Association of a Comprehensive ST-Segment-Elevation Myocardial Infarction Protocol With Key Process Metrics Among
Radoslav Zinoviev1, Anirudh Kumar2, Chetan P Huded3
1Division of Cardiology University of California Los Angeles Los Angeles CA USA.
Insights
A new comprehensive STEMI protocol improved door-to-balloon times for heart attack patients. This led to better treatment and a reduced 30-day mortality rate, enhancing STEMI care.
Area of Science:
- Cardiology
- Emergency Medicine
- Healthcare Systems Improvement
Background:
- Most US ST-segment-elevation myocardial infarction (STEMI) patients transferred for percutaneous coronary intervention (PCI) do not meet the door-to-balloon time (D2BT) goal of ≤120 minutes.
- Timely reperfusion therapy is critical for STEMI outcomes.
- Existing protocols often fall short in optimizing STEMI care pathways.
Purpose of the Study:
- To evaluate the impact of a comprehensive STEMI protocol (CSP) on STEMI process metrics.
- To assess improvements in guideline-directed medical therapy, radial access, and D2BT.
- To determine the effect of the CSP on 30-day mortality rates in STEMI patients.
Main Methods:
- A 4-step CSP was implemented, including ED cardiac catheterization laboratory activation, a STEMI Safe Handoff Checklist, immediate transfer, and a radial-first approach to PCI.
- A comparative analysis was conducted on 1274 STEMI patients transferred for PCI, divided into pre-CSP (n=499) and CSP (n=775) groups.
- Key metrics including medical therapy use, access site, D2BT, and 30-day mortality were analyzed before and after CSP implementation.
Main Results:
- Guideline-directed medical therapy use increased from 84.6% to 93.9% (P<0.001).
- Radial access significantly increased from 19.0% to 77.7% (P<0.001).
- Median D2BT decreased from 114 to 97 minutes (P<0.001), with 80.1% of patients achieving D2BT ≤120 minutes post-CSP, compared to 55.7% pre-CSP.
Conclusions:
- The comprehensive STEMI protocol significantly improved key process metrics for STEMI patients.
- Implementation of the CSP was associated with a substantial reduction in door-to-balloon times.
- Achieving D2BT <120 minutes correlated with a 50% relative risk reduction in 30-day mortality.
Background:
Most US patients with ST-segment-elevation myocardial infarction (STEMI) transferred for percutaneous coronary intervention (PCI) do not achieve the goal door-to-balloon time (D2BT) of ≤120 minutes. We evaluated the impact of a comprehensive STEMI protocol (CSP) implemented in our health care system on STEMI process metrics in patients transferred for PCI.
Methods And Results:
The CSP is a 4-step protocol including (1) emergency department (ED) cardiac catheterization laboratory activation; (2) a STEMI Safe Handoff Checklist; (3) immediate transfer to an available cardiac catheterization laboratory; and (4) radial-first approach to PCI. We compared the use of guideline-directed medical therapy before angiography, radial-first access, and D2BT in 1274 consecutive patients with STEMI transferred to our hospital for PCI before (pre-CSP group; January 1, 2011, to July 14, 2014) and after (CSP group; July 15, 2014, to July 15, 2019) CSP implementation. The study population included 499 patients in the pre-CSP group and 775 patients in the CSP group. After CSP implementation, guideline-directed medical therapy before angiography (84.6% versus 93.9%, P<0.001) and radial access (19.0% versus 77.7%, P<0.001) both increased significantly. Median D2BT decreased from 114 (interquartile range, 94-146 minutes) to 97 minutes (interquartile range, 82-115 minutes; P<0.001) after CSP implementation, with substantially more patients treated with D2BT of ≤120 minutes (55.7% versus 80.1%, P<0.001). Achievement of D2BT <120 minutes in the CSP group was associated with a 50% relative risk reduction in the 30-day mortality rate (odds ratio, 0.50; P=0.04) and an absolute risk reduction of 0.7%.
Conclusions:
In patients with STEMI transferred for PCI, a standardized protocol for STEMI care was associated in improvements in key process metrics (guideline-directed medical therapy, radial access, and D2BT) with associated reduction in the 30-day mortality rate.
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