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Published on: June 12, 2021
Delays in Primary Percutaneous Coronary Intervention in ST-Segment Elevation Myocardial Infarction Patients
Ajar Kochar1, Hussein R Al-Khalidi1, Steen M Hansen1
1Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina.
Insights
Fewer than 40% of ST-segment elevation myocardial infarction (STEMI) patients with cardiogenic shock (CS) met treatment time goals. Delays in reperfusion for direct STEMI patients with CS were linked to increased mortality.
Area of Science:
- Cardiology
- Health Services Research
- Quality Improvement Science
Background:
- Limited contemporary data exist on achieving guideline-directed first medical contact (FMC)-to-device times for ST-segment elevation myocardial infarction (STEMI) patients with cardiogenic shock (CS).
- Quality improvement initiatives aim to optimize reperfusion times in STEMI care.
Purpose of the Study:
- To evaluate if quality improvement initiatives improved FMC-to-device times for STEMI patients with CS.
- To assess the association between achieving guideline-directed FMC-to-device times and mortality in STEMI patients with CS.
Main Methods:
- Analysis of 23,785 STEMI patients from the American Heart Association Mission: Lifeline STEMI Systems Accelerator project (2012-2014).
- Stratification of patients by cardiogenic shock (CS) versus no CS.
- Cochrane-Armitage tests and multivariable logistic regression to assess trends and mortality associations.
Main Results:
- 8.4% of STEMI patients presented with CS.
- CS patients were less likely to achieve FMC-to-device time targets compared to non-CS patients.
- The Accelerator intervention did not improve times for direct-presenting CS patients but showed improvement for transferred CS patients.
Conclusions:
- Less than 40% of STEMI patients with CS achieved guideline-directed FMC-to-device targets.
- Reperfusion delays in direct-presenting STEMI patients with CS were associated with significantly higher mortality.
Objectives:
This study sought to examine whether quality improvement initiatives across multiple ST-segment elevation myocardial infarction (STEMI) systems translated to faster first medical contact (FMC)-to-device times for patients presenting with cardiogenic shock (CS).
Background:
There are limited data describing contemporary rates of achieving guideline-directed FMC-to-device times for STEMI patients with CS.
Methods:
From 2012 to 2014, the American Heart Association Mission: Lifeline STEMI Systems Accelerator project established a protocol-guided approach to STEMI reperfusion systems in 484 U.S. hospitals. The study was stratified by CS versus no CS at presentation and performed Cochrane-Armitage tests to evaluate trends of achieving FMC-to-device time targets. A multivariable logistic regression model assessed the association between achieving guideline-directed FMC-to-device times and mortality.
Results:
Among 23,785 STEMI patients, 1,993 (8.4%) experienced CS at presentation. For direct presenters, patients with CS were less likely to achieve the 90-min FMC-to-device time compared with no-CS patients (37% vs. 54%; p < 0.001). For transferred patients, CS patients were even less likely to reach the 120-min FMC-to-device time compared with no-CS patients (34% vs. 47%; p < 0.0001). The Accelerator intervention did not result in improvements in the FMC-to-device times for direct-presenting CS patients (p for trend = 0.53), although there was an improvement for transferred patients (p for trend = 0.04). Direct-presenting patients arriving within 90 min had lower mortality rates compared with patients who reached after 90 min (20.49% vs. 39.12%; p < 0.001).
Conclusions:
Fewer than 40% of STEMI patients presenting with CS achieved guideline-directed FMC-to-device targets; delays in reperfusion for direct-presenting patients were associated with higher mortality.
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