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Contemporary mortality differences between primary percutaneous coronary intervention and thrombolysis in ST-segment elevation myocardial infarction

Marc J Claeys, Antoine de Meester, Carl Convens, Philippe Dubois, Jean Boland, Herbert De Raedt, Parscal Vranckx, Patrick Coussement, Sofie Gevaert UGent and Peter Sinnaeve, et al. (2011) ARCHIVES OF INTERNAL MEDICINE. 171(6). p.544-549
abstract
Background: Current ST-segment elevation myocardial infarction guidelines regarding reperfusion strategy are based on trials conducted before the application of routine invasive evaluation after thrombolysis. Modern thrombolysis may affect the previously observed mortality difference between primary percutaneous coronary intervention (PPCI) and thrombolysis. Methods: In-hospital mortality was prospectively assessed in 5295 patients with ST-segment elevation myocardial infarction admitted to 73 Belgian hospitals from July 1, 2007, through December 31, 2009. A total of 4574 patients (86.4%) were treated with PPCI and 721 (13.6%) received thrombolysis; of these thrombolysis patients, 603 (83.6%) underwent subsequent invasive evaluation. The Thrombolysis in Myocardial Infarction risk score was used to stratify the study population by low (n = 1934), intermediate (n = 2382), and high (n = 979) risk. Results: In-hospital mortality in the PPCI patients was 5.9% vs 6.6% in the thrombolysis patients. After adjustment for differences in baseline risk profile, a significant mortality benefit was only present in the high-risk groups: 23.7% in the PPCI patients vs 30.6% in the thrombolysis patients. For patients not at high risk, the mortality difference was marginal. For low-risk patients, mortality was 0.3% in the PPCI patients vs 0.4% in the thrombolysis patients. For intermediate-risk patients, mortality was 2.9% in the PPCI patients vs 3.1% in the thrombolysis patients. Subgroup analysis revealed that the mortality benefit of PPCI compared with early thrombolysis (door-to-needle time <30 minutes) was offset if the door-to-balloon time exceeded 60 minutes. Conclusions: Modern thrombolytic strategies have substantially attenuated the absolute mortality benefit of PPCI over thrombolysis, particularly in patients not at high risk. Our study findings suggest that target door-to-balloon time should be less than 60 minutes to maintain the lowest mortality rates.
Please use this url to cite or link to this publication:
author
organization
year
type
journalArticle (original)
publication status
published
subject
keyword
LONG, NATIONAL REGISTRY, HOSPITAL MORTALITY, REPERFUSION THERAPY, IMMEDIATE ANGIOPLASTY, PRIMARY ANGIOPLASTY, TIMI RISK SCORE, MANAGEMENT, TRIAL, FIBRINOLYSIS
journal title
ARCHIVES OF INTERNAL MEDICINE
Arch. Intern. Med.
volume
171
issue
6
pages
544 - 549
Web of Science type
Article
Web of Science id
000288864100010
JCR category
MEDICINE, GENERAL & INTERNAL
JCR impact factor
11.462 (2011)
JCR rank
7/153 (2011)
JCR quartile
1 (2011)
ISSN
0003-9926
DOI
10.1001/archinternmed.2011.57
language
English
UGent publication?
yes
classification
A1
copyright statement
I have transferred the copyright for this publication to the publisher
id
3051938
handle
http://hdl.handle.net/1854/LU-3051938
date created
2012-11-13 10:49:45
date last changed
2015-06-17 10:18:16
@article{3051938,
  abstract     = {Background: Current ST-segment elevation myocardial infarction guidelines regarding reperfusion strategy are based on trials conducted before the application of routine invasive evaluation after thrombolysis. Modern thrombolysis may affect the previously observed mortality difference between primary percutaneous coronary intervention (PPCI) and thrombolysis. 
Methods: In-hospital mortality was prospectively assessed in 5295 patients with ST-segment elevation myocardial infarction admitted to 73 Belgian hospitals from July 1, 2007, through December 31, 2009. A total of 4574 patients (86.4\%) were treated with PPCI and 721 (13.6\%) received thrombolysis; of these thrombolysis patients, 603 (83.6\%) underwent subsequent invasive evaluation. The Thrombolysis in Myocardial Infarction risk score was used to stratify the study population by low (n = 1934), intermediate (n = 2382), and high (n = 979) risk. 
Results: In-hospital mortality in the PPCI patients was 5.9\% vs 6.6\% in the thrombolysis patients. After adjustment for differences in baseline risk profile, a significant mortality benefit was only present in the high-risk groups: 23.7\% in the PPCI patients vs 30.6\% in the thrombolysis patients. For patients not at high risk, the mortality difference was marginal. For low-risk patients, mortality was 0.3\% in the PPCI patients vs 0.4\% in the thrombolysis patients. For intermediate-risk patients, mortality was 2.9\% in the PPCI patients vs 3.1\% in the thrombolysis patients. Subgroup analysis revealed that the mortality benefit of PPCI compared with early thrombolysis (door-to-needle time {\textlangle}30 minutes) was offset if the door-to-balloon time exceeded 60 minutes. 
Conclusions: Modern thrombolytic strategies have substantially attenuated the absolute mortality benefit of PPCI over thrombolysis, particularly in patients not at high risk. Our study findings suggest that target door-to-balloon time should be less than 60 minutes to maintain the lowest mortality rates.},
  author       = {Claeys, Marc J and de Meester, Antoine and Convens, Carl and Dubois, Philippe and Boland, Jean and De Raedt, Herbert and Vranckx, Parscal and Coussement, Patrick and Gevaert, Sofie and Sinnaeve, Peter and Evrard, Patrick and Beauloye, Christophe and Renard, Marc and Vrints, Christiaan},
  issn         = {0003-9926},
  journal      = {ARCHIVES OF INTERNAL MEDICINE},
  keyword      = {LONG,NATIONAL REGISTRY,HOSPITAL MORTALITY,REPERFUSION THERAPY,IMMEDIATE ANGIOPLASTY,PRIMARY ANGIOPLASTY,TIMI RISK SCORE,MANAGEMENT,TRIAL,FIBRINOLYSIS},
  language     = {eng},
  number       = {6},
  pages        = {544--549},
  title        = {Contemporary mortality differences between primary percutaneous coronary intervention and thrombolysis in ST-segment elevation myocardial infarction},
  url          = {http://dx.doi.org/10.1001/archinternmed.2011.57},
  volume       = {171},
  year         = {2011},
}

Chicago
Claeys, Marc J, Antoine de Meester, Carl Convens, Philippe Dubois, Jean Boland, Herbert De Raedt, Parscal Vranckx, et al. 2011. “Contemporary Mortality Differences Between Primary Percutaneous Coronary Intervention and Thrombolysis in ST-segment Elevation Myocardial Infarction.” Archives of Internal Medicine 171 (6): 544–549.
APA
Claeys, M. J., de Meester, A., Convens, C., Dubois, P., Boland, J., De Raedt, H., Vranckx, P., et al. (2011). Contemporary mortality differences between primary percutaneous coronary intervention and thrombolysis in ST-segment elevation myocardial infarction. ARCHIVES OF INTERNAL MEDICINE, 171(6), 544–549.
Vancouver
1.
Claeys MJ, de Meester A, Convens C, Dubois P, Boland J, De Raedt H, et al. Contemporary mortality differences between primary percutaneous coronary intervention and thrombolysis in ST-segment elevation myocardial infarction. ARCHIVES OF INTERNAL MEDICINE. 2011;171(6):544–9.
MLA
Claeys, Marc J, Antoine de Meester, Carl Convens, et al. “Contemporary Mortality Differences Between Primary Percutaneous Coronary Intervention and Thrombolysis in ST-segment Elevation Myocardial Infarction.” ARCHIVES OF INTERNAL MEDICINE 171.6 (2011): 544–549. Print.