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The Thrombotic AMI Lesion: Lessons from Pathology more...

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Electrocardiographic Identification of the Culprit Lesion in ST-Segment Elevation Myocardial more...

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The Role of Thrombolysis in the Era of STEMI Interventions more...

Chapter 4

STEMI Interventions: A Review of Relevant Clinical Trials more...

Chapter 5

Updated Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction more...

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Chapter 10
Lessons from the Single Individual Community Experience Registry for Primary PCI (SINCERE) Database
Sameer Mehta, MD, FACC, Carlos Alfonso, MD, Estefania Oliveros, MD, Rosanna Briceno, MD, Camilo Peña, MD

The Current Status of Primary Percutaneous Coronary Intervention

Numerous publications and randomized clinical trials have convincingly demonstrated the superiority of primary percutaneous coronary intervention (PCI) over thrombolytic therapy for ST-elevation myocardial infarction (STEMI), provided that it is instituted in a timely fashion. In a quantitative review of 23 randomized trials, primary PCI was better than thrombolytic therapy at reducing overall short-term death, 7% vs 9%, respectively, and also demonstrated improved long-term outcomes. Several trials have shown that short door-to-balloon (D2B) times improve early and late outcomes in primary PCI. D2B times of 90 minutes or less have been shown to be associated with smaller infarct sizes, fewer major adverse cardiovascular events (MACE), and better long-term survival. The National Registry of Myocardial Infarction (NRMI) database demonstrated a strong relationship between D2B time and in-hospital mortality among 29,222 patients with STEMI. 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% with delays of 91 to 120 minutes, 121 to 150 minutes, and more than 150 minutes, respectively. After adjustment for differences, each 15-minute reduction in D2B time was associated with 6.3 fewer deaths per 1,000 patients treated. Similarly, 30-day and 1-year mortality are also proportional to the D2B time. With such clear and demonstrable improvements in morbidity and mortality benefits, it was a natural transition for guidelines and practices to rapidly shift. Based on this data, the American College of Cardiology (ACC), in conjunction with the American Heart Association (AHA) as well as the European Society of Cardiology, recommend that primary angioplasty should be done within 90 minutes of presentation (or the time from initial medical contact).

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