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Hospital delays in reperfusion for ST-elevation myocardial infarction: implications when selecting a reperfusion strategy.

Abstract：

BACKGROUND:It has been suggested that the survival benefit associated with primary percutaneous coronary intervention (PPCI) in ST-segment elevation myocardial infarction may be attenuated if door-to-balloon (DB) time is delayed by >1 hour beyond door-to-needle (DN) times for fibrinolytic therapy. Whereas DB times are rapid in randomized trials, they are often prolonged in routine practice. We hypothesized that in clinical practice, longer DB-DN times would be associated with higher mortality rates and reduced PPCI survival advantage. We also hypothesized that in addition to PPCI delays, patient risk factors would significantly modulate the relative survival advantage of PPCI over fibrinolysis. METHODS AND RESULTS:DB-DN times were calculated by subtracting median DN time from median DB time at a hospital using data from 192,509 patients at 645 National Registry of Myocardial Infarction hospitals. Hierarchical models that adjusted simultaneously for both patient-level risk factors and hospital-level covariates were used to evaluate the relationship between PCI-related delay, patient risk factors, and in-hospital mortality. Longer DB-DN times were associated with increased mortality (P<0.0001). The DB-DN time at which mortality rates with PPCI were no better than that of fibrinolysis varied considerably depending on patient age, symptom duration, and infarct location. CONCLUSIONS:As DB-DN times increase, the mortality advantage of PPCI over fibrinolysis declines, and this advantage varies considerably depending on patient characteristics. As indicated in the American College of Cardiology/American Heart Association guidelines, both the hospital-based PPCI-related delay (DB-DN time) and patient characteristics should be considered when a reperfusion strategy is selected.

journal_name

Circulation

journal_title

Circulation

authors

Pinto DS,Kirtane AJ,Nallamothu BK,Murphy SA,Cohen DJ,Laham RJ,Cutlip DE,Bates ER,Frederick PD,Miller DP,Carrozza JP Jr,Antman EM,Cannon CP,Gibson CM

doi

10.1161/CIRCULATIONAHA.106.638353

subject

Has Abstract

pub_date

2006-11-07 00:00:00

pages

2019-25

issue

eissn

0009-7322

issn

1524-4539

pii

CIRCULATIONAHA.106.638353

journal_volume

114

pub_type

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Hospital delays in reperfusion for ST-elevation myocardial infarction: implications when selecting a reperfusion strategy.