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.

June 25th, 2010

Start The Timer!

In a province-wide evaluation of STEMI care in Quebec, primary PCI was the preferred method of reperfusion therapy: 80% of patients who underwent reperfusion received primary PCI, whereas 20% were given fibrinolytic therapy.

Disappointingly, PCI was performed > 90 minutes after presentation in 68% of recipients; fibrinolysis was performed >30 minutes in 54%. Time to reperfusion had a stronger effect on outcomes than the method of reperfusion. Transfer from a non-PCI center to a hospital with PCI capability was strongly associated with delayed reperfusion (odds ratio, 4.6), which translated to a higher risk of death at 30 days and higher risk of the combined outcome of death of hospital readmssion for CHF or MI at 1 year.

These data suggest that timely fibrinolysis may be more effective than delayed primary PCI in some situations.

If you presented to a non-PCI hospital with an STEMI, would you prefer immediate fibrinolysis or transfer to a PCI-capable facility?

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2 Responses to “Start The Timer!”

  1. Harlan M. Krumholz, MD, SM says:
    June 30, 2010 at 6:18 pm

    depends

    Wouldn’t the answer depend on the time it would take to get to the PCI hospital and whether there is a system in place to whisk you to the cath lab. I am concerned that many patients who are transferred have d2b times (door of first hospital to balloon at second hospital) of 3+ hours. For those individuals, assuming no contraindication to lytics, wouldn’t they be better off with lytics – at least until the system improved. And I like the NC RACE example showing how you can create a system within a state that enables rapid transfers and quick PCIs (kudos to the NC hospitals and Jollis and Granger for their leadership).

  2. William L Blanchet, MD says:
    July 9, 2010 at 6:48 pm

    is there an option to combine the two?

    Is there a protocol to initiate lytic therapy at the first hospital and then abort the lytic treatment upon arrival at the cath lab?