primary PCI, as compared with fibrinolysis, is associated with a significant mortality reduction irrespective of PCI-related delays (up to 120 min).
Antman (1) uses data from a National Registry of Myocardial Infarction registry-study by Pinto et al. (6) to comment on the magnitude of the effects of prolonged PCI-related delays. Use of registries or observational data to evaluate PCI-related delay is questionable, and it should be appreciated that the National Registry of Myocardial Infarction includes <5% of ST-segment elevation myocardial infarction patients in the U.S. and at best compares a near optimal fibrinolytic strategy (92% given fibrin-specific lytics) with an inferior primary PCI strategy (PCI centers performing on average 21 primary PCI procedures a year with a median door-to-balloon time of 116 min and a first-door-to-balloon time of 180 min in patients transferred for PCI).
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1. Antman EM. Time is muscle: translation into practice J Am Coll Cardiol 2008;52:1216-1221.[Abstract/Free Full Text]2. Terkelsen CJ, Soerensen 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] 3. 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: developed in collaboration with the Canadian Cardiovascular Society; endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction, writing on behalf of the 2004 Writing Committee J Am Coll Cardiol 2008;51:210-247.[Free Full Text] 4. Morrow DA, Antman EM, Savah A, et al. ER-TIMI 19 Investigators Evaluation of the time saved by prehospital initiation of reteplase for ST-elevation myocardial infarction: results of the Early Retavase-Thrombolysis In Myocardial Infarction (ER-TIMI) 19 trial J Am Coll Cardiol 2002;40:71-77.[Abstract/Free Full Text] 5. Boersma E, The Primary Coronary Angioplasty vs. Thrombolysis Group Does time matter? A pooled analysis of randomized clinical trials comparing primary percutaneous coronary intervention and in-hospital fibrinolysis in acute myocardial infarction patients Eur Heart J 2006;27:779-788.[Abstract/Free Full Text] 6. Pinto SD, Kirtane AJ, Nallamothu BK, et al. Hospital delays in reperfusion for ST-elevation myocardial infarction: implications when selecting a reperfusion strategy Circulation 2006;114:2019-2025.[Abstract/Free Full Text]
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