Interplay Between Time of Presentation, Timeliness of Reperfusion, and Outcome After ST-Segment–Elevation Myocardial Infarction

Abstract

Disparities in care and outcomes among patients presenting with acute ST-segment-elevation myocardial infarction (STEMI) during off-hours remain a matter of considerable interest because they uncover gaps in the healthcare system and opportunities for improvement. Article see p 656In the report by Dasari et al, 1 the investigators revisited care processes and outcomes among patients presenting with STEMI during off-hours (weeknights, weekends, and holidays) in contemporary clinical practices. They used the Acute Coronary Treatment and Intervention Outcomes Network registry-Get With the Guidelines database to compare STEMI performance measures during off-versus on-hours at 447 US hospitals between 2007 and 2010. The investigators reported similar rates of early aspirin use and attainment of door-to-ECG ≤10 minutes and door-to-needle ≤30 minutes in both groups.1 However, patients undergoing primary percutaneous coronary intervention (pPCI) during off-hours experienced slower mechanical reperfusion, were less likely to achieve timely door-to-balloon (D2B ≤90 minutes), and had higher risk of adjusted all-cause mortality. 1The current report 1 is the latest of several investigations in the field 2-5 and demonstrates notable improvements in care. Compared with earlier reports, 3,5 the investigators report salient findings including shorter D2B and door-to-needle times overall and during off-hours and smaller time differential in D2B between off-and on-hours.1 A remarkable finding in their study is that >97% of patients received pPCI as the reperfusion therapy, which reflects the widespread adoption of this superior reperfusion strategy. This is in contrast to prior reports such as the one from the National Registry for Myocardial Infarction registry (2000)(2001)(2002)(2003)(2004)(2005)(2006) in which the use of pPCI, although progressively increasing over time, accounted for slightly >64% of reperfusion therapies at PCI-capable hospitals.6 Additional in-hospital periprocedural adverse outcomes (bleeding, stroke, shock, etc) were also comparable among patients undergoing pPCI during off-and on-hours.1 The latter observation speaksfor the high quality of pPCI performed during off-hours and contrasts with earlier reports showing more failed angioplasty procedures during this time period.2 However, it is interesting to note that the proportion of patients achieving timely door-to-needle in the current report 1 was much less than that achieving timely D2B. This finding was previously documented 5 and likely reflects the complexity of decision making for pharmacological reperfusion. Realizing that only 39% of all hospitals have interventional cardiology capabilities in the current era, 7 it is noteworthy that establishing systems of care to transfer patients to PCI-capable hospitals and administer timely fibrinolytic therapy remains also of paramount importance. 8 In addition, the study by Dasari et al 1 assessed limited aspects of STEMI care: only 3 of 13 established clinical performance measures 9 for acute myocardial inf...

Temporal Trends in Care and Outcomes of Patients Receiving Fibrinolytic Therapy Compared to Primary Percutaneous Coronary Intervention: Insights From the Get With The Guidelines Coronary Artery Disease (GWTG‐CAD) Registry

“…Our results corroborate these findings. We previously argued that some of the time differential in DTB times observed in clinical studies may be too small to exert a meaningful clinical impact, especially when short‐term outcomes are examined . A prior report from the National Registry of Myocardial Infarction (NRMI) evaluating reperfusion strategies in STEMI patients in 1990 through 2006 found a decrease in fibrinolysis from 52.5% to 27.6% with a nearly linear decline in DTN from 59 to 29 minutes and a corresponding decrease in mortality from 7.0% to 6.0% over the study period.…”