Minutes between life and death

2778 CardioPulse doi:10.1093/eurheartj/ehy392 Minutes between life and death When a few minutes make the difference between life and death. Timely reperfusion therapy saves lives of cardiogenic shock patients with acute myocardial infarction treated patients with cardiogenic shock. This finding indicates that the treatment time-related increase in mortality was 10-fold higher in STEMI patients with shock as compared to their counterparts with a stable haemodynamic condition. Although the management of this subset of high-risk patients is challenging and demands high-standard procedural requirements for a continued optimization of the care pathways, our observations nonetheless underscore that efforts to shorten the time to reperfusion therapy should be applied particularly to unstable STEMI patients, in order to improve outcome in local STEMI treatment networks. Our findings suggest that any laborious and time-consuming procedure for haemodynamic stabilization before PCI therapy, such as leftventricular unloading by transvalvular axial flow pumping or implantation of intra-aortic balloon pumps, should be deferred in order not to retard the causal treatment of restoring antegrade blood flow in the occluded coronary vessel. The impressive influence of prevention of reperfusion delays on survival, as shown in our study, must be discussed in the context of the limitations of the FITT-STEMI study design. The main objective of the FITT-STEMI trial is to prospectively determine the prognostic impact of systematic data assessment and interactive feedback-driven quality management interventions on time to PCI therapy and mortality in STEMI patients treated in existing regional cardiac care networks. The formalized feedback interventions given in regular site monitor visits include slide presentations on site-specific descriptive statistics regarding pre-hospital and intra-hospital transportation times to identify centre-specific treatment delays during the time from the first medical contact to PCI treatment. Although in total 48 large PCI-capable, university and non-university hospitals participate in the FITT-STEMI trial and enrol currently 5500 STEMI cases per year, who correspond to approximately 12% of all German acute STEMI,4 the ambitious aim of the FITT-STEMI study could still not be reached, as more clinics and STEMI patients must participate to address the main hypothesis of the FITT-STEMI trial. Since there is a need for optimizing treatment pathways in local STEMI treatment networks for shock patients, we are however confident that future protocols implementing timely reperfusion strategies for these patients will help to decrease mortality and improve the long-time prognosis. Our study has shown that timely PCI treatment considerably reduces mortality in high-risk STEMI patients presenting with cardiogenic shock. Downloaded from https://academic.oup.com/eurheartj/article/39/30/2778/5069149 by guest on 12 October 2021 Haemodynamically unstable patients with acute ST-segment elevation myocardial infarction (STEMI) benefit from reperfusion therapy as was shown by the SHOCK trial published in 1999,1,2 but their long-term morbidity and mortality still remains high. Despite sophisticated STEMI treatment protocols which include transfer to the nearest percutaneous coronary intervention (PCI)-capable hospital for primary PCI (pPCI), there is a high risk of death of patients presenting with cardiogenic shock due to inadequate cardiac output and also to multiple organ failure resulting from tissue hypoxia. With recent advances in the pre-hospital electrocardiographic detection and treatment of life-threatening arrhythmias using automated external defibrillators, cardiogenic shock has emerged as the most common cause of in-hospital death in STEMI patients. Given that the incidence of cardiogenic shock accounts considerably for the in-hospital and post-discharge mortality in STEMI patients, every effort should be made to improve the survival of these patients, as the number of patients needed to be treated to save one additional life is especially low in this high-risk group, as has been demonstrated in a paper from the German FITT-STEMI investigators published recently in the European Heart Journal (3see also the accompanying editorial by Drs William Wijns and Christoph K. Naber4). Data from our prospective and multicentre FITT-STEMI (Feedback Intervention and Treatment Times in ST-Elevation Myocardial Infarction) trial showed that STEMI patients presenting with cardiogenic shock, who had been transferred from the scene by emergency medical service (EMS) transportation, benefitted most from timely PCI treatment to improve survival. In the ongoing FITT-STEMI study, we analysed 12 675 PCItreated STEMI patients regarding in-hospital mortality, including 1899 study participants with cardiogenic shock and/or out-ofhospital cardiac arrest. Our results demonstrated that, in the patient group with cardiogenic shock, the time interval from the first medical contact to balloon inflation in the cardiac catheterization laboratory is a strong predictor for mortality, since 1 out of 5 shock patients additionally survived when the time from the first medical contact to reperfusion was reduced to 90 min or less, compared with 1 out of 53 in the group of haemodynamically stable patients with no signs of cardiogenic shock. For contact-toballoon times ranging from 60 to 180 min, every 10-min treatment delay resulted in more than three additional deaths in 100 PCI- 2779 CardioPulse Thomas Meyer, MD, PhD, and Karl Heinrich Scholz, MD, for the FITTSTEMI Investigators Conflict of interest: none declared. References Thomas Meyer MD PhD Department of Psychosomatic Medicine and Psychotherapy University Medical Center Göttingen University of Göttingen, Germany References are available as supplementary material at European Heart Journal online. Cardio Pulse contact: Andros Tofield, Managing Editor. Email: [email protected] Downloaded from https://academic.oup.com/eurheartj/article/39/30/2778/5069149 by guest on 12 October 2021 Karl Heinrich Scholz MD Department of Cardiology St. Bernward´s Hospital, Hildesheim, Germany Correspondence: Professor Karl Heinrich Scholz, Medizinische Klinik I, St. Bernward-Krankenhaus, Treibestr. 9, 31134 Hildesheim, Germany, Tel: +49-5121-90-5035, Fax: +49-5121-90-1282, E-mail: [email protected]