Transferring patients for primary infarct angioplasty.

Although primary angioplasty (PTCA) achieves reper-fusion in acute myocardial infarction (AMI) more readily than thrombolysis without the risk of intracranial haemorrhage , economic and logistic issues limit its applicability. 1 Most patients with AMI present to hospitals without cardiac catheterisation facilities, let alone PTCA expertise. The safety and feasibility of the emergency transfer of such patients for primary PTCA have been reported by Zijlstra et al in Zwolle, a high volume centre in the Netherlands performing 1600 angioplasties annually. 2 During five years there were 520 cases of primary PTCA, 104 of which were transferred from other hospitals, 91% from within a 50 km radius. One patient was ventilated before transfer. During transfer, another was intubated, three patients had ventricular fibrillation or tachycardia, and one of 10 patients in cardiogenic shock on inotropic support died. Although the time lost between admission to the local hospital and arrival at the PTCA laboratory averaged 70 minutes , the first balloon inflation was performed within six hours of symptom onset in 78% of cases. In this well established programme, there was no diVerence in mean time from symptom onset to first inflation between transferred (200 minutes) and directly admitted (196 minutes) patients. The Hull experience Our tertiary centre serves a population of 1.2 million and performs over 400 PTCA procedures each year. During two years, 83 patients with AMI received rescue (n = 53) or primary (n = 30) PTCA. We oVer a 24 hour primary PTCA service for patients who appear not to benefit from or cannot receive thrombolysis. For certain patients, we feel that the greater likelihood of restoring coronary patency earlier is a decisive factor in preferring PTCA to thrombolysis. Although we do not operate a time restrictive policy because it can be diYcult to be exact about the time of acute coronary occlusion, we emphasise the need to minimise delay in transferring suitable patients. We believe that unremitting symptoms plus persistent electrocardio-graphic ST changes are more important than an estimate of the time of symptom onset in recommending emergency transfer for PTCA. No deaths have occurred during transfer over the past two years. With our clinically driven policy of selecting high risk cases, the median time to primary PTCA was four hours; there was no major diVerence in outcome between patients undergoing PTCA within four hours or later. Which patients should be transferred? It is diYcult to justify a …