Trends in Acute Reperfusion Therapy for ST-Segment Elevation MI
Trends in Acute Reperfusion Therapy for ST-Segment Elevation MI
Aim: Many patients who are eligible for acute reperfusion therapy receive it after substantial delays or not at all. We wanted to determine whether over the years more patients are receiving reperfusion therapy.
Methods and Results: This analysis is based on 10 954 patients with ST elevation or left bundle-branch block presenting within 12 h of symptom onset and enrolled in the GRACE registry between April 1999 and June 2006. Over this time, there was an increasing trend in use of primary percutaneous coronary intervention (PCI) from 15% to 44% (P < 0.001), while use of fibrinolytic therapy decreased (from 41 to 16%; P < 0.01). No trend in median time to primary PCI was seen but that for fibrinolysis declined significantly (from 40 to 34%; P < 0.0001). Hospital mortality declined (6.9–5.4%; P < 0.01); the relationship between observed and expected mortality improved over time (P = 0.06). Nevertheless, 33% of patients still received no reperfusion therapy. Factors associated with reperfusion use included age; prior myocardial infarction, heart failure or coronary artery bypass graft surgery; history of diabetes; female sex; and delay from symptom onset to hospital arrival. In 2006, 52% of patients receiving fibrinolysis had door-to-needle times >30 min and 42% of those undergoing primary PCI had door-to-balloon times >90 min.
Conclusion: Primary PCI is now used much more than fibrinolysis. Although hospital mortality and delays to fibrinolytic reperfusion have improved, over 40% of patients reperfused still receive it outside the time window recommended, and one-third of potentially eligible patients receive no reperfusion.
Acute reperfusion therapy with either primary percutaneous coronary intervention (PCI) or fibrinolysis reduces mortality in eligible patients with ST-segment elevation myocardial infarction (STEMI). Despite this, earlier reports suggest that a substantial proportion of patients receive inadequate therapy—either too late or, in some instances, not at all. Guidelines from both Europe and the United States have emphasized the need for identifying patients early and minimizing delays in the delivery of reperfusion therapy, citing studies that have established improved outcomes with rapid treatment. Recent meta-analyses of randomized clinical trials have suggested that primary PCI may offer some advantages when compared with fibrinolysis in patients who are eligible for both treatments. However, the primary objective of contemporary management for STEMI is to treat more patients with any type of reperfusion therapy. Depending on local facilities, the optimal approach is either immediate (including pre-hospital) fibrinolysis or rapid transfer to a high-volume tertiary care centre for primary PCI.
The goals of this study were to assess overall trends in the use of reperfusion therapy for patients with STEMI using data from the Global Registry of Acute Coronary Events (GRACE). We were particularly interested in determining whether the number of eligible patients receiving any form of reperfusion therapy is increasing; if the speed with which reperfusion therapy is delivered is improving; and whether these potential trends are associated with changes in hospital mortality rates.
Aim: Many patients who are eligible for acute reperfusion therapy receive it after substantial delays or not at all. We wanted to determine whether over the years more patients are receiving reperfusion therapy.
Methods and Results: This analysis is based on 10 954 patients with ST elevation or left bundle-branch block presenting within 12 h of symptom onset and enrolled in the GRACE registry between April 1999 and June 2006. Over this time, there was an increasing trend in use of primary percutaneous coronary intervention (PCI) from 15% to 44% (P < 0.001), while use of fibrinolytic therapy decreased (from 41 to 16%; P < 0.01). No trend in median time to primary PCI was seen but that for fibrinolysis declined significantly (from 40 to 34%; P < 0.0001). Hospital mortality declined (6.9–5.4%; P < 0.01); the relationship between observed and expected mortality improved over time (P = 0.06). Nevertheless, 33% of patients still received no reperfusion therapy. Factors associated with reperfusion use included age; prior myocardial infarction, heart failure or coronary artery bypass graft surgery; history of diabetes; female sex; and delay from symptom onset to hospital arrival. In 2006, 52% of patients receiving fibrinolysis had door-to-needle times >30 min and 42% of those undergoing primary PCI had door-to-balloon times >90 min.
Conclusion: Primary PCI is now used much more than fibrinolysis. Although hospital mortality and delays to fibrinolytic reperfusion have improved, over 40% of patients reperfused still receive it outside the time window recommended, and one-third of potentially eligible patients receive no reperfusion.
Acute reperfusion therapy with either primary percutaneous coronary intervention (PCI) or fibrinolysis reduces mortality in eligible patients with ST-segment elevation myocardial infarction (STEMI). Despite this, earlier reports suggest that a substantial proportion of patients receive inadequate therapy—either too late or, in some instances, not at all. Guidelines from both Europe and the United States have emphasized the need for identifying patients early and minimizing delays in the delivery of reperfusion therapy, citing studies that have established improved outcomes with rapid treatment. Recent meta-analyses of randomized clinical trials have suggested that primary PCI may offer some advantages when compared with fibrinolysis in patients who are eligible for both treatments. However, the primary objective of contemporary management for STEMI is to treat more patients with any type of reperfusion therapy. Depending on local facilities, the optimal approach is either immediate (including pre-hospital) fibrinolysis or rapid transfer to a high-volume tertiary care centre for primary PCI.
The goals of this study were to assess overall trends in the use of reperfusion therapy for patients with STEMI using data from the Global Registry of Acute Coronary Events (GRACE). We were particularly interested in determining whether the number of eligible patients receiving any form of reperfusion therapy is increasing; if the speed with which reperfusion therapy is delivered is improving; and whether these potential trends are associated with changes in hospital mortality rates.
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