Clinical Research
Acute Myocardial Infarction
Efficacy and Safety of Immediate Angioplasty Versus Ischemia-Guided Management After Thrombolysis in Acute Myocardial Infarction in Areas With Very Long Transfer Distances: Results of the NORDISTEMI (NORwegian study on DIstrict treatment of ST-Elevation Myocardial Infarction)

https://doi.org/10.1016/j.jacc.2009.08.007Get rights and content
Under an Elsevier user license
open archive

Objectives

The goal of this study was to compare a strategy of immediate transfer for percutaneous coronary intervention (PCI) with an ischemia-guided approach after thrombolysis in patients with very long transfer distances to PCI.

Background

Thrombolysis remains the treatment of choice in ST-segment elevation myocardial infarction (STEMI) when primary PCI cannot be performed within 90 to 120 min. The optimal treatment after thrombolysis is still unclear.

Methods

A total of 266 patients with acute STEMI living in rural areas with more than 90-min transfer delays to PCI were treated with tenecteplase, aspirin, enoxaparin, and clopidogrel and randomized to immediate transfer for PCI or to standard management in the local hospitals with early transfer, only if indicated for rescue or clinical deterioration. The primary outcome was a composite of death, reinfarction, stroke, or new ischemia at 12 months, and analysis was by intention to treat.

Results

The primary end point was reached in 28 patients (21%) in the early invasive group compared with 36 (27%) in the conservative group (hazard ratio: 0.72, 95% confidence interval: 0.44 to 1.18, p = 0.19). The composite of death, reinfarction, or stroke at 12 months was significantly reduced in the early invasive compared with the conservative group (6% vs. 16%, hazard ratio: 0.36, 95% confidence interval: 0.16 to 0.81, p = 0.01). No significant differences in bleeding or infarct size were observed.

Conclusions

Immediate transfer for PCI did not improve the primary outcome significantly, but reduced the rate of death, reinfarction, or stroke at 12 months in patients with STEMI, treated with thrombolysis and clopidogrel in areas with long transfer distances. (Norwegian Study on District Treatment of ST-Elevation Myocardial Infarction; NCT00161005).

Key Words

acute myocardial infarction
ST-segment elevation
pre-hospital thrombolysis
percutaneous coronary intervention

Abbreviations and Acronyms

CI
confidence interval
ECG
electrocardiogram
HR
hazard ratio
IQR
interquartile range
PCI
percutaneous coronary intervention
SPECT
single-photon emission computed tomography
STEMI
ST-segment elevation myocardial infarction
TIMI
Thrombolysis In Myocardial Infarction

Cited by (0)

This study was funded by grants from the Scientific Board of the Eastern Norway Regional Health Authority, Hamar, Norway; Ada and Hagbarth Waage's Humanitære og Veldedige Stiftelse, Oslo, Norway; and the Innlandet Hospital Trust, Hamar, Norway. The funding sources had no role in the design and organization of the trial, data collection, data analysis, or writing of the report. Dr. Bøhmer received speakers' honoraria and travel grants (2008) from Boehringer Ingelheim. Dr. Hoffmann received travel grants from Eli Lilly and Medtronic. Dr. Arnesen received speakers' honoraria from Bristol-Myers Squibb and Nycomed AS. Dr. Halvorsen received speakers' honoraria from Sanofi, Bristol-Myers Squibb, Eli Lilly, and Boehringer Ingelheim.