Trends in acute reperfusion therapy for ST-segment elevation myocardial infarction from 1999 to 2006: we are getting better but we have got a long way to go
1 University of Michigan Cardiovascular Center, Ann Arbor, MI, USA
2 Duke University Medical Center, Durham, NC, USA
3 Hôpital Bichat, Paris, France
4 Universitair Ziekenhuis Gasthuisberg, Leuven, Belgium
5 Hospital Universitario La Paz, Madrid, Spain
6 Canadian Heart Research Centre and Terrence Donnelly Heart Centre, Division of Cardiology, St. Michael’s Hospital, University of Toronto, Toronto, ON, Canada
7 Center for Outcomes Research, University of Massachusetts Medical School, Worcester, MA, USA
8 Cardiovascular Research, Division of Medical & Radiological Sciences, The University of Edinburgh, The Royal Infirmary of Edinburgh, Edinburgh, UK
Received 24 January 2007; revised 14 January 2008; accepted 1 February 2008.
* Corresponding author: University of Michigan Cardiovascular Center, 300 N. Ingalls, 8B02, Ann Arbor, MI 48109-0477, USA. Tel: +1 734 936 5275, Fax: +1 734 764 4119, Email: keagle{at}umich.edu
See page 571 for the editorial comment on this article (doi:10.1093/eurheartj/ehm277)
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.
Key Words: Reperfusion therapy • Fibrinolysis • Percutaneous coronary intervention • Hospital mortality
This paper was guest edited by Prof. Maarten L. Simoons, Dept. of Cardiology—Thoraxcenter, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
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