Article Citation: Andersen HR, Nielsen TT, Rasmussen K, Thuesen L, et al; DANAMI-2 Investigators. A comparison of coronary angioplasty with fibrinolytic therapy in acute myocardial infarction. N Engl J Med. 2003 Aug 21;349(8):733-42. PMID: 12930925
What we already know about the topic: Globally, ischemic heart disease is the leading cause of death amongst adults. The AHA/ESC estimate the incidence of STEMI at ~50 / 100,000 people. Over the last 30 years the management of STEMI has drastically changed. By the mid-1990s, there was strong evidence to support percutaneous coronary intervention (PCI) over primary fibrinolysis in STEMI patients who arrived at PCI capable centers.
Why this study is important: Despite this evidence, a significant amount of hospitals are not PCI centers. The authors of this study sought to compare 30 day mortality, reinfarction, and stroke amongst STEMI patients who presented at non-PCI capable centers that then were randomized to either (1) primary fibrinolysis or (2) immediate transfer to a PCI capable center.
Brief overview of the study: This was a multicenter (24 referral hospitals, 5 PCI centers) randomized control trial in Denmark that enrolled consecutive patients 18 years or older with STEMI (4mm of cumulative elevation in 2 leads) with chest pain less than 12 hours. Patients were excluded if they had LBBB, previous AMI with fibrinolysis in the previous 30 days, pulseless femoral arteries, previous CABG, renal failure, DM on metformin, nonischemic heart disease, or were too high risk for transfer (patients in cardiogenic shock, need for mechanical ventilation, persistent life threatening arrhythmias). At the referral centers, 1129 STEMI patients were randomized to fibrinolysis (562) or transport for angioplasty (567). The median distance between referral center and PCI center was 50km and the median transfer time from referral center to the receiving cath lab of 67 minutes. 96% of patients arrived at the cath lab within 2 hours of randomization. 30 day mortality, reinfarction, and stroke were assessed. The authors found a no statistically significant difference in 30 day mortality or stroke. There was a statistically significant difference in 30 day reinfarction rate, however, in favor of transfer for PCI with an overall NNT of 17. Of note, a follow up analysis of those that did re-infarct had their own 30 day mortality of 24.2%.
Limitations: Overall I think this was a great study. The population under study is very homogenous, which may limit the studies applicability in more diverse settings of the United States. Because 96% of patients were transported from referral center to cath lab occurred in 2 hours or less, there may be limited applicability of this data to more remote places in North America.
Take home points: If your hospital is within 2 hours of a PCI capable center, you should be transferring all your STEMI patients without contraindications for primary PCI as it dramatically reduces the rate of 30 day reinfarction. NNT= 17!