Systems of care: need for hub-and-spoke systems for both primary and systematic percutaneous coronary intervention after fibrinolysis.

Primary percutaneous coronary intervention (PCI) is currently considered the best reperfusion therapy if performed in a timely manner. However, in many developed countries, it is difficult to offer primary angioplasty to more than 20% to 30% of eligible patients because of logistical issues. Fibrinolytic therapy has recently improved, with the addition of clopidogrel resulting in both improved infarct artery patency1 and mortality2 and enoxaparin reducing reinfarction.3 In addition, rescue PCI has been shown to reduce reinfarction after fibrinolytic therapy by 42% (P 0.05),4 and in a meta-analysis of 8 trials that included 1117 patients, rescue PCI resulted in a reduction in death, reinfarction, and heart failure at 6 months from 41.0% to 29.2% (P 0.001) compared with fibrinolysis and PCI only for recurrent ischemia.5 There also was a trend for a reduction in mortality (odds ratio [OR], 0.69; 95% CI, 0.46 to 1.05; P 0.09).