What's the Best Reperfusion Strategy for STEMI in a non-PCI Hospital?

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Summary and Comment

What’s the Best Reperfusion Strategy for STEMI in a non-PCI Hospital?

A treat-versus-transfer framework based on duration of symptoms and transport time

For patients with ST-segment-elevation myocardial infarction (STEMI), definitive opening of the affected artery with percutaneous coronary intervention (PCI), preferably within 90 minutes and ideally within 60 minutes of presentation, is recommended based on substantial evidence. However, as only half of U.S. hospitals have PCI capability, the question of alternative therapy arises. These authors constructed a framework for selecting a reperfusion strategy for patients with STEMI, based on the abundant evidence available.

Central to their approach is the concept of dividing the time from symptom onset to open artery into two parts: (1) time from symptom onset to arrival and (2) transport time to a PCI center.

If PCI is available, it should be used. If PCI is not available, eligibility for fibrinolysis should be assessed. Patients not eligible for fibrinolytic therapy should be transported for PCI, regardless of symptom duration and transport time. If patients are eligible for fibrinolysis, a strategy should be selected based on the times shown in Table 1:

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Table 1. Reperfusion Strategies

Options other than those listed in Table 1 have not been proven effective and should be used only in a research setting, as they have the potential to do harm (for example, the combination of a fibrinolytic agent and a GP IIb/IIIa inhibitor).

Comment: This helpful analysis translates research findings into a tool for dealing with a common problem. The tool supports clinical decision making and can serve as the basis for development, or improvement, of systems for care of acute MI patients.

— J. Stephen Bohan, MD, MS, FACP, FACEP

Published in Journal Watch Emergency Medicine December 1, 2006