We read with interest the study by Labarere et al1 that compared the treatment and outcome of patients with ST-segment elevation myocardial infarction (STEMI) admitted to hospitals with vs without PCI facilities. We would like to offer an alternative explanation for the observed difference in outcome.
Although Labarere and colleagues1 suggested that the more frequent use of PCI within 48 hours of hospitalization accounted for the improved 1-year survival among patients admitted to PCI hospitals (Table 6 of their article), it should be emphasized that the overall rate of reperfusion therapy (primary PCI or thrombolytic) was also substantially higher (58% vs 40%) compared with non-PCI hospitals. Of note, neither facilitated PCI nor early routine invasive management conferred a mortality benefit in the ASSENT-4 PCI (Assessment of the Safety and Efficacy of a New Treatment Strategy With Percutaneous Coronary Intervention) and GRACIA (Grupo de Análisis de la Cardiopatía Isquémica Aguda)-1 trials.2- 3 Furthermore, in the study by Labarere et al,1 patients in non-PCI hospitals were more likely to present late and with worse Killip class—clinical characteristics that favor the use of PCI as the preferred reperfusion therapy.4 Thus, it is plausible that the better outcome in PCI hospitals was due to the overall greater use and type of reperfusion therapy, rather than any PCI use within 48 hours of admission. It would also be useful to provide more data on the type of PCI (eg, facilitated, rescue, and ischemia guided) performed in the PCI hospitals.