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Acute coronary syndromes
Relationship of treatment delays and mortality in patients undergoing fibrinolysis and primary percutaneous coronary intervention. The Global Registry of Acute Coronary Events
  1. B Nallamothu1,
  2. K A A Fox2,
  3. B M Kennelly3,
  4. F Van de Werf4,
  5. J M Gore5,
  6. P G Steg6,
  7. C B Granger7,
  8. O H Dabbous8,
  9. E Kline-Rogers9,
  10. K A Eagle9
  1. 1
    VA Health Services Research & Development Center of Excellence, Ann Arbor VA Medical Center, Ann Arbor, USA
  2. 2
    Cardiovascular Research, Division of Medical & Radiological Sciences, The University of Edinburgh, Edinburgh, UK
  3. 3
    Department of Cardiology, Hoag Memorial Hospital Presbyterian, Newport Beach, USA
  4. 4
    Department of Cardiology, Universitair Ziekenhuis Gasthuisberg, Leuven, Belgium
  5. 5
    Division of Cardiovascular Medicine, University of Massachusetts Medical School, Worcester, USA
  6. 6
    Cardiology, Hôpital Bichat, Paris, France
  7. 7
    Duke University Medical Center, Durham, USA
  8. 8
    Center for Outcomes Research, University of Massachusetts Medical School, Worcester, USA
  9. 9
    University of Michigan Medical School, Ann Arbor, USA
  1. Kim A Eagle, University of Michigan Cardiovascular Center, 300 N. Ingalls, 8B02, Ann Arbor, MI 48109-0477, USA; keagle{at}umich.edu

Abstract

Objective: Treatment delays may result in different clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI) who receive fibrinolytic therapy vs primary percutaneous coronary intervention (PCI). The aim of this analysis was to examine how treatment delays relate to 6-month mortality in reperfusion-treated patients enrolled in the Global Registry of Acute Coronary Events (GRACE).

Design: Prospective, observational cohort study.

Setting: 106 hospitals in 14 countries.

Patients: 3959 patients who presented with STEMI within 6 h of symptom onset and received reperfusion with either a fibrin-specific fibrinolytic drug or primary PCI.

Main outcome measures: 6-month mortality.

Methods: Multivariable logistic regression was used to assess the relationship between outcomes and treatment delay separately in each cohort, with time modelled with a quadratic term after adjusting for covariates from the GRACE risk score.

Results: A total of 1786 (45.1%) patients received fibrinolytic therapy, and 2173 (54.9%) underwent primary PCI. After multivariable adjustment, longer treatment delays were associated with a higher 6-month mortality in both fibrinolytic therapy and primary PCI patients (p<0.001 for both cohorts). For patients who received fibrinolytic therapy, 6-month mortality increased by 0.30% per 10-min delay in door-to-needle time between 30 and 60 min compared with 0.18% per 10-min delay in door-to-balloon time between 90 and 150 min for patients undergoing primary PCI.

Conclusions: Treatment delays in reperfusion therapy are associated with higher 6-month mortality, but this relationship may be even more critical in patients receiving fibrinolytic therapy.

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Footnotes

  • Funding: GRACE is funded by an unrestricted educational grant from sanofi-aventis (Paris, France) to the Center for Outcomes Research, University of Massachusetts Medical School (Worcester, MA).

  • Competing interests: B K Nallamothu: none. K A A Fox: British Heart foundation, Medical Research Council, The Wellcome Trust, Aventis, Sanofi Synthelabo, GlaxoSmithKline, Bristol-Myers Squibb. B M Kennelly: sanofi-aventis. F Van de Werf: sanofi-aventis. J M Gore: sanofi-aventis. P G Steg: Speakers bureau; Boehringer-Ingelheim, BMS, GSK, MSD, Novartis, Nycomed, sanofi-aventis, Sankyo, Servier, ZLB-Behring. Consulting/advisory board: AstraZeneca, BMS, GSK, MSD, Pfizer, sanofi-aventis, Servier, Takeda. Stockholding: none. C B Granger: sanofi-aventis, Procter and Gamble, Alexion, Bristol-Myers Squibb, Boehringer Ingelheim, GlaxoSmithKline, Novartis, The Medicines Company. O H Dabbous: none. E Kline-Rogers: none. K A Eagle: Biosite, Bristol Myers Squibb, Cardiac Sciences, Blue Cross Blue Shield of Michigan, Hewlett Foundation, Mardigian Fund, Pfizer, sanofi-aventis, Varbedian fund, National Heart, Lung & Blood NIH.

  • Abbreviations:
    ACS
    acute coronary syndromes
    GRACE
    Global Registry of Acute Coronary Events
    IQR
    interquartile range
    PCI
    percutaneous coronary intervention
    STEMI
    ST-segment elevation myocardial infarction
    TIMI
    Thrombosis in Myocardial Infarction

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