rss
Heart 99:1154-1156 doi:10.1136/heartjnl-2013-304117
  • Point-Counterpoint

2012 ESC STEMI guidelines and reperfusion therapy

Evidence base ignored, threatening optimal patient management

Open Access
  1. Eric Boersma12
  1. 1Department of Cardiology, Aarhus University Hospital in Skejby, Aarhus, Denmark
  2. 2Department of Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
  3. 3Department of Cardiology, University of Leipzig-Heart Center, Leipzig, Germany
  4. 4Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
  5. 5Department of Cardiology, Heart Center, Tampere University Hospital, Tampere, Finland
  6. 6Department of Cardiology, Sussex Cardiac Centre, Brighton and Sussex University Hospitals, Brighton, UK
  7. 7Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
  8. 8Department of Cardiology, Clinical Center of Serbia and Medical School of Belgrade, Belgrade, Serbia
  9. 9Department of Cardiology, Odense University Hospital, Odense, Denmark
  10. 10Department of Cardiology, AHEPA University Hospital, Thessaloniki, Greece
  11. 11Department of Cardiology, Skane University Hospital, Lund, Sweden
  12. 12Department of Cardiology, Erasmus Medical Centre, Rotterdam, Netherlands
  1. Correspondence to Dr Christian Juhl Terkelsen, Department of Cardiology, B, Aarhus University Hospital in Skejby, Aarhus 8450, Denmark;chriterk{at}rm.dk

The 2012 European Society of Cardiology (ESC) ST-Elevation Myocardial Infarction (STEMI) guideline acknowledges that STEMI patients should receive reperfusion therapy as soon as possible, and that prehospital fibrinolysis or field-triage directly to Primary Percutaneous Coronary Intervention (PPCI) centres is the preferred reperfusion strategy.1 However, when recommending fibrinolytic therapy (FT) within 30 min from First Medical Contact (FMC), if PPCI cannot be performed ‘within 60 min of FMC in patients presenting early, with a large amount of myocardium at risk’, the guidelines imply that only 30 min extra may be expended to perform PPCI instead of administering FT (‘PCI-related delay’) (figure 1).

Figure 1

Various delays when treating patients with ST-Elevation Myocardial Infarction (STEMI) with fibrinolysis or primary percutaneous coronary intervention (PPCI). ‘Healthcare system delay’ is the total delay from emergency medical service (EMS) call to PPCI. ‘PCI-related delay’ is the extra delay that one may use to perform PPCI instead of administering fibrinolysis and still achieve a mortality benefit from PPCI. First Medical Contact (either EMS call, EMS arrival on scene, or arrival at hospital according to regional STEMI system of care).

Throughout the years, successive guidelines have mistakenly equated ‘PCI-related delay’ and ‘FMC to PPCI’ (the total delay from FMC to PPCI) (figure 1). This error persists in the recently updated ESC guideline.1 Clarification of this distinction is of paramount importance because of the suggested reduction in the ‘window of opportunity for PPCI’, a suggestion not clearly supported by evidence, which has significant public health implications. In paragraph 3.5.2, the ESC STEMI guideline references a registry analysis from the National Registry of Myocardial Infarction (NRMI),2 concluding: ‘primary PCI (wire passage) should be performed within 90 min after FMC in all cases. In patients presenting early, with a large amount of myocardium at risk, the delay should be shorter (<60 min).’ The NRMI …