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Prehospital triage and direct transport of patients with ST-elevation myocardial infarction to primary percutaneous coronary intervention centres: a systematic review and meta-analysis

Published online by Cambridge University Press:  21 May 2015

Steven C. Brooks ,
Katherine S. Allan ,
Michelle Welsford ,
P. Richard Verbeek ,
Hans-Richard Arntz  and
Laurie J. Morrison
Steven C. Brooks*
Affiliation:
Rescu, Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ont. Program for Trauma, Emergency and Critical Care, Department of Emergency Services, Sunnybrook Health Sciences Centre, Toronto, Ont. Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ont.
Katherine S. Allan
Affiliation:
Rescu, Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ont. Electrophysiology Research, Department of Cardiology, St. Michael's Hospital, Toronto, Ont.
Michelle Welsford
Affiliation:
Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, Ont.
P. Richard Verbeek
Affiliation:
Program for Trauma, Emergency and Critical Care, Department of Emergency Services, Sunnybrook Health Sciences Centre, Toronto, Ont. Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ont. Sunnybrook Osler Centre for Prehospital Care, Toronto, Ont.
Hans-Richard Arntz
Affiliation:
Department of Cardiopulmonology, Charité, Campus Benjamin Franklin, Berlin, Germany
Laurie J. Morrison
Affiliation:
Rescu, Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ont. Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ont.
*
Rescu, St. Michael's Hospital, 193 Yonge St., 5th Floor, Toronto ON M5B 1M8; brooksst@smh.toronto.on.ca

Abstract

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Objective:

Percutaneous coronary intervention (PCI) appears to be superior to in-hospital fibrinolysis for most patients with ST-elevation myocardial infarction (STEMI). However, few hospitals have PCI capability. The optimal prehospital strategy for facilitating rapid coronary reperfusion in STEMI patients is unclear. We sought to determine whether direct transport of adult STEMI patients by emergency medical services to primary PCI centres improves 30-day all-cause mortality when compared with a strategy of transportation to the closest hospital.

Methods:

We systematically searched MEDLINE, EMBASE, Cochrane “CENTRAL” database (1980-July 2007) and several other electronic databases. Two authors independently assessed citations for relevance. Two authors independently abstracted data from included studies. We included studies that, 1) transported patients directly to a PCI-capable centre for primary PCI, 2) had a control group that was transported to the closest hospital and 3) reported outcomes of treatment time intervals, all-cause mortality, reinfarction rate, stroke rate or the frequency of cardiogenic shock. We used a random effects model to provide pooled estimates of relative risk (RR) when data allowed.

Results:

We identified 2264 citations with the search. Five studies, including 980 STEMI patients, met inclusion criteria, and were clinically heterogeneous and of variable quality. Most studies were European (3/5) and involved physician out-of-hospital care providers. There was a trend toward increased survival with direct transport to primary PCI but this was not statistically significant (RR 0.51, 95% confidence interval [CI] 0.24–1.10). One study reported nonsignificant reductions in reinfarction (RR 0.43, 95% CI 0.11–1.60) and stroke (RR 0.33, 95% CI 0.01–8.06) with direct transport for primary PCI.

Conclusion:

There is insufficient evidence to support the effectiveness of direct transport of patients with STEMI for primary PCI when compared with transportation to the closest hospital.

Keywords

ST-elevation myocardial infarctionemergency medical servicesEMSreperfusion strategiesprimary percutaneous coronary interventionPCI
Type
State of the Art • À la fine pointe
Information
Canadian Journal of Emergency Medicine , Volume 11 , Issue 5 , September 2009 , pp. 481 - 492
Copyright
Copyright © Canadian Association of Emergency Physicians 2009

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