Date of Graduation

Summer 8-8-2014

Degree Type

Capstone Project

Degree Name

Master of Science in Physician Assistant Studies

Abstract

Background: Current guidelines recommend primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) as long as it can be performed quickly by an experienced provider. Unfortunately as time from the onset of symptoms increases, so does the incidence of adverse cardiac events. For patients in rural areas who face inevitable delays due to long-distance transfers, primary PCI is a less than perfect option. Other options include full-dose fibrinolytic therapy with routine transfer to a PCI capable hospital and a relatively new reperfusion strategy called pharmaco-invasive PCI. With multiple treatment options available, what is the most appropriate management of rural patients with STEMIs when delays are expected due to long-distance transfers?

Methods: An exhaustive search of available medical literature was conducted using Medline-OVID, CINAHL, and Web of Science using the keywords: myocardial infarction, fibrinolytic agents, myocardial reperfusion, and patient transfer. Articles evaluating the efficacy and safety of treatment options for STEMI patients in rural locations were included. Relevant articles were assessed for quality using GRADE.

Results: Two studies met inclusion criteria and were included in this systematic review. A retrospective observational study with 259 rural STEMI patients found that in-hospital mortality was higher in patients with primary PCI (9.3%) compared with fibrinolysis patients (1.9%; P=0.03). A prospective observational study with 2634 patients found that there was no significant difference in 30-day mortality (5.5 vs 5.6%; P= 0.94), stroke (1.1 vs 1.3%; P= 0.66) or major bleeding (1.5 vs 1.8%; P= 0.65), or re-infarction/ischemia (1.2 vs 2.5%; P= 0.088) in rural patients receiving a pharmaco-invasive therapy compared with patients presenting directly to the PCI center.

Conclusion: In rural patients with STEMIs, as delays in transfer time increase due to long-distance travel, the use of fibrinolytic or pharmaco-invasive therapy may be more effective and beneficial than primary PCI reperfusion therapy.

Keywords: Myocardial infarction, myocardial reperfusion, fibrinolytic agents, transfer time, rural healthcare

Background: Current guidelines recommend primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) as long as it can be performed quickly by an experienced provider. Unfortunately as time from the onset of symptoms increases, so does the incidence of adverse cardiac events. For patients in rural areas who face inevitable delays due to long-distance transfers, primary PCI is a less than perfect option. Other options include full-dose fibrinolytic therapy with routine transfer to a PCI capable hospital and a relatively new reperfusion strategy called pharmaco-invasive PCI. With multiple treatment options available, what is the most appropriate management of rural patients with STEMIs when delays are expected due to long-distance transfers?

Methods: An exhaustive search of available medical literature was conducted using Medline-OVID, CINAHL, and Web of Science using the keywords: myocardial infarction, fibrinolytic agents, myocardial reperfusion, and patient transfer. Articles evaluating the efficacy and safety of treatment options for STEMI patients in rural locations were included. Relevant articles were assessed for quality using GRADE.

Results: Two studies met inclusion criteria and were included in this systematic review. A retrospective observational study with 259 rural STEMI patients found that in-hospital mortality was higher in patients with primary PCI (9.3%) compared with fibrinolysis patients (1.9%; P=0.03). A prospective observational study with 2634 patients found that there was no significant difference in 30-day mortality (5.5 vs 5.6%; P= 0.94), stroke (1.1 vs 1.3%; P= 0.66) or major bleeding (1.5 vs 1.8%; P= 0.65), or re-infarction/ischemia (1.2 vs 2.5%; P= 0.088) in rural patients receiving a pharmaco-invasive therapy compared with patients presenting directly to the PCI center.

Conclusion: In rural patients with STEMIs, as delays in transfer time increase due to long-distance travel, the use of fibrinolytic or pharmaco-invasive therapy may be more effective and beneficial than primary PCI reperfusion therapy.

Keywords: Myocardial infarction, myocardial reperfusion, fibrinolytic agents, transfer time, rural healthcare

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