CardioExchange Archive

CardioExchange, an NEJM practice community for medical professionals dedicated to improving cardiac patient care, was active from 2009 to 2015. CardioExchange fostered discussion between clinicians from across the globe.

November 30th, 2011

Should FedEx Be in Charge of Primary PCI?

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Federal Express built its business on being a leader in transportation and delivering on time.  Perhaps the results of primary PCI in the U.S. would be better if FedEx ran the program.

In patients with acute MI who must be transferred to another hospital for primary PCI, experts agree that the door-in to door-out (so called, DIDO) time should not exceed 30 minutes.  Two studies — one from the Get With the Guidelines ACTION Registry and the other from CMS data — show that only ≈10% of patients transferred for PCI in the U.S. are delivered on time (i.e., DIDO <30 minutes). Distressingly, DIDO was more than 90 minutes in about one third of patients and more than 110 minutes in 25%.

If primary PCI were a business (i.e., FedEx), the transfer unit of the company would be in bankruptcy proceedings.   

Customers complain about packages that are delivered late, but little outrage is voiced over patients whose acute MI treatment is unnecessarily delayed, leading to a higher mortality.  In fact, DIDO time has not changed much over the past 5 years, and the problem is not limited to rural hospitals.  In another recent study from a hospital in a major metropolitan area, the median DIDO time was >130 minutes, even though four primary PCI-capable hospitals were located within 5 miles.

The message for hospitals that advocate transfer of primary PCI patients should be the same as it would be for FedEx: deliver the goods on time or get out of the business.

In an accompanying editorial, Rita Redberg notes that “modern thrombolytic strategies have substantially attenuated the mortality benefit of primary PCI over thrombolytic therapy such that differences are trivial except for the highest-risk subgroup.”  For acute MI patients who present to a hospital without primary PCI capability, thrombolytic therapy should be administered, and transfer “should not be performed unless the patient is at high risk and there is reason to believe that with transfer the patient will receive primary PCI within 60 minutes.” Dr. Redberg also offers a short post on this topic here at CardioExchange.

If you were to present with an acute MI to a hospital without primary PCI capability, which would you choose: immediate thrombolytic therapy or transfer (without knowing what the DIDO time will be)?  

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2 Responses to “Should FedEx Be in Charge of Primary PCI?”

  1. David Powell , MD, FACC says:
    December 1, 2011 at 10:13 pm

    Hopefully, my STEMI would be recognized in the ambulance. If conscious, I would naturally read my EKG and direct the ambulance to a PCI hospital (right to the lab), but they might not follow my recommendation. Assuming I am less than 3 hours into chest pain and that the expected time for transfer and PCI exceeds 60 minutes, I think I would get a thrombolytic and then transfer. I suppose one might debate PCI after I reperfuse successfully after T N K. But I believe there is a study to support this post-thrombolytic transfer.

  2. Venkatesan Sangareddi, MD.DM says:
    December 1, 2011 at 10:26 pm

    When it comes to heart … even express shipping amounts to delay !

    Excellent reasoning and common sense !
    The fact is primary PCI was introduced nearly two decades ago
    still struggling to prove a point.(Not simply a logistic issue )
    As we know the advantage of primary PCI over thrombolysis is wafer thin in most of low risk STEMIs.

    It is a billion dollor mystery, while every NSTEMI is risk stratified
    on arrival all ,STEMI population is put on a single basket and hence we give room for this therapeutic misadventure !
    I would go one step further pPCI should be carefully contemplated in low risk STEMI even if the DIDO is less than 30 minutes !

    please allow me to link a related article from my blog.

    http://drsvenkatesan.wordpress.com/2011/03/27/traffic-jams-and-timi-blood-flows-in-national-highways/