Published online before print October 30, 2006, doi: 10.1161/CIRCULATIONAHA.106.638353
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(Circulation. 2006;114:2019-2025.)
© 2006 American Heart Association, Inc.
Coronary Heart Disease |
Hospital Delays in Reperfusion for ST-Elevation Myocardial Infarction
Implications When Selecting a Reperfusion Strategy
From the TIMI Study Group and the Cardiovascular Divisions, Departments of Medicine, Beth Israel Deaconess Medical Center (D.S.P., A.J.K., D.J.C., R.J.L., D.E.C., J.P.C., C.M.G.) and Brigham & Women’s Hospital (S.A.M., E.M.A., C.P.C.), Harvard Medical School, Boston, Mass; Cardiovascular Division (B.K.N., E.R.B.), University of Michigan, Ann Arbor, Mich; and Ovation Research Group (P.D.F., D.P.M.), San Francisco, Calif.
Reprint requests to C. Michael Gibson, MS, MD, Division of Cardiology, Interventional Section, Beth Israel Deaconess Medical Center, 185 Pilgrim Rd, Boston, MA 02115. E-mail mgibson{at}perfuse.org
Received May 5, 2006; revision received July 21, 2006; accepted August 8, 2006.
Background— It has been suggested that the survival benefit associated with primary percutaneous coronary intervention (PPCI) in ST-segment elevation myocardial infarction may be attenuated if door-to-balloon (DB) time is delayed by >1 hour beyond door-to-needle (DN) times for fibrinolytic therapy. Whereas DB times are rapid in randomized trials, they are often prolonged in routine practice. We hypothesized that in clinical practice, longer DB-DN times would be associated with higher mortality rates and reduced PPCI survival advantage. We also hypothesized that in addition to PPCI delays, patient risk factors would significantly modulate the relative survival advantage of PPCI over fibrinolysis.
Methods and Results— DB-DN times were calculated by subtracting median DN time from median DB time at a hospital using data from 192 509 patients at 645 National Registry of Myocardial Infarction hospitals. Hierarchical models that adjusted simultaneously for both patient-level risk factors and hospital-level covariates were used to evaluate the relationship between PCI-related delay, patient risk factors, and in-hospital mortality. Longer DB-DN times were associated with increased mortality (P<0.0001). The DB-DN time at which mortality rates with PPCI were no better than that of fibrinolysis varied considerably depending on patient age, symptom duration, and infarct location.
Conclusions— As DB-DN times increase, the mortality advantage of PPCI over fibrinolysis declines, and this advantage varies considerably depending on patient characteristics. As indicated in the American College of Cardiology/American Heart Association guidelines, both the hospital-based PPCI-related delay (DB-DN time) and patient characteristics should be considered when a reperfusion strategy is selected.
CLINICAL PERSPECTIVE
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