Impact of Patient- and System-Level Delays on Reperfusion Among Patients With ST-Elevation Myocardial Infarction
Joshua B Wenner1,2, Graham C Wong1,3, John A Cairns1,3
1Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada.
Insights
Reducing delays in primary percutaneous coronary intervention (pPCI) for ST-elevation myocardial infarction (STEMI) is crucial. Emergency department dwell time significantly impacts reperfusion times and patient outcomes, including mortality.
Area of Science:
- Cardiology
- Emergency Medicine
- Health Services Research
Background:
- ST-elevation myocardial infarction (STEMI) patients often face delays in receiving primary percutaneous coronary intervention (pPCI) at PCI-capable hospitals.
- Timely reperfusion is critical for STEMI patient outcomes.
Purpose of the Study:
- To investigate the impact of specific delay intervals and patient/system factors on STEMI reperfusion times.
- To compare reperfusion times and outcomes based on presentation pathways (direct EHS, inter-hospital transfer, self-presentation).
Main Methods:
- Analysis of STEMI patients undergoing successful pPCI at two PCI-capable hospitals (June 2007-March 2016).
- Exclusion of patients with prehospital cardiac arrest.
- Comparison of timely (≤90/≤120 min) versus delayed (>90/>120 min) pPCI based on first medical contact-to-device time, considering patient characteristics and system delays.
Main Results:
- Of 1936 patients, 47% of direct EHS arrivals, 42% of transfers, and 33% of self-presenters met guideline reperfusion times.
- Emergency department (ED) dwell time was the largest contributor to prolonged reperfusion.
- Presentation time, comorbidities, and sex were associated with delayed reperfusion; prolonged delays increased mortality, bleeding, and shock in direct EHS arrivals.
Conclusions:
- Reducing ED dwell time and other systemic delays in pPCI is essential for improving STEMI outcomes.
- System-level interventions targeting ED efficiency can significantly impact STEMI patient survival and morbidity.
Background:
Patients with ST-elevation myocardial infarction (STEMI) presenting to percutaneous coronary intervention (PCI)-capable hospitals often experience delays for primary PCI (pPCI). We sought to describe the effect of specific delay intervals and patient/system-level factors on STEMI reperfusion times.
Methods:
We analyzed all consecutive patients with STEMI who presented to 2 PCI-capable hospital emergency departments (EDs) between June 2007 and March 2016 who received successful pPCI. We excluded patients with prehospital cardiac arrest. We compared specific system delay intervals, patient characteristics, and in-hospital outcomes among patients who received timely (first medical contact-device ≤90/≤120 minutes) vs delayed >90/>120 minutes) pPCI.
Results:
Of 1936 patients with STEMI, 1127 (58%) presented directly to a PCI-capable hospital via emergency health services (EHS), 499 (26%) were transferred from the ED of a non-PCI hospital, and 310 (16%) self-presented to the ED of a pPCI-capable hospital. Guideline-recommended reperfusion times were met in 47% of direct-EHS, 42% of transfers, and 33% of self-presenters. Each time interval from first medical contact to device deployment was significantly prolonged in the delayed vs timely reperfusion cohorts across all 3 groups, excepting vascular access time. ED dwell time contributed the most to the difference in median reperfusion time within each group. Time of presentation, comorbidities, and sex were each significantly associated with delayed reperfusion. Within the EHS-direct group, prolonged reperfusion and ED dwell times were significantly associated with increased mortality, major bleeding, and cardiogenic shock.
Conclusion:
Ongoing efforts to identify and reduce ED dwell time and other systemic pPCI delays may improve STEMI outcomes, including mortality.
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