Early ST elevation myocardial infarction in non-capable percutaneous coronary intervention centres: in situ fibrinolysis vs. percutaneous coronary intervention transfer

• Published in: European heart journal Vol. 37; no. 13; pp. 1034 - 1040
• Main Authors: Carrillo, Xavier, Fernandez-Nofrerias, Eduard, Rodriguez-Leor, Oriol, Oliveras, Teresa, Serra, Jordi, Mauri, Josepa, Curos, Antoni, Rueda, Ferran, García-García, Cosme, Tresserras, Ricard, Rosas, Alba, Faixedas, Maria Teresa, Bayes-Genis, Antoni
• Format: Journal Article
• Language: English
• Published: England 01-04-2016
• Subjects: Female; Hospitalization - statistics & numerical data; Humans; Male; Middle Aged; Patient Transfer; Percutaneous Coronary Intervention - methods; Percutaneous Coronary Intervention - mortality; Prospective Studies; Retrospective Studies; Spain - epidemiology; ST Elevation Myocardial Infarction - mortality; ST Elevation Myocardial Infarction - therapy; Thrombolytic Therapy - methods; Thrombolytic Therapy - mortality; Time-to-Treatment; Codi IAM; STEMI; STEMI network; Fibrinolysis; Primary angioplasty
• ISSN: 0195-668X; 1522-9645
• DOI: 10.1093/eurheartj/ehv619

The preferred reperfusion strategy for early ST elevation myocardial infarction (STEMI, defined as time from symptoms onset ≤120 min) in non-capable percutaneous coronary intervention (PCI) centres remains controversial. We sought to compare mortality of in situ fibrinolysis vs. PCI transfer in a real-life consecutive cohort of early STEMI.
Prospective multicentre STEMI registry (Catalonia 'Codi IAM' network) of all-comers in a non-capable PCI centre with symptom onset to first medical contact (FMC) <120 min. Two groups were identified: in situ fibrinolysis and transfer to a PCI-capable centre. Primary endpoint was 30-day mortality. We included 2470 patients, of whom 2227 (90.2%) and 243 (9.8%) comprised the transfer and fibrinolysis groups, respectively. In the fibrinolysis group, diagnostic and system delays were shorter (24 vs. 31 min, P < 0.001; 45 vs. 119 min, P < 0.001, respectively). Thirty-day mortality was 7.7 and 5.1% in fibrinolysis and transfer groups, respectively (P = 0.09). However, patients in the transfer group whose time FMC-device was achieved within 140 min were associated with significantly lower mortality (2.0% for FMC-device <99 min, and 4.6% for FMC-device 99-140 min; P < 0.01 and P = 0.03, respectively vs. fibrinolysis). In multivariable logistic regression analysis, reperfusion with fibrinolysis was an independent 30-day mortality predictive factor (odds ratio: 1.91, 95% confidence interval: 1.01-3.50; P = 0.04), together with age and Killip-Kimball class (both P < 0.001).
In early STEMI patients assisted in non-capable PCI centres, in situ fibrinolysis had worse prognosis than patient transfer. Transfer to a PCI-capable centre seems recommended in patients with FMC-device delay <140 min.