Guidelines for STEMI

We commend Peter Bogaty and colleagues1 for their Canadian adaptation of the ST-elevation myocardial infarction (STEMI) guidelines. They have appropriately emphasized the importance of time to reperfusion, whether thrombolysis or primary percutaneous coronary intervention (PCI) is used. Although primary PCI may be superior to thrombolysis when performed in a timely manner, this benefit may be attenuated or lost altogether when PCI is delayed more than 60 minutes.2 However, it may be possible to derive the benefits of primary PCI without the inherent treatment delay by administering thrombolysis followed by immediate transfer for PCI. This strategy, termed “facilitated PCI,” may be the optimal mode of reperfusion for many patients in Canada, where interventional centres are regionalized. Although early studies failed to show a benefit of routine PCI immediately after thrombolysis,3 PCI technology has changed considerably in recent years. More recent studies have indicated that facilitated PCI may indeed be safe and effective,4 but larger studies are needed to provide definitive answers.

The TRANSFER-AMI trial, initiated by Canadian investigators and funded by the Canadian Institutes of Health Research, will randomly assign approximately 1200 high-risk STEMI patients treated with thrombolysis in non-PCI hospitals to be transferred immediately for facilitated PCI or to receive standard care. This study could have a significant impact on the treatment of STEMI in Canada, and we strongly encourage Canadian centres to participate (for further information, see the Web site of the Canadian Heart Research Centre, www.chrc.net).