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Frequency and factors associated with inappropriate for intervention cardiac catheterization laboratory activation
Apurva Patel1, Roosha Parikh1, Kanhaiya L Poddar2
1Department of Internal Medicine, Cleveland Clinic, Cleveland, OH.
Insights
Inappropriate cardiac catheterization laboratory activations for ST-elevation myocardial infarction (STEMI) occurred in 17.9% of cases. Female gender, African American race, and prior bypass surgery were associated with incorrect STEMI diagnosis.
Area of Science:
- Cardiology
- Interventional Cardiology
- Health Services Research
Background:
- Current guidelines recommend door-to-balloon times ≤90 minutes for ST-elevation myocardial infarction (STEMI) survival.
- Achieving STEMI targets may lead to unnecessary emergent cardiac catheterization laboratory (CCL) activations.
- This study investigates the frequency and predictors of inappropriate CCL activations.
Purpose of the Study:
- To evaluate the frequency and trends of inappropriate for intervention CCL activations.
- To identify factors significantly associated with inappropriate CCL activations for possible STEMI.
Main Methods:
- Analysis of 1764 consecutive emergent CCL activations for possible STEMI (July 2005–August 2013).
- Inappropriate activation defined as negative STEMI diagnosis or inappropriate patient candidacy.
- Multivariable analysis to identify associated factors.
Main Results:
- Inappropriate activations occurred in 17.9% of patients (317/1764).
- Incorrect diagnosis (negative STEMI) accounted for most inappropriate activations (292/317).
- Female gender, African American race, and prior coronary artery bypass graft surgery were associated with incorrect diagnosis. Hyperlipidemia, tobacco use, and stroke/TIA showed inverse association.
Conclusions:
- Inappropriate CCL activation is a significant issue impacting resource utilization.
- Female gender, African American race, and specific ECG findings (ST elevation without reciprocal depression) warrant attention.
- Targeted monitoring and potential interventions are needed to optimize CCL resource allocation.
Background:
Current guidelines emphasize timely coronary intervention with a door to balloon time of ≤90min for favorable survival impact after STEMI. Efforts to achieve these targets may result in unnecessary emergent angiography for inappropriate activations.
Objective:
Evaluate the frequency, trend and factors which are significantly associated with inappropriate for intervention cardiac catheterization laboratory (CCL) activation.
Methods:
We analyzed 1764 consecutive emergent CCL activation for possible ST segment elevation myocardial infarction (STEMI) between 7/2005 and 8/2013. Inappropriate for intervention activation was defined as negative STEMI (incorrect diagnosis: insignificant coronary lesion, not requiring any intervention) and inappropriate patients (true STEMI but poor CCL candidacy).
Results:
Inappropriate for intervention CCL activation occurred in 317 patients (17.9%): 292 incorrect diagnosis (negative STEMI diagnosis), 25 inappropriate patients, with no difference in the frequency based on time of the day (18.6% regular hours vs. 17.6% off-hours, p=0.6). On multivariable analysis, female gender (OR 1.9 [1.2-3.0]), African American race (OR 1.9[1.3-2.7]), and prior coronary artery bypass graft surgery (OR 3.6 [2.3-5.5]) were significantly associated with incorrect diagnosis (negative STEMI diagnosis) (all p<0.005) and hyperlipidemia (OR 0.2 [0.1-0.3]), tobacco use (OR 0.2 [0.1-0.3]), and stroke/TIA (OR 0.2 [0.1-0.4]) had a significant inverse association (all p<0.001). ST Elevation with no reciprocal depression and pericarditis/myocarditis were the most common ECG finding and etiology respectively.
Conclusion:
Inappropriate for intervention CCL activation is not uncommon and should be closely monitored to maximize resource utilization. Females, African American patients with few or no risk factors and patients presenting ST elevation but no reciprocal depression constitute a population that may require attention.
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