TY - JOUR
T1 - Comparison of Mortality Benefit of Immediate Thrombolytic Therapy Versus Delayed Primary Angioplasty for Acute Myocardial Infarction
AU - Kent, David M.
AU - Ruthazer, Robin
AU - Griffith, John L.
AU - Beshansky, Joni R.
AU - Grines, Cindy L.
AU - Aversano, Thomas
AU - Concannon, Thomas W.
AU - Zalenski, Robert J.
AU - Selker, Harry P.
N1 - Funding Information:
This research was supported by Grants R01 HS10280 from AHRQ, Rockville, Maryland, and K23 NS044929 from the National Institutes of Health, NINDS, Bethesda, Maryland.
PY - 2007/5/15
Y1 - 2007/5/15
N2 - Primary percutaneous coronary intervention (PPCI) yields superior mortality outcomes compared with thrombolysis in ST-elevation acute myocardial infarction (STEMI) but takes longer to administer. Previous meta-regressions have estimated that a procedure-related delay of 60 minutes would nullify the benefits of PPCI on mortality. Using a combined database from randomized clinical trials and registries (n = 2,781) and an independently developed model of mortality risk in STEMI, we developed logistic regression models predicting 30-day mortality for PPCI and thrombolysis by examining the influence of baseline risk on the treatment effect of PPCI and on the hazard of treatment delay. We used these models to solve mathematically for "time interval to mortality equivalence," defined as the PPCI-related delay that would nullify its expected mortality benefit over thrombolysis, and to explore the influence of baseline risk on this value. As baseline risk increases, the relative benefit of PPCI compared with thrombolytic therapy significantly increases (p = 0.002); patients with STEMI at relatively low risk of mortality accrue little or no incremental mortality benefit from PPCI, but high-risk patients benefit greatly. However, as baseline risk increases, the hazard associated with longer treatment-related delay also increases (p = 0.007). These 2 effects are compensatory and yield a roughly uniform time interval to mortality equivalence of ∼100 minutes in patients who have at least a moderate degree of mortality risk (>∼4%). In conclusion, the mortality benefits of PPCI and the hazard of PPCI-related delay depend on baseline risk. Previous meta-regressions appear to have underestimated the PPCI-related delay that would nullify the incremental benefits of PPCI.
AB - Primary percutaneous coronary intervention (PPCI) yields superior mortality outcomes compared with thrombolysis in ST-elevation acute myocardial infarction (STEMI) but takes longer to administer. Previous meta-regressions have estimated that a procedure-related delay of 60 minutes would nullify the benefits of PPCI on mortality. Using a combined database from randomized clinical trials and registries (n = 2,781) and an independently developed model of mortality risk in STEMI, we developed logistic regression models predicting 30-day mortality for PPCI and thrombolysis by examining the influence of baseline risk on the treatment effect of PPCI and on the hazard of treatment delay. We used these models to solve mathematically for "time interval to mortality equivalence," defined as the PPCI-related delay that would nullify its expected mortality benefit over thrombolysis, and to explore the influence of baseline risk on this value. As baseline risk increases, the relative benefit of PPCI compared with thrombolytic therapy significantly increases (p = 0.002); patients with STEMI at relatively low risk of mortality accrue little or no incremental mortality benefit from PPCI, but high-risk patients benefit greatly. However, as baseline risk increases, the hazard associated with longer treatment-related delay also increases (p = 0.007). These 2 effects are compensatory and yield a roughly uniform time interval to mortality equivalence of ∼100 minutes in patients who have at least a moderate degree of mortality risk (>∼4%). In conclusion, the mortality benefits of PPCI and the hazard of PPCI-related delay depend on baseline risk. Previous meta-regressions appear to have underestimated the PPCI-related delay that would nullify the incremental benefits of PPCI.
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U2 - 10.1016/j.amjcard.2006.12.068
DO - 10.1016/j.amjcard.2006.12.068
M3 - Article
C2 - 17493465
AN - SCOPUS:34247644421
SN - 0002-9149
VL - 99
SP - 1384
EP - 1388
JO - American Journal of Cardiology
JF - American Journal of Cardiology
IS - 10
ER -