Primary PCI for STEMI — Pushing the Limits

The optimal management of patients with ST-elevation myocardial infarction (STEMI) has been the subject of ongoing clinical investigations for the past several decades. When it became apparent that primary angioplasty was not only feasible, but superior, to thrombolytic therapy in randomized clinical trials,1 there was universal adoption of primary percutaneous coronary intervention (PCI) for those centers that perform PCI. The belief that primary PCI was superior to thrombolytic therapy as the initial treatment of STEMI is so strong that many centers that previously administered thrombolytic therapy for STEMI have switched to triage for primary PCI centers for primary PCI, although definitive evidence supporting this strategy is lacking. In this issue of the Journal, Aplin and colleagues2 present the results of a regionally implemented triage for primary PCI for STEMI experience. Acting as the hub of a wheel 100 miles in radius in central Minnesota, 25 hospitals which had previously administered thrombolytics were switched to primary PCI at St. Cloud Hospital, the PCI center, using helicopter transfer for the vast majority of patients (71%). This experience was notable for a median door-to-balloon (D2B) time of 110 minutes (mins) from the referral sites compared to only 56 mins at the PCI center. Primary PCI success was over 99% for both referral patients as well as those presenting to the PCI center itself, with the majority receiving drug-eluting stents. In-hospital outcomes appeared to be excellent, with low mortality rates of approximately 2% and 1-year mortality rates of 120 mins. ACC/AHA guidelines have recently been updated describing the goals for patients presenting with STEMI at non-PCI-capable hospitals.3 These guidelines recommend that transfer for primary PCI in lieu of thrombolytic therapy should be considered if the door-to-needle time can be achieved in 60 mins, there is still a benefit of reperfusion therapy, but the relative benefit is reduced. Almost none of the patients undergoing primary PCI achieve reperfusion times of From the Section of Cardiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina. The author reports no conflicts of interest regarding the content herein. Address for correspondence: Robert J. Applegate, MD, FACC, FSCAI, Section of Cardiology, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157-1045. E-mail: bapplega@wfubmc.edu

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