Early referral for intentional rescue PTCA after initiation of thrombolytic therapy in patients admitted to a community hospital because of a large acute myocardial infarction

Background If no in-house facilities For percutaneous transluminal coronary angioplasty (PTCA) ore present, thrombolytic therapy is the treatment of c hoice for acute myocardial infarction (AMI). A few studies have shown benef it from rescue PTCA in patients directly admitted to centers with PTCA faci lities. The obvious question arises whether patients with AMI initially adm itted to a community hospital can benefit from early transfer for intention al rescue PTCA. Methods and Results One hundred sixty-five patients were transferred early for intentional rescue PTCA from a community hospital at a distance of 20 m iles. On arrival at the angioplasty center, bedside markers were used to de termine reperfusion. In case of obvious reperfusion, no invasive procedure was done; otherwise, coronary angiography and rescue PTCA, if necessary was performed. During transfer, 1 (1%) patient died and 15 (9%) patients had a rrhythmic or hemodynamic problems. Median time delay between onset of chest pain and arrival at the community hospital and the PTCA center was 61 minu tes (range 0 to 413) and 150 minutes (range 28 to 472), respectively, ln 66 (40%) patients, reperfusion was diagnosed by noninvasive reperfusion crite ria on arrival at the PTCA center(group I). Ninety-eight (59%) patients wit hout evident noninvasive criteria of reperfusion underwent angiography 187 median minutes after the onset of chest pain. Forty one (25%) patients had Thrombolysis In Myocardial Infarction grade 3 flow, and no further interven tion wets performed (group 2). In the remaining 57 (35%) patients, rescue P TCA was performed, which:was successful in 96% (group 3). In-hospital morta lity rate was lowest in group 1 compared with the other 2 groups (0% vs 7% vs 11%; P < .05). Reinfarction was highest in group 1 compared with the oth er groups (17% vs 5% vs 2%; P < .01). No significant differences were Found in coronary artery bypass grafting, stroke, or bleeding complications. The 1-year follow-up data showed low revascularization rates; 2 (1%) patients died after discharge from the hospital. Conclusions Early transfer of patients with large AMI for intentional rescu e PTCA cbn be done with acceptable safety and is feasible within therapeuti cally acceptable time limits and results in additional early reperfusion in 33% of patients. A large, randomized, multicenter trial is needed to compa re efficacy of intravenous thrombolytic treatment in a community hospital v ersus early referral for either rescue or primary PTCA.