Although Warren Cantor and Laurie Morrison suggest that primary PCI may be superior to fibrinolysis, the converse may be true in the early hours after symptom onset, and this remains an important and unresolved issue.1,2 Facilitated PCI should encompass a broader definition than prior fibrinolytic therapy alone, as articulated in the recent guidelines: “Facilitated PCI refers to a strategy of planned immediate PCI after an initial pharmacologic regimen such as full dose fibrinolysis, half dose fibrinolysis, a GP [glycoprotein] IIb/IIIa inhibitor or a combination of reduced dose fibrinolytic therapy in a platelet GP IIb/IIIa inhibitor.”3
We commend Cantor and Morrison for their involvement in the TRANSFER-AMI study and await with interest its results, as well as those of the large ASSENT IV (Assessment of the Safety and Efficacy of a New Treatment Strategy for Acute Myocardial Infarction) and FINESSE (Facilitated Intervention with Enhanced Reperfusion Speed to Stop Events) studies, as they relate to the issue of facilitated PCI.4 If these studies demonstrate positive results, it will be important to consider the resource implications and ensure, at a minimum, the targeting of high-risk patients.
Cathal O'Donnell and Richard Verbeek opine that we have not considered the challenges for emergency services related to achieving a 60-minute transfer for PCI. Unfortunately, CMAJ space restrictions precluded discussion of this issue in our case-based report,5 but our broader discussion of the topic has recently been published elsewhere.1 We agree that enhancement of EMS should occur pari passu with enhanced tertiary and quaternary care for such patients. For maximal resource efficiency, we believe that the STEMI algorithm in Fig. 2 of our CMAJ article5 provides a useful destination template.
Paul W. Armstrong Department of Medicine University of Alberta Edmonton, Alta. Peter Bogaty Quebec Heart Institute Laval Hospital Sainte-Foy, Que. Christopher E. Buller Division of Cardiology St. Paul's Hospital University of British Columbia Vancouver, BC Blair J. O'Neill Department of Medicine Dalhousie University Halifax, NS
Footnotes
Competing interests: None declared for Drs. Bogaty and O'Neill. Dr. Armstrong has received research funding from Hoffmann–La Roche, Aventis and Boehringer Ingelheim, and educational and consultant funding from Hoffmann–La Roche and Aventis. Dr. Buller has received research support from Guidant Corp. and Cordis Johnson & Johnson, consultant fees from Guidant Corp. and Aventis, and speaker fees from Hoffman–La Roche.
References
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- 2.Steg PG, Bonnefoy E, Chabaud S, Lapostolle F, Dubien PY, Cristofini P, et al; Comparison of Angioplasty and Prehospital Thrombolysis In acute Myocardial infarction (CAPTIM) Investigators. Impact of time to treatment on mortality after prehospital fibrinolysis or primary angioplasty: data from the CAPTIM randomized clinical trial. Circulation 2003;108(23): 2851-6. [DOI] [PubMed]
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