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Mongkhon P, Dilokthornsakul P, Tepwang K, Tapanya K, Sopitprasan C, Chaliawsin P, Saokaew S. The effects of fibrinolytic before referring STEMI patients: A systematic review and meta-analysis. IJC HEART & VASCULATURE 2017; 15:9-14. [PMID: 28616566 PMCID: PMC5458129 DOI: 10.1016/j.ijcha.2017.03.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 03/31/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Accessibility of primary percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI) in primary care settings is limited. Referring patients to PCI-capable hospitals might increase cardiac events. Hence, fibrinolytic injection before referring patients to PCI-capable settings decreases cardiac events, however, the effect of fibrinolytic injection before the referral has not been systematically evaluated. This study aimed to systematically review the effect of fibrinolytic injection before referring patients with STEMI to PCI-capable settings. METHODS A systematic search with Embase, Cochrane CENTRAL, Google scholar, and PubMed was conducted. Studies conducted in patients with STEMI presented to non PCI-capable settings and compared fibrinolytic injection with no injection before referring patients to PCI-capable settings were included. The primary outcome was the composite outcomes of major adverse cardiac events (MACEs) at 30 days. Meta-analyses were performed using random-effect model. RESULTS Of 912 articles, three RCTs and three non-RCTs were included. Based on RCTs, fibrinolytic injection before the referral has failed to decrease MACEs compared to non-fibrinolytic injection [relative risk (RR) 1.18; 95% confidence interval (CI), 0.89-1.57, p = 0.237]. Fibrinolytic injection has also failed to decrease mortality, re-infarction, and ischemic stroke. On the other hand, fibrinolytic injection was associated with a higher risk of major bleeding. CONCLUSIONS In non PCI-capable settings, fibrinolytic injection before referring patients with STEMI to PCI-capable settings has no clinical benefit but could increase risk of major bleeding. Clinicians might more carefully consider whether fibrinolytic injection should be used in patients with STEMI before the referral.
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Affiliation(s)
- Pajaree Mongkhon
- Center of Health Outcomes Research and Therapeutic Safety (Cohorts), School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
| | - Piyameth Dilokthornsakul
- Center of Pharmaceutical Outcomes Research (CPOR), Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand
| | - Kanokkorn Tepwang
- Center of Health Outcomes Research and Therapeutic Safety (Cohorts), School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
| | - Kannika Tapanya
- Center of Health Outcomes Research and Therapeutic Safety (Cohorts), School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
| | - Chompoonut Sopitprasan
- Center of Health Outcomes Research and Therapeutic Safety (Cohorts), School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
| | - Pitchapat Chaliawsin
- Center of Health Outcomes Research and Therapeutic Safety (Cohorts), School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
| | - Surasak Saokaew
- Center of Health Outcomes Research and Therapeutic Safety (Cohorts), School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
- Center of Pharmaceutical Outcomes Research (CPOR), Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand
- School of Pharmacy, Monash University Malaysia, Selangor Darul Ehsan, Malaysia
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Patel N, Patel NJ, Thakkar B, Singh V, Arora S, Patel N, Savani C, Deshmukh A, Thadani U, Badheka AO, Alfonso C, Fonarow GC, Cohen MG. Management Strategies and Outcomes of ST-Segment Elevation Myocardial Infarction Patients Transferred After Receiving Fibrinolytic Therapy in the United States. Clin Cardiol 2016; 39:9-18. [PMID: 26785349 DOI: 10.1002/clc.22491] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2015] [Revised: 10/25/2015] [Indexed: 01/26/2023] Open
Abstract
Fibrinolytic therapy is still used in patients with ST-segment elevation myocardial infarction (STEMI) when the primary percutaneous coronary intervention cannot be provided in a timely fashion. Management strategies and outcomes in transferred fibrinolytic-treated STEMI patients have not been well assessed in real-world settings. Using the Nationwide Inpatient Sample from 2008 to 2012, we identified 18 814 patients with STEMI who received fibrinolytic therapy and were transferred to a different facility within 24 hours. The primary outcome was in-hospital mortality. Secondary outcomes included gastrointestinal bleeding, bleeding requiring transfusion, intracranial hemorrhage (ICH), length of stay, and cost. The patients were divided into 3 groups: those who received medical therapy alone (n = 853; 4.5%), those who underwent coronary artery angiography without revascularization (n = 2573; 13.7%), and those who underwent coronary artery angiography with revascularization (n = 15 388; 81.8%). Rates of in-hospital mortality among the groups were 20% vs 6.6% vs 2.1%, respectively (P < 0.001); ICH was 8.5% vs 1.1% vs 0.6%, respectively (P < 0.001); and gastrointestinal bleeding was 1.1% vs 0.4% vs 0.4%, respectively (P = 0.011). Multivariate analysis identified increasing age, higher Charlson Comorbidity Index score, cardiogenic shock, cardiac arrest, and ICH as the independent predictors of not performing coronary artery angiography and/or revascularization in patients with STEMI initially treated with fibrinolytic therapy. The majority of STEMI patients transferred after receiving fibrinolytic therapy undergo coronary angiography. However, notable numbers of patients do not receive revascularization, especially patients with cardiogenic shock and following a cardiac arrest.
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Affiliation(s)
- Nish Patel
- Department of Cardiology, University of Miami Miller School of Medicine, Miami, Florida
| | - Nileshkumar J Patel
- Department of Cardiology, University of Miami Miller School of Medicine, Miami, Florida
| | - Badal Thakkar
- Department of Internal Medicine, Tulane School of Public Health and Tropical Medicine, New Orleans, Louisiana
| | - Vikas Singh
- Department of Cardiovascular Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Shilpkumar Arora
- Department of Internal Medicine, Mount Sinai St. Luke's Roosevelt Hospital, New York, New York
| | - Nilay Patel
- Department of Internal Medicine, Saint Peter's University Hospital, New Brunswick, New Jersey
| | - Chirag Savani
- Department of Internal Medicine, New York Medical College, Valhalla, New York
| | | | - Udho Thadani
- Cardiovascular Section/Internal Medicine, VA Medical Center, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Apurva O Badheka
- Department of Cardiology, Heart and Vascular Center, Everett Clinic, Everett, Washington
| | - Carlos Alfonso
- Department of Cardiovascular Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Gregg C Fonarow
- Department of Cardiology, Ahmanson-UCLA Cardiomyopathy Center, University of California, Los Angeles, California
| | - Mauricio G Cohen
- Department of Cardiovascular Medicine, University of Miami Miller School of Medicine, Miami, Florida
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Pathak EB, Comins MM, Forsyth CJ, Strom JA. Routine diversion of patients with STEMI to high-volume PCI centres: modelling the financial impact on referral hospitals. Open Heart 2015. [PMID: 26196014 PMCID: PMC4488887 DOI: 10.1136/openhrt-2014-000042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To quantify possible revenue losses from proposed ST-elevation myocardial infarction (STEMI) patient diversion policies for small hospitals that lack high-volume percutaneous coronary intervention (PCI) capability status (ie, 'STEMI referral hospitals'). BACKGROUND Negative financial impacts on STEMI referral hospitals have been discussed as an important barrier to implementing regional STEMI bypass/transfer protocols. However, there is little empirical data available that directly quantifies this potential financial impact. METHODS Using detailed financial charges from Florida hospital discharge data, we examined the potential negative financial impact on 112 STEMI referral hospitals from losing all inpatient STEMI revenue. The main outcome was projected revenue loss (PRL), defined as total annual patient with STEMI charges as a proportion of total annual charges for all patients. We hypothesised that for most community hospitals (>90%), STEMI revenue represented only a small fraction of total revenue (<1%). We further examined the financial impact of the 'worst case' scenario of loss of all acute coronary syndrome (ACS) (ie, chest pain) patients. RESULTS PRLs were $0.33 for every $100 of patient revenue statewide for STEMI and $1.73 for ACS. At the individual hospital level, the 90th centile PRL was $0.74 for STEMI and $2.77 for ACS. PRLs for STEMI were not greater in rural areas compared with major metropolitan areas. Hospital revenue centres that would be most impacted by loss of patients with STEMI were cardiology procedures and intensive care units. CONCLUSIONS Loss of patient with STEMI revenues would result in only a small financial impact on STEMI referral hospitals in Florida under proposed STEMI diversion/rapid transfer protocols. However, spillover loss of patients with ACS would increase revenue loss for many hospitals.
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Affiliation(s)
| | - Meg M Comins
- Department of Health Policy and Management , University of South Florida , Tampa, Florida , USA
| | - Colin J Forsyth
- Department of Anthropology , University of South Florida , Tampa, Florida , USA
| | - Joel A Strom
- Department of Medicine , University of Florida College of Medicine , Jacksonville, Florida , USA
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Bossaert L, O'Connor RE, Arntz HR, Brooks SC, Diercks D, Feitosa-Filho G, Nolan JP, Hoek TLV, Walters DL, Wong A, Welsford M, Woolfrey K. Part 9: Acute coronary syndromes: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 2011; 81 Suppl 1:e175-212. [PMID: 20959169 DOI: 10.1016/j.resuscitation.2010.09.001] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Bøhmer E, Kristiansen IS, Arnesen H, Halvorsen S. Health and cost consequences of early versus late invasive strategy after thrombolysis for acute myocardial infarction. ACTA ACUST UNITED AC 2011; 18:717-23. [DOI: 10.1177/1741826711398425] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- Ellen Bøhmer
- Department of Medicine, Innlandet Hospital Trust, Lillehammer, Norway
- Department of Cardiology, Oslo University Hospital, Ulleval, Oslo, Norway
| | | | - Harald Arnesen
- Center for Clinical Heart Research,Oslo University Hospital,Ulleval, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital, Ulleval, Oslo, Norway
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O'Connor RE, Bossaert L, Arntz HR, Brooks SC, Diercks D, Feitosa-Filho G, Nolan JP, Vanden Hoek TL, Walters DL, Wong A, Welsford M, Woolfrey K. Part 9: Acute coronary syndromes: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2010; 122:S422-65. [PMID: 20956257 DOI: 10.1161/circulationaha.110.985549] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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7
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De Luca G, Marino P. Facilitated angioplasty with combo therapy among patients with ST-segment elevation myocardial infarction: a meta-analysis of randomized trials. Am J Emerg Med 2009; 27:683-90. [DOI: 10.1016/j.ajem.2008.05.021] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2008] [Revised: 05/17/2008] [Accepted: 05/21/2008] [Indexed: 12/01/2022] Open
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Guarga A, Pla R, Benet J, Pozuelo A. Planificación de los servicios de alta especialización en Cataluña. Med Clin (Barc) 2008; 131 Suppl 4:55-9. [DOI: 10.1016/s0025-7753(08)76476-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Hilleman DE, Tsikouris JP, Seals AA, Marmur JD. Fibrinolytic Agents for the Management of ST-Segment Elevation Myocardial Infarction. Pharmacotherapy 2007; 27:1558-70. [DOI: 10.1592/phco.27.11.1558] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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10
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Boden WE, Eagle K, Granger CB. Reperfusion strategies in acute ST-segment elevation myocardial infarction: a comprehensive review of contemporary management options. J Am Coll Cardiol 2007; 50:917-29. [PMID: 17765117 DOI: 10.1016/j.jacc.2007.04.084] [Citation(s) in RCA: 108] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2007] [Revised: 04/25/2007] [Accepted: 04/30/2007] [Indexed: 11/21/2022]
Abstract
There are an estimated 500,000 ST-segment elevation myocardial infarction (STEMI) events in the U.S. annually. Despite improvements in care, up to one-third of patients presenting with STEMI within 12 h of symptom onset still receive no reperfusion therapy acutely. Clinical studies indicate that speed of reperfusion after infarct onset may be more important than whether pharmacologic or mechanical intervention is used. Primary percutaneous coronary intervention (PCI), when performed rapidly at high-volume centers, generally has superior efficacy to fibrinolysis, although fibrinolysis may be more suitable for many patients as an initial reperfusion strategy. Because up to 70% of STEMI patients present to hospitals without on-site PCI facilities, and prolonged door-to-balloon times due to inevitable transport delays commonly limit the benefit of PCI, the continued role and importance of the prompt, early use of fibrinolytic therapy may be underappreciated. Logistical complexities such as triage or transportation delays must be considered when a reperfusion strategy is selected, because prompt fibrinolysis may achieve greater benefit, especially if the fibrinolytic-to-PCI time delay associated with transfer exceeds approximately 1 h. Selection of a fibrinolytic requires consideration of several factors, including ease of dosing and combination with adjunctive therapies. Careful attention to these variables is critical to ensuring safe and rapid reperfusion, particularly in the prehospital setting. The emerging modality of pharmacoinvasive therapy, although controversial, seeks to combine the benefits of mechanical and pharmacologic reperfusion. Results from ongoing clinical trials will provide guidance regarding the utility of this strategy.
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Affiliation(s)
- William E Boden
- School of Medicine and Biomedical Sciences, State University of New York, and Kaleida Health System, Buffalo, New York, USA.
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