Letter by Melandri Regarding Article, “A Regional System to Provide Timely Access to Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction”
To the Editor:
Henry and colleagues1 should be congratulated on their effort to implement a regional system to provide timely access to percutaneous coronary intervention for treatment of ST-elevation acute myocardial infarction (STEMI). Because of the lack of robust data showing a reduction in the death rate from primary percutaneous coronary intervention compared with accelerated rt-PA2 or prehospital thrombolysis, it is imperative that these efforts be successful.
However, I am surprised to see that in such a large catchment area, only 1345 consecutive patients were enrolled from March 2003 to November 2006. The Twin Cities metropolitan area has nearly 3 000 000 residents. Because it is estimated that about 700 STEMI patients are admitted each year for every million people,3 my perception is that only a small fraction of STEMI patients have been enrolled in the database. How can that be explained? Is there any cross-reference with all hospital administrative data of the catchment area as a whole? If the enrolled patients are only a fraction of those occurring in the catchment area, what is known about the clinical profile, the clinical pathway, and clinical outcomes of those patients who were not enrolled?
Also, the described population appears to be low-risk: The mean age is 62 years, considerably lower than the mean age of 67 years in the RIKS-HIA (Register of Information and Knowledge About Swedish Heart Intensive Care Admissions) registry.4 In my hospital, the mean age of STEMI patients in 2004 was 70 years (median 72). Diabetic patients account for 15%, and the average Thrombolysis In Myocardial Infarction (TIMI) risk score is below 4.5 I suggest that before jumping to the conclusion that the system works well, more data are needed about the population as a whole.
Henry TD, Sharkey SW, Burke MN, Chavez IJ, Graham KJ, Henry CR, Lips DL, Madison JD, Menssen KM, Mooney MR, Newell MC, Pedersen WR, Poulose AK, Traverse JH, Unger BT, Wang YL, Larson DM. A regional system to provide timely access to percutaneous coronary intervention for ST-elevation myocardial infarction. Circulation. 2007; 116: 721–728.
Olivari Z, Di Pede F, Schievano E, Brocco S, Ramondo A, La Vecchia L, Giujusa T, Zuin G, Neri R, Pasquetto G, Iavernaro A, Rossi L, Corbara F. Hospital epidemiology of ST-segment elevation myocardial infarction and feasibility of primary percutaneous coronary intervention in an interhospital network: data from a multicenter, prospective and observational study VENERE (VENEto acute myocardial infarction Registry) [in Italian]. Ital Heart J. 2005; 6 (suppl 6): 57S–64S.
Thune JJ, Hoefsten DE, Lindholm MG, Mortensen LS, Andersen HR, Nielsen TT, Kober L, Kelbaek H, for the Danish Multicenter Randomized Study on Fibrinolytic Therapy Versus Acute Coronary Angioplasty in Acute Myocardial Infarction (DANAMI)-2 Investigators. Simple risk stratification at admission to identify patients with reduced mortality from primary angioplasty. Circulation. 2005; 112: 2017–2021.