The latest analysis of 2009 CMS data for 13,776 STEMI patients of door-in to door-out (DIDO) time by Herrin and colleagues does not bring encouraging news. After many years of hard work to reduce DIDO time for patients who present at facilities without primary PCI capability, only a small fraction of patients (<10%) are transferred within the national benchmark of 30 minutes, which is not appreciably better than the authors’ previous analysis in 2005. With recent studies showing no mortality benefit for primary PCI over thrombolytics in low and intermediate risk STEMI patients, and insurmountable barriers to shortening DIDO times in the vast majority of cases, hospitals and patients often would be better served by timely reperfusion with thrombolytics.
I recommend that:
- low and intermediate risk patients receive thrombolytics (either prehospital or in ED) if primary PCI is not available in a timely fashion on site
- high risk patients be transferred only if DIDO would be close to 30 minutes, as after that the mortality advantage is no longer present for primary PCI.
Do you think that it’s time to rethink our approach to STEMI patients or should we double down on trying to improve DIDO?
[EDITOR'S NOTE: See also this post on the latest DIDO data—and on Dr. Redberg's argument—in CardioExchange's Interventional blog: Should FedEx Be in Charge of Primary PCI?]