High-risk myocardial infarction patients appear to derive more mortality benefit from short door-to-balloon time than low-risk patients
P K Kong1, D Connolly, C Varma
1Department of Cardiology, Sandwell General Hospital, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK. pkdd210@yahoo.co.uk
Insights
Implementing a collaborative physician-to-patient model in district general hospitals significantly reduced door-to-balloon times for primary percutaneous coronary interventions. This improvement translated into a mortality benefit, particularly for high-risk ST-segment elevation myocardial infarction patients.
Area of Science:
- Cardiology
- Interventional Cardiology
- Public Health
Background:
- Short door-to-balloon (DTB) times in primary percutaneous coronary interventions (PPCI) are crucial for ST-segment elevation myocardial infarction (STEMI) mortality benefit.
- Evidence is conflicting regarding this benefit in high-risk versus low-risk patient populations.
- A unique physician-to-patient model was implemented across district general hospitals (DGH) to provide 24-hour PPCI.
Purpose of the Study:
- To assess the reduction in DTB time within a collaborative DGH network.
- To evaluate the impact of reduced DTB time on in-hospital mortality, specifically for high-risk STEMI patients.
- To explore the feasibility of a mobile interventional cardiology team model.
Main Methods:
- Retrospective audit of 459 PPCI cases over three years (July 2005-June 2008) using the British Cardiovascular Intervention Society database.
- Data analysis across four periods reflecting the transition from daytime-only to 24-hour PPCI availability.
- Primary outcome measures were DTB time and in-hospital mortality.
Main Results:
- Median DTB time significantly improved from 89 to 68 minutes (p=0.005).
- The proportion of patients achieving the target 90-minute DTB time increased from 53% to 75% (p=0.005).
- In-hospital mortality was lower with shorter DTB times (4.6% vs. 11.5%, p=0.008). Long DTB times (>90 min) were associated with higher mortality in high-risk patients (15.6% vs. 7.1%, p=0.024) but not in low-risk patients.
Conclusions:
- A collaborative DGH model with a physician-to-patient approach can achieve timely PPCI.
- This model demonstrates a mortality benefit, particularly for high-risk STEMI patients.
- Mobile interventional cardiology teams could serve as an alternative strategy for high-risk patients requiring timely PPCI.
Objectives:
To evaluate reduction of door-to-balloon (DTB) time and its impact on in-hospital mortality of high-risk infarct patients in a collaboration of district general hospitals (DGH) with a physician-to-patient model.
Methods:
Primary percutaneous coronary interventions (PPCI) with short DTB time offer mortality benefit for ST-segment elevation myocardial infarction but literatures are conflicting on this benefit for high- vs. low-risk patients. In a unique model at Sandwell and West Birmingham Hospitals, five interventional cardiologists provide 24-h PPCI at whichever one of its two DGH that patients present to. A retrospective audit was performed on 3 years (July 2005-June 2008) of PPCI data in the British Cardiovascular Intervention Society database. Data were analysed in four periods corresponding to change from daytime-only to 24-h PPCI. DTB time and in-hospital mortality were the main outcome measures.
Results:
Of the 459 patients, median DTB time improved from 89 min (interquartile range: 49-120) to 68 min (50-91) (p = 0.005) and proportion of patients achieving target 90-min DTB time increased from 53% (21/40) to 75% (93/124) (p = 0.005). In-hospital mortality was less for short DTB time [4.6% (13/284) vs. 11.5% (20/174); odds ratio (OR) 0.37, 95% confidence interval (CI): 0.18-0.75; p = 0.008]. With the proviso that our study was limited in power, long DTB time (> 90 min vs. < or = 90 min) was associated with higher in-hospital mortality in high-risk patients [15.6% (20/128) vs. 7.1% (12/168); OR 2.41, 95% CI: 1.14-5.06; p = 0.024] and not in low-risk patients [0% (0/46) vs. 0.9% (1/117); OR 0, 95% CI: 0-9.88; p = 1.000].
Conclusions:
A collaboration of DGH with a physician-to-patient model can deliver timely PPCI that appear to translate into mortality benefit more so in high-risk patients. Low-risk patients would therefore probably tolerate delays associated with transfer to large centres while high-risk patients would not and need alternative strategy. A collaboration of smaller hospitals with a pool of mobile interventional cardiologists could be such an alternative.
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