Research Original Investigation
Fibrinolysis Use Among Hospital Transfer Patients
Invited Commentary
Is Primary Percutaneous Coronary Intervention Still the Superior Reperfusion Strategy? Marc J. Claeys, MD, PhD
The current guidelines for the management of ST-segment elevation myocardial infarction (STEMI) recommend primary percutaneous coronary intervention (pPCI) as the preferred treatment strategy if it can be conducted in a timely fashRelated article page 207 ion by an experienced catheterization team.1 Because of the restricted availability of hospitals providing pPCI support 24 hours 7 days a week, the concept of STEMI networks with prearranged rapid transfer protocols between community hospitals and PCI-capable centers has been developed. The goal is to offer pPCI, which is currently considered the superior reperfusion therapy, to a maximum number of patients with STEMI. Although initial experiences with local STEMI networks were encouraging, the transition from thrombolysis to PCI for patients admitted to community hospitals requires close follow-up because changes in delays may offset the benefit of pPCI over thrombolysis. Therefore, the study by Vora et al2 in this issue of JAMA Internal Medicine from the National Cardiovascular Data Registry is eagerly welcome, providing important information on delays, reperfusion therapy selection, and outcomes in a large community-based population. Vora et al focused on interhospital drive time as being an important, but variable, component in the chain of time, which lasts from the onset of pain until the initiation of reperfusion therapy. During the past years, many periods have been defined (which may have led to some confusion); generally, they can be divided into patientrelated delays and system-related delays (Figure). The systemrelated delay starts from the first medical contact, which usually corresponds to the first hospital door time, and ends with the initiation of reperfusion therapy; it includes time to diagnosis, time for transfer to the PCI hospital, and time for preparation of the reperfusion therapy (thrombolysis or PCI). The good news is that the proportion of patients achieving a first hospital door-to-balloon (DTB) time within 120 minutes (system delay) has almost doubled over approximately 5 years. This is most likely attributed to the implementation of awareness programs such as the Acute Coronary Treatment and Intervention Outcomes Network Registry–Get With the Guidelines program. The bad news is that approximately half of all patients still do not achieve these recommended time targets. Therefore, continuous efforts should be made to improve these system-related delays. Improvement measures may include the public reporting of time-related quality indicators or the promotion of prehospital triage, with transfer of patients directly from home to PCI-capable hospitals, bypassing the nearest community hospitals. In addition, the appropriate selection of patients for reperfusion therapy will also help to achieve a higher proportion of patients with optimal de216
Figure. Patient-Related Delay and System-Related Delay
Symptom onset
First medical contact
Diagnosis
Reperfusion therapy
Patient delay System delay
Time to reperfusion therapy
lays. The article by Vora et al2 demonstrates that, when the estimated drive time exceeded 30 minutes, half of the patients failed to achieve a first DTB time within 120 minutes; among some of these patients, fibrinolysis may have been an equivalent or more effective therapy. The current reluctance of starting fibrinolysis is driven, at least in part, by the overwhelming evidence of the superiority of pPCI over thrombolysis. This evidence has been subsequently incorporated into international guidelines.1 However, these guidelines are based mainly on studies that were conducted before the use of newer adjunctive pharmacotherapies or the application of routine invasive evaluation after thrombolysis, both of which have been associated with better outcomes. More recent trials and registries have shown lower mortality rates with fibrinolysis compared with their historical cohorts.3,4 For many subgroups, pPCI is no longer superior to thrombolysis when considering mortality rates.3,5,6 This was also evident in the study by Vora et al, which showed comparable adjusted mortality rates among patients with estimated drive times of 30 to 120 minutes who were eligible for fibrinolysis or pPCI. The major drawback to the use of fibrinolysis remains an associated increased risk of bleeding complications. However, by using half-dose thrombolytic regimens and by planning the invasive evaluation beyond the 3-hour window following drug administration, the risk seems to decrease.6 Based on these recent findings, some will argue for a revival of thrombolysis in the management of patients with STEMI admitted to hospitals without PCI capability. However, medical appropriateness aims to provide the best treatment strategy for each patient. As such, all efforts should be made to try to achieve the shortest DTB time as possible because evidence shows that pPCI remains superior to fibrinolysis if the DTB time is 60 minutes or less.3,7 If these strict time lines cannot be achieved, the selection of optimal reperfusion therapy remains a complex decision process that should take into account the following 4 factors.
JAMA Internal Medicine February 2015 Volume 175, Number 2 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a Nanyang Technological University User on 05/20/2015
jamainternalmedicine.com
Fibrinolysis Use Among Hospital Transfer Patients
Original Investigation Research
First is the estimated system delay (first DTB time). The benefit of pPCI over thrombolysis is offset if the first DTB time exceeds 90 to 120 minutes. The study by Vora et al2 highlights that, even for estimated driving times of 60 minutes, most patients will not receive pPCI within 120 minutes following admission to a community hospital. Second is the patient-related delay. Thrombolysis is most effective on a fresh thrombus, and high reperfusion rates are documented for early arrivers (
Fibrinolysis Use Among Hospital Transfer Patients
Invited Commentary
Is Primary Percutaneous Coronary Intervention Still the Superior Reperfusion Strategy? Marc J. Claeys, MD, PhD
The current guidelines for the management of ST-segment elevation myocardial infarction (STEMI) recommend primary percutaneous coronary intervention (pPCI) as the preferred treatment strategy if it can be conducted in a timely fashRelated article page 207 ion by an experienced catheterization team.1 Because of the restricted availability of hospitals providing pPCI support 24 hours 7 days a week, the concept of STEMI networks with prearranged rapid transfer protocols between community hospitals and PCI-capable centers has been developed. The goal is to offer pPCI, which is currently considered the superior reperfusion therapy, to a maximum number of patients with STEMI. Although initial experiences with local STEMI networks were encouraging, the transition from thrombolysis to PCI for patients admitted to community hospitals requires close follow-up because changes in delays may offset the benefit of pPCI over thrombolysis. Therefore, the study by Vora et al2 in this issue of JAMA Internal Medicine from the National Cardiovascular Data Registry is eagerly welcome, providing important information on delays, reperfusion therapy selection, and outcomes in a large community-based population. Vora et al focused on interhospital drive time as being an important, but variable, component in the chain of time, which lasts from the onset of pain until the initiation of reperfusion therapy. During the past years, many periods have been defined (which may have led to some confusion); generally, they can be divided into patientrelated delays and system-related delays (Figure). The systemrelated delay starts from the first medical contact, which usually corresponds to the first hospital door time, and ends with the initiation of reperfusion therapy; it includes time to diagnosis, time for transfer to the PCI hospital, and time for preparation of the reperfusion therapy (thrombolysis or PCI). The good news is that the proportion of patients achieving a first hospital door-to-balloon (DTB) time within 120 minutes (system delay) has almost doubled over approximately 5 years. This is most likely attributed to the implementation of awareness programs such as the Acute Coronary Treatment and Intervention Outcomes Network Registry–Get With the Guidelines program. The bad news is that approximately half of all patients still do not achieve these recommended time targets. Therefore, continuous efforts should be made to improve these system-related delays. Improvement measures may include the public reporting of time-related quality indicators or the promotion of prehospital triage, with transfer of patients directly from home to PCI-capable hospitals, bypassing the nearest community hospitals. In addition, the appropriate selection of patients for reperfusion therapy will also help to achieve a higher proportion of patients with optimal de216
Figure. Patient-Related Delay and System-Related Delay
Symptom onset
First medical contact
Diagnosis
Reperfusion therapy
Patient delay System delay
Time to reperfusion therapy
lays. The article by Vora et al2 demonstrates that, when the estimated drive time exceeded 30 minutes, half of the patients failed to achieve a first DTB time within 120 minutes; among some of these patients, fibrinolysis may have been an equivalent or more effective therapy. The current reluctance of starting fibrinolysis is driven, at least in part, by the overwhelming evidence of the superiority of pPCI over thrombolysis. This evidence has been subsequently incorporated into international guidelines.1 However, these guidelines are based mainly on studies that were conducted before the use of newer adjunctive pharmacotherapies or the application of routine invasive evaluation after thrombolysis, both of which have been associated with better outcomes. More recent trials and registries have shown lower mortality rates with fibrinolysis compared with their historical cohorts.3,4 For many subgroups, pPCI is no longer superior to thrombolysis when considering mortality rates.3,5,6 This was also evident in the study by Vora et al, which showed comparable adjusted mortality rates among patients with estimated drive times of 30 to 120 minutes who were eligible for fibrinolysis or pPCI. The major drawback to the use of fibrinolysis remains an associated increased risk of bleeding complications. However, by using half-dose thrombolytic regimens and by planning the invasive evaluation beyond the 3-hour window following drug administration, the risk seems to decrease.6 Based on these recent findings, some will argue for a revival of thrombolysis in the management of patients with STEMI admitted to hospitals without PCI capability. However, medical appropriateness aims to provide the best treatment strategy for each patient. As such, all efforts should be made to try to achieve the shortest DTB time as possible because evidence shows that pPCI remains superior to fibrinolysis if the DTB time is 60 minutes or less.3,7 If these strict time lines cannot be achieved, the selection of optimal reperfusion therapy remains a complex decision process that should take into account the following 4 factors.
JAMA Internal Medicine February 2015 Volume 175, Number 2 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a Nanyang Technological University User on 05/20/2015
jamainternalmedicine.com
Fibrinolysis Use Among Hospital Transfer Patients
Original Investigation Research
First is the estimated system delay (first DTB time). The benefit of pPCI over thrombolysis is offset if the first DTB time exceeds 90 to 120 minutes. The study by Vora et al2 highlights that, even for estimated driving times of 60 minutes, most patients will not receive pPCI within 120 minutes following admission to a community hospital. Second is the patient-related delay. Thrombolysis is most effective on a fresh thrombus, and high reperfusion rates are documented for early arrivers (
