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In the Balance |

Primary Percutaneous Coronary Intervention for Every Patient with ST-Segment Elevation Myocardial Infarction: What Stands in the Way?

Ellen C. Keeley, MD; and Cindy L. Grines, MD
[+] Article and Author Information

From the University of Texas Southwestern Medical Center, Dallas, Texas; and William Beaumont Hospital, Royal Oak, Michigan.


Potential Financial Conflicts of Interest:Consultancies: C.L. Grines (Aventis, Guidant, Pfizer, Innercool Therapies, The Medicines Company); Grants received: C.L. Grines (Berlex, GlaxoSmithKline, Pfizer, Guidant, Eli Lilly and Company, SCIMED, Johnson & Johnson, Aventis, Amersham Health, Otsuka, Esperion Therapeutics, Innercool Therapies).

Requests for Single Reprints: Ellen C. Keeley, MD, Division of Cardiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-8837; e-mail, ellen.keeley@utsouthwestern.edu.

Current Author Addresses: Dr. Keeley: Division of Cardiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-8837.

Dr. Grines: William Beaumont Hospital, 3601 West Thirteen Mile Road, Royal Oak, MI 48073-6769.


Ann Intern Med. 2004;141(4):298-304. doi:10.7326/0003-4819-141-4-200408170-00010
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According to data from randomized, controlled trials, primary percutaneous coronary intervention (PCI) is the treatment of choice for ST-segment elevation myocardial infarction (MI). In these trials, 1 life was saved and 2 other life-threatening complications, including stroke and reinfarction, were prevented for every 50 patients with ST-segment elevation MI treated with primary PCI rather than thrombolytic therapy. Only 1 major bleeding episode occurred.How can these superior results be realized outside the context of randomized trials? We anticipate 4 obstacles to instituting primary PCI as the universal treatment of ST-segment elevation MI: 1) lack of timely availability, 2) technical expertise of center and operator, 3) the need to address patient subgroups that are not studied in randomized trials, and 4) comparisons of primary PCI to newer pharmacologic regimens.We propose 3 strategies to increase the availability of this procedure: 1) perform primary PCI in qualified community hospitals without surgical back-up; 2) transfer patients from community hospitals without primary PCI capability to hospitals with primary PCI capability; and 3) develop a universal system in which ambulances directly transfer patients to a regional primary PCI center, not necessarily to the closest hospital, similar to the system used for trauma patients. We contend that, in light of the superior clinical outcomes seen with primary PCI for treating ST-segment elevation MI, this procedure should be available to all patients with ST-segment elevation MI and efforts should be made to institute these measures.

Figures

Grahic Jump Location
Figure.
Proposed algorithm to increase the availability of primary percutaneous coronary intervention (PCI) for patients with ST-segment elevation myocardial infarction (MI).

Primary PCI is the treatment of choice for ST-segment elevation myocardial infarction. Three strategies are proposed to increase the availability of this procedure: 1) perform primary PCI in community hospitals that lack on-site surgical back-up; 2) transfer patients from hospitals that lack primary PCI capability to primary PCI centers, provided that the transfer time is less than 3 hours; and 3) develop a triage system, similar to that seen with trauma patients, wherein the patient is directly transferred by the emergency medical system to a primary PCI center, not necessarily the closest emergency department. Data on “prehospital” thrombolytic therapy administered in the ambulance compared with primary PCI are limited (dotted line). If adopted, this approach would require eligibility for thrombolytic therapy; presence of a physician in the ambulance; and immediate transfer to a primary PCI center, since rescue PCI was required in one quarter of patients.

Grahic Jump Location

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