November 30th, 2011
Thrombolysis Instead of Primary PCI
Sanjiv Shah, MD
The latest analysis of 2009 CMS data for 13,776 STEMI patients of door-in to door-out (DIDO) time by Herrin and colleagues does not bring encouraging news. After many years of hard work to reduce DIDO time for patients who present at facilities without primary PCI capability, only a small fraction of patients (<10%) are transferred within the national benchmark of 30 minutes, which is not appreciably better than the authors’ previous analysis in 2005. With recent studies showing no mortality benefit for primary PCI over thrombolytics in low and intermediate risk STEMI patients, and insurmountable barriers to shortening DIDO times in the vast majority of cases, hospitals and patients often would be better served by timely reperfusion with thrombolytics.
I recommend that:
- low and intermediate risk patients receive thrombolytics (either prehospital or in ED) if primary PCI is not available in a timely fashion on site
- high risk patients be transferred only if DIDO would be close to 30 minutes, as after that the mortality advantage is no longer present for primary PCI.
Do you think that it’s time to rethink our approach to STEMI patients or should we double down on trying to improve DIDO?
[EDITOR’S NOTE: See also this post on the latest DIDO data—and on Dr. Redberg’s argument—in CardioExchange’s Interventional blog: Should FedEx Be in Charge of Primary PCI?]
12 Responses to “Thrombolysis Instead of Primary PCI”
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I am in favor of Dr Redberg’s approach.
As an interventionalist who lived thru the “lytic era”, I can attest not only to the benefit of timely lytic treatment but also the unavoidable delays in transfer that occur on a regular basis, even in metropolitan areas, to PCI centers. The retraining effort for the emergency departments would be acceptable, the financial costs of transfer mitigated, the care of our overall patient cohort would be improved and perhaps the headlong rush for many of our smaller community hospitals to develop very low volume “PCI centers” for fear of “losing that business” would mitigate. This approach would not stop the efforts to improve overall STEMI care but would provide an immediate response to the DIDO dilemma and allow such investigation to proceed with circumspection.
Competing interests pertaining specifically to this post, comment, or both:
I am the president of my private practice group and serve on several ACC committees pro bono.
+1
Competing interests pertaining specifically to this post, comment, or both:
none
Would such a bifurcated paradigm unintentionally create further delay to treatment with fibrinolysis and/or transfer for PCI by introducing a decision matrix of determining which patients are low to intermediate vs high risk? The RACE-ER system has abandoned a “mixed” strategy for just such confounding decision making results in inordinate delay. Furthermore, Nallamothou et al(Circulation 2006; 113:222-229) has previously demonstrated that “specialization”- a committed strategy to PCI vs fibrinolysis in PCI hospitals results in best reperfusion timliness performance, therefore, avoiding reperfusion confusion.
The objective should be to use the reperfusion strategy that you can offer on time.
The two processes should continue simultaneously – i.e. to continue efforts to improve DIDO time and use fibrinolytic therapy when primary PCI can not be offered in a timely fashion (on site or on transfer)
While DIDO, DTN and DTB times have received adequate attention , another time factor that needs focus and matters in outcome is time from onset of symptoms to first medical contact/hospitalization.
Competing interests pertaining specifically to this post, comment, or both:
Nil
Many interesting point of view
There appear to be clear benefits with Primary PCI when compared with thrombolysis. Does anyone clearly know how long the delay has to be between the opportunity to give thrombolysis and delivering primary PCI before that advantage evaporates. Is it really 30 minutes? I live in a rural region. Some patients can get PCI quickly, whereas for others the delays seem unacceptable.
Mark
I have served on the voluntary staff at major teaching hospitals. Many cardiology fellows are not trained in the proper use of thrombolytic therapy. Many practicing cardiologists are fearful of using thrombolytic agents. Major centers would lose business for their interventional programs if they trained their fellows how to use thrombolytic therapy in the community hospitals, in which they will subsequently practice, rather than referring patients to the major center for PCI. Few, if any, attending physicians in major centers have any experience using thrombolysis in acute MI patients, and therefore do not have the ability to train cardiology fellows how to use such therapy.
Competing interests pertaining specifically to this post, comment, or both:
None, I am retired.
I have always wondered if interventional radiologists were to perform primary PCI, instead of interventional cardiologists, would cardiologists still refer STEMI patients for primary PCI?
Sanjay! Yes, of course!
This is a lovely debate about the futility of primary PCI in majority of STEMI treated globally .
In India , in a large tertiary Govt hospital we practice only thromolysis in all uncomplicated STEMI .The mortality rate over 25 year period is about 6-7 % and I am sure primary PCI has nothing to improve upon this .
(Rather we have found it as an interference to our logical thinking towards rapid re-perfusion )
Please allow me to link the related article in my blog.
How to lose the golden hour in STEMI ? The curious helicopter ride to the cath lab !
Interesting discussions and points…
As a cardiology fellow, I agree that we do not get as much experience managing STEMIs via thrombolytics. I have in a few cases given tPA and although it seems that you don’t need to do it too many times to know the dosages and protocol, the experience managing the adverse effects seen is valuable. Many of us still do “drip and ship” when at our community hospital rotations.
To Dr. Politis’ post above, I have seen many patients get PCI for a STEMI in cath labs without CT surgery backup, but I think the main issue is elective (nonurgent) PCIs.
Competing interests pertaining specifically to this post, comment, or both:
None
As a fellow involved in the RACE program in North Carolina, I have experienced the frustration of bringing patients to our tertiary care hospital per protocol based on estimated transit time only to have their definitive care delayed by transit or inefficiencies at the referring or receiving hospital. In order to make a thrombolytic therapy first strategy viable for low to medium risk patients, there would need to be a clinical decision tool which was simple enough that it could easily be utilized in community emergency departments or possibly even in pre-hospital/EMS settings.