Prospective multicenter randomized trial comparing physician versus patient transfer for primary percutaneous
Qi Zhang1, Rui-yan Zhang, Jian-ping Qiu
1Department of Cardiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China.
Insights
Transferring physicians to local hospitals for primary percutaneous coronary intervention (PCI) in ST-segment elevation myocardial infarction (STEMI) patients significantly reduces door-to-balloon times and 30-day major adverse cardiac events (MACE). This strategy is feasible, safe, and efficient.
Area of Science:
- Cardiology
- Interventional Cardiology
- Acute Myocardial Infarction Management
Background:
- Primary percutaneous coronary intervention (PCI) is the preferred treatment for ST-segment elevation myocardial infarction (STEMI).
- Transferring STEMI patients to PCI-capable centers is recommended when local facilities or operators are unavailable.
- In China, local hospitals often have PCI facilities but lack qualified interventional physicians, necessitating alternative strategies.
Purpose of the Study:
- To evaluate the feasibility, safety, and efficacy of transferring physicians to PCI-equipped local hospitals for primary PCI in STEMI patients.
- To compare the outcomes of a physician transfer strategy versus a patient transfer strategy.
Main Methods:
- A randomized trial involving 334 STEMI patients presenting within 12 hours of symptom onset across five local hospitals.
- Patients were assigned to either a physician transfer group (n=165) or a patient transfer group (n=169).
- Key outcome measures included door-to-balloon time, in-hospital, and 30-day major adverse cardiac events (MACE).
Main Results:
- The physician transfer group demonstrated significantly shorter door-to-balloon times (95±20 min vs. 147±29 min, P<0.0001).
- More patients achieved TIMI 3 flow in the physician transfer group (17.6% vs. 10.1%, P<0.05).
- The physician transfer strategy resulted in significantly reduced 30-day MACE (8.9% vs. 17.2%, P=0.03) and improved MACE-free survival (91.0% vs. 82.9%, P<0.05).
Conclusions:
- Transferring physicians to local hospitals for primary PCI in STEMI is a feasible and safe approach.
- This strategy effectively reduces door-to-balloon times and improves 30-day MACE rates.
- The physician transfer model offers an efficient solution for STEMI management in resource-limited settings.
Background:
Primary percutaneous coronary intervention (PCI) has been identified as the first therapeutic option for patients with acute ST-segment elevation myocardial infarction (STEMI). The strategy of transferring patient to a PCI center was recently recommended for those with acute STEMI who were present to PCI incapable hospitals, which include lack of facilities or experienced operators. In China, some local hospitals have been equipped with PCI facilities, but they have no interventional physicians qualified for performing primary PCI. This study was conducted to assess the feasibility, safety and efficacy of the strategy of transferring physician to a PCI-equipped hospital to perform primary PCI for patients with acute STEMI.
Methods:
Three hundred and thirty-four consecutive STEMI patients with symptom presentation = 12 hours in five local hospitals from November 2005 to November 2007 were randomized to receive primary PCI by either physician transfer (physician transfer group, n=165) or patient transfer (patient transfer group, n=169) strategy. Door-to-balloon time, in-hospital and 30-day major adverse cardiac events (MACE, including death, non-fatal re-infarction, and target vessel revascularization) were compared between the two groups.
Results:
Baseline characteristics between the two groups were comparable. Thrombolysis in myocardial infarction (TIMI) 3 flow was revealed in more patients in the physician transfer group at initial angiography (17.6% vs 10.1%, P<0.05). The success rate of primary PCI (96.3% vs 95.4%, P>0.05) and length of hospital stay were similar between the two groups ((15+/-4) days vs (14+/-3) days, P>0.05). In the physician transfer group, door-to-balloon time was significantly shortened ((95+/-20) minutes vs (147+/-29) minutes, P<0.0001) and more patients received primary PCI with door-to-balloon time less than 90 minutes (21.2% vs 7.7%, P<0.001). During hospitalization, MACE occurred in 6.7% and 11.2% of patients in the physician and patient transfer groups, respectively (P=0.14). At 30-day clinical follow-up, the occurrence rates of death, non-fatal re-infarction, and target vessel revascularization (TVR) were 3.6% vs 5.9%, 4.2% vs 8.9%, and 1.2% vs 2.4% in the physician and patient transfer groups, respectively (all P>0.05). The cumulative composite of MACE was significantly reduced (8.9% vs 17.2%, P=0.03) and MACE free survival (91.0% vs 82.9%, P<0.05) was significantly improved in the physician transfer group at 30 days.
Conclusion:
The strategy of transferring physician to local hospital to perform primary PCI for patients with acute STEMI is feasible, safe and efficient in reducing the door-to-balloon time and 30-day MACE rate.
Related Concept Videos
01:30Acute Coronary Syndrome I: Introduction
01:30Acute Coronary Syndrome III: Diagnostic Studies
01:28Acute Coronary Syndrome IV: Interprofessional Care
01:27Coronary Artery Disease V: Interprofessional Care
01:19Acute Coronary Syndrome II: Pathophysiology and Clinical Manifestations
01:28Cardiac Catheterization I: Pre-Procedure Overview