Steven Borzak, MD
In patients with ST-segment elevation myocardial infarction (STEMI), what is the effectiveness of early transfer for angiography and percutaneous coronary intervention (PCI) compared with transfer for rescue PCI or delayed angiography?
Randomized controlled trial (Trial of Routine Angioplasty and Stenting after Fibrinolysis to Enhance Reperfusion in Acute Myocardial Infarction [TRANSFER-AMI]). ClinicalTrials.gov NCT00164190.
Blinded (adjudication committee for nonfatal components of primary outcome).*
30 days (primary outcome).
52 centers in Ontario, Manitoba, and Quebec, Canada, that did not have PCI capability.
1059 patients (80% men) with STEMI who presented within 12 hours of symptom onset, had ST-segment elevation ≥ 2 mm in 2 anterior leads or ≥ 1 mm in 2 inferior leads, and ≥ 1 of systolic blood pressure < 100 mm Hg, heart rate > 100 beats/min, Killip class II or III heart failure, ST-segment depression ≥ 2 mm in anterior leads, or right ventricular involvement. Exclusion criteria included cardiogenic shock, PCI in previous month, previous coronary artery bypass surgery, and PCI availability with anticipated door-to-balloon time < 60 minutes.
Early transfer for angiography and PCI within 6 hours of fibrinolysis (n = 537, median age 57 y) or standard care (n = 522, median age 56 y). All patients received tenecteplase, aspirin, and unfractionated heparin or enoxaparin. In the standard care group, those with unsuccessful fibrinolysis were transferred for rescue PCI; all other patients remained at the presenting hospital for 24 hours, with recommendation for catheterization within 2 weeks.
Composite of death, reinfarction, recurrent ischemia, new or worsening heart failure (HF), or cardiogenic shock. Secondary outcomes included bleeding complications.
99.9% (intention-to-treat analysis).
Early transfer had a lower rate of the composite outcome, recurrent ischemia, and new or worsening HF than did standard care (Table) but did not differ for reinfarction, death, cardiogenic shock, or in-hospital bleeding complications.
In patients with ST-segment elevation myocardial infarction, early transfer for angiography and PCI reduced ischemic events compared with selective emergency and delayed elective transfer.
Early transfer for angiography vs standard care in ST-segment elevation myocardial infarction†
†HF = heart failure; other abbreviations defined in Glossary. RRR, NNT, and CI calculated from data in article.
‡Death, reinfarction, recurrent ischemia, new or worsening heart failure, or cardiogenic shock.
Borzak S. Early transfer for angiography after fibrinolysis reduced ischemic events in patients with STEMI. Ann Intern Med. 2009;151:JC5–4. doi: 10.7326/0003-4819-151-10-200911170-02004
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Published: Ann Intern Med. 2009;151(10):JC5-4.
Acute Coronary Syndromes, Cardiology, Coronary Heart Disease, Emergency Medicine.
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