Comprehensive meta-analysis of radial vs femoral approach in primary angioplasty for STEMI

Introduction

Primary angioplasty has improved survival as compared to thormbolysis. However, bleeding complications still represent the Achille's heel, mainly related to access site. Although the radial approach is getting larger consensus for elective percutaneous procedures, its safety and advantages in the setting of ST-segment elevation (STEMI) is controversial. Therefore, the aim of the current study was to perform a comprehensive meta-analysis of randomized and non randomized trials comparing radial vs transfemoral approach in primary angioplasty for STEMI.

Methods

The literature was scanned by formal searches of electronic databases (MEDLINE, Pubmed) from January 1990 to October 2012. No language restrictions were enforced.

Results

A total of 27 trials were finally included, with 29,194 patients (4685 enrolled in 11 randomized trials and 24,509 in 15 non randomized trials). A total of 10,052 patients underwent radial approach and 19,142 patients underwent femoral approach. A total of 2499 patients (8.6%) had died at follow-up. Radial approach was associated with a significant reduction in short-term mortality (5.2% vs 10.3%, OR [95% CI] = 0.55 [0.40, 0.76], p < 0.001, p het = 0.97) (primary endpoint). Significant benefits were observed in both randomized (2.7% vs 4.7%, OR [95% CI] = 0.55 [0.40, 0.76], p < 0.001, p het = 0.97) and observational studies (5.9% vs 11.1%, OR [95% CI] = 0.48 [0.43, 0.54, p < 0.001, p het = 0.44]). Major bleeding complications were observed in a total of 808 patients (2.8%). Radial approach was associated with a significant reduction in major bleeding complications as compared to femoral approach (1.9% vs 4.7%, OR [95% CI] = 0.38 [0.31, 0.47], p < 0.0001, p het = 0.17), similarly in both randomized (2.7% vs 5%, OR [95% CI] = 0.51 [0.37, 0.70], p < 0.001, p het = 0.87) and observational studies (1.4% vs 4.6%, OR [95% CI] = 0.32 [0.25, 0.42], p < 0.0001, p het = 0.32). Both benefits in death and major bleeding complications were not related to baseline risk profile.

Conclusions

This meta-analysis of randomized and non-randomized trials showed that among STEMI patients undergoing primary angioplasty the radial approach is associated with a consistent reduction in mortality and major bleeding complications and. Therefore, routine use of radial approach should be strongly encouraged in primary angioplasty.     

Cilostazol added to aspirin and clopidogrel reduces revascularization without increases in major adverse events in patients with drug-eluting stents: A meta-analysis of randomized controlled trials

Background

The effects of cilostazol added to aspirin and clopidogrel (triple antiplatelet therapy: TAT) on clinical outcomes after drug-eluting stent (DES) implantation are unknown.

Methods

We conducted a meta-analysis of randomized controlled trials (RCTs) comparing TAT with aspirin and clopidogrel (dual antiplatelet therapy: DAT) in DES patients. Clinical end points were target lesion (TLR) and/or vessel (TVR) revascularization, death, myocardial infarction (MI), stent thrombosis (ST), bleeding, rash, gastrointestinal (GI) side effects, and drug discontinuation. We calculated the pooled estimate based on a fixed-effects model using Peto odds ratio (OR) for rare events. If heterogeneity was observed across an individual RCT, an analysis based on a random-effects model was performed.

Results

Eight RCTs were included in this meta-analysis, involving 3590 patients (TAT:DAT = 1800:1790). Up to 24 months, TAT showed a significant reduction in TLR (OR: 0.58, 95% confidence interval (CI): 0.43 to 0.78, p < 0.001) and TVR (OR: 0.58, 95% CI: 0.40 to 0.83, p = 0.003) compared with DAT. The incidence of death, MI, ST, or overall or major bleeding was comparable between the 2 groups, whereas the proportion of rash (OR: 2.50, 95% CI: 1.52 to 4.10, p < 0.001), GI side effects (OR: 3.14, 95% CI: 1.79 to 5.50, p < 0.001), or drug discontinuation (OR: 6.81, 95% CI: 2.12 to 21.86, p < 0.001) was higher in TAT than DAT.

Conclusions

In this meta-analysis, TAT was associated with significantly effective outcomes for TLR and TVR without any increase in major adverse events but was associated with tolerance issues compared with DAT after DES implantation.     

Short and long-term benefits of sirolimus-eluting stent in ST-segment elevation myocardial infarction: a meta-analysis of randomized trials

Background Recent concerns have emerged on the potential higher risk of stent thrombosis after DES implantation, that might be even more pronounced among STEMI patients. The aim of the current study was to perform a meta-analysis to evaluate the benefits and safety of Sirolimus-Eluting Stent (SES) as compared to BMS in patients undergoing primary angioplasty for STEMI. Methods The literature was scanned by formal searches of electronic databases (MEDLINE and CENTRAL). We examined all completed randomized trials of DES for STEMI. The following keywords were used for study selection: randomized trial, myocardial infarction, reperfusion, primary angioplasty, stenting, DES, sirolimus-eluting stent (SES), Cypher. Information on study design, type of stent, inclusion and exclusion criteria, primary endpoint, number of patients, angiographic and clinical outcome, were extracted by two investigators. Disagreements were resolved by consensus. Results A total of 9 trials were included in the meta-analysis, involving 2,769 patients (1389 or 50.2% randomized to DES and 1,380 or 49.8% randomized to BMS). At 12 months follow-up, SES was associated with a significant reduction in TVR (4.9% vs. 13.6%, p < 0.0001), with a trend in benefits in mortality (2.9% vs. 4.2%, p = 0.08) and reinfarction (3.0% vs. 4.3%, p = 0.06), without any significant difference in stent thrombosis (1.9% vs. 2.5%, p = 0.36). Safety and efficacy of DES were confirmed at 2–3 years follow-up (data available from 4 trials including 569 patients). Conclusions This meta-analysis shows that among selected STEMI patients undergoing primary angioplasty, SES as compared to BMS is safe and associated with a significant reduction in TVR at 1 and 2–3 years follow-up.     

Impact of Omega-3 supplementation on homocysteine levels in humans: A systematic review and meta-regression analysis of randomized controlled trials

AimsAlthough some evidence suggests that omega-3 polyunsaturated fatty acids (PUFAs) supplementation influences enzymes involved in forming homocysteine (Hcy) and improving hyperhomocysteinemia, these findings are still contradictory in humans. The aim of this systematic and meta-analysis study was to investigate the effects of omega-3 supplementation on Hcy using existing randomized controlled trials (RCTs).Data synthesisAvailable databases, including PubMed/MEDLINE, Web of Science, Scopus, Cochrane Library, and Embase, were searched to find relevant RCTs up to June 2021. The effect size was expressed as weighted mean difference (WMD) and 95% confidence interval (CI).ConclusionA total of 20 RCT studies with 2676 participants were included in this article. Our analyses have shown that omega-3 supplementation significantly reduced plasma Hcy levels (WMD: 1.34 μmol/L; 95% CI: 1.97 to ?0.72; P < 0.001) compared to the control group. The results of subgroup analysis showed that omega-3 supplementation during the intervention <12 weeks and with a dose ≥3 gr per day causes a more significant decrease in Hcy levels than the intervention ≥12 weeks and at a dose <3 gr. In addition, omega-3 supplements appear to have more beneficial effects in individuals with high levels of normal Hcy. This meta-analysis showed that omega-3 supplementation significantly improved Hcy. However, further studies are needed to confirm the findings.     

Is bare-metal stenting superior to balloon angioplasty for small vessel coronary artery disease? Evidence from a meta-analysis of randomized trials.

AIMS: To compare, by meta-analytical techniques, the clinical impact of bare-metal stenting vs. balloon angioplasty for the treatment of lesions in small coronary arteries. METHODS AND RESULTS: We included trials with random allocation and prospective comparison of angioplasty vs. stenting, reference vessel diameter<3 mm, and follow-up>or=6 months. Random effect odds ratios (OR) for death, myocardial infarction (MI), repeat revascularization (RR), and major adverse cardiac events (MACEs) were computed. In a pre-specified subgroup analysis, we compared stenting with optimal (post-procedural stenosis<20%) and suboptimal (>20%) angioplasty. Thirteen studies (4383 patients) were selected. No differences were found in terms of death and MI, while MACEs, mainly driven by RR, were significantly less common after stenting (17.6%) than after angioplasty (22.7%), OR 0.71 (0.57-0.90). Heterogeneity among trials was present. When considering only optimal angioplasty, MACE rates were homogeneously similar, 17.9 vs. 21.1%, OR 0.86 (0.66-1.11). If angioplasty were suboptimal, MACEs were significantly more common after angioplasty (24%) than after stenting (17.3%), OR 0.62 (0.44-0.88). CONCLUSION: Stenting is superior to balloon angioplasty for the treatment of small vessels, in particular after suboptimal angioplasty. However, MACE and RR rates remain high after stenting, and the advantage of stent over angioplasty is moderate. An optimal balloon angioplasty strategy (with provisional stenting) may achieve results not inferior to routine stenting.     

Facilitation of primary coronary angioplasty by early start of a glycoprotein 2b/3a inhibitor: results of the ongoing tirofiban in myocardial infarction evaluation (On-TIME) trial.

AIM: Although primary angioplasty is effective despite additional transportation delay, improved patency before PCI might be obtained by starting pharmacological pre-treatment before transportation. METHODS AND RESULTS: From June 2001 to November 2002, 507 patients with acute myocardial infarction, who were transferred to a PCI centre, were randomised to early, pre-hospital initiation of Tirofiban (Early) or to initiation in the catheterisation laboratory (Late). The primary end-point was TIMI flow grade 3 of the infarct-related vessel (IRV) at initial angiography, as assessed by an independent core-lab. The effect of Tirofiban on each TIMI flow component, the presence of thrombus at initial angiography and pre-PCI myocardial blush grade were secondary end-points. A large proportion of patients (41%) was diagnosed and randomised in the ambulance, without intervention of a physician. In the Early group, Tirofiban was administered a median of 59 min (range 11-178 min) earlier than in the Late group. At initial angiography, TIMI 3 flow was present in 19% the Early group and in 15% in the Late group (P = 0.22). The combined incidence of TIMI 2 or 3 flow was present in 43% in the Early group and in 34% in the Late group, respectively (P = 0.04). Thrombus or a fresh occlusion was present in 60% and 73% in the Early and Late group, respectively (P = 0.002). A pre-PCI myocardial blush grades 2 or 3 was more often present in the Early group (30% vs. 22%, P = 0.04). However, no difference in TIMI 3 flow or myocardial blush grade was found between the groups, post-PCI. At one-year follow-up, the combined incidence of death or recurrent MI was not different between the groups (7.0% vs. 7.0%, P = 0.99). CONCLUSION: Early initiation of Tirofiban did not improve initial TIMI 3 flow of the IRV significantly. Despite a better patency (TIMI 2 or 3 flow), a lower prevalence of thrombus or fresh occlusion and a better myocardial perfusion in the infarct-related region pre-PCI, no beneficial effect on post-PCI angiographic or clinical outcome was found, as compared to initiation of Tirofiban in the catheterisation laboratory.     

Impact of multivessel disease on infarct size among STEMI patients undergoing primary angioplasty

Background

Although primary angioplasty achieves Thrombolysis In Myocardial Infarction (TIMI) 3 flow in most patients with ST-elevation myocardial infarction, epicardial recanalization does not guarantee optimal perfusion in a large proportion of patients. Multivessel disease has been demonstrated to be associated with impaired survival, however its impact on infarct size has not been largely investigated, that therefore is the aim of the current study.

Methods

Our population is represented by 827 STEMI patients undergoing primary PCI. Infarct size was evaluated at 30 days by technetium-99m-sestamibi.

Results

Multivessel disease was observed in 343 patients (41.5%). It was associated with older age (65 [57–74] vs 63 [53–71], p < 0.001), higher rate of previous MI (6.4% vs 2.5%, p = 0.005), longer ischemia time evaluated as continuous variable (210 [155–280] min vs 196 [145–270] min, p = 0.065) or percentage of patients with ischemia time >3 h (63.7% vs 56.4%, p = 0.038), and a trend in more cardiogenic shock (5.5% vs 2.9%, p = 0.055). Patients with multivessel disease received more often Abciximab (92.1% vs 88.4%, p < 0.001), Intra-aortic balloon pump (6.4% vs 1.9%, p < 0.001). No differences were observed in other clinical or angiographic characteristics. In particular, multivessel disease did not affect the rate of postprocedural TIMI 3 flow (90.9% vs 93.4%, p = 0.18) and ST-segment resolution (52.4% vs 54.9%, p = 0.48). Multivessel disease did not affect infarct size (12.7% [4.5%–24.9%] vs 12.3% [4%–24.1%], p = 0.58). Similar results were observed in subanalyses without any significant interaction for each variable (anterior infarct location (p int = 0.23), gender (p int = 0.9), age (p int = 0.7), diabetes (p int = 0.15)). The absence of any impact of multivessel disease on infarct size was confirmed when the analysis was conducted according to the percentage of patients with infarct size above the median, even after correction for baseline characteristics, such as age, previous MI, ischemia time, use of Gp IIb–IIIa inhibitors, cardiogenic shock, ischemia time (OR [95% CI] = 1.09 [0.82–1.45], p = 0.58).

Conclusions

This study shows that among STEMI patients undergoing primary PCI multivessel disease does not affect infarct size.     

Impact of vessel size on distal embolization, myocardial perfusion and clinical outcome in patients undergoing primary angioplasty for ST-segment elevation myocardial infarction

Background Mounting interest has emerged on the role of distal embolization as a major explanation of poor myocardial perfusion among patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary angioplasty. The aim of the current study was to evaluate the relationship between vessel size, distal embolization, myocardial perfusion and clinical outcome in patients with STEMI treated by primary angioplasty. Methods Our population is represented by 1969 patients with STEMI undergoing primary stenting from 1997 to 2002. All clinical, angiographic, and follow-up data were prospectively collected. Results Vessel size was linearly associated with gender, diabetes, anterior infarction location, shorter time-delay, the rate of stenting and glycoprotein IIb-IIIa inhibitors. Small vessel size was associated with poor perfusion, despite lower rates of distal embolization. These data were confirmed after correction for confounding factors. The higher risk profile and poor myocardial perfusion contribute to explain the worse outcome observed in patients with smaller vessel size. Conclusions This study shows that in patients undergoing primary angioplasty for STEMI, small vessel size is associated with poor myocardial perfusion, despite less distal embolization, that contributes to explain the worse outcome observed among patients with small infarct related arteries.     

Impact of diabetes on survival in patients with ST-segment elevation myocardial infarction treated by primary angioplasty: Insights from the POLISH STEMI registry

Background

It has been shown that, among patients with ST-segment elevation myocardial infarction (STEMI), diabetes is associated with a significantly higher mortality. The aim of this study was to investigate in a large cohort of patients the impact of diabetes on mortality in a large cohort of patients with STEMI treated with primary angioplasty.

Methods

Our population is represented by consecutive patients with STEMI treated by primary angioplasty and enrolled in the POLISH registry in 2003. All clinical, angiographic, and follow-up data were prospectively collected. Diagnosis of diabetes was based on history of diabetes at admission.

Results

Among 7193 patients, 877 (12.2%) had diabetes at admission. Diabetes was associated with more advanced age (p < 0.0001), higher prevalence of female gender (p < 0.0001), hyperlipidemia (p < 0.0001), shock at presentation (p < 0.0001), renal failure (p < 0.0001), previous myocardial infarction (p < 0.0001), more often treated after 6 h from symptom onset (p < 0.0001). Diabetes was associated with more extensive coronary artery disease (p < 0.0001), less often treated with stenting (p < 0.0001). Diabetes was significantly associated with impaired epicardial reperfusion (TIMI 0–2: OR [95% CI] = 1.81 [1.5–2.18], p < 0.0001), that persisted after correction for baseline confounding factors (OR [95% CI] = 1.33 [1.075–1.64], p = 0.009). At a mean follow-up of 524 ± 194 days, diabetes was associated with higher mortality (unadjusted cumulative mortality: 23.5% vs. 12.6%, unadjusted HR = 1.95 [1.66–2.3], p < 0.0001), that persisted after correction for confounding factors (adjusted cumulative mortality: 13.3% vs. 10.7%, adjusted HR = 1.23 [1.04–1.46], p = 0.013).

Conclusions

This study shows that among STEMI treated by primary angioplasty diabetes is independently associated with impaired epicardial reperfusion and higher mortality.     

Benefits from intracoronary as compared to intravenous abciximab administration for STEMI patients undergoing primary angioplasty: a meta-analysis of 8 randomized trials

BackgroundAdjunctive abciximab administration has been demonstrated to reduce mortality and reinfarction in patients with ST-elevation myocardial infarction (STEMI) referred to invasive management. Standard abciximab regimen consists of an intravenous (IV) bolus followed by a 12-h IV infusion. Experimental studies and small clinical trials suggest the superiority of intracoronary (IC) injection of abciximab over IV route. Therefore, the aim of the current study was to perform a meta-analysis of randomized trials (RCTs) to assess the clinical efficacy and safety of IC vs IV abciximab administration in STEMI patients undergoing primary angioplasty.MethodsWe obtained results from all RCTs enrolling STEMI patients undergoing primary percutaneous coronary intervention (PCI). The primary endpoint was mortality, while recurrent myocardial infarction, postprocedural epicardial (TIMI 3) and myocardial (MBG 2–3) perfusion were identified as secondary endpoints. The safety endpoint was the risk of major bleeding complications.ResultsA total of 8 randomized trials were finally included in the meta-analysis, enrolling a total of 3259 patients. As compared to IV route, IC abciximab was associated with a significant improvement in myocardial perfusion (OR [95% CI] = 1.76 [1.28–2.42], p < 0.001), without significant benefits in terms of mortality (OR [95% CI] = 0.85 [0.59–1.23], p = 0.39), reinfarction (OR [95% CI] = 0.79 [0.46–1.33], p = 0.37), or major bleeding complications (OR [95% CI] = 1.19 [0.76–1.87], p = 0.44). However, we observed a significant relationship between patient's risk profile and mortality benefits from IC abciximab administration (p = 0.011).ConclusionsThe present updated meta-analysis showed that IC administration of abciximab is associated with significant benefits in myocardial perfusion, but not in clinical outcome at short-term follow-up as compared to IV abciximab administration, without any excess of major bleedings in STEMI patients undergoing primary PCI. However, a significant relationship was observed between patient's risk profile and mortality benefits from IC abciximab administration. Therefore, waiting for long-term follow-up results and additional randomized trials, IC abciximab administration cannot be routinely recommended, but may be considered in high-risk patients.     

Evaluation of the long-term functional outcome assessed by myocardial perfusion scintigraphy following excimer laser angioplasty compared to balloon angioplasty in longer coronary lesions

Objectives: Evaluation of the long-term functional outcome assessed by exercise myocardial perfusion imaging following excimer laser angioplasty compared to balloon angioplasty in coronary lesions >10 mm in length. Background: Previous randomized studies evaluating the effect of coronary interventions mainly focused on the long-term clinical and angiographic outcome. The functional outcome, assessed by myocardial perfusion scintigraphy, has not been evaluated in a randomized setting. Methods: A total of 308 patients with stable angina and a longer coronary lesion (>10 mm) were randomized to excimer laser angioplasty or balloon angioplasty. A ^99mTechnetium-2-methoxy isobutyl isonitrile (MIBI) single-photon emission computed tomography (SPECT) study was performed in 139 patients before the initial angioplasty procedure and at 6 months follow-up (73 patients in the laser group versus 66 patients in the balloon group, respectively). Exercise tolerance at follow-up was compared to baseline values by means of exercise duration and double product at peak exercise. Myocardial perfusion of the randomized vascular bed was assessed semi-quantitatively on the MIBI SPECT images. The reversible defects were graded as mild, moderate or severe. Myocardial perfusion at follow-up was expressed as a percentage reduction in incidence and grading of the reversible defects compared to baseline values. Results: Forty-four (61%) patients assigned to laser angioplasty were asymptomatic at 6 months follow-up compared to 34 (52%) patients assigned to balloon angioplasty (p = NS). Improvement in exercise duration and double product were 0.7 ± 2.1 min and 4.3 ± 6.2 min/mmHg/1000, respectively, in the laser group, versus 0.3 ± 2.5 min and 3.1 ± 5.5 min/mmHg/1000, respectively, in the balloon group (both p = NS). The percentage reduction of reversible defects was 23% in patients assigned to laser angioplasty vs. 29% in patients assigned to balloon angioplasty (Relative risk [RR]: 0.79, 95% confidence interval [CI]: 0.40–1.57; p = 0.50). The mild, moderate and severe reversible defects improved in 44.4, 63.6 and 66.6%, respectively, in the laser angioplasty group vs. 66.6, 53.8 and 90%, respectively, in the balloon angioplasty group. None of the comparisons were significantly different. Conclusion: Excimer laser angioplasty compared to balloon angioplasty in coronary lesions >10 mm in length yields a similar long-term functional outcome assessed by anginal status, exercise tolerance and myocardial perfusion.     

Impact of renin angiotensin system inhibitors on homocysteine levels and platelets reactivity in patients on dual antiplatelet therapy

Background and aimsDual antiplatelet therapy (DAPT) and Renin-angiotensin system inhibitors (RASi) represent the cornerstone in the treatment of patients undergoing percutaneous coronary interventions (PCI), mainly after an acute ischemic event. However, high-on treatment residual platelet reactivity (HRPR), is not infrequent despite optimal medical treatment. Homocysteine (Hcy) is a metabolite of methionine catabolism linked to atherothrombosis. Recently, a potential crosstalk between RAS and Hcy has been suggested, potentially favouring platelet aggregation and cardiovascular disease.Therefore, we aimed to investigate the impact of RASi on Hcy levels and platelet aggregation in patients on DAPT after PCI.Methods and resultsPatients undergoing PCI on DAPT with ASA plus an ADP-antagonist (clopidogrel, ticagrelor or prasugrel), were included. RASi comprised angiotensin converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARB). Aggregation tests were performed by Multiple Electrode Aggregometry. We included 1210 patients, of whom 862 (71.2%) were on treatment with RASi. Overall, DAPT composition was ASA+clopidogrel in 566 (46.8%) patients, ASA+ticagrelor in 428 (35.4%) and ASA+prasugrel in 216 (17.9%). Median values of Hcy were higher in RASi patients (p = 0.006), who displayed a higher percentage of Hcy above the median value (52.4% vs. 44.8%, p = 0.019, adjustedOR [95%CI] = 1.40 [1.04–1.88], p = 0.027). No differences in HRPR rate were found according to RASi use for ASPI test (3.6% vs. 3.3%, p = 0.88) and ADP test (25.6% vs. 24.3%,p = 0.62; adjustedOR [95%CI] = 1.23 [0.89–1.70], p = 0.220) and according to ADP-antagonist type. A direct linear relationship was observed between platelet reactivity and Hcy in both patients receiving RASi and untreated ones, with higher values of platelet aggregation being observed in patients with Hcy above the median, independently from RASi administration and DAPT strategy.ConclusionIn patients on DAPT after PCI, RASi treatment did not emerge as an independent predictor of HRPR. However, the levels of Hcy were significantly elevated in patients on RASi and related to higher values of platelet reactivity, independently from the DAPT strategy.     

Impact of day versus night as intervention time on the outcomes of primary angioplasty for acute myocardial infarction

Background: Conflicting datas exist regarding the outcomes of primary percutaneous coronary intervention (PCI) for ST‐segment elevation myocardial infarction (STEMI) when the intervention is performed during night hours. Methods and Results: 2,644 consecutive patients with STEMI (mean age 56.7 ± 11.9, years, 2,188 male) undergoing primary PCI between October 2003 and March 2008 were retrospectively enrolled into this study (single high‐volume center: >3,000 PCIs/year). Day time was defined according to intervention between 08:00 am and 06:00 pm and night as intervention time between 06:00 pm and 08:00 am. 1,141 patients (43.2%) were treated during the day and 1,503 (56.8%) at night. The baseline characteristics of both groups were similar except for more frequent hypertension (42.6 vs. 36.5%; P = 0.002), women (19.7 vs. 15.4%; P = 0.003), and old (≥75y) patients (9.6 vs. 7.4; P = 0.046) in the day time group. Compared with those treated during night time, day time patients had longer angina‐reperfusion times (mean, 205 vs. 188 minutes, P = 0.016). Door‐to‐balloon times were similar (P = 0.87), and less than 90 minutes in both groups. There were no differences concerning clinical events and PCI success between the two groups. Hospital mortality was 6.1% during the day and 5.2% during the night (OR 0.98, 95% CI 0.7–1.36; P = 0.89). The median follow‐up time was 21 months. The Kaplan‐Meier survival plot for long‐term cardiovascular death was not different for both groups (P = 0.78). In‐hospital and long‐term cardiovascular mortality was also similar in shock and nonshock subgroups. Conclusions: Primary PCI can be performed safely during the night at a high‐volume PCI center with suitable and effective organization of cardiology department and catheterisation laboratory with 24 hours per day, 7 days per week onsite staffing. © 2009 Wiley‐Liss, Inc.     

Timely reperfusion for ST-segment elevation myocardial infarction:Effect of direct transfer to primary angioplasty on time delays and clinical outcomes

Primary percutaneous coronary intervention(PPCI) is the preferred reperfusion therapy for patients presenting with ST-segment elevation myocardial infarction(STEMI) when it can be performed expeditiously and by experienced operators. In spite of excellent clinical results this technique is associated with longer delays than thrombolysis and this fact may nullify the benefit of selecting this therapeutic option. Several strategies have been proposed to decrease the temporal delays to deliver PPCI. Among them,prehospital diagnosis and direct transfer to the cath lab,by-passing the emergency department of hospitals,has emerged as anattractive way of diminishing delays. The purpose of this review is to address the effect of direct transfer on time delays and clinical events of patients with STEMI treated by PPCI.