Impact of Time to Treatment on Mortality After Prehospital Fibrinolysis or Primary Angioplasty
Why the study?
Does prehospital thrombolysis compared to primary PCI reduce the composite of death, nonfatal reinfarction, and disabling stroke in patients with STEMI based on time from symptom onset?
Population
834 patients with ST-segment-elevation myocardial infarction randomized within 2 hours or ≥2 hours after…
Comparison
Prehospital thrombolysis with transfer to an… vs Primary percutaneous coronary intervention (PCI)
Design
RCT, Randomized
Follow-up
30-day
Authors
Discussion
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Implication
Supports prehospital thrombolysis preference in early STEMI; extends randomized evidence on time-dependent reperfusion effects.
Key Points
- To evaluate whether time elapsed from symptom onset influences the comparative efficacy of prehospital thrombolysis versus primary percutaneous coronary intervention in patients with STEMI.
- Subgroup analysis of the randomized CAPTIM trial comparing prehospital thrombolysis (with transfer for potential PCI) versus primary PCI in patients with ST-segment-elevation myocardial infarction.
- Patients were categorized by symptom-to-randomization delay: early (<2 hours, n=460) or late (≥2 hours, n=374).
- Evaluated outcomes included 30-day mortality, cardiogenic shock, and a combined primary endpoint of death, nonfatal reinfarction, and disabling stroke.
- In patients randomized within 2 hours, 30-day mortality showed a strong trend favoring prehospital thrombolysis over primary PCI (2.2% vs 5.7%, P=0.058), with a significant treatment-by-delay interaction (hazard ratio 4.19, 95% CI 1.033 to 17.004, P=0.045); mortality was 5.9% vs 3.7% in those randomized at ≥2 hours (P=0.47).
- Cardiogenic shock occurred significantly less often with prehospital thrombolysis than primary PCI in the <2-hour cohort (1.3% vs 5.3%, P=0.032), whereas incidence rates were similar in patients randomized after 2 hours.
- Time to randomization had no significant effect on the 30-day composite endpoint of death, nonfatal reinfarction, and disabling stroke.
Structured PICO
Does prehospital thrombolysis compared to primary PCI reduce the composite of death, nonfatal reinfarction, and disabling stroke in patients with STEMI based on time from symptom onset?
P
Population
834 patients with ST-segment-elevation myocardial infarction (STEMI) randomized within 2 hours (n=460) or ≥2 hours (n=374) after symptom onset
I
Intervention
Prehospital thrombolysis with transfer to an interventional facility (and, if needed, percutaneous intervention)
C
Comparator
Primary percutaneous coronary intervention (PCI)
O
Outcome
30-day combined primary end point of death, nonfatal reinfarction, and disabling strokecomposite
Prehospital thrombolysis may be preferable to primary PCI for STEMI patients treated within the first 2 hours after symptom onset, highlighting the critical importance of time to reperfusion.
Cite This Study
Steg et al. (2003) studied this question.