Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Interhospital transfer for primary angioplasty: the call for a goal
- Mario Ivanusa (18 April 2005)
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Reducing mortality in myocardial infarction
- Michael P Pitt, Gordon Murray, James Beattie, Nadia ElGaylani (19 April 2005)
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Cuba: Thrombolysis for all
- Pedro O. Ordúñez-García, MD, Marcos Iraola-Ferrer, MD, Yanelis La Rosa-Linares, MD (19 April 2005)
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Aborted myocardial infarction with prehospital thrombolysis
- Wolfgang Kasper (20 April 2005)
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re Reducing mortality in myocardial infarction
- Iain J Mungall, A Gordon Baird, the White House, Sandhead, Stranraer, RCGP Rural Practice Group (25 April 2005)
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Mario Ivanusa, Internist, Cardiologist Dept. of Internal Medicine, Bjelovar General Hospital, HR-43000 Bjelovar, Croatia
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I read with interest the editorial by Townend and Doshi.[1] Regarding the benefit of primary percutaneous coronary intervention (pPCI) the authors did not point out two advantages of this treatment: long-term benefit and better preservation of working ability with consequently reduction of direct and indirect costs of coronary heart disease (CHD). One-size fibrinolytic therapy with streptokinase is associated with worse long-term clinical outcomes in relation to pPCI, especially in anterior ST segment elevation myocardial infarction.[2,3] The largest contributors to the expenditure of CHD are indirect cost of lost productivity resulting from morbidity and mortality (50.2% from the total cost of CHD in USA in 2005) and hospital charges (28.1%).[4] As shown by Le May et al. the pPCI is cost saving compared with thrombolysis.[5] However, indirect costs would also be expected to be less, because this strategy reduced hospitalization days. The waiting list for percutaneous coronary intervention will shorten and the return-to-work rates will increase. References 1. Townend JN, Doshi SN. Reducing mortality in myocardial infarction. BMJ 2005:330:856-7. 2. Zijlstra F, Hoorntje JCA, de Boer MJ. Reiffers S, Miedema K, Ottervanger JP, et al. Long-term benefit of primary angioplasty as compared with thrombolytic therapy for acute myocardial infarction. N Engl J Med 1999;341:1413–9. 3. Henriques JPS, Zijlstra F, van 't Hof AWJ, de Boer MJ, Dambrink JHE, Gosselink M, et al. Apr 14, 2005. Primary PCI versus thrombolytic therapy: long-term follow-up according to infarct location. Heart doi:10.1136/hrt.2005.060152 4. American Heart Association. Heart Disease and Stroke Statistics — 2005 Update. Dallas, Texas.: American Heart Association; 2005. 5. Le May MR, Davies RF, Labinaz M, Sherrard H, Marquis JF, Laramee LA, et al. Hospitalization costs of primary stenting versus thrombolysis in acute myocardial infarction: cost analysis of the Canadian STAT study. Circulation 2003;108:2624-30. Competing interests: None declared |
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Michael P Pitt, Consultant Cardiologist Heart of England NHS Trust, Bordesley Green East, Birmingham. B9 5SS, Gordon Murray, James Beattie, Nadia ElGaylani
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Dear Sir, A short ambulance ride distant to the tertiary cardiac centre from where doctors Townend and Doshi (1) expound the virtues of prehospital thrombolysis plus early revascularisation lies a district hospital which has operated a policy of primary angioplasty for over 2 years. In the latter institution staffed by 4 cardiologists (see author list), over 200 primary angioplasty procedures have been performed with a 30 day mortality of 6.5%, reduced hospital lengths of stay and comparable longterm cost effectiveness as compared to thrombolysed patients. Although sometimes inconvenient, true unsocial hours cases (midnight to 8am) represent only 20% of the total primary angioplasty burden. Few now dispute the evidence for primary angioplasty (2). As yet there are no robust data demonstrating superiority of prehospital thrombolysis over primary angioplasty. CAPTIM (3) was not completed and a quarter of the study population required rescue angioplasty for failed reperfusion. Townend and Doshi do not clearly state their position on the management of failed thrombolysis. GRACIA 1 (4) merely tells us that thrombolysed patients are probably better off with revascularisation prior to discharge rather than later, irrespective of whether ongoing ischaemia is demonstrated (the open artery hypothesis). Several ongoing and planned trials will tell us whether facilitated intervention (thrombolysis plus angioplasty within 3 –12 hours) is superior to primary angioplasty. Until the case for primary angioplasty is undermined in appropriate randomised trials then perhaps we should be striving to introduce the optimal and proven strategy concentrating on an evidence based rather than convenience based approach. References 1. Townend JN, Doshi SN. Reducing mortality in myocardial infarction. BMJ 2005;330:856-857. 2. Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials. Lancet 2003;361: 13-20 3. Bonnefoy E, Lapostolle F, Leizorovicz A, Steg G, McFadden EP, Dubien PY, et al. Primary angioplasty versus prehospital fibrinolysis in acute myocardial infarction: a randomised study. Lancet 2002;360: 825-9. 4. Fernandez-Aviles F, Alonso JJ, Castro-Beiras A, Vazquez N, Blanco J, Alonso-Briales J, et al. Routine invasive strategy within 24 hours of thrombolysis versus ischaemia-guided conservative approach for acute myocardial infarction with ST-segment elevation (GRACIA-1): a randomised controlled trial. Lancet 2004;364: 1045-53 Competing interests: None declared |
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Pedro O. Ordúñez-García, MD, General Director Hospital Gustavo ALdereguía, Cienfuegos 55 100. Cuba, Marcos Iraola-Ferrer, MD, Yanelis La Rosa-Linares, MD
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Editor- The CVD epidemic has reached full maturity in Cuba and accounts for 40% of deaths. The age-adjusted mortality in 2003 was 41% lower than the comparable rate recorded in 1970. The reduction in mortality from coronary heart disease, which account for nearly 74% of all cardiovascular deaths, drove the overall decline in cardiovascular mortality.1 Data from Cuba are highly accuracy since registration has been consistently high over this 30 year period and deaths attributed to ill- defined causes have remained very low (0.7%). Virtually all deaths are certified by a physician. In Cienfuegos province, demonstration site of Cuba to CVD prevention and control, the number of admissions for acute myocardial infarction (AMI) doubled over the period 1990-2003. Over this same period the case fatality rates have declined 40-50% suggests that less severe cases are being admitted, although the quality of care is also improving. This latter possibility is supported by the fact that over this period thrombolytic therapy –the standard treatment in Cuba-- became widely available and it was recently reinforce with the pre-hospital treatment units that were created in each municipality. In addition, Cienfuegos Hospital reached a total thrombolysis rate over 60% and a door-needle time around 30 minutes for more than 90% of all patients with AMI and ST elevation.2,3 Since we recognize the importance of a “three Ps” approach4 we consider that on the circumstance of poor countries the optimization of thrombolysis therapy including the promotion of “Golden Hour” still had a great potential to reduce the mortality for AMI before the angioplasty will be introduce. Given the high level of education of the Cubans, the universal access to health care and large public health infrastructure, Cuba offers an exceptional opportunity to answer some of the questions associated to thrombolytic treatment particularly on the context of a public, accessible and free health system for all. References: 1. Cooper RS, Ordunez P, Iraola-Ferrer M, et al. Cardiovascular disease and associated risk factors in Cuba: Prospects for prevention and control. Am J Public Health. In press. 2. Iraola MD, Valladares FJ, Álvarez FC, Nodal JR, Rodríguez B. Optimización del tratamiento médico en el infarto agudo de miocardio. Clínica Cardiovascular 2000; 18: 11-16. 3. Iraola M, Ordúñez P, Alvarez F, Santos M, Valladares F, Rodríguez B, González C. Unidad de cuidados intensivos cardiológicos: impacto sobre la mortalidad por infarto agudo del miocardio. Mejora continua de la calidad. MIO 2002; 2 (4): 23. 4. Townend JN, Doshi SN. Reducing mortality in myocardial infarction. BMJ 2005; 330; 856-857. Competing interests: None declared |
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Wolfgang Kasper, Chief of Cardiology 65189 Wiesbaden
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The authors discussed that prehospital thrombolysis within 2 hrs of symptom onset may be superior at least equivalent to early mechanical reperfusion. I would like to add another interesting observation favoring prehospital thrombolysis ,which was not discussed in that article.We and others have observed aborted myocardial infarction with prehospital thrombolysis a clinical effect not yet described for studies using mechanical reperfusion (1,2). In our study prehospital thrombolysis was performed on 93 Patients with ST-elevation myocardial ischemia with rt-PA in an urban area.Thrombolysis could be initiated within 2 hrs after symptom onset in 67 (73.6%) patients. Aborted infarction (cardiac enzymes CK,CK-MB rise less than 2 times upper limit and no new Q-waves) was observed in 18 patients (20%), despite obvious signs of myocardial ischemia on the prehospital ECG.Thus, randomised trials testing reperfusion strategies on acute myocardial infarction should include the rate of aborted infaction as one major treatment goal in the future. 1)Kasper W, Furtwängler A,Martin U, et al. Prehospital thrombolysis with rt-PA. A reperfusion strategy in the time management concept of acute myocardial infarction. Med Klin 1999,94:361-66 2)Lamfers EJP, Hooghoudt THE, Uppelschoten A,et al. The effect of prehospital thrombolysis on aborting myocardial infarction. Am J Cardiol 1999;84:928-30 Competing interests: None declared |
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Iain J Mungall, General Practitioner Bellingham NE48 2HE, A Gordon Baird, the White House, Sandhead, Stranraer, RCGP Rural Practice Group
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Townend’s [1] editorial should be a useful reminder of the importance of access to highly specialised care if outcomes are to be improved. It has been demonstrated that distance to tertiary care for ischaemic heart disease leads to reduced intervention rates[2]. Where general practitioners have been able to provide care locally such as thrombolysis this has been taken up effectively[3]. Rural patients suffer significant geographical and organisational barriers to tertiary care. If we are to produce an equitable service that will reduce mortality overall by delivering time dependent treatments in centralised facilities we need to engage in a more robust dialogue. This will require careful thinking involving general practitioners, specialists, community hospitals, manager and tertiary referral centres. Everyone will benefit from clear referral pathways. The challenge is to make sure that care is provided in a way that rural patients are not further disadvantaged by centralisation. It is not impossible to meet these challenges[4]. Yours sincerely 1. Townend, J.N. and S.N. Doshi, Reducing mortality in myocardial infarction. p. 856-7, 2005 Apr 16. 2. Black, N., S. Langham, and M. Petticrew, Coronary revascularisation: why do rates vary geographically in the UK?[see comment]. p. 408-12, 1995 Aug. 3. Rawles, J., Halving of mortality at 1 year by domiciliary thrombolysis in the Grampian Region Early Anistreplase Trial (GREAT). p. 1-5, 1994 Jan. 4. Seidel, J.E., et al., Geographical location of residence and uniformity of access to cardiac revascularization services after catheterization. p. 517-23, 2004 Apr. Competing interests: None declared |
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