Transfer for primary angioplasty: time is important.

Time is Important To the Editor: Dalby et al1 have produced a meta-analysis on the transfer of patients for primary angioplasty versus non-transfer thrombolysis in acute myocardial infarction. Their conclusion from a collaboration of 6 papers is that primary angioplasty is the optimal method of treatment, rather than local thrombolytic therapy, despite delays in transfer times to tertiary referral centers with angioplasty facilities and expertise. Their conclusions are scientifically sound from the data that they have extracted; however, they state, “The findings are in keeping with the observation that time to reperfusion is much less critical with primary [percutaneous intracoronary intervention; PCI] than thrombolysis.” (p 1812) Five of the studies they have used have a mean time to PCI from randomization of 80 minutes. Despite favorable results compared with thrombolysis, there is good evidence that doorto-balloon time is related to in-hospital mortality.2,3 One recent study claims that the mortality benefit associated with PCI may be lost if door-to-balloon time is delayed by 1 hour.4 Another suggests that if door-to-balloon time is expected to exceed 60 minutes, there should be a strong consideration for thrombolysis before angioplasty.5 The fear is that despite long door-to-balloon times producing favorable results compared with thrombolysis, this may produce a culture of complacency whereby fast transfer for PCI may become an unimportant issue. This is clearly unsatisfactory and should require addressing. Reducing door-to-balloon time is likely to provide primary angioplasty results that are even better than those already quoted. Perhaps reduction in door-to-balloon time can only be realistically achieved if carried out without hospital transfer. This would mean an increase in requirement for angioplasty facilities and trained interventionalists nationally.