Fibrinolytic Therapy Use Among STEMI Patients Transferred to a Primary PCI
Hospital in the United States: A Mission: Lifeline Report
Amit N. Vora, DaJuanicia N. Holmes, Ivan Rokos, Matthew T. Roe, Christopher B. Granger, William J. French,
Elliott Antman, Timothy Henry, Laine Thomas, Eric R. Bates, Tracy Y. Wang
Background
• Guidelines recommend consideration of fibrinolytic
therapy if unable to achieve a door to balloon time ≤120
minutes for STEMI patients transferred for primary
percutaneous coronary intervention (PCI).
• ACTION Registry-GWTG offers a unique perspective
on the patterns of fibrinolytic therapy use among
contemporary STEMI patients across multiple hospitals
in the United States.
Methods
• From ACTION Registry-GWTG between 7/2008–
3/2012, we identified 15,437 fibrinolytic-eligible STEMI
patients first evaluated at a non-primary PCI hospital
then transferred to a primary PCI center 30 -120 min
drive time away.
• Among the 15,437 patients in the study sample 5,296
(34.3%) received pre-transfer fibrinolysis and 10,141
(65.7%) underwent primary PCI.
• Among patients receiving fibrinolytics, the most common
agent was tenecteplase (74.6%), then reteplase (21.6%);
alteplase and streptokinase accounted for <5% of overall
fibrinolytic use.
• There was no difference in overall adjusted in-hospital
mortality between fibrinolysis versus primary PCI, but an
association of increased mortality for patients receiving
pre-transfer fibrinolysis in lower risk patients (Figure 2).
Table 1. Baseline characteristics
Fibrinolysis (n=5296)
Primary PCI
(n = 10141)
p-value
59 (51-69)
0.03
Fibrinolysis (n=5296)
Primary PCI
(n = 10141)
ECG findings (n, %)
ST-elevation
LBBB
Isolated posterior MI
Hypotension (SBP ≤
90mmHg) (n, %)
Tachycardia (HR ≥
100) (n, %)
Signs of heart failure
(n, %)
Cardiogenic shock (n,
%)
ACTION mortality risk
score, median (IQR)
5230 (98.8)
34 (0.6)
27 (0.5)
286 (5.4)
9967 (98.3)
93 (0.9)
72 (0.7)
570 (5.6)
Age, median (IQR),
years
59 (51-67)
Percent female, n (%)
1430 (27.0)
2762 (27.2)
0.76
Non-white race, n (%)
666 (12.6)
951 (9.4)
<0.001
Low risk
Moderate risk
0.58
High risk
626 (11.8)
1341 (13.2)
0.01
343 (6.5)
675 (6.7)
0.69
328 (6.2)
770 (7.6)
0.002
31 (26-37)
32 (26-38)
0.002
Figure 1: Time to presentation
250
239 min
IQR 183-331
Primary PCI better
Lytic
better
Primary PCI better
Limitations
• ACTION Registry-GWTG data does not capture
information on whether local or regional STEMI care
transfer systems are established.
• Timeliness of reperfusion regardless of strategy remains
a target for improvement for transferred STEMI patients.
194 min
IQR 141-299
200
28.6 (25.3-32.7)
0.63
Hypertension (%)
3280 (62.0)
6276 (61.9)
0.93
We selected a time frame of 30 minutes as
approximately the 5th percentile drive time for
fibrinolytic use and 120 minutes is the 95th
percentile of primary PCI use in this patient
population.
Diabetes (%)
1103 (20.8)
2311 (22.8)
0.006
Dyslipidemia (%)
2627 (49.6)
5179 (51.1)
0.08
Current / recent
smoker (%)
2705 (51.1)
4954 (48.9)
0.009
Prior MI (%)
965 (18.2)
1746 (17.2)
0.12
Prior CHF (%)
196 (3.7)
391 (3.9)
0.64
• Logistic regression generalized estimating equations
method was used to calculate the adjusted odds ratios
for outcomes comparing patients receiving pre-transfer
fibrinolytics with those treated with primary PCI.
Prior PCI (%)
1010 (19.1)
1905 (18.8)
0.63
Prior CABG (%)
287 (5.4)
531 (5.2)
0.62
Prior stroke (%)
182 (3.4)
433 (4.3)
0.01
90 (68-116)
91 (67-119)
0.04
CrCl, median (IQR),
ml/min
Lytic
better
Conclusions
Clinical characteristics
BMI, median (IQR),
kg/m2
Bleeding
Overall
0.07
Demographics
Patients were excluded if prior ICH, neoplasm,
AVM, aneurysm, ischemic stroke within 3 months,
suspected aortic dissection, bleeding diathesis,
significant
head/facial
trauma,
allergy
to
fibrinolytics, recent surgery/trauma, uncontrolled
hypertension, recent bleeding within 4 months,
active peptic ulcer, or pregnancy.
Mortality
p-value
300
28.6 (25.3-32.5)
•
Figure 2: In-hospital outcomes by ACTION mortality risk score tertiles
Table 2: Clinical presentation
Minutes
•
Results
179 min
IQR 109-999
150
126 min
IQR 104-165
Characteristics were compared using the Wilcoxon-rank sum test for continuous
variables and the chi-square test for categorical variables.
46 min
IQR
28-70
34 min
IQR 23-53
• Further investigation is needed to determine the
optimal reperfusion strategy for lower-risk
transferred STEMI patients.
0
Symptoms to Door to lytic Lytic to door Lytic to cath Symptoms to Door to PCI
door
out
door
Fibrinolysis
• Fibrinolysis remains a viable reperfusion strategy for
eligible patients in the US.
• Among patients with the lowest ACTION mortality risk
score, patients treated with fibrinolysis had higher
mortality and bleeding risk compared to primary PCI
patients.
100
50
• Compared with primary PCI, fibrinolysis was associated
with no significant difference in adjusted mortality risk,
but a modestly higher adjusted major bleeding risk.
Primary PCI
DISCLOSURE INFORMATION
The following relationships exist related to this presentation: NONE