Choice of Reperfusion Strategy at Hospitals With Primary Percutaneous Coronary Intervention
A National Registry of Myocardial Infarction Analysis
Background— Many hospitals with percutaneous coronary intervention (PCI) capability also use fibrinolytic therapy in patients with ST-segment elevation myocardial infarction, but factors influencing the choice of reperfusion strategy at these hospitals are poorly understood. We examined clinical and system-related factors associated with choice of reperfusion strategy in patients with ST-segment elevation myocardial infarction at PCI-capable hospitals.
Methods and Results— We analyzed patients with ST-segment elevation myocardial infarction who presented to PCI-capable hospitals between July 1, 2000, and December 31, 2006, in the National Registry of Myocardial Infarction. Hierarchical multivariable logistic regression was used to examine the association between choice of reperfusion strategy and patient-, hospital-, and system-related factors. We identified 25 579 patients who received primary PCI and 14 332 patients who received fibrinolytic therapy at 444 PCI-capable hospitals. Use of reperfusion strategies varied widely across hospitals, although primary PCI use increased over the study period. Among the key clinical factors that favored primary PCI, cardiogenic shock and delayed presentation were associated with greater use of primary PCI (adjusted odds ratios 2.14 [95% confidence interval 1.72 to 2.66] and 1.18 [95% confidence interval 1.09 to 1.27], respectively), whereas a Thrombolysis in Myocardial Infarction risk score ≥5 was not. In contrast, female gender, advanced age, and nonwhite race, all risk factors for intracranial hemorrhage after fibrinolytic therapy, were not associated with increased use of primary PCI. Off-hours presentation had the strongest association overall, with an ≈70% lower likelihood of patients undergoing primary PCI (adjusted odds ratio 0.27, 95% confidence interval 0.25 to 0.29).
Conclusions— Use of primary PCI, although increasing over recent years, is not universal at PCI-capable hospitals, and optimization of its use at such hospitals represents a potential opportunity to improve outcomes in patients with ST-segment elevation myocardial infarction.
Received February 25, 2009; accepted September 17, 2009.
Primary percutaneous coronary intervention (PCI) is more effective than fibrinolytic therapy as a reperfusion strategy in patients with ST-segment elevation myocardial infarction (STEMI) when delivered rapidly at experienced centers.1 Despite its advantages, however, the use of primary PCI is not universal at hospitals with PCI capability.2 Although the reasons for this are poorly understood, prior studies suggest that system-related factors, such as the time or day of hospital arrival, may play an important role in the decision to use primary PCI given the availability of fewer resources during off-hours.3 It is less clear how clinical factors that are linked with better outcomes with primary PCI, such as cardiogenic shock or delayed presentation, influence this decision. Given that more than one third of PCI-capable hospitals in the United States also report using fibrinolytic therapy,4 an improved understanding of how reperfusion strategies are used at these facilities (eg, when and in what types of patients) is crucial to elucidating opportunities for improving care as strategies for the regionalization of STEMI care move forward.5
Editorial see p 2411
Clinical Perspective on p 2461
Accordingly, we analyzed recent data from the National Registry of Myocardial Infarction (NRMI), a large observational study of acute myocardial infarction in the United States, to assess how patient-, hospital-, and system-related factors, including time of presentation, were associated with use of primary PCI rather than fibrinolytic therapy as a reperfusion strategy at PCI-capable hospitals. A particular focus of the present analysis was to determine whether STEMI patients with stronger clinical indications for primary PCI, such as cardiogenic shock, were more likely to receive primary PCI and how such key clinical factors interacted with the day or time of hospital arrival.
We included patients in the NRMI-4 and NRMI-5 cohorts who were admitted between July 1, 2000, and December 31, 2006. Details of NRMI hospitals, cohorts, and data collection methods have been described elsewhere.6,7 Briefly, the NRMI protocol specifies that all consecutive patients with the diagnosis of acute myocardial infarction are enrolled at participating hospitals. Cases are typically screened with the International Classification of Diseases, 9th Revision, Clinical Modification discharge diagnosis code of 410.x1. Myocardial infarction is then confirmed on the basis of a suggestive patient history and 1 or more of the following criteria: (1) Cardiac biomarker (creatine kinase-MB, troponin) elevation; (2) ECG evidence; and (3) scintigraphic, echocardiographic, or autopsy evidence. The internal validity of prior collections of NRMI data has been established through a comparison with the Cooperative Cardiovascular Project.8 Institutional review board approval for data collection was obtained at all participating hospitals in NRMI as required.
Patients with STEMI at hospitals where primary PCI and fibrinolytic therapy were both used during the same calendar year were eligible for the present study. Primary PCI was specifically defined as PCI during STEMI, without prior administration of fibrinolytic therapy.9 We included patients who received either form of reperfusion strategy and who (1) had ST-segment elevation in 2 or more contiguous leads or a presumed new left bundle-branch block on their first ECG, (2) presented within 12 hours of symptom onset, and (3) were not transferred in from another acute-care hospital. We excluded any patients who received primary PCI and also had contraindications to fibrinolytic therapy because of prior stroke, bleeding diathesis, or active malignancy. Finally, we only included hospitals that identified themselves as having PCI capability and that had 10 or more STEMI patients in a calendar year. Our use of the term “PCI capability” simply reflected that the hospital had the structural (ie, catheterization laboratory) and process (ie, interventional cardiology team) factors available to perform PCI; it did not necessarily indicate that PCI was routinely available “around-the-clock” or even at the specific moment a patient arrived. The final study population consisted of 39 911 patients treated at 444 PCI-capable hospitals.
Figure 1 displays the sample-selection process and specific exclusion criteria used to define the final study population. Because hospitals may have had variable reporting within NRMI during this long study period, we performed a sensitivity analysis looking at 118 hospitals that provided data for at least 4 years. In addition, because the around-the-clock (versus only regular hours) PCI capability of hospitals was not explicitly characterized in NRMI, we performed a sensitivity analysis that included only those patients who presented to hospitals that reported at least 10 off-hours PCIs per year.
Patient and Hospital Data
Patient records included data elements on demographic characteristics (age, gender, race, and insurance status), cardiovascular risk factors (history of hypertension, diabetes mellitus, hyperlipidemia, and smoking), and other comorbidities (history of myocardial infarction, coronary artery bypass graft surgery or PCI, chronic renal insufficiency, and stroke). Clinical data also were available on presenting characteristics, including chest pain, symptoms of congestive heart failure, systolic blood pressure, heart rate, time of symptom onset, and time of hospital arrival. Time of hospital arrival was categorized on the basis of those who presented during “regular” working hours (weekdays between 6 am and 6 pm) and those who presented during off-hours, to approximate earlier reports.3,10,11 ECG data included location of myocardial infarction, the number of leads with ST elevation, the presence of ST depression, nonspecific ST- or T-wave changes, and left bundle-branch block. Hospital information included data elements on annual STEMI volume, teaching status, number of beds, the presence of on-site cardiac surgery, urban or rural location, nonprofit status, and US census region.
Finally, we categorized patients into a “PCI-preferred” group based on the presence of (1) cardiogenic shock, (2) a delayed presentation from symptom onset of ≥4 hours, or (3) a Thrombolysis in Myocardial Infarction risk score12 of ≥5. Although primary PCI has demonstrated superior outcomes to fibrinolytic therapy in several clinical trials, these 3 groups identify those patients for whom the advantage of primary PCI over fibrinolytic therapy is better established and less controversial.13–15 We also assessed the relationship between choice of reperfusion strategy and the presence of risk factors for intracranial hemorrhage after fibrinolytic therapy, including advanced age, female gender, and nonwhite race.16,17
The primary outcome of the present study was the use of primary PCI as opposed to fibrinolytic therapy. Unadjusted analyses compared baseline characteristics between patients treated with the 2 reperfusion strategies with Student t test used for continuous variables and χ2 tests used for categorical variables. We then constructed hierarchical multivariable logistic regression models to examine the independent relationship between patient and hospital factors and use of primary PCI. Candidate variables included those data elements listed above and the year of admission to account for potential secular trends in greater use of primary PCI over the study period.
To determine how the presence of key clinical factors potentially influenced the decision to use primary PCI in relation to the time of hospital arrival, we included interaction terms between the covariates for the clinical factors that identified the PCI-preferred group and time of hospital arrival in the multivariable models. Hierarchical modeling was used to account for the potential effects of clustering of patients within hospitals (ie, the unit of enrollment in NRMI). All analyses were performed with SAS version 9.1 (SAS Institute Inc, Cary, NC).
We identified 25 579 patients (64%) who received primary PCI and 14 332 (36%) who received fibrinolytic therapy at 444 PCI-capable hospitals during the study period. Mean age was 61±12 years, 11 090 (28%) were women, 33 893 (85%) were white, 13 869 (35%) had anterior infarction, and 23 177 (58%) arrived at the hospital during regular working hours. Among these hospitals, the rate of primary PCI varied widely (median 64%, range 40% to 86%). Use of primary PCI also increased significantly every year, rising from 54% of patients in 2000% to 86% of patients in 2006 (χ2 test for trend over time, P<0.001; Figure 2). Although this trend was present in patients who arrived at the hospital during both regular hours and off-hours, use of primary PCI during off-hours was consistently lower, with the gap between regular and off-hours primary PCI use narrowing over time. Importantly, a sensitivity analysis of data from hospitals that contributed data during at least 4 years of the study period (n=118) showed a similar trend of increasing use of primary PCI.
Tables 1 and 2⇓ display baseline characteristics of the study population stratified by reperfusion strategy. Primary PCI was used more frequently in patients who were white, had a prior history of PCI, and had anterior myocardial infarction. Prior coronary artery bypass grafting was associated with less frequent use of primary PCI, but women and the elderly were not any more or less likely to receive primary PCI. Primary PCI was also used more frequently at large hospitals with higher annual STEMI volumes and on-site cardiac surgery; at urban teaching hospitals; at not-for-profit hospitals; and in the Northeast and Midwest census regions. Patients who arrived during regular working hours were significantly more likely to receive primary PCI than those who presented during off-hours (76% versus 56%, P<0.001). Among the nearly one third of patients in the PCI-preferred group, those with cardiogenic shock or delayed presentation were more likely to receive primary PCI. Because of the large size of the data set, statistically significant differences were found in patients for several variables across the 2 reperfusion strategies; however, for several variables, absolute differences were small and were not deemed clinically significant.
Table 3⇓ and Figure 3 summarize the results of the multivariable analysis. In general, several patient and hospital factors were significantly associated with greater use of primary PCI after multivariable adjustment. Many factors were related to potential clinical uncertainty in the diagnosis. For example, patients with absence of chest pain or fewer ECG leads with ST-segment elevation were more likely to undergo primary PCI. Other factors traditionally linked to greater risk of STEMI (anterior involvement or a new left bundle-branch block) also were associated with a higher likelihood of undergoing primary PCI. In contrast, there was a lower likelihood of undergoing primary PCI among patients with prior coronary artery bypass graft (odds ratio [OR] 0.75, 95% confidence interval [CI] 0.67 to 0.84, P<0.0001), those with a history of congestive heart failure (OR 0.80, 95% CI 0.68 to 0.94, P=0.004), and those with right ventricular involvement (OR 0.66, 95% CI 0.52 to 0.84, P=0.0006). Advanced age, female gender, and nonwhite race, which are all risk factors for intracranial hemorrhage after fibrinolytic therapy,16,17 were also not associated with increased use of primary PCI. In fact, we noted a lower likelihood of undergoing primary PCI among older patients (OR for patients 85 years or older 0.69, 95% CI 0.58 to 0.82, P<0.0001) and among nonwhite patients (OR 0.90, 95% CI 0.83 to 0.97, P=0.007).
A particular focus of the present analysis was to determine whether STEMI patients with stronger clinical indications for primary PCI, or the PCI-preferred group, were more likely to receive primary PCI. Use of primary PCI was higher among patients who presented with cardiogenic shock (OR 2.14, 95% CI 1.72 to 2.66, P<0.0001) or with delayed presentation (OR 1.18, 95% CI 1.09 to 1.27, P<0.0001). In contrast, patients with Thrombolysis in Myocardial Infarction risk scores ≥5 did not have a significantly higher likelihood of undergoing primary PCI (OR 1.00, 95% CI 0.91 to 1.11, P=0.6). Overall, the most striking factor associated with a lower likelihood of undergoing primary PCI was arrival at the hospital during off-hours (OR 0.27, 95% CI 0.25 to 0.29, P<0.0001). Interaction terms between the key clinical factors that identified patients in the PCI-preferred group and time of hospital arrival were not statistically significant in the multivariable models. Importantly, this last finding suggested that use of primary PCI during off-hours was not being reserved for the PCI-preferred group, despite a much lower overall use during off-hours.
Finally, we also considered that some PCI-capable hospitals may be incapable of performing primary PCI during off-hours owing to restricted resources. We therefore repeated the analysis after excluding 209 hospitals with 17 172 patients (ie, 43.0% of the total study population) that did not perform at least 10 off-hours primary PCIs per year during the study period. Importantly, the exclusion of these patients and hospitals did not substantially impact our overall conclusions.
More than one third of PCI-capable hospitals in the United States also report using fibrinolytic therapy,4 but little is known about factors associated with the choice of reperfusion strategy at these facilities. Accordingly, we found a substantial number of STEMI patients treated at these hospitals actually received fibrinolytic therapy, although these numbers have declined dramatically in recent years. Furthermore, we identified several key clinical factors, such as cardiogenic shock or delayed presentation, that are associated with increased use of primary PCI but that had not been as well described. However, we also found that the single strongest factor associated with the use of primary PCI was the day and time of hospital arrival. Presentation during weekends and evenings was associated with an ≈70% lower likelihood of undergoing primary PCI. Of course, this may reflect in part the anticipation of long time-to-treatment delays with primary PCI during off-hours, leading to the appropriate selection of fibrinolytic therapy.10
A key finding of the present study was the observation of the possible role that key clinical factors that favor primary PCI over fibrinolytic therapy may play in the decision about which reperfusion strategy to use. Among the “PCI-preferred” characteristics we examined, cardiogenic shock and delayed presentation significantly influenced the use of primary PCI, but a Thrombolysis in Myocardial Infarction risk score ≥5 had no impact. Even among those with cardiogenic shock and delayed presentation, however, a substantial number of patients did not actually receive primary PCI. For example, nearly 25% of the 879 patients with cardiogenic shock received fibrinolytic therapy despite the clear survival benefit of primary PCI in this setting.18 Finally, we found no interaction between the key clinical factors in the PCI-preferred group and time of hospital arrival, which suggests that the use of primary PCI during off-hours was not being reserved for those patients who were most likely to benefit. All of these issues represent potentially missed opportunities for improving care and outcomes in STEMI patients.
Among the factors associated with greater use of primary PCI, some deserve to be specifically highlighted. Several factors related to clinical uncertainty, such as the absence of chest pain, presence of left bundle-branch block, and ST-segment elevation in <3 leads, may have led to greater use of primary PCI. We postulate that in these cases, the diagnostic uncertainty of STEMI may drive clinicians toward emergency cardiac catheterization, a lower-risk strategy, to define the coronary anatomy before treatment. We also found that patients who were elderly, of nonwhite race, and female all factors that have been linked to higher risks of intracranial hemorrhage after fibrinolytic therapy,16,17 were not more likely to receive primary PCI. In fact, the first 2 factors were associated with a significantly lower use of primary PCI. These concerning patterns are consistent with published literature on disparities of care for resource-intensive therapies among vulnerable populations.19,20
Additional implications of the present study relate to the growing interest in regionalization of STEMI care across the United States.5 For example, the Mission: Lifeline, the Reperfusion of Acute Myocardial Infarction in Carolina Emergency Departments (RACE), the D2B Alliance: Sustain the Gain programs, and others have focused on developing community-based approaches to optimizing reperfusion strategies in STEMI patients.21–24 These programs, which have been linked to marked improvements in time to treatment at participating institutions,24 have advocated for broadening timely access to primary PCI and centralizing the care of critically ill STEMI patients at specialized centers with PCI capability. Although the present findings suggest that the use of primary PCI at such hospitals is increasing, it is still not universal. Many facilities continue to use a “mixed” reperfusion strategy that includes the use of both primary PCI and fibrinolytic therapy.
Although the decision to use both reperfusion strategies at PCI-capable hospitals may be appropriate if anticipated time-to-treatment delays are expected to be excessive, a lack of specialization with primary PCI has been linked to delays in reperfusion and worse outcomes.2 Confusion in the emergency department over which therapy to institute and the complexity of streamlining processes of care across several providers have been cited as factors contributing to these delays in treatment.2,25 This is one reason why the Mission: Lifeline program has endorsed STEMI receiving centers as hospitals that have primary PCI capability around the clock. In fact, the proportion of PCI-eligible STEMI patients treated with primary PCI may provide an additional metric for assessing quality of care at PCI-capable hospitals and perhaps even play a role in certifying some as STEMI receiving centers.
The present study should be interpreted in the context of the following limitations. First, the study was observational in design and relied on data voluntarily submitted to the NRMI. PCI hospitals participating in the NRMI may not be representative of all PCI hospitals in the United States, especially because the use of primary PCI has changed dramatically in recent years, with many new centers now available, including those without on-site cardiac surgery. Second, we determined the PCI capability of hospitals at annual intervals based on self-reporting by the hospitals and whether they performed PCIs in a given year. Although changes during the middle of the calendar year would not be recognized until the beginning of the following year, these events are unlikely to have systematically biased the present results.
Third, owing to limitations of the NRMI database, admissions during specific holidays could not be identified and treated as weekend days in the analysis. However, holidays accounted for only 45 days (2%) of the overall study period, and any potential bias from this misclassification is likely to have biased the findings toward the null. Finally, we were unable to account for why a particular reperfusion strategy may have been chosen by a clinician. For example, it could be that off-hours mobilization of the cardiac catheterization laboratory is a major barrier to its use at some hospitals owing to its intense resource requirements. Importantly, we did find similar results when we performed a sensitivity analysis that limited the study population to those patients who presented to hospitals that performed primary PCI during off-hours on at least 10 occasions per year during the study period, which suggests a greater likelihood of around-the-clock PCI capability. However, this remains an important concern given that the provision of primary PCI around the clock will not be possible at some facilities. Of course, if true, this also would represent a potential opportunity to improve care as strategies for the regionalization of STEMI care move forward.
In conclusion, there has been a growing trend in the use of primary PCI in recent years at PCI-capable hospitals, but some STEMI patients still receive fibrinolytic therapy at these facilities. The choice of reperfusion strategy at such PCI-capable hospitals in the United States appears to be complex and likely influenced by a number of patient-, hospital-, and systems-related factors. Optimization of the use of primary PCI at PCI-capable hospitals represents an excellent opportunity to improve clinical outcomes in STEMI patients, particularly as interest in the regionalization of STEMI care across the United States continues to grow through national and regional initiatives.
Dr Krumholz reports consulting fees for serving on the UnitedHealthcare Cardiac Scientific Advisory Board. Dr French reports having received research grants from Portola Pharmaceuticals, Roche Pharmaceuticals, The Medicines Company, and Schering-Plough, as well as honoraria from The Medicines Company. P.D. Frederick is an employee of ICON Clinical Research, which was paid by Genentech to provide biostatistical and analytic services. The remaining authors report no conflicts.
Nallamothu BK, Wang Y, Magid DJ, McNamara RL, Herrin J, Bradley EH, Bates ER, Pollack CV Jr, Krumholz HM. Relation between hospital specialization with primary percutaneous coronary intervention and clinical outcomes in ST-segment elevation myocardial infarction: National Registry of Myocardial Infarction-4 analysis. Circulation. 2006; 113: 222–229.
Jneid H, Fonarow GC, Cannon CP, Palacios IF, Kilic T, Moukarbel GV, Maree AO, LaBresh KA, Liang L, Newby LK, Fletcher G, Wexler L, Peterson E. Impact of time of presentation on the care and outcomes of acute myocardial infarction. Circulation. 2008; 117: 2502–2509.
Department of Health and Human Services Hospital Compare Database, January 2006–December 2006. Available at: http://www.hospitalcompare.hhs.gov/Hospital/Static/Resources-DownloadDB.asp?dest=NAVHomeResourcesDownloadDB#TabTop.Accessed April 18, 2008.
Jacobs AK, Antman EM, Ellrodt G, Faxon DP, Gregory T, Mensah GA, Moyer P, Ornato J, Peterson ED, Sadwin L, Smith SC. Recommendation to develop strategies to increase the number of ST-segment-elevation myocardial infarction patients with timely access to primary percutaneous coronary intervention. Circulation. 2006; 113: 2152–2163.
Nallamothu BK, Bates ER, Herrin J, Wang Y, Bradley EH, Krumholz HM. Times to treatment in transfer patients undergoing primary percutaneous coronary intervention in the United States: National Registry of Myocardial Infarction (NRMI)-3/4 analysis. Circulation. 2005; 111: 761–767.
Peterson ED, Pollack CV Jr, Roe MT, Parsons LS, Littrell KA, Canto JG, Barron HV. Early use of glycoprotein IIb/IIIa inhibitors in non-ST-elevation acute myocardial infarction: observations from the National Registry of Myocardial Infarction 4. J Am Coll Cardiol. 2003; 42: 45–53.
Magid DJ, Wang Y, Herrin J, McNamara RL, Bradley EH, Curtis JP, Pollack CV Jr, French WJ, Blaney ME, Krumholz HM. Relationship between time of day, day of week, timeliness of reperfusion, and in-hospital mortality for patients with acute ST-segment elevation myocardial infarction. JAMA. 2005; 294: 803–812.
Ortolani P, Marzocchi A, Marrozzini C, Palmerini T, Saia F, Aquilina M, Baldazzi F, Silenzi S, Taglieri N, Grosseto D, Bacchi-Reggiani ML, Guastaroba P, Grilli R, Branzi A. Clinical comparison of “normal-hours” vs “off-hours” percutaneous coronary interventions for ST-elevation myocardial infarction. Am Heart J. 2007; 154: 366–372.
Morrow DA, Antman EM, Charlesworth A, Cairns R, Murphy SA, de Lemos JA, Giugliano RP, McCabe CH, Braunwald E. TIMI risk score for ST-elevation myocardial infarction: a convenient, bedside, clinical score for risk assessment at presentation: an Intravenous nPA for Treatment of Infarcting Myocardium Early II Trial substudy. Circulation. 2000; 102: 2031–2037.
Thune JJ, Hoefsten DE, Lindholm MG, Mortensen LS, Andersen HR, Nielsen TT, Kober L, Kelbaek H. Simple risk stratification at admission to identify patients with reduced mortality from primary angioplasty. Circulation. 2005; 112: 2017–2021.
Hochman JS, Sleeper LA, Webb JG, Sanborn TA, White HD, Talley JD, Buller CE, Jacobs AK, Slater JN, Col J, McKinlay SM, LeJemtel TH. Early revascularization in acute myocardial infarction complicated by cardiogenic shock: SHOCK Investigators: Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock. N Engl J Med. 1999; 341: 625–634.
Brass LM, Lichtman JH, Wang Y, Gurwitz JH, Radford MJ, Krumholz HM. Intracranial hemorrhage associated with thrombolytic therapy for elderly patients with acute myocardial infarction: results from the Cooperative Cardiovascular Project. Stroke. 2000; 31: 1802–1811.
Gurwitz JH, Gore JM, Goldberg RJ, Barron HV, Breen T, Rundle AC, Sloan MA, French W, Rogers WJ; Participants in the National Registry of Myocardial Infarction 2. Risk for intracranial hemorrhage after tissue plasminogen activator treatment for acute myocardial infarction. Ann Intern Med. 1998; 129: 597–604.
Hochman JS, Sleeper LA, White HD, Dzavik V, Wong SC, Menon V, Webb JG, Steingart R, Picard MH, Menegus MA, Boland J, Sanborn T, Buller CE, Modur S, Forman R, Desvigne-Nickens P, Jacobs AK, Slater JN, LeJemtel TH. One-year survival following early revascularization for cardiogenic shock. JAMA. 2001; 285: 190–192.
American Heart Association. Mission Lifeline: A New Plan to Decrease Deaths from Major Heart Blockages. Available at: http://www.americanheart.org/presenter.jhtml?identifier=3050213. Accessed August 30, 2008.
Jollis JG, Roettig ML, Aluko AO, Anstrom KJ, Applegate RJ, Babb JD, Berger PB, Bohle DJ, Fletcher SM, Garvey JL, Hathaway WR, Hoekstra JW, Kelly RV, Maddox WT Jr, Shiber JR, Valeri FS, Watling BA, Wilson BH, Granger CB. Implementation of a statewide system for coronary reperfusion for ST-segment elevation myocardial infarction. JAMA. 2007; 298: 2371–2380.
Krumholz HM, Bradley EH, Nallamothu BK, Ting HH, Batchelor WB, Kline-Rogers E, Stern AF, Byrd JR, Brush JE Jr. A campaign to improve the timeliness of primary percutaneous coronary intervention: Door-to-Balloon: an Alliance for Quality. J Am Coll Cardiol Interv. 2008; 1: 97–104.
Rokos IC, French WJ, Koenig WJ, Stratton SJ, Nighswonger B, Strunk B, Jewell J, Mahmud E, Dunford JV, Hokanson J, Smith SW, Baran KW, Swor R, Berman A, Wilson BH, Aluko AO, Gross BW, Rostykus PS, Salvucci A, Dev V, McNally B, Manoukian SV, King SB III. Integration of pre-hospital electrocardiograms and ST-elevation myocardial infarction receiving center (SRC) networks: impact on door-to-balloon times across 10 independent regions. J Am Coll Cardiol Interv. 2009; 2: 339–346.
Doorey A, Patel S, Reese C, O'Connor R, Geloo N, Sutherland S, Price N, Gleasner E, Rodrigue R. Dangers of delay of initiation of either thrombolysis or primary angioplasty in acute myocardial infarction with increasing use of primary angioplasty. Am J Cardiol. 1998; 81: 1173–1177.
This report uses the National Registry of Myocardial Infarction to better understand patterns of reperfusion therapy use in hospitals with percutaneous coronary intervention capability. The superiority of primary percutaneous coronary intervention versus fibrinolytic therapy in the setting of ST-segment elevation myocardial infarction has been well established, yet its use is not universal at hospitals with this capability in the United States, with more than one third of these facilities also reporting the use of fibrinolytic therapy during recent years. We found that although primary percutaneous coronary intervention use has been increasing steadily over recent years, a substantial number of patients with ST-segment elevation myocardial infarction continue to receive fibrinolytic therapy. This finding is particularly concerning in that primary percutaneous coronary intervention may not be used universally even in high-risk groups of patients who may stand to gain the most from it. We believe these findings have broad implications for the design of future ST-segment elevation myocardial infarction systems of care.
Guest Editor for this article was David J. Moliterno, MD.