Treatment time key for heart attack surviva

[tniuqs]

http://www.cbc.ca/health/story/2010/06/02/heart-attack-treatment-time.html

Time to treatment, not the type of therapy used, is key to restoring blood flow following a heart attack, a new Quebec study shows.

The research, published Wednesday in the Journal of the American Medical Association, suggests getting treatment within the recommended window is more important than whether that treatment is a shot of clot-busting drugs or an angioplasty procedure to open a blocked artery.The findings inject some real-world practicality to what has been the growing belief that angioplasty is the preferred option after a heart attack. That belief has arisen from randomized controlled trials, where the two techniques were tested head-to-head under optimum conditions."Because of randomized trials, there is a perception that angioplasty is better," lead author Laurie Lambert of Quebec's health technology and health services evaluation agency said in an interview."But the randomized trials don't have delays that we see in the real world. So that's the big issue."Lambert and her co-authors conducted what is called an observational study, looking at the results of six months worth of heart attack responses at 80 Quebec hospitals.All hospitals that treated more than 30 heart attacks during that period were included in the study, which covered the period from October 2006 to the end of March 2007.

Time targets missed

Of 1,832 patients who received one of the two treatments, 21 per cent got clot-busting drugs while 79 per cent underwent angioplasty, a procedure where a tiny balloon is snaked into the affected artery and then inflated to release the blockage.

For maximum benefit, the former is meant to be administered within 30 minutes of arrival at hospital while the latter should be done within 90 minutes of hospital arrival.But those time targets were not reached in 54 per cent of patients treated with clot-busting drugs and 68 per cent of those given angioplasty.Only 15 of the 80 hospitals had the capacity to do the angioplasty, meaning many patients who underwent the procedure had to be transported from the community hospital where they first sought care to a larger hospital in an urban centre.

Quick drug treatment

The rate of deaths or readmission to hospital within a year was virtually the same for the two groups, 13.5 per cent. But the patients who received treatment late — either treatment — were twice as likely to die within 30 days as those who were treated within the recommended window."It's better to give either of the options quickly than to delay giving one treatment in order to give the other treatment," said Dr. Jack Tu, a senior scientist with the Institute for Clinical Evaluative Sciences in Toronto."You're better off to give lytics" — clot-busting drugs — "quickly than to give primary angioplasty in a delayed manner."Tu was not involved in the study, but has done similar work looking at the situation in Ontario. The findings, not yet published, back what Lambert and her colleagues saw, he said."What this shows is that in a real world setting, the outcomes are probably pretty similar at one year, regardless of how you're treated," he said. "So what's more important is speed than the modality."That is a critical piece of knowledge in a country like Canada, where a small population is stretched across a wide geographic expanse."You're not going to have a cath[ether] lab in every hospital," Lambert said.Tu noted that in densely populated Britain, health authorities aim to treat the vast majority of heart attack patients with angioplasty and to do it within the recommended time, which is easier and more feasible to do in such a geographically dense area.

Yea Yea I know but I cant find the REAL study .... well just yet.

cheers

Receiving Treatment for Heart Attack Past Recommended Times Associated With Significantly Increased Risk of Death

CHICAGO—An examination of the treatment received by patients with myocardial infarction (heart attack) at 80 hospitals in Quebec indicates that those who received either primary percutaneous coronary intervention (PPCI; such as angioplasty) or fibrinolysis (administration of medication to dissolve blood clots) beyond the times recommended in international guidelines had a significantly increased risk of death within 30 days, along with an increased risk of the combined outcome of death or readmission for heart attack or heart failure at one year, according to a study in the June 2 issue of JAMA.

"Both primary percutaneous coronary intervention and fibrinolysis are well-recognized treatments for STEMI in international guidelines, and benefits are maximized when treatment occurs early," according to background information in the article. STEMI (ST-segment elevation myocardial infarction) is a certain pattern on an electrocardiogram following a heart attack. "However, randomized trials and selective registries are limited in their ability to assess the effect of timeliness of reperfusion on outcomes in real-world STEMI patients."

Laurie Lambert, Ph.D., of the Quebec Healthcare Assessment Agency, Montreal, Canada, and colleagues conducted a province-wide evaluation of STEMI care in Quebec (population, 7.8 million) to determine the use of reperfusion treatments (such as PPCI or fibrinolysis) and their delays and whether STEMI reperfusion treatment outside of the guideline-recommended delays was associated with poorer outcomes than treatment within recommended delays. The researchers analyzed data of STEMI care for 6 months during 2006-2007 in 80 hospitals in Quebec. Maximum delays recommended in international guidelines for PPCI are 90 minutes; 30 minutes for fibrinolysis.

Of the patients treated with acute reperfusion (n = 1,832), 78.6 percent (1,440) underwent PPCI and 21.4 percent (392) received fibrinolytic therapy. Among patients who underwent PPCI, the median (midpoint) door-to-balloon time was 110 minutes. PPCI was untimely (greater than 90 minutes) in 68 percent of patients. For patients who received fibrinolysis, the median delay was 33 minutes, and untimely (greater than 30 minutes) in 54 percent of patients. Incidence of the combined outcome (death or readmission for heart failure or heart attack) at 1 year was 13.5 percent for fibrinolysis patients and 13.6 percent for PPCI patients.

"When the 2 treatment groups were combined, patients treated outside of recommended delays had an adjusted higher risk of death at 30 days (6.6 percent vs. 3.3 percent) and a statistically nonsignificant increase in risk of death at 1 year (9.3 percent vs. 5.2 percent) compared with patients who received timely treatment. Patients treated outside of recommended delays also had an adjusted higher risk for the combined outcome of death or hospital readmission for congestive heart failure or acute myocardial infarction [heart attack] at 1 year (15.0 percent vs. 9.2 percent). At the regional level, after adjustment, each 10 percent increase in patients treated within the recommended time was associated with a decrease in the region-level odds of overall 30-day mortality," the authors write.

"Our study, while consistent with registry and clinical data associating longer treatment delays with poorer outcomes, is novel and robust in several ways. Above all, it represents not a sampling but more than 95 percent of all STEMI patients within a large and complex system of care and provides very recent information that transcends the relative selectivity of randomized clinical trials and most registries."

" ...we believe this evaluation represents a needed contribution to the evidence base for deriving clinical practice guidelines and an important advance in knowledge of the outcomes associated with contemporary processes of STEMI care. This 'real-world' information is relevant both clinically and from a perspective of evidence-based health care policy and planning, pointing to the lifesaving potential for approaches that focus on offering the most timely reperfusion treatment to patients with STEMI," the researchers write.

They add that time, rather than mode of reperfusion, emerges as a critical determinant of outcome in this systematic evaluation of STEMI care. "Regardless of reperfusion strategy, patients treated beyond maximum recommended delays had increased mortality."

(JAMA 2010;303[21]:2148-2155. Available pre-embargo to the media at www.jamamedia.org)

More evidence based medicine "sideways" promoting thrombolitic therapy to be put in the field and on car ... I am hours from a Angio Lab let alone a hospital.

[HERBIE1]

I am hours from a Angio Lab let alone a hospital.

Another example of the vast differences between our various systems. I can see the benefits of thrombolytics in a situation such as yours. I cannot imagine working in such a remote area.