Impact of treatment delay on mortality in ST-segment elevation myocardial infarction (STEMI) patients presenting with and without haemodynamic instability: results from the German prospective, multicentre FITT-STEMI trial

Abstract

AimsThe aim of this study was to investigate the effect of contact-to-balloon time on mortality in ST-segment elevation myocardial infarction (STEMI) patients with and without haemodynamic instability.Methods and resultsUsing data from the prospective, multicentre Feedback Intervention and Treatment Times in ST-Elevation Myocardial Infarction (FITT-STEMI) trial, we assessed the prognostic relevance of first medical contact-to-balloon time in n = 12 675 STEMI patients who used emergency medical service transportation and were treated with primary percutaneous coronary intervention (PCI). Patients were stratified by cardiogenic shock (CS) and out-of-hospital cardiac arrest (OHCA). For patients treated within 60 to 180 min from the first medical contact, we found a nearly linear relationship between contact-to-balloon times and mortality in all four STEMI groups. In CS patients with no OHCA, every 10-min treatment delay resulted in 3.31 additional deaths in 100 PCI-treated patients. This treatment delay-related increase in mortality was significantly higher as compared to the two groups of OHCA patients with shock (2.09) and without shock (1.34), as well as to haemodynamically stable patients (0.34, P < 0.0001).ConclusionsIn patients with CS, the time elapsing from the first medical contact to primary PCI is a strong predictor of an adverse outcome. This patient group benefitted most from immediate PCI treatment, hence special efforts to shorten contact-to-balloon time should be applied in particular to these high-risk STEMI patients.Clinical Trial RegistrationNCT00794001.

2018 ESC/EACTS Guidelines on myocardial revascularization

“…198 A recent analysis of 12 675 STEMI patients in the FITT-STEMI (Feedback Intervention and Treatment Times in ST-Elevation Myocardial Infarction) trial emphasizes the strong impact of time delays on mortality, particularly in STEMI patients with cardiogenic shock or out-of-hospital cardiac arrest. 199 In shock without out-ofhospital cardiac arrest, every 10 min treatment delay between 60-180 min from the first medical contact resulted in 3.3 additional deaths per 100 PCI-treated patients, and in 1.3 additional deaths after out-of-hospital cardiac arrest without cardiogenic shock. In stable STEMI patients, time delays were substantially less relevant (0.3 additional deaths per 100 PCI-treated patients for every 10 min delay between 60-180 min from the first medical contact).…”

The necessity of conversion from coronary care unit to the cardiovascular intensive care unit required for cardiologists

“…In ST-elevation myocardial infarction (STEMI), it was revealed that the mortality rate is higher if the time from the first contact with medical staff to the reperfusion by catheterization is delayed. It was reported that the 3.3% mortality rate increases with each 10-min delay in cardiogenic shock [16]. Even in acute heart failure, the death rate increases as the time to hospitalization is delayed [17,18].…”

“…Patients with acute heart failure and cardiogenic shock were quickly transported to an expert center before it became severe, then prepared for respiratory and circulation management before admission through the medical team that was familiar with rapid diagnosis and treatment [18,20]. For STEMI with cardiogenic shock, the 12-lead electrocardiogram and information on the severity are reported from the ambulance so that the catheterization room and percutaneous cardiopulmonary support (PCPS) and Impella (Abiomed, Danvers, MA, USA) [21] will be prepared [16,18].…”

‚Combat‛ Approach to Cardiogenic Shock

“…[11][12][13][14] In the decades since, in-hospital survival rates have plateaued while the incidence of AMI CS and acute decompensated heart failure (ADHF) CS has increased despite improvements in door-to-balloon times (the cardiovascular specialist's version of the surgeon's 'Golden Hour') and adjunctive pharmacotherapy. [15][16][17][18][19][20][21][22][23][24][25][26][27][28] Early survivors also suffer unacceptably high rates of post-discharge heart failure, rehospitalisation and death. [29][30][31][32] Revascularisation is necessary but not sufficient for survival in AMI CS.…”