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Background Patients with a myocardial infarction with ST-segment elevation who present to hospitals that do not have the capability of performing percutaneous coronary intervention (PCI) often cannot undergo timely primary PCI and therefore receive fibrinolysis. The role and optimal timing of routine PCI after fibrinolysis have not been established.
Methods We randomly assigned 1059 high-risk patients who had a myocardial infarction with ST-segment elevation and who were receiving fibrinolytic therapy at centers that did not have the capability of performing PCI to either standard treatment (including rescue PCI, if required, or delayed angiography) or a strategy of immediate transfer to another hospital and PCI within 6 hours after fibrinolysis. All patients received aspirin, tenecteplase, and heparin or enoxaparin; concomitant clopidogrel was recommended. The primary end point was the composite of death, reinfarction, recurrent ischemia, new or worsening congestive heart failure, or cardiogenic shock within 30 days.
Results Cardiac catheterization was performed in 88.7% of the patients assigned to standard treatment a median of 32.5 hours after randomization and in 98.5% of the patients assigned to routine early PCI a median of 2.8 hours after randomization. At 30 days, the primary end point occurred in 11.0% of the patients who were assigned to routine early PCI and in 17.2% of the patients assigned to standard treatment (relative risk with early PCI, 0.64; 95% confidence interval, 0.47 to 0.87; P=0.004). There were no significant differences between the groups in the incidence of major bleeding.
Conclusions Among high-risk patients who had a myocardial infarction with ST-segment elevation and who were treated with fibrinolysis, transfer for PCI within 6 hours after fibrinolysis was associated with significantly fewer ischemic complications than was standard treatment. (ClinicalTrials.gov number, NCT00164190
[ClinicalTrials.gov]
.)
Source Information
From Southlake Regional Health Centre, Newmarket, ON (W.J.C.); the University of Toronto (W.J.C., D.F., B.B., E.A.C., L.J.M., A.L., V.D., B.S., S.G.G.), Terrence Donnelly Heart Centre, Division of Cardiology, St. Michael's Hospital (D.F., A.L., S.G.G.), Canadian Heart Research Centre (D.F., A.L., A.C., S.G.G.), Mount Sinai Hospital (B.B.), Sunnybrook Health Sciences Centre (E.A.C., L.J.M., B.S.), and University Health Network (V.D.) — all in Toronto; Saint Boniface Hospital, Winnipeg, MB (J.D.); Halton Healthcare Services, Oakville, ON (M.H.); McMaster University and Hamilton Health Sciences Corporation, Hamilton, ON (S.R.M.); and Trillium Health Centre, Mississauga, ON (C.L.) — all in Canada.
Address reprint requests to Dr. Cantor at the Southlake Regional Health Centre, 596 Davis Dr., Newmarket, ON L3Y 2P9, Canada, or at cantorw{at}rogers.com.
Related Letters:
Routine Early Angioplasty after Fibrinolysis
Wilsmore B. R., Wilsmore A. D., Cooper H. A., Bogaty P., Brophy J. M., Hof A. v. t, Ottervanger J. P., Wang Z., Liang B., Mei Q., Cantor W. J., Goodman S. G., the TRANSFER-AMI Investigators , Verheugt F. W.A.
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N Engl J Med 2009;
361:1507-1510, Oct 8, 2009.
Correspondence
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