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European Heart Journal Advance Access published online on November 27, 2009
European Heart Journal, doi:10.1093/eurheartj/ehp506
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Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2009. For permissions please email: journals.permissions@oxfordjournals.org

Acceptable reperfusion delay to prefer primary angioplasty over fibrin-specific thrombolytic therapy is affected (mainly) by the patient's mortality risk: 1 h does not fit all

Giuseppe Tarantini*, Renato Razzolini, Massimo Napodano, Claudio Bilato, Angelo Ramondo and Sabino Iliceto

Division of Cardiology, Department of Cardiac, Thoracic, and Vascular Sciences, University of Padua Medical School, Via Giustiniani, 2, 35128 Padua, Italy

Received 22 December 2008; revised 25 June 2009; accepted 28 September 2009 * Corresponding author. Tel: +39 049 8211844, Fax: +39 049 8761764, Email: giuseppe.tarantini.1{at}unipd.it

Aims: The mortality benefit of primary percutaneous coronary angioplasty (PPCI) is time-dependent. We explored the relationship between risk and PPCI delay, adjusted for the delay at presentation, which leads to equivalent 30-day mortality between PPCI and fibrin-specific thrombolytic therapy (TT).

Methods and results: Sixteen randomized trials were analysed. The mortality rate in the TT arm was interpreted as a proxy for mortality risk. We calculated the PPCI-related delay as the difference between ‘door-to-balloon minus door-to-needle’ time and PPCI survival benefit as 30-day mortality after TT minus 30-day mortality after PPCI. Baseline mortality risk (P = 0.004), PPCI delay (P = 0.006), and presentation delay (P = 0.03) were correlated with 30-day survival benefit of PPCI. By the regression analysis, the following equation: Z = 0.59X – 0.033Y – 0.0003W – 1.3 (where Z is the absolute reduction in mortality of PPCI over TT, X the mortality risk, Y the PPCI-delay, and W the presentation delay), can be calculated. According to this equation, acceptable angioplasty-related delay shows a wide range based mainly on the different risk profiles.

Conclusion: Baseline mortality risk of ST elevation myocardial infarction patients is a major determinant of the acceptable time delay to choose the most appropriate therapy. Although a longer delay lowers the survival advantage of PPCI, a longer PPCI-related delay could be acceptable in high-risk STEMI patients.

Key Words: Myocardial infarction • Angioplasty • Fibrinolysis


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