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Hospital delays in reperfusion for ST-elevation myocardial infarction: implications when selecting a reperfusion
Duane S Pinto1, Ajay J Kirtane, Brahmajee K Nallamothu
1TIMI Study Group and the Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, 185 Pilgrim Rd, Boston, MA 02115, USA.
Insights
Delays in primary percutaneous coronary intervention (PPCI) beyond fibrinolysis door-to-needle (DN) times increase mortality. The survival benefit of PPCI over fibrinolysis diminishes with longer door-to-balloon (DB)-DN times and varies by patient factors.
Area of Science:
- Cardiology
- Interventional Cardiology
- Health Services Research
Background:
- Primary percutaneous coronary intervention (PPCI) offers survival benefits for ST-segment elevation myocardial infarction (STEMI).
- Delays in door-to-balloon (DB) times compared to door-to-needle (DN) times for fibrinolysis may reduce PPCI's survival advantage in routine practice.
- Patient risk factors may also influence the relative benefits of PPCI versus fibrinolysis.
Purpose of the Study:
- To investigate the association between door-to-balloon (DB) minus door-to-needle (DN) time delays and in-hospital mortality in ST-segment elevation myocardial infarction (STEMI) patients.
- To assess how patient risk factors modulate the survival advantage of primary percutaneous coronary intervention (PPCI) over fibrinolysis based on these delays.
Main Methods:
- Utilized data from 192,509 STEMI patients across 645 hospitals in the National Registry of Myocardial Infarction.
- Calculated DB-DN times by subtracting median DN time from median DB time for each hospital.
- Employed hierarchical models to adjust for patient-level risk factors and hospital-level covariates to analyze mortality.
Main Results:
- Longer DB-DN times were significantly associated with increased in-hospital mortality (P<0.0001).
- The threshold DB-DN time at which PPCI offered no mortality benefit over fibrinolysis varied based on patient age, symptom duration, and infarct location.
- Patient characteristics substantially influenced the relative survival advantage of PPCI compared to fibrinolysis.
Conclusions:
- Increasing DB-DN time delays reduce the mortality benefit of PPCI over fibrinolysis.
- The relative survival advantage of PPCI is significantly modulated by individual patient characteristics.
- Both hospital-based delays (DB-DN time) and patient factors are critical considerations for selecting the optimal reperfusion strategy in STEMI.
Background:
It has been suggested that the survival benefit associated with primary percutaneous coronary intervention (PPCI) in ST-segment elevation myocardial infarction may be attenuated if door-to-balloon (DB) time is delayed by >1 hour beyond door-to-needle (DN) times for fibrinolytic therapy. Whereas DB times are rapid in randomized trials, they are often prolonged in routine practice. We hypothesized that in clinical practice, longer DB-DN times would be associated with higher mortality rates and reduced PPCI survival advantage. We also hypothesized that in addition to PPCI delays, patient risk factors would significantly modulate the relative survival advantage of PPCI over fibrinolysis.
Methods And Results:
DB-DN times were calculated by subtracting median DN time from median DB time at a hospital using data from 192,509 patients at 645 National Registry of Myocardial Infarction hospitals. Hierarchical models that adjusted simultaneously for both patient-level risk factors and hospital-level covariates were used to evaluate the relationship between PCI-related delay, patient risk factors, and in-hospital mortality. Longer DB-DN times were associated with increased mortality (P<0.0001). The DB-DN time at which mortality rates with PPCI were no better than that of fibrinolysis varied considerably depending on patient age, symptom duration, and infarct location.
Conclusions:
As DB-DN times increase, the mortality advantage of PPCI over fibrinolysis declines, and this advantage varies considerably depending on patient characteristics. As indicated in the American College of Cardiology/American Heart Association guidelines, both the hospital-based PPCI-related delay (DB-DN time) and patient characteristics should be considered when a reperfusion strategy is selected.
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