Author + information
- Hendrik-Jan Dieker, MD⁎ (, )
- Stephan S.B. Liem, MD,
- Marc A. Brouwer, MD, PhD and
- Freek W.A. Verheugt, MD, PhD
- ↵⁎Radboud University Nijmegen Medical Center, Heart Lung Center, Department of Cardiology 670, Experimental Cardiology, P.O. Box 9101, 6500 HB, Nijmegen, the Netherlands
With interest we read the comments of Dr. Lozano and colleagues and Dr. Harper on the issue of reperfusion therapy for “pre-hospitally” diagnosed ST-segment elevation myocardial infarction patients presenting early after symptom onset. Although Dr. Harper suggests fibrinolysis with an early invasive strategy in all pre-hospital patients, Dr. Lozano and colleagues suggest this strategy under “certain circumstances.” Our registry data show that with our strategy of pre-hospital diagnosis, catheter laboratory notification from the ambulance, and direct transportation to an intervention center with optimal in-hospital logistics, primary angioplasty can be performed within 90 min of diagnosis in more than 80% of patients. We acknowledge that pre-hospital and in-hospital infrastructure varies per country and region, which might affect the preferred reperfusion therapy.
The current guidelines state that primary angioplasty is the unequivocally preferred reperfusion strategy, if it can be performed within 90 min of presentation by an experienced team of personnel (1). The guidelines are based on the currently available evidence, including the CAPTIM (Comparison of Primary Angioplasty and Prehospital Fibrinolysis in Acute Myocardial Infarction Trial) results, and they do not make an exception for pre-hospital (or early) presenting patients. Dr. Harper's statement that an early pre-hospital fibrinolytic strategy is superior to primary angioplasty lacks sufficient scientific evidence and therefore is not supported by current guidelines. The remark that our results would have been better if a pre-hospital fibrinolytic strategy would have been used instead of primary angioplasty is presumptuous.
We agree with Dr. Lozano and colleagues that pre-hospital fibrinolysis with a routine early invasive strategy is the preferred reperfusion strategy under certain circumstances—namely if high-quality primary angioplasty performed in a timely fashion is not available. Our registry was initiated to monitor treatment delays in primary angioplasty. Before the initiation of primary angioplasty, pre-hospital fibrinolysis with a liberal rescue strategy has been successfully used for more than 1 decade, with two-thirds of patients being treated within 2 h of symptom onset. Our primary angioplasty data demonstrate that most patients are treated within the time window of the guideline. Moreover, we show that guideline adherence can be substantially improved if all patients are referred directly to an intervention center instead of through a nonintervention center.
We concur with both authors that the impact of (early) pre-hospital fibrinolysis with an early invasive strategy in patients at low risk of bleeding might be underestimated, and this strategy deserves further study. To date, the CAPTIM study is the only available randomized trial in the pre-hospital setting comparing both reperfusion strategies in the optimal setting. The suggested superiority of early fibrinolysis stems from a subgroup analysis of a prematurely discontinued, overall neutral trial, and these results should be interpreted with caution. The currently enrolling STREAM (Strategic Reperfusion Early After Myocardial Infarction) trial compares both reperfusion strategies in patients presenting within 3 h of symptom onset, and results are eagerly awaited. At least until then, timely high-quality primary angioplasty remains the treatment of preference.
- American College of Cardiology Foundation
- Frederick G.,
- Kushner F.G.,
- Hand M.,
- et al.