Prehospital fibrinolytic therapy for ST-elevation acute myocardial infarction
- PDF / 233,721 Bytes
- 6 Pages / 612 x 792 pts (letter) Page_size
- 87 Downloads / 234 Views
Corresponding author Ali E. Denktas, MD Division of Cardiovascular Medicine, University of Texas at Houston, 6431 Fannin 1.246, Houston, TX 77030, USA. E-mail: [email protected] Current Cardiovascular Risk Reports 2009, 3:339–344 Current Medicine Group LLC ISSN 1932-9520 Copyright © 2009 by Current Medicine Group LLC
Despite advances in medications and interventional techniques, ST-segment elevation myocardial infarction (STEMI) remains a major cause of mortality in the United States. Reducing the time from the onset of symptoms to reperfusion (ischemic time) is the major determinant for mortality reduction. An ongoing controversy exists regarding whether there is more benefit of percutaneous coronary intervention (PCI) preceded by prehospital fibrinolytic treatment (facilitated PCI) compared with primary percutaneous coronary intervention (PPCI) in patients with STEMI. In different clinical trials, prehospital fibrinolysis markedly reduced the time from symptom onset to treatment, allowing earlier ST-segment elevation resolution and higher initial thrombolysis in myocardial infarction (TIMI) flow rates compared with PPCI. After prehospital fibrinolysis, patients who had subsequent PCI had lower in-hospital mortality rates and higher 1-year survival rates compared with those who underwent PPCI. In contrast, fulldose fibrinolytic agents without glycoprotein IIb/IIIa inhibitors immediately followed by PCI may increase major adverse events and should not be used.
Introduction Despite advances in medications and interventional techniques, ST-segment elevation myocardial infarction (STEMI) remains a major cause of mortality in the United States. Data from 3377 hospitals nationwide showed that in-hospital mortality is 8% among STEMI patients [1]. Predictors of death include age, size and site of infarction, concurrent medical conditions, previous history of myocardial infarction (MI), low blood pressure, Killip class on admission, and extent of ischemia. Any delay in treatment is associated with increased mortality rates [2]. In patients
who are treated with primary percutaneous coronary intervention (PPCI), every 30 minutes of delay increases the relative risk of 1-year mortality by 7.5% [1]. Reducing the time from symptom onset to reperfusion (ischemic time) is the major determinant for reducing mortality. Percutaneous coronary intervention (PCI) for STEMI is superior to fibrinolysis when it can be performed in a timely manner by experienced operators in high-volume centers. According to the National Registry of Myocardial Infarction (NRMI) data, most US patients who are transferred for PPCI have door-to-balloon times exceeding the currently recommended 90-minute window, potentially negating the advantage of PCI over on-site fibrinolysis [3,4]. In the United States, the mean time to PCI is 253 minutes (median, 180 minutes), and the mean time to hospital-administered fibrinolysis is 54 minutes [1]. Only 4.2% of patients are treated within 90 minutes, the current door-to-balloon time recommended by the most re
Data Loading...
