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Background  Timely reperfusion after ST‐elevation myocardial infarction ( STEMI ) improves survival. Guidelines recommend primary percutaneous coronary intervention ( PPCI ) within 90 minutes of arrival at a  PCI ‐capable hospital. The alternative is fibrinolysis within 30 minutes for those in those for whom timely transfer to a  PCI ‐capable hospital is not feasible.    Methods and Results  We identified  STEMI  patients receiving reperfusion therapy at 229 hospitals participating in the  Get With the Guidelines—Coronary Artery Disease  ( GWTG ‐ CAD ) database (January 1, 2003 through December 31, 2008). Temporal trends in the use of fibrinolysis and  PPCI , its timeliness, and in‐hospital mortality outcomes were assessed. We also assessed predictors of fibrinolysis versus  PPCI  and compliance with performance measures. Defect‐free care was defined as 100% compliance with all performance measures. We identified 29 190  STEMI  patients, of whom 2441 (8.4%) received fibrinolysis; 38.2% of these patients achieved door‐to‐needle times ≤30 minutes. Median door‐to‐needle times increased from 36 to 60 minutes ( P =0.005) over the study period. Among  PPCI  patients, median door‐to‐balloon times decreased from 94 to 64 minutes ( P <0.0001) over the same period. In‐hospital mortality was higher with fibrinolysis than with  PPCI  (4.6% vs 3.3%,  P =0.001) and did not change significantly over time. Patients receiving fibrinolysis were less likely to receive defect‐free care compared with their  PPCI  counterparts.    Conclusions  Use of fibrinolysis for  STEMI  has decreased over time with concomitant worsening of door‐to‐needle times. Over the same time period, use of  PPCI  increased with improvement in door‐to‐balloon times. In‐hospital mortality was higher with fibrinolysis than with  PPCI . As reperfusion for  STEMI  continues to shift from fibrinolysis to  PPCI , it will be critical to ensure that door‐to‐needle times and outcomes do not worsen.

journal of the american heart association

Temporal Trends in Care and Outcomes of Patients Receiving Fibrinolytic Therapy Compared to Primary Percutaneous Coronary Intervention: Insights From the Get With The Guidelines Coronary Artery Disease ( GWTG ‐ CAD ) Registry