Incremental Prognostic Value of Guideline-Directed Medical Therapy, Transradial Access, and Door-to-Balloon Time on Outcomes in ST-Segment–Elevation Myocardial Infarction

Abstract

Background: Systems to improve ST-segment–elevation myocardial infarction (STEMI) care have traditionally focused on improving door-to-balloon time. However, prompt guideline-directed medical therapy and transradial primary percutaneous coronary intervention (PCI) are also associated with reduced STEMI mortality. The incremental prognostic value of each facet of STEMI care on clinical outcomes within a STEMI system of care is unknown. Methods and Results: We implemented systems-based strategies at our hospital to improve 3 STEMI care metrics: (1) prompt guideline-directed medical therapy before sheath insertion for PCI, (2) use of transradial primary PCI, and (3) door-to-balloon time. We assessed the incremental association of metrics achieved with in-hospital adverse events and 30-day mortality. Of 1272 consecutive patients with STEMI treated with PCI at our hospital (January 1, 2011, to December 31, 2016), the percentage with achievement of zero, 1, 2, or 3 STEMI care metrics was 7.1%, 24.1%, 43.8%, and 25.1%; and 30-day mortality was 15.6%, 8.6%, 3.6%, and 3.2%, respectively (log-rank P <0.001). After adjusting for known clinical predictors of STEMI in-hospital mortality, achievement of at least 2 STEMI care metrics was associated with significantly reduced in-hospital mortality (odds ratio, 0.39; 95% CI, 0.16–0.96; P =0.041). Each metric provided incremental prognostic value when modeled in stepwise order of their occurrence in clinical practice (final model C statistic, 0.677; P <0.001). Conclusions: Prompt guideline-directed medical therapy before sheath insertion for PCI, transradial primary PCI, and door-to-balloon time add incremental prognostic value in STEMI care. Expanding STEMI systems of care from a singular focus on door-to-balloon time to a comprehensive focus on multifaceted STEMI care offers an opportunity to further improve STEMI outcomes.

Guideline adherence and long-term clinical outcomes in patients with acute myocardial infarction: a Japanese Registry of Acute Myocardial Infarction Diagnosed by Universal Definition (J-MINUET) substudy

“…In that study, the achievement of at least two of these three STEMI care metrics was associated with significantly reduced rates of in-hospital mortality. 19 Our study extended these findings by demonstrating decreases in adverse cardiac events at 3 years post-discharge with increasing adherence to guideline-recommended care among patients who survive hospital discharge. Few reports have evaluated associations between guideline adherence and long-term clinical outcomes after treatment of AMI.…”

“…[16][17][18] Some reports have described the relationship between patient levels of guidelinerecommended therapies and short-term outcomes after AMI. 14,19 Huded et al 19 evaluated the prognostic values of STEMI care metrics, consisting of guideline-recommended medical therapy, transradial primary percutaneous coronary intervention (PCI) and The incidence of cardiovascular events was significantly different among groups in both STEMI and NSTEMI patients. NSTEMI: non-ST-elevation myocardial infarction; STEMI: ST-elevation myocardial infarction.…”

Prognostic implications and outcomes of cardiac arrest among contemporary patients with STEMI treated with PCI

“…It remains unknown if implementation of a system of care which standardizes guideline-directed medical therapy, improves door-to-balloon times, and promotes revascularization and access to mechanical circulatory support could result in improvement in in-hospital mortality and thus translate to superior outcomes. 16 , 17 …”

“…18 , 19 , 20 Importantly, different aspects of STEMI care have been shown to provide incremental prognostic value via mortality benefit and a reduction in adverse events. 17 However, patients with STEMI and CA are often excluded from door-to-balloon time reporting due to non-system delay, a subpopulation of STEMI patients that have been shown to have increased in-hospital mortality. 21 Whether a systems of care targeting this high-risk population can improve quality of care and outcomes remains unclear.…”

Implementation of a Comprehensive ST-Elevation Myocardial Infarction Protocol Improves Mortality Among Patients With ST-Elevation Myocardial Infarction and Cardiogenic Shock

“…9 We recently showed the complementary impact on mortality of guideline-directed medical therapy (GDMT), use of trans-radial access (TRA) for primary PCI, and lower D2BT in patients with STEMI. 10 The value of systems of care focusing on improving these key issues for patients with STEMI and CS is unknown. Accordingly, we implemented a 4-step comprehensive STEMI protocol (CSP) aimed at systematically targeting these tenets of STEMI care and investigated its impact on (1) the incidence of CS in all patients with STEMI and (2) care delivery and outcomes in patients with STEMI and CS.…”