Coleman Craig I, McKay Raymond G, Boden William E, Mather Jeffrey F, White C Michael
Division of Cardiology, Hartford Hospital, Hartford, CT 06102-5037, USA.
Clin Ther. 2006 Jul;28(7):1054-62. doi: 10.1016/j.clinthera.2006.07.007.
Primary percutaneous coronary intervention ([PCI], percutaneous transluminal coronary angioplasty+stenting) for ST-segment elevation myocardial infarction (STEMI) is regarded as superior to fibrinolysis even if it means that patients need to be transferred from one center to another to undergo the procedure. However, this inevitable delay between symptom onset and PCI, caused by the time required to travel, might increase the occurrence of cardiac events. A hybrid method called facilitated PCI uses fibrinolysis and/or glycoprotein (GP) IIb/IIIa inhibitors before transfer to a tertiary medical center where urgent PCI might be performed. This approach, however, has not been systematically evaluated.
The purpose of this study was to compare the effectiveness (combined end point of in-hospital mortality, reinfarction, stroke, or emergency revascularization) and cost-effectiveness of utilizing a bolus thrombolytic agent with GP IIb/IIIa inhibitor followed by transfer to a tertiary institution for facilitated PCI or standard of care transfer without primary PCI drugs among patients presenting to a community hospital with STEMI.
This was a prospective, single-center, cohort study comprising data from STEMI patients transferred from community hospitals to Hartford Hospital, Hartford, Connecticut, from the years 2000 to 2003. At the time of analysis, patients receiving primary PCI were matched (1:1) with those receiving facilitated PCI, utilizing propensity scores to assure similar demographics. The combined incidence of major adverse cardiac end points (MACE) and total hospital costs was compared between groups. Non-parametric bootstrapping was conducted to calculate CIs for the incremental cost-effectiveness ratio and generate a quadrant analysis.
Based on 254 propensity score-matched patients (127 facilitated PCI and 127 primary PCI), in-hospital MACE and total hospital costs were reduced by 61.3% and US 4563 dollars (2005), respectively, in patients receiving facilitated compared with primary PCI (P=0.021 and P=NS, respectively). Patients receiving facilitated PCI were more likely to have target lesion Thrombolysis in Myocardial Infarction (TIMI) III (normal) blood flow on cardiac catheterization than those receiving primary PCI (49.6% vs 30.7%; P=0.002). However, the rate of TIMI bleeding was similar in both groups (21.3% in the facilitated PCI group vs 18.9% in the primary PCI group). Nonsignificant reductions were observed in both intensive care unit (ICU) and total length of stay (LOS) (0.8 day and 1.0 day, respectively) compared with the primary PCI group. Bootstrap analysis revealed that of 25,000 samplings, facilitated PCI would likely be both more effective and less costly 94.6% of the time.
The use of facilitated PCI in STEMI patients who initially presented to community hospitals and were transferred for PCI appeared to significantly reduce the incidence of MACE, and increase the likelihood of having baseline TIMI III blood flow at time of catheterization. Nonsignificant reductions were observed in total ICU and hospital LOS. However, there did not appear to be a significant effect on the incidence of bleeding in patients receiving facilitated PCI. Bootstrap analysis confirmed that facilitated PCI would be both a more effective and less costly strategy.
对于ST段抬高型心肌梗死（STEMI）患者，即使这意味着患者需要从一个中心转运至另一个中心接受治疗，直接经皮冠状动脉介入治疗（PCI，即经皮腔内冠状动脉成形术+支架置入术）仍被认为优于纤溶治疗。然而，因转运所需时间导致的症状发作与PCI之间不可避免的延迟，可能会增加心脏事件的发生率。一种名为易化PCI的混合方法是在转运至可能进行紧急PCI的三级医疗中心之前使用纤溶治疗和/或糖蛋白（GP）IIb/IIIa抑制剂。然而，这种方法尚未得到系统评估。
本研究旨在比较在社区医院就诊的STEMI患者中，使用大剂量溶栓剂联合GP IIb/IIIa抑制剂后转运至三级医疗机构进行易化PCI与不使用初级PCI药物进行标准护理转运的有效性（住院死亡率、再梗死、中风或紧急血运重建的联合终点）和成本效益。
这是一项前瞻性、单中心队列研究，纳入了2000年至2003年从社区医院转运至康涅狄格州哈特福德市哈特福德医院的STEMI患者的数据。在分析时，利用倾向评分将接受直接PCI的患者与接受易化PCI的患者进行1:1匹配，以确保人口统计学特征相似。比较两组主要不良心脏终点（MACE）的合并发生率和总住院费用。进行非参数自抽样以计算增量成本效益比的置信区间并进行象限分析。
基于254例倾向评分匹配患者（127例易化PCI和127例直接PCI），与直接PCI相比，接受易化PCI的患者住院期间MACE和总住院费用分别降低了61.3%和4563美元（2005年）（分别为P=0.021和P=无统计学意义）。接受易化PCI的患者在心脏导管检查时比接受直接PCI的患者更有可能出现目标病变心肌梗死溶栓（TIMI）III级（正常）血流（49.6%对30.7%；P=0.002）。然而，两组的TIMI出血率相似（易化PCI组为21.3%，直接PCI组为18.9%）。与直接PCI组相比，重症监护病房（ICU）和总住院时间（LOS）均有非显著性缩短（分别为0.8天和1.0天）。自抽样分析显示，在25000次抽样中，易化PCI在94.6%的时间里可能既更有效又成本更低。
对于最初在社区医院就诊并转运接受PCI的STEMI患者，使用易化PCI似乎可显著降低MACE的发生率，并增加导管检查时出现基线TIMI III级血流的可能性。ICU和总住院时间有非显著性缩短。然而，接受易化PCI的患者出血发生率似乎没有显著影响。自抽样分析证实易化PCI将是一种更有效且成本更低的策略。
