Abstract 2073: Reduction in Time to Reperfusion and Improved Myocardial Perfusion with Pre-Hospital Facilitated Coronary Intervention Compared to Primary PCI in STEMI Patients Treated in an Urban Setting
Background: Primary coronary intervention (PCI) for ST elevation myocardial infarction (STEMI) has been limited by lack of PCI center availability and prolonged time to reperfusion from onset of pain. In-field diagnosis (12-lead ECG) with pre-hospital activation of the interventional team can reduce the time to reperfusion and avoid delays associated with primary PCI. As part of the PATCAR pilot trial, we evaluated the benefit of pre-hospital administration of ½ dose thrombolytic followed by transport to a Level I PCI center for urgent infarct related artery coronary intervention compared to primary coronary intervention on reperfusion times and angiographic indices of myocardial perfusion.
Methods: Patients were evaluated for STEMI with 12 lead ECGs by EMS personnel with remote over read of the ECG by Emergency Center (EC) physicians. Patients meeting inclusion criteria were given in-field thrombolytic therapy (10 units reteplase) and transported directly to the Level I CV Center for urgent revascularization (Group 1). Patients without pre-hospital thrombolysis and those presenting directly to the EC were treated with primary PCI (Group 2). Analysis of time to therapy and angiographic parameters were compared between both strategies.
Results: 146 patients were enrolled in the PATCAR pilot trial. Group 1 demonstrated a reduction in time to treatment (39min vs. 57min; p= 0.0009) and an improved door to balloon time (66min vs. 104min; p< 0.0001) compared to Group 2. Initial TIMI II/III flow of the infarct related artery was more frequent in Group 1 compared to group 2 (81% vs. 47%; p= 0.0005) and percentage of patients with full reperfusion (angiographic perfusion score > 10) was improved in Group 1 compared to Group 2. (72% vs. 36%; p= 0.0018). There were no differences in adverse events between the groups and no episodes of intracranial hemorrhage.
Conclusion: Pre-hospital facilitated PCI can significantly reduce time to reperfusion with improved angiographic indices of myocardial perfusion in an urban setting compared to primary PCI. This strategy was safe with a bleeding complication rate no different than primary PCI. The pivotal trial of PATCAR will analyze a mortality and infarct size benefit utilizing this coordinated treatment approach.