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Published on: May 28, 2019
Comprehensive electrocardiogram-to-device time for primary percutaneous coronary intervention in ST-segment elevation
Jay S Shavadia1, William French2, Anne S Hellkamp3
1Duke Clinical Research Institute, Durham, NC; University of Alberta, Alberta, Canada.
Insights
A new metric, comprehensive ECG-to-device time, assesses hospital performance for ST-elevation myocardial infarction (STEMI) primary PCI. Faster times at high-performing hospitals correlate with better outcomes, aiding STEMI care improvements.
Area of Science:
- Cardiology
- Health Services Research
- Public Health
Background:
- Assessing hospital network performance for ST-elevation myocardial infarction (STEMI) primary percutaneous coronary intervention (PCI) is complex due to varied time-to-treatment metrics.
- The location of the initial electrocardiogram (ECG) diagnosis influences time-to-treatment calculations for STEMI patients.
Purpose of the Study:
- To develop and evaluate a novel metric for assessing hospital-level network performance in primary PCI for STEMI.
- To determine if this metric, comprehensive ECG-to-device time, can provide a unified assessment of reperfusion timing regardless of initial STEMI identification location.
Main Methods:
- Utilized data from 588 PCI-capable hospitals participating in AHA Mission: Lifeline (2008-2013) for 117,857 STEMI patients.
- Categorized patients by STEMI identification location: PCI-capable hospitals, pre-hospital, or non-PCI-capable hospitals.
- Calculated comprehensive ECG-to-device time by averaging patient-specific time differences relative to group means; stratified hospitals into tertiles based on this metric.
Main Results:
- High-performing hospitals (shortest comprehensive ECG-to-device time, median -9 minutes) showed lower rates of heart failure and cardiac arrest at presentation.
- Middle-performing hospitals had a median time of 1 minute, while low-performing hospitals had a median time of 11 minutes.
- While unadjusted mortality rates varied slightly, adjusted in-hospital mortality risk was similar across performance tertiles.
Conclusions:
- Comprehensive ECG-to-device time offers an integrated assessment of reperfusion timing for STEMI primary PCI across hospital networks.
- This metric's utility in improving STEMI care requires further validation and study.
- The findings suggest a potential tool for quality improvement initiatives in STEMI management.
Background:
Assessing hospital-related network-level primary percutaneous coronary intervention (PCI) performance for ST-segment elevation myocardial infarction (STEMI) is challenging due to differential time-to-treatment metrics based on location of diagnostic electrocardiogram (ECG) for STEMI.
Methods:
STEMI patients undergoing primary PCI at 588 PCI-capable hospitals in AHA Mission: Lifeline (2008-2013) were categorized by initial STEMI identification location: PCI-capable hospitals (Group 1); pre-hospital setting (Group 2); and non-PCI-capable hospitals (Group 3). Patient-specific time-to-treatment categories were converted to minutes ahead of or behind their group-specific mean; average time-to-treatment difference for all patients at a given hospital was termed comprehensive ECG-to-device time. Hospitals were then stratified into tertiles based on their comprehensive ECG-to-device times with negative values below the mean representing shorter (faster) time intervals.
Results:
Of 117,857 patients, the proportion in Groups 1, 2, and 3 were 42%, 33%, and 25%, respectively. Lower rates of heart failure and cardiac arrest at presentation are noted within patients presenting to high-performing hospitals. Median comprehensive ECG-to-device time was shortest at -9 minutes (25th, 75th percentiles: -13, -6) for the high-performing hospital tertile, 1 minute (-1, 3) for middle-performing, and 11 minutes (7, 16) for low-performing. Unadjusted rates of in-hospital mortality were 2.3%, 2.6%, and 2.7%, respectively, but the adjusted risk of in-hospital mortality was similar across tertiles.
Conclusions:
Comprehensive ECG-to-device time provides an integrated hospital-related network-level assessment of reperfusion timing metrics for primary PCI, regardless of the location for STEMI identification; further validation will delineate how this metric can be used to facilitate STEMI care improvements.
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