Review Article
Current Concepts
Time to Treatment in Primary Percutaneous Coronary Intervention
N Engl J Med 2007; 357:1631-1638October 18, 2007
- Article
Early administration of reperfusion therapy improves survival in patients with ST-elevation myocardial infarction by reestablishing coronary blood flow within the occluded infarct-related artery.1 Primary percutaneous coronary intervention (PCI) is superior to fibrinolytic therapy when performed rapidly by expert teams,2 but its effectiveness may be limited by delays in delivery.3
Recent national efforts are drawing attention to the importance of door-to-balloon time as a key indicator of quality of care for patients with ST-elevation myocardial infarction who are treated with primary PCI.4 The American College of Cardiology (ACC), in collaboration with the American Heart Association (AHA), the American College of Emergency Physicians (ACEP), the National Heart, Lung, and Blood Institute (NHLBI), and other partners, has implemented a national quality-improvement campaign to decrease door-to-balloon time in primary PCI.5 The convergence of clinical and policy interest in door-to-balloon time makes this an opportune occasion to review current knowledge on this topic.
Pathophysiology of Myocardial Necrosis
Animal models demonstrate a direct relationship between the duration of coronary-artery occlusion and the extent of myocardial necrosis.6 Myocardial cell death begins as early as 20 minutes after coronary-artery occlusion and is usually complete within 6 hours. This period may be extended considerably, however, depending on several clinical factors, including the presence or absence of intermittent episodes of transient reperfusion, the extent of collateral circulation, and the presence or absence of a history of ischemic preconditioning.7,8 Prompt reperfusion therapy can limit myocardial necrosis, although delayed treatment may still provide some benefit by improving left ventricular remodeling and electrical stability.9 Nevertheless, timely treatment produces the most pronounced benefit.
Fibrinolytic Therapy
Patients with ST-elevation myocardial infarction who receive fibrinolytic therapy have better short- and long-term survival when treatment is instituted rapidly, with early reestablishment of flow.10 This relationship between time to treatment and outcomes of fibrinolytic therapy appears to be nonlinear, with the best chance of survival when fibrinolytic therapy is administered within 2 to 3 hours after the onset of symptoms.11 Little benefit is seen with fibrinolytic therapy after 12 hours, probably because of lost opportunities for both myocardial salvage12 and restoration of blood flow, as the thrombus organizes within the coronary artery over time.13
Primary PCI
Longer intervals between the onset of symptoms and balloon time have been correlated with poorer outcomes in several,14-17 but not all, studies of primary PCI.18-20 Some studies have also suggested that delays in the delivery of primary PCI are important only within the first 2 or 3 hours after the onset of symptoms (since this is the time when myocardial salvage is greatest)21 or in high-risk patients, such as those with cardiogenic shock.22 In general, studies that have not shown a relationship between the time from the onset of symptoms to treatment and outcome have had smaller samples, involved special subpopulations of patients, or included narrower ranges of time than studies that have shown such a relationship. However, it is also possible that even though the extent of myocardial salvage may be similar for fibrinolytic therapy and primary PCI in the early period after the onset of symptoms, PCI is more effective in restoring flow and improving outcomes during later periods. Accordingly, some investigators have hypothesized that there is a longer treatment window for primary PCI than has been suggested in studies of fibrinolytic therapy.23 Data supporting this theory are sparse at this time and are not incorporated into current guideline recommendations.
In contrast, delays in door-to-balloon time have been consistently associated with poorer outcomes in many studies.15,18-20,24 Using data from the National Registry of Myocardial Infarction, McNamara and colleagues recently noted a strong relationship between door-to-balloon time and in-hospital mortality among 29,222 patients with ST-elevation myocardial infarction.20 When treatment was started within 90 minutes after arrival, in-hospital mortality was 3.0%, but it increased to 4.2%, 5.7%, and 7.4% when delays were 91 to 120 minutes, 121 to 150 minutes, and more than 150 minutes, respectively. When adjusted for differences in patient characteristics, each 15-minute reduction in door-to-balloon time from 150 to less than 90 minutes was associated with 6.3 fewer deaths per 1000 patients treated (Figure 1Figure 1
Relative Risk of In-Hospital Death with Each Additional 15-Minute Interval and Number of Deaths Associated with Increases in Door-to-Balloon Time as Compared with Treatment within 90 Minutes.). This relationship was particularly apparent in patients who arrived at the hospital within 1 hour after the onset of symptoms and had high-risk features, a finding consistent with that in other reports.14,21,24 Other researchers have noted similar findings, with evidence of smaller infarct sizes, fewer major adverse cardiovascular events, and better long-term survival with door-to-balloon times of 90 minutes or less.24,25 Performance with Respect to Door-to-Balloon Time
Guidelines from the ACC–AHA and the European Society of Cardiology recommend a treatment goal of 90 minutes or less for door-to-balloon time (or the time from initial medical contact to treatment),26,27 and this measure is incorporated into national, publicly reported quality indicators for hospital performance. The Health Quality Alliance program, which is a combined effort of the Centers for Medicare and Medicaid Services and the Joint Commission, includes door-to-balloon time among its core measures of quality of care for acute myocardial infarction.4
Door-to-balloon time, as currently measured by the Health Quality Alliance, addresses several practical concerns. First (despite its terminology), the measure permits the use of devices other than angioplasty balloons that are occasionally used to initially reestablish reperfusion. Second, reporting on the measure changed substantially in July 2006, shifting from a treatment goal of 120 minutes or less to one of 90 minutes or less, reporting hospital median as opposed to mean door-to-balloon time, and allowing for clinicians to exclude from the calculation patients for whom delays are considered unavoidable. These modifications encourage a treatment goal that is consistent with the guidelines, reduce the influence of outlier times, and acknowledge that delays may be due to extenuating circumstances in which time is spent on other necessary clinical activities, such as ruling out an aortic dissection. Despite these improvements, the current measure still has some limitations. For example, patients in whom ST-elevation myocardial infarction develops after admission to the hospital or who are transferred from another hospital for primary PCI are not currently included. These issues deserve more attention in future iterations of the measure.
Currently available data suggest that there has been little improvement in door-to-balloon times in the recent past, and performance on this indicator lags behind performance on other quality measures for the treatment of acute myocardial infarction.28,29 In recently reported data from hospitals participating in the National Registry of Myocardial Infarction between 1999 and 2002, only 35% of all patients were treated within 90 minutes after arrival at the hospital, and less than 15% of hospitals had a median time of less than 90 minutes.30 Two particular patient subgroups appear to be at highest risk for long delays in door-to-balloon time: patients who present during off-hours (nights and weekends) and those who are transferred from other acute-care facilities. Patients with ST-elevation myocardial infarction frequently present during off-hours, and many health care facilities are challenged to maintain the availability of primary PCI around the clock. Outcomes with primary PCI are also poorer during off-hours in part because of longer delays in activating cardiac-catheterization laboratories.31 For patients who are transferred from other hospitals, there is the additional challenge of coordinating efforts between facilities on an emergency basis. Unlike trauma care systems in many states, for example, care for patients with ST-elevation myocardial infarction is frequently disjointed. In the United States, data on the time from arrival at the initial hospital to PCI at the receiving hospital suggest that median delays are as long as 180 minutes and that less than 5% of patients are treated within 90 minutes.32
Although several clinical trials have shown promising results of emergency transfer for primary PCI as compared with on-site fibrinolytic therapy,33 only one of these studies involved hospitals in the United States.34 European health care systems have been more successful at rapidly transferring and coordinating care for patients with ST-elevation myocardial infarction because of better integration of emergency medical systems and hospital networks.35 In limited areas of the United States, the emergency transfer of such patients between referral and tertiary care hospitals has also been successfully demonstrated.36-38
Selecting a Reperfusion Therapy
Given the substantial resources required, many hospitals in the United States and Europe lack PCI capabilities, and even fewer provide around-the-clock staffing for these procedures. The decision to use primary PCI could substantially delay access to reperfusion for some patients with ST-elevation myocardial infarction who otherwise could immediately be given fibrinolytic therapy. When both reperfusion strategies can be rapidly performed, current evidence from clinical trials and registries strongly supports the use of primary PCI, based on its superiority in reestablishing coronary blood flow and the lower risks of reinfarction and intracerebral hemorrhage.2,39 PCI is also the best option for patients with cardiogenic shock40 and the only option for those with contraindications to fibrinolytic therapy. However, fibrinolytic therapy remains a practical option for a large number of patients when there is no immediate access to a catheterization laboratory, particularly since the reduced risk of death associated with primary PCI may be restricted to high-risk patients.41
The relevant question for clinicians is how long a delay in access to primary PCI would make fibrinolytic therapy the preferred reperfusion therapy. Unfortunately, there is no clear answer. Several meta-regression analyses and a recent pooled analysis of patient-level data have examined this issue.42-45 Although results vary substantially among these studies, all suggest that differences between reperfusion therapies with respect to mortality favor primary PCI but diminish as PCI-related delays increase, potentially reaching equipoise between 60 and 120 minutes. A recent observational study from the National Registry of Myocardial Infarction46 showed a similar association, but the report noted that the effect of PCI-related delays may depend on the patient's age, location of the infarct, and duration of symptoms. Patients who are younger, have anterior infarction, and present with a shorter duration of symptoms — all factors related to the efficacy and safety of fibrinolytic therapy as well as the dangers of delaying treatment — may have worse outcomes with delays in primary PCI as compared with rapid fibrinolytic therapy. This study, however, does not provide strong enough evidence that there are subgroups for which PCI-related delays are unimportant.
Because of the lack of definitive data, there is no consensus on the selection of reperfusion therapy in situations in which primary PCI is not readily available. Triage protocols to determine which patients are better candidates for primary PCI than for immediate fibrinolytic therapy have been proposed, but they have not gained widespread support in the United States. As discussions of improved coordination of care for patients with ST-elevation myocardial infarction across hospitals moves forward, matching individual patients with the most appropriate treatment will be an important goal for health care systems. In most situations, rapid administration of fibrinolytic therapy — within 30 minutes after arrival at the hospital for patients without contraindications to its use — is recommended when door-to-balloon times of more than 90 minutes are anticipated with primary PCI. As noted earlier, however, some experts have suggested that equipoise between the strategies may occur with delays in access to primary PCI of as much as 120 minutes or more, depending on the clinical scenario.47
Reducing Door-to-Balloon Time
Evidence is emerging about the best approaches to improving the timeliness of treatment. Establishing hospital-based strategies to reduce door-to-balloon time in primary PCI requires fundamental changes within complex clinical systems. Bradley and colleagues performed in-depth site visits at 11 top-performing hospitals within the National Registry of Myocardial Infarction that had dramatically shortened their median door-to-balloon time over recent years.48 Several critical innovations at the organizational level were noted at these facilities, including the support of senior management, innovative and flexible protocols, individual clinical leaders and collaborative teams, use of data feedback to monitor progress and identify problems and successes, and an organizational culture that fostered improvement efforts.
More recent work has quantified the effects of different specific strategies associated with shorter door-to-balloon times, with the use of data from a national survey of 365 hospitals.49 Strategies identified as beneficial in this study ranged from approaches with minimal resource requirements, such as activation of the catheterization laboratory by emergency medicine physicians rather than cardiologists and single-call activation by a central page operator, to more complex practices, such as the use of prehospital electrocardiography and 24-hour availability of an on-site cardiologist. Others have reported similar findings, with available data particularly supporting the use of prehospital electrocardiography,50,51 activation of the catheterization laboratory by emergency medicine physicians,52,53 and data-monitoring systems with prompt feedback on door-to-balloon time.54 Only a minority of the hospitals surveyed used many of these strategies.49
In an effort to help hospitals improve door-to-balloon time and translate research into practice, the ACC, in partnership with the AHA, the ACEP, the NHLBI, and others, initiated the Door-to-Balloon (D2B) Alliance, a national quality-improvement effort.5 A tool kit and an implementation package for the D2B Alliance have been created on the basis of an expert review of the literature on strategies for improving door-to-balloon time (Table 1Table 1
Hospital-Based Strategies Associated with Shorter Door-to-Balloon Time and Potential Tools to Implement Them.).Combination Strategies
Given that there is a limit to how much door-to-balloon time can be shortened, attempts have been made to minimize the impact of delays on outcomes by combining the two reperfusion strategies. In one strategy, commonly referred to as facilitated PCI, pharmacologic reperfusion with fibrinolytic therapy and glycoprotein IIb/IIIa receptor blockers is used to reestablish flow early on and is followed by emergency PCI. Clinical trials have failed to demonstrate that facilitated PCI improves outcomes as compared with primary PCI, and it may actually result in higher mortality.55,56 However, many of these trials included patients at hospitals where primary PCI was already rapidly available, and the approach has yet to be evaluated in a large number of patients at high risk for prolonged delays to mechanical reperfusion, such as transfer patients. Another widely discussed strategy is the pharmacoinvasive approach,57 in which emergency PCI is not routinely performed after fibrinolytic therapy but is reserved for failed reperfusion based on evidence of improved clinical outcomes in this setting (i.e., rescue PCI).58 After successful reperfusion, routine (nonemergency) catheterization with the pharmacoinvasive approach is performed at a later time (e.g., the next day) as opposed to noninvasive risk stratification.
Although anecdotal reports indicate that clinicians are increasingly using facilitated PCI and the pharmacoinvasive approach, neither can be recommended at this time. This is especially true when full-dose fibrinolytic therapy is combined with emergency PCI. This practice, one form of facilitated PCI, should be strongly discouraged, given its potential harm.
Future Challenges in Improving Time to Treatment in Primary PCI
Targeting improvement of door-to-balloon time at hospitals that already provide primary PCI is the aim of current efforts such as the D2B Alliance. If successful, this work will enhance quality at these facilities. Future challenges will be to optimize primary PCI as its use extends to larger populations of patients by shortening the overall time from the onset of symptoms to treatment. This focus will include strategies for reducing the time from symptom onset to initial contact by patients with the health care system and improving the use of emergency medical systems, both of which have been largely unresponsive to traditional public education campaigns.59
In an effort to expand the availability of PCI, some regions are now permitting primary PCI at hospitals with catheterization laboratories but no on-site cardiac surgery or elective PCI. Early studies suggest improved clinical outcomes with this approach, as compared with fibrinolytic therapy, when it is associated with a dedicated, primary PCI development program.60 As compared with transfer for primary PCI, primary PCI at hospitals without on-site cardiac surgery has been associated with shorter times to treatment, with some data suggesting similar short-term mortality.61,62 The evidence in this area, however, is very limited. More recently, there has been great interest in using “bypass” protocols that are similar to the trauma model. This would allow patients with ST-elevation myocardial infarction to be triaged directly to hospitals with PCI capabilities by emergency medical services rather than to the nearest hospital. However, this approach would be best implemented with the use of prehospital electrocardiography, which is still uncommon in the United States.63
Systems of care that integrate many of these approaches are being developed in some regions of the United States and are the focus of the AHA program Mission Lifeline.64 Although there is early evidence of success in limited areas, broad generalizability of these systems has yet to be demonstrated. Any improvements in access to primary PCI with these strategies also must be balanced against the use of immediate fibrinolytic therapy, which remains a reasonable alternative for reperfusion therapy in selected instances. Matching patients with the most appropriate treatment and location will entail developing a level of coordination and collaboration among hospitals beyond what is currently available in the U.S. health care system but is achievable.
Supported by grants from the National Heart, Lung, and Blood Institute (R01HL072575) and the Patrick and Catherine Weldon Donaghue Medical Research Foundation (02-102, to Dr. Bradley).
No potential conflict of interest relevant to this article was reported.
We thank Drs. Eric R. Bates and Henry H. Ting for their review of earlier drafts of the manuscript, Mr. Yongfei Wang for providing analytic support, and Ms. Maria Johnson for help with the preparation of the manuscript.
Source Information
From the Health Services Research and Development Center of Excellence, Ann Arbor Veterans Affairs Medical Center, and the Department of Internal Medicine, Division of Cardiovascular Disease, University of Michigan Medical School — both in Ann Arbor (B.K.N.); the Section of Health Policy and Administration, Department of Epidemiology and Public Health and the Robert Wood Johnson Clinical Scholars Program, Department of Medicine, Yale University School of Medicine, New Haven, CT (E.H.B., H.M.K.); and the Section of Cardiovascular Medicine, Department of Medicine, Yale University School of Medicine, and the Center for Outcomes Research and Evaluation, Yale–New Haven Hospital — both in New Haven, CT (H.M.K.).
Address reprint requests to Dr. Krumholz at 333 Cedar St., Rm. I-456 SHM, P.O. Box 208088, New Haven, CT 06520-8088, or at harlan.krumholz@yale.edu.
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Citing Articles
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Stephen H. Thomas, Annette O. Arthur. (2012) Helicopter EMS: Research Endpoints and Potential Benefits. Emergency Medicine International 2012, 1-14
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Margrethe Herning, Peter R. Hansen, Birgitte Bygbjerg, Tove Lindhardt. (2011) Women's experiences and behaviour at onset of symptoms of ST segment elevation acute myocardial infarction. European Journal of Cardiovascular Nursing 10:4, 241-247
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Natale Daniele Brunetti, Luisa De Gennaro, Giulia Dellegrottaglie, Daniele Amoruso, Gianfranco Antonelli, Matteo Di Biase. (2011) A Regional Prehospital Electrocardiogram Network with a Single Telecardiology “Hub” for Public Emergency Medical Service: Technical Requirements, Logistics, Manpower, and Preliminary Results. Telemedicine and e-Health 17:9, 727-733
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Giampaolo Niccoli, Cristina Spaziani, Nicola Cosentino, Antonella Lombardo, Francesco Fracassi, Leonardo Cataneo, Valentina Loria, Carlo Trani, Francesco Burzotta, Italo Porto, Antonio Maria Leone, Filippo Crea. (2011) Predictors of myocardial microvascular obstruction in patients treated by primary percutaneous coronary intervention and a short ischemic time. International Journal of Cardiology 153:1, 113-115
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Teresa Camp-Rogers, Siddhartha Dante, Michael C. Kontos, Charlotte S. Roberts, Laura Kreisa, Michael Christopher Kurz. (2011) The impact of prehospital activation of the cardiac catheterization team on time to treatment for patients presenting with ST-segment-elevation myocardial infarction. The American Journal of Emergency Medicine 29:9, 1117-1124
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Michael C. Kontos, Michael C. Kurz, Charlotte S. Roberts, Sarah E. Joyner, Laura Kreisa, Joseph P. Ornato, George W. Vetrovec. (2011) Emergency physician–initiated cath lab activation reduces door to balloon times in ST-segment elevation myocardial infarction patients. The American Journal of Emergency Medicine 29:8, 868-874
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Giuseppe De Luca. (2011) Glycoprotein IIb-IIIa Inhibitors. Cardiovascular Therapeuticsno-no
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Wolfgang Scheidt, Christian Thilo. (2011) As time goes by? The fallacy of thrombolysis in STEMI networks. Clinical Research in Cardiology 100:10, 867-877
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Peter H. Nielsen, Christian J. Terkelsen, Torsten T. Nielsen, Leif Thuesen, Lars R. Krusell, Per Thayssen, Henning Kelbæk, Ulrik Abildgaard, Anton B. Villadsen, Henning R. Andersen, Michael Maeng. (2011) System Delay and Timing of Intervention in Acute Myocardial Infarction (from the Danish Acute Myocardial Infarction-2 [DANAMI-2] Trial). The American Journal of Cardiology 108:6, 776-781
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Christof Havel, Wolfgang Schreiber, Günter Christ, Susanne Winkler, Harald Herkner. (2011) Accelerated management of patients with ST-segment elevation myocardial infarction in the ED. The American Journal of Emergency Medicine 29:6, 650-655
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Hervé Le Breton. (2011) Prise en charge de l’infarctus du myocarde : les délais. La Presse Médicale 40:6, 600-605
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Giampaolo Niccoli, Nicola Cosentino, Cristina Spaziani, Silvia Minelli, Francesco Fracassi, Filippo Crea. (2011) New strategies for the management of no-reflow after primary percutaneous coronary intervention. Expert Review of Cardiovascular Therapy 9:5, 615-630
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Scott A. Waldman, Andre Terzic. (2011) Bionic Technologies Transforming the Science of Healthcare Delivery. Clinical and Translational Science 4:2, 84-86
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Dennis T. Ko, Clare L. Atzema, Linda R. Donovan, Michelle M. Graham, Thao Huynh, Derek Y. So, Julie Wang, Harindra C. Wijeysundera, Jack V. Tu. (2011) Rescue percutaneous coronary interventions for failed fibrinolytic therapy in ST-segment elevation myocardial infarction: A population-based study. American Heart Journal 161:4, 764-770.e1
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Jan Trojanowski, Russell D. MacDonald. (2011) Safe Transport of Patients with Acute Coronary Syndrome or Cardiogenic Shock by Skilled Air Medical Crews. Prehospital Emergency Care 15:2, 240-245
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R. M. West, B. A. Cattle, M. Bouyssie, I. Squire, M. de Belder, K. A. A. Fox, R. Boyle, J. M. McLenachan, P. D. Batin, D. C. Greenwood, C. P. Gale. (2011) Impact of hospital proportion and volume on primary percutaneous coronary intervention performance in England and Wales. European Heart Journal 32:6, 706-711
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C. Thilo, A. Blüthgen, B. Kuch, W. Scheidt. (2011) Herzinfarktnetzwerk Region Augsburg (HERA). Notfall + Rettungsmedizin 14:2, 128-134
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Christoph Liebetrau, Sebastian Szardien, Johannes Rixe, Mariella Woelken, Andreas Rolf, Timm Bauer, Holger Nef, Helge Möllmann, Christian Hamm, Michael Weber. (2011) Direct admission versus transfer of AMI patients for primary PCI. Clinical Research in Cardiology 100:3, 217-225
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Zorana Vasiljevic, Natasa Mickovski-Katalina, Gordana Krljanac, Gordana Panic, Biljana Putnikovic, Miodrag Ostojic, Bojan Stojanovic, Sladjan Milanovic. (2011) Coronary care unit and primary percutaneous coronary intervention networks improve the standard of care: reperfusion therapy in ST elevation myocardial infarction in Serbia from 2002 to 2008. Journal of Cardiovascular Medicine1
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M. Mulder, F. M. Zant, P. Knaapen, J. H. Cornel, V. A. W. M. Umans. (2011) Long-term Clinical Outcome and MIBI SPECT Parameters in Percutaneous Coronary Interventions. Netherlands Heart Journal 19:2, 68-72
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Xavier Bosch, Antoni Curós, Josep M. Argimon, Meia Faixedas, Jaume Figueras, F. Xavier Jiménez Fàbrega, Rafael Masià, Josepa Mauri, Ricard Tresserras. (2011) Modelo de intervención coronaria percutánea primaria en Cataluña. Revista Española de Cardiología Suplementos 11, 51-60
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Jeng-Feng Lin, Shun-Yi Hsu, Semon Wu, Chiau-Suong Liau, Heng-Chia Chang, Chih-Jen Liu, Hsuan-Li Huang, Yao-Tsan Ho, Shu-Li Weng, Yu-Lin Ko. (2011) Data feedback reduces door-to-balloon time in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention. Heart and Vessels 26:1, 25-30
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Koyu Sakai, Shinya Nagayama, Kasumi Ihara, Kenji Ando, Shinichi Shirai, Katsuhiro Kondo, Hiroyoshi Yokoi, Masashi Iwabuchi, Hideyuki Nosaka, Masakiyo Nobuyoshi. (2011) Primary percutaneous coronary intervention for acute myocardial infarction in the elderly aged ≥75 years. Catheterization and Cardiovascular Interventions 79:1, 50-56
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P. Barash, S. Akhtar. (2010) Coronary stents: factors contributing to perioperative major adverse cardiovascular events. British Journal of Anaesthesia 105:Supplement 1, i3-i15
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Michel R. Le May, Richard Dionne, Justin Maloney, Pierre Poirier. (2010) The Role of Paramedics in a Primary PCI Program for ST-Elevation Myocardial Infarction. Progress in Cardiovascular Diseases 53:3, 183-187
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Terrence Baruch, Alisa Rock, William J. Koenig, Ivan Rokos, William J. French. (2010) “Call 911” STEMI Protocol to Reduce Delays in Transfer of Patients From Non Primary Percutaneous Coronary Intervention Referral Centers. Critical Pathways in Cardiology: A Journal of Evidence-Based Medicine 9:3, 113-115
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Giampaolo Niccoli, Marcello Marino, Cristina Spaziani, Filippo Crea. (2010) Prevention and treatment of no-reflow. Acute Cardiac Care 12:3, 81-91
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Michael C Reed, Brahmajee K Nallamothu. (2010) Optimizing primary percutaneous coronary intervention in ST-segment elevation myocardial infarction. Interventional Cardiology 2:4, 449-453
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Ingo Eitel, Steffen Desch, Georg Fuernau, Lysann Hildebrand, Matthias Gutberlet, Gerhard Schuler, Holger Thiele. (2010) Prognostic Significance and Determinants of Myocardial Salvage Assessed by Cardiovascular Magnetic Resonance in Acute Reperfused Myocardial Infarction. Journal of the American College of Cardiology 55:22, 2470-2479
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L Galiuto, L Paraggio, G Liuzzo, AR de Caterina, F Crea. (2010) Predicting the no-reflow phenomenon following successful percutaneous coronary intervention. Biomarkers in Medicine 4:3, 403-420
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Mitsuaki Endo, Kiyoshi Hibi, Tomoaki Shimizu, Naohiro Komura, Ikuyoshi Kusama, Fumiyuki Otsuka, Takayuki Mitsuhashi, Noriaki Iwahashi, Jun Okuda, Kengo Tsukahara, Masami Kosuge, Toshiaki Ebina, Satoshi Umemura, Kazuo Kimura. (2010) Impact of Ultrasound Attenuation and Plaque Rupture as Detected by Intravascular Ultrasound on the Incidence of No-Reflow Phenomenon After Percutaneous Coronary Intervention in ST-Segment Elevation Myocardial Infarction. JACC: Cardiovascular Interventions 3:5, 540-549
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George W. Vetrovec. (2010) Its all about time and talent. Catheterization and Cardiovascular Interventions 75:5, 700-700
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J. Mark Peterman, Soren Bisgaard. (2010) Door-to-Balloon Time: Performance Improvement in the Multidisciplinary Treatment of Myocardial Infarction. Journal for Healthcare Quality
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Suhail Allaqaband, M. Fuad Jan, Wamiq Y. Banday, Angela Schlemm, S. Hinan Ahmed, Naoyo Mori, Neil Oldridge, Anjan Gupta, Tanvir Bajwa. (2010) Impact of 24-hr in-hospital interventional cardiology team on timeliness of reperfusion for ST-segment elevation myocardial infarction. Catheterization and Cardiovascular InterventionsNA-NA
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Christian Hagl, Nawid Khaladj, Sven Peterss, Andreas Martens, Ingo Kutschka, Heidi Goerler, Malakh Shrestha, Axel Haverich. (2009) Acute Treatment of ST-Segment-Elevation Myocardial Infarction: Is There a Role for the Cardiac Surgeon?. The Annals of Thoracic Surgery 88:6, 1786-1792
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Sune H. Pedersen, Soren Galatius, Peter R. Hansen, Rasmus Mogelvang, Steen Z. Abildstrom, Rikke Sørensen, Ulla Davidsen, Anders Galloe, Ulrik Abildgaard, Allan Iversen, Jan Bech, Jan K. Madsen, Jan S. Jensen. (2009) Field Triage Reduces Treatment Delay and Improves Long-Term Clinical Outcome in Patients With Acute ST-Segment Elevation Myocardial Infarction Treated With Primary Percutaneous Coronary Intervention. Journal of the American College of Cardiology 54:24, 2296-2302
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Jeffrey S. Berger, Matthew T. Roe, C. Michael Gibson, Rakhi Kilaru, Cynthia L. Green, Laura Melton, James D. Blankenship, D. Christopher Metzger, Christopher B. Granger, Daniel D. Gretler, Cindy L. Grines, Kurt Huber, Uwe Zeymer, Pawel Buszman, Robert A. Harrington, Paul W. Armstrong. (2009) Safety and feasibility of adjunctive antiplatelet therapy with intravenous elinogrel, a direct-acting and reversible P2Y12 ADP-receptor antagonist, before primary percutaneous intervention in patients with ST-elevation myocardial infarction: The Early Rapid ReversAl of Platelet ThromboSis with Intravenous Elinogrel before PCI to Optimize REperfusion in Acute Myocardial Infarction (ERASE MI) pilot trial. American Heart Journal 158:6, 998-1004.e1
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Mark A. Kotowycz, Renu Pal Syal, Rizwan Afzal, Madhu K. Natarajan. (2009) Can we improve length of hospitalization in ST elevation myocardial infarction patients treated with primary percutaneous coronary intervention?. Canadian Journal of Cardiology 25:10, 585-588
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John X Rolley, Patricia M Davidson, Yenna Salamonson, Ritin Fernandez, Cheryl R Dennison. (2009) Review of nursing care for patients undergoing percutaneous coronary intervention: a patient journey approach. Journal of Clinical Nursing 18:17, 2394-2405
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T. R. Porter. (2009) The utilization of ultrasound and microbubbles for therapy in acute coronary syndromes. Cardiovascular Research 83:4, 636-642
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Derek P Chew, Lucy JH Blows. (2009) Randomized trials of clinical networks in the management of ST-elevation MI: can they be performed?. Current Opinion in Cardiology 24:4, 301-306
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Giampaolo Niccoli, Francesco Burzotta, Leonarda Galiuto, Filippo Crea. (2009) Myocardial No-Reflow in Humans. Journal of the American College of Cardiology 54:4, 281-292
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Efstathios K. Iliodromitis, Ioannis A. Paraskevaidis, Katerina Fountoulaki, Dimitrios Farmakis, Ioanna Andreadou, Aias Antoniadis, Ignatios Ikonomidis, Dionyssios Leftheriotis, Dimitrios T. Kremastinos. (2009) Staccato reperfusion prevents reperfusion injury in patients undergoing coronary angioplasty: A 1-year follow-up pilot study. Atherosclerosis 204:2, 497-502
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Guglielmo Bernardi, Antonio Di Chiara, Ilaria Armellini. (2009) The Acute Myocardial Infarction with ST Segment Elevation Udine Registry (Come-to-Udine): predictors of 3 years mortality. Journal of Cardiovascular Medicine 10:6, 474-484
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Naik, Aanand D., Petersen, Laura A., . (2009) The Neglected Purpose of Comparative-Effectiveness Research. New England Journal of Medicine 360:19, 1929-1931
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Matthias G. Friedrich. (2009) A Closer Look on the Battlefield. JACC: Cardiovascular Imaging 2:5, 577-579
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Ivan C. Rokos, William J. French, William J. Koenig, Samuel J. Stratton, Beverly Nighswonger, Brian Strunk, Jackie Jewell, Ehtisham Mahmud, James V. Dunford, Jon Hokanson, Stephen W. Smith, Kenneth W. Baran, Robert Swor, Aaron Berman, B. Hadley Wilson, Akinyele O. Aluko, Brian W. Gross, Paul S. Rostykus, Angelo Salvucci, Vishva Dev, Bryan McNally, Steven V. Manoukian, Spencer B. King. (2009) Integration of Pre-Hospital Electrocardiograms and ST-Elevation Myocardial Infarction Receiving Center (SRC) Networks. JACC: Cardiovascular Interventions 2:4, 339-346
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Gopal Sivagangabalan, Andrew T.L. Ong, Arun Narayan, Norman Sadick, Peter S. Hansen, Greg C.I. Nelson, Michael Flynn, David L. Ross, Steven C. Boyages, Pramesh Kovoor. (2009) Effect of Prehospital Triage on Revascularization Times, Left Ventricular Function, and Survival in Patients With ST-Elevation Myocardial Infarction. The American Journal of Cardiology 103:7, 907-912
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Paul W. Armstrong, Yuling Fu, Cynthia M. Westerhout, Michael P. Hudson, Kenneth W. Mahaffey, Harvey D. White, Thomas G. Todaro, Peter X. Adams, Philip E.G. Aylward, Christopher B. Granger. (2009) Baseline Q-Wave Surpasses Time From Symptom Onset as a Prognostic Marker in ST-Segment Elevation Myocardial Infarction Patients Treated With Primary Percutaneous Coronary Intervention. Journal of the American College of Cardiology 53:17, 1503-1509
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Brahmajee K. Nallamothu, Harlan M. Krumholz, Eric D. Peterson, Wenqin Pan, Elizabeth Bradley, Amy F. Stern, Frederick A. Masoudi, David M. Janicke, Adrian F. Hernandez, Christopher P. Cannon, Gregg C. Fonarow. (2009) Door-to-Balloon Times in Hospitals Within the Get-With-The-Guidelines Registry After Initiation of the Door-to-Balloon (D2B) Alliance. The American Journal of Cardiology 103:8, 1051-1055
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Paul Knaapen, Maarten Mulder, Friso M. Zant, Hans O. Peels, Jos W. R. Twisk, Albert C. Rossum, Jan H. Cornel, Victor A. W. M. Umans. (2009) Infarct size in primary angioplasty without on-site cardiac surgical backup versus transferal to a tertiary center: a single photon emission computed tomography study. European Journal of Nuclear Medicine and Molecular Imaging 36:2, 237-243
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G. De Luca. (2008) Adjunctive antithrombotic therapy during primary percutaneous coronary intervention. European Heart Journal Supplements 10:Suppl J, J2-J14
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Diane E. Head. (2008) Reply. Journal of Clinical Anesthesia 20:8, 626
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Dennis T. Ko, Linda R. Donovan, Thao Huynh, Stéphane Rinfret, Derek Y. So, Michael P. Love, Diane Galbraith, Jack V. Tu. (2008) A survey of primary percutaneous coronary intervention for patients with ST segment elevation myocardial infarction in Canadian hospitals. Canadian Journal of Cardiology 24:11, 839-843
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Rachna Shah, Susan M. Goldstein, Barbara T. Unger, Timothy D. Henry. (2008) Explaining Anomalous High Performance in a Health Care Supply Chain*. Decision Sciences 39:4, 759-789
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Diane E. Head, Paul Barash. (2008) Progress Is Precarious. Anesthesia & Analgesia 107:2, 362-364
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Simon R. Dixon, Cindy L. Grines, William W. O'Neill. (2008) The Year in Interventional Cardiology. Journal of the American College of Cardiology 51:24, 2355-2369
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Arnd Timmermann, Sebastian G Russo, Markus W Hollmann. (2008) Paramedic versus emergency physician emergency medical service: role of the anaesthesiologist and the European versus the Anglo-American concept. Current Opinion in Anaesthesiology 21:2, 222-227
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Ben Roitberg. (2008) Research news and notes. Surgical Neurology 69:3, 224-225
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Vetrovec, George W., . (2008) Improving Reperfusion in Patients with Myocardial Infarction. New England Journal of Medicine 358:6, 634-637
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Carlo Di Mario, Dariusz Dudek, Federico Piscione, Waldemar Mielecki, Stefano Savonitto, Ernesto Murena, Konstantinos Dimopoulos, Antonio Manari, Achille Gaspardone, Andrzej Ochala, Krzysztof Zmudka, Leonardo Bolognese, Philippe Gabriel Steg, Marcus Flather. (2008) Immediate angioplasty versus standard therapy with rescue angioplasty after thrombolysis in the Combined Abciximab REteplase Stent Study in Acute Myocardial Infarction (CARESS-in-AMI): an open, prospective, randomised, multicentre trial. The Lancet 371:9612, 559-568
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(2008) Primary Percutaneous Coronary Intervention. New England Journal of Medicine 358:4, 431-433
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