LETTER TO THE EDITOR
Reply
Elliott M. Antman, MD*
* TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, 75 Francis Street, Boston, Massachusetts 02115 (Email: eantman{at}rics.bwh.harvard.edu).
I thank Dr. Terkelsen and colleagues for their interest in my editorial comment (1). In response to the points raised by Terkelsen et al. (2) it is worth noting:- 1 Clearly the Writing Committee (3) was addressing a systems goal when recommending that if the emergency medical service (EMS) is not capable of administering pre-hospital fibrinolysis and the patient is transported to a nonpercutaneous coronary intervention (PCI)–capable hospital, the door-to-needle time should be within 30 min. It is not logical to "start the clock" for administration of a fibrinolytic in an EMS setting that is not capable of delivering such a treatment. In contrast, 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, emphasizing the system goal of communication to the PCI-capable hospital to shorten the delays for arrival of the critical personnel to perform the procedure.
- 2 The field and transport times in the U.S., in general, are much longer than those cited by Terkelsen et al. (2), as evidenced by the findings from ER–TIMI 19 (Early Retavase–Thrombolysis In Myocardial Infarction 19) trial (4). The Writing Committee (3) stressed the need for systems efforts to reduce time to reperfusion with the full appreciation, in contrast to the opinion of Terkelsen et al. (2), that pre-hospital delays are harmful to both patients treated with fibrinolysis as well as those treated by PCI.
- 3 The explanation regarding the unusual pattern of mortality in the fibrinolytic-treated patients in the PCAT-2 (Primary Coronary Angioplasty vs. Thrombolysis-2) meta-analysis (5) actually underscores the concern about using it to buttress the statement that primary PCI, as compared with fibrinolysis, is associated with a significant mortality reduction irrespective of PCI-related delays. The mixing of trial designs and failure to account for patient characteristics remain substantial shortcomings of the PCAT-2 analysis.
- 4 The statements about the National Registry of Myocardial Infarction are not correct. The National Registry of Myocardial Infarction is the largest voluntary myocardial infarction database in the world and provides data from 2,157 unique hospitals, more than one-third of all U.S. acute care hospitals. In contrast to the numbers cited by Terkelsen et al. (2), between 1990 and 2006, there was a switch in the distribution of reperfusion methods used so that by 2006, 43.2% of patients received primary PCI and 27.6% received fibrinolysis (6). The real-world experience from the National Registry of Myocardial Infarction and the analysis from Pinto et al. (7) remain important contributions to our global understanding of the complex decision making in reperfusion for ST-segment elevation myocardial infarction. Age, location of infarction, and time from onset of occlusion are key determinants of prognosis and it is logical that they should be factored into decision making about treatment for ST-segment elevation myocardial infarction.
Terkelsen et al. (2) perseverate on technical details of selection of a reperfusion strategy rather than address the need for re-engineering of systems of care. Without attention to such systems efforts it is unlikely we will see further clinically meaningful shortening of the time from occlusion of a patient's coronary artery to restoration of antegrade blood flow in that vessel.
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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. 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. Gibson CM, Pride YB, Frederick PD, et al. Trends in reperfusion strategies, door-to-needle and door-to-balloon times, and in-hospital mortality among patients with ST-segment elevation myocardial infarction enrolled in the National Registry of Myocardial Infarction from 1990 to 2006 Am Heart J 2008;156:1035-1044.[CrossRef][Web of Science][Medline] 7. 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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