Circulation. 2003;108:2851-2856
Published online before print November 17, 2003, doi: 10.1161/01.CIR.0000103122.10021.F2
Published online before print November 17, 2003, doi: 10.1161/01.CIR.0000103122.10021.F2
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(Circulation. 2003;108:2851.)
© 2003 American Heart Association, Inc.
Clinical Investigation and Reports |
Impact of Time to Treatment on Mortality After Prehospital Fibrinolysis or Primary Angioplasty
Data From the CAPTIM Randomized Clinical Trial
From the Service de Cardiologie (P.G.S.), Hôpital Bichat, Paris, and Service de Cardiologie (E.B., P.T.), Hôpital Cardio-Vasculaire et Pneumologique Louis Pradel, Lyon; Service de Pharmacologie Clinique (S.C., A.L.), Faculte RTH Laennec, Lyon; SAMU 93 (F.L.), Bobigny; SAMU 69 (P.-Y.D.), Lyon; and SAMU 75 (P.C.), Paris, France.
Reprint requests to Philippe Gabriel Steg, Hôpital Bichat, 46 rue Henri Huchard, 75877 Paris Cedex 18, France. E-mail gabriel.steg{at}bch.ap-hop-paris.fr
Received August 1, 2003; revision received September 16, 2003; accepted September 22, 2003.
Background— CAPTIM was a randomized trial comparing prehospital thrombolysis with transfer to an interventional facility (and, if needed, percutaneous intervention) with primary percutaneous coronary intervention (PCI) in patients with ST-segment-elevation myocardial infarction (STEMI). Because the benefit of thrombolysis is maximal during the first 2 hours after symptom onset, and because prehospital thrombolysis can be implemented earlier than PCI, this analysis studied the relationship between the effect of assigned treatment and the time elapsed from symptom onset.
Methods and Results— Randomization within 2 hours (n=460) or 
2 hours (n=374) after symptom onset had no impact on the effect of treatment on the 30-day combined primary end point of death, nonfatal reinfarction, and disabling stroke. However, patients randomized <2 hours after symptom onset had a strong trend toward lower 30-day mortality with prehospital thrombolysis compared with those randomized to primary PCI (2.2% versus 5.7%, P=0.058), whereas mortality was similar in patients randomized 2 hours (5.9% versus 3.7%, P=0.47). There was a significant interaction between treatment effect and delay with respect to 30-day mortality (hazard ratio 4.19, 95% CI 1.033 to 17.004, P=0.045). Among patients randomized in the first 2 hours, cardiogenic shock was less frequent with lytic therapy than with primary PCI (1.3% versus 5.3%, P=0.032), whereas rates were similar in patients randomized later.
Conclusions— Time from symptom onset should be considered when one selects reperfusion therapy in STEMI. Prehospital thrombolysis may be preferable to primary PCI for patients treated within the first 2 hours after symptom onset.
Key Words: angioplasty • myocardial infarction • reperfusion • thrombolysis
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H. C. Herrmann Transfer for Primary Angioplasty: The Importance of Time Circulation, February 15, 2005; 111(6): 718 - 720. [Full Text] [PDF]
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P. P de Jaegere, P. W Serruys, and M. L Simoons Should all patients with an acute myocardial infarction be referred for direct PTCA? Heart, November 1, 2004; 90(11): 1352 - 1357. [Full Text] [PDF]
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S D Kristensen, H R Andersen, L Thuesen, L R Krusell, H E Botker, J F Lassen, and T T Nielsen Should patients with acute ST elevation MI be transferred for primary PCI? Heart, November 1, 2004; 90(11): 1358 - 1363. [Full Text] [PDF]
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N. Danchin, D. Blanchard, P. G. Steg, P. Sauval, G. Hanania, P. Goldstein, J.-P. Cambou, P. Gueret, L. Vaur, Y. Boutalbi, et al. Impact of Prehospital Thrombolysis for Acute Myocardial Infarction on 1-Year Outcome: Results From the French Nationwide USIC 2000 Registry Circulation, October 5, 2004; 110(14): 1909 - 1915. [Abstract] [Full Text] [PDF]
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J S Birkhead, L Walker, M Pearson, C Weston, A D Cunningham, and A F Rickards Improving care for patients with acute coronary syndromes: initial results from the National Audit of Myocardial Infarction Project (MINAP) Heart, September 1, 2004; 90(9): 1004 - 1009. [Abstract] [Full Text] [PDF]
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E. C. Keeley and C. L. Grines Primary Percutaneous Coronary Intervention for Every Patient with ST-Segment Elevation Myocardial Infarction: What Stands in the Way? Ann Intern Med, August 17, 2004; 141(4): 298 - 304. [Abstract] [Full Text] [PDF]
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Writing Committee Members, E. M. Antman, D. T. Anbe, P. W. Armstrong, E. R. Bates, L. A. Green, M. Hand, J. S. Hochman, H. M. Krumholz, F. G. Kushner, 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., August 4, 2004; 44(3): 671 - 719. [Full Text] [PDF]
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E. M. Antman, D. T. Anbe, P. W. Armstrong, E. R. Bates, L. A. Green, M. Hand, J. S. Hochman, H. M. Krumholz, F. G. Kushner, G. A. Lamas, 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) Circulation, August 3, 2004; 110(5): 588 - 636. [Full Text] [PDF]
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G. Montalescot, M. Borentain, L. Payot, J. P. Collet, and D. Thomas Early vs Late Administration of Glycoprotein IIb/IIIa Inhibitors in Primary Percutaneous Coronary Intervention of Acute ST-Segment Elevation Myocardial Infarction: A Meta-analysis JAMA, July 21, 2004; 292(3): 362 - 366. [Abstract] [Full Text] [PDF]
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R. E. Waters II, K. P. Singh, M. T. Roe, M. Lotfi, M. H. Sketch Jr, K. W. Mahaffey, L. K. Newby, J. H. Alexander, R. A. Harrington, R. M. Califf, et al. Rationale and strategies for implementing community-based transfer protocols for primary percutaneous coronary intervention for acute ST-segment elevation myocardial infarction J. Am. Coll. Cardiol., June 16, 2004; 43(12): 2153 - 2159. [Abstract] [Full Text] [PDF]
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E. M. Antman and F. Van de Werf Pharmacoinvasive Therapy: The Future of Treatment for ST-Elevation Myocardial Infarction Circulation, June 1, 2004; 109(21): 2480 - 2486. [Full Text] [PDF]
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R. Manfredini, B. Boari, P. G. Steg, E. Bonnefoy, P. Touboul, S. Chabaud, A. Leizorovicz, F. Lapostolle, P.-Y. Dubien, and P. Cristofini Impact of Time to Treatment on Mortality After Prehospital Fibrinolysis or Primary Angioplasty * Response Circulation, May 11, 2004; 109(18): e219 - e219. [Full Text] [PDF]
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D. O. Williams Treatment Delayed Is Treatment Denied Circulation, April 20, 2004; 109(15): 1806 - 1808. [Full Text] [PDF]
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 Time to Treatment Affects the Relative Benefits of Reperfusion Strategies Journal Watch Cardiology, February 20, 2004; 2004(220): 2 - 2. [Full Text]
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 Best Therapy for STEMI May Depend on Duration of Symptoms Journal Watch Emergency Medicine, February 3, 2004; 2004(203): 2 - 2. [Full Text]
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 Prehospital Thrombolysis vs. Primary Angioplasty for Acute MI: Time to Treatment Matters Journal Watch (General), January 20, 2004; 2004(120): 6 - 6. [Full Text]
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R. P. Giugliano and E. Braunwald Selecting the Best Reperfusion Strategy in ST-Elevation Myocardial Infarction: It's All a Matter of Time Circulation, December 9, 2003; 108(23): 2828 - 2830. [Full Text] [PDF]
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