Elsevier

American Heart Journal

Volume 151, Issue 6, June 2006, Pages 1231-1238
American Heart Journal

Clinical Investigation
Acute Ischemic Heart Disease
Impact of treatment delays on outcomes of primary percutaneous coronary intervention for acute myocardial infarction: Analysis from the CADILLAC trial

https://doi.org/10.1016/j.ahj.2005.07.016Get rights and content

Background

The impact of treatment delays on outcomes after primary percutaneous coronary intervention for acute myocardial infarction is controversial.

Methods

The CADILLAC trial randomized 2082 patients with acute myocardial infarction to stenting versus percutaneous transluminal coronary angioplasty, each with or without abciximab.

Results

Earlier reperfusion (<3 vs 3-6 vs >6 hours) was associated with lower 1-year mortality (2.6% vs 4.3% vs 4.8%, P = .046 for <3 vs ≥3 hours), more frequent grade 2 to 3 myocardial blush (55% vs 53% vs 44%, P = .003), more frequent complete ST-segment resolution (64% vs 68% vs 47%, P = .006), and greater improvement in left ventricular function. Early reperfusion (<3 vs 3-6 vs ≥3 hours) was associated with lower mortality in high-risk patients (3.8% vs 6.9% vs 7.0%, P = .051 for <3 vs ≥3 hours) but not in low-risk patients (1.4% vs 0.6% vs 1.0%, P = .63). Door-to-balloon times were independently correlated with mortality in patients presenting early after the onset of symptoms (≤2 hours, hazard ratio 1.24, P = .013) but not late (>2 hours, heart rate 0.88, P = .33).

Conclusions

Early reperfusion results in superior clinical outcomes, enhanced microvascular reperfusion, and better recovery of left ventricular function. Incremental treatment delays impact mortality more in high-risk versus low-risk patients and more in patients presenting early versus late after the onset of symptoms. These data emphasize the importance of minimizing treatment delays and have implications regarding patient triage for primary percutaneous coronary intervention.

Section snippets

Study population and study protocol

The CADILLAC trial enrolled patients with no shock but with AMI of <12 hours' duration who had either ST-segment elevation or left bundle-branch block, or angiographically severe coronary stenosis associated with a regional wall motion (RWM) abnormality. Patients (n = 2082) were randomized to 1 of 4 reperfusion strategies: balloon angioplasty alone, angioplasty plus abciximab, stent alone, or stent plus abciximab.8 Time to reperfusion data were available in 2002 patients and door-to-balloon

Treatment times

Median treatment times were as follows: time to presentation, 1.78 (1.00, 3.43) hours; door-to-balloon time, 2.00 (1.48, 2.72) hours; and time to reperfusion, 3.97 (2.88, 6.10) hours. Only 21% of patients presented to the hospital within 1 hour of symptom onset, only 26% of patients had door-to-balloon times <90 minutes, and only 27% of patients were reperfused within 3 hours of symptom onset (Figure 1).

Baseline variables and treatment times

Patients with longer times to reperfusion were more likely to be older, female, and treated

Discussion

The major findings of this study are (1) early reperfusion with primary PCI for AMI is associated with superior clinical outcomes, enhanced microvascular reperfusion, and better recovery of left ventricular function; (2) delays in reperfusion impact mortality in high-risk patients but not low-risk patients; (3) incremental delays in reperfusion appear to have a greater impact on mortality in patients presenting early versus late after the onset of symptoms; and (4) Only a minority of patients

References (27)

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    According to the prevailing guidelines, patients with STEMI should undergo reperfusion therapy as expeditiously as possible (28). Study results are inconclusive regarding the prognostic significance of time from symptom onset to reperfusion therapy: the results from some studies indicate that STEMI patients with a longer time delay have worse outcome, while other studies found no clear evidence for an independent role of time delays (29–34). Previous studies showed that compared to patients with G2I, those with G3I have higher in-hospital and 30-day mortality and less myocardial salvage when presenting late - two to three hours from symptom onset - but not when presenting earlier (2,20,35).

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