This is a paper cited in the most recent ACEP Weekend review that tries to draw more profound conclusions than it probably should.
It’s another piece of the growing body of literature that says “Hurry! Prehospital activation is all we need in STEMI!” From Israel, it’s a retrospective review of performance variables and patient outcomes between a cohort that was assessed in the ER and a cohort that went straight to the lab. They draw a few conclusions, some of which are valid.
First, time. One of the two “primary” outcome variables is door-to-balloon time. No argument that skipping steps along the way will save you time. No study is needed to prove that.
The second “primary” outcome variable is MACE within 30 days – another combined endpoint kludge of death, CHF, reinfarction, CVA, TIA, and urgent revascularization. This one favored the direct-to-ICCU group, 22% to 30%. How is 30-day CVA/TIA directly related to the effectiveness of PCI? Looking at their secondary outcomes – death was not significantly different – but CHF was 8% different, which therefore accounts for essentially the entire difference between groups in this primary outcome.
And the problem? Well, they also show in a secondary outcome that LVEF >30% was 7% greater in the direct-to-ICCU group…from which it follows there would obviously be less heart failure in that group. But, in their demographic information, they don’t know the pre-intervention LVEF for their patients – only the Killip class on presentation, which is a measure of the heart failure associated with the acute cardiac event, not their pre-existing LVEF.
So, the only thing they’ve effectively proven in this study is that skipping steps saves time. And, they don’t comment on the number of false positives in each group, either.