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Dharma S, Kamarullah W, Sabrina AP. Association of Admission Time and Mortality in STEMI Patients: A Systematic Review and Meta-analysis. Int J Angiol 2022; 31:273-283. [PMID: 36588865 PMCID: PMC9803553 DOI: 10.1055/s-0042-1742610] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
This systematic review and meta-analysis aimed to evaluate patients with acute ST-segment elevation myocardial infarction (STEMI) who were admitted during off-hours and treated with primary angioplasty associated with an increased risk of mortality compared with those admitted during regular working hours. We performed a systematic literature search using PubMed, SCOPUS, Europe PMC, and Cochrane CENTRAL databases that was finalized on March 15, 2021. The primary outcome was mortality comprising early (in-hospital), midterm (30 days to 1 year), and long-term mortality (>1 year). A total of 384,452 patients from 56 studies were included. The overall mortality of acute STEMI patients admitted during off-hours and regular hours were 6.1 and 6.7%, respectively. Patients admitted during off-hours had similar risk of early, midterm, and long-term mortality compared to those admitted during regular working hours ([relative risk or RR = 1.07, 95% confidence interval or CI, 1.00-1.14, p = 0.06; I 2 = 45%, p = 0.0009], [RR = 1.00, 95% CI, 0.95-1.05, p = 0.92; I 2 = 13%, p = 0.26], and [RR = 0.95, 95% CI, 0.86-1.04, p = 0.26; I 2 = 0%, p = 0.76], respectively). Subgroup analyses indicated that the results were consistent across all subgroups ([women vs. men], [age >65 years vs. ≤65 years], and [Killip classification II to IV vs. Killip I]). Funnel plot was asymmetrical. However, Egger's test suggests no significance of small-study effects ( p = 0.19). This meta-analysis showed that patients with acute STEMI who were admitted during off-hours and treated with primary angioplasty had similar risk of early, midterm, and long-term mortality compared with those admitted during regular working hours.
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Affiliation(s)
- Surya Dharma
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, University of Indonesia, Indonesian Cardiovascular Research Center, National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
- Faculty of Medicine, University of Prima Indonesia, Medan, Indonesia
| | - William Kamarullah
- Indonesian Cardiovascular Research Center, National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
| | - Adelia Putri Sabrina
- Indonesian Cardiovascular Research Center, National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
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Bailey D, Lehman M, Tuohy K, Ko E, Hatten S, Rizk E. The Impact of Surgical Scheduling on Outcomes in Lumbar Laminectomy. Cureus 2021; 13:e20272. [PMID: 35018266 PMCID: PMC8741263 DOI: 10.7759/cureus.20272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2021] [Indexed: 11/25/2022] Open
Abstract
Objective The purpose of this study was to determine whether surgical scheduling affected patient outcomes following lumbar laminectomy. Physician fatigue caused by prolonged work hours has been shown to worsen outcomes. Previous research has also established a relationship between surgical scheduling and outcomes. Methods This was a retrospective chart review of single-level lumbar laminectomy patients at the Penn State Milton S. Hershey Medical Center between 1992 and 2019. Patients who underwent a one-level laminectomy between 1992 and 2019 were included in the study. Patients with procedures defined as complex (>1 level, tumor or abscess removal, discectomy, implant removal) were excluded. The surgical complication rate [cerebrospinal fluid (CSF) leak, 30-day redo, 30-day ED visit, weakness, sensation loss, infection, urinary retention] was compared across surgical start times, day of the week, proximity to a holiday, and procedure length. Results Procedures that started between 9:01-11:00 were more likely to have a complication than those between 7:01-9:00 (p=0.04). For every 60-min increase in surgery length, odds of having a complication increased by 2.01 times (p=0.0041). Surgeries that started between 11:01-13:00 had a significantly longer median surgery length than those between 7:01-9:00. Conclusion The time of the day when the procedure was started was predictive of worse outcomes following laminectomy. This may be attributed to several factors, including fatigue and staff turnover. Additionally, increased surgical length was predictive of more complications. It remains unclear whether increased surgical time results from correction of noticed errors or a fatigue-related decline in speed and performance. These findings on one-level laminectomy warrant further investigations since they have implications for reducing systemic failures that impact patient outcomes.
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Affiliation(s)
- David Bailey
- Neurological Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| | - Morgan Lehman
- Neurological Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| | - Kyle Tuohy
- Neurological Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| | - Elizabeth Ko
- Neurological Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| | - Steven Hatten
- Neurological Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| | - Elias Rizk
- Neurological Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
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Ullah W, Cheema MA, Abdullah HMA, Roomi S, Saeed R, Balaratna A. ST-Segment Elevation Myocardial Infaction Alert During the Night Shift, A Misfortune for the Patient or an Overstatement? Cardiol Res 2019; 10:150-156. [PMID: 31236177 PMCID: PMC6575109 DOI: 10.14740/cr862] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 04/29/2019] [Indexed: 11/11/2022] Open
Abstract
Background Conflicting data exist regarding the outcomes of primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) based on intervention timings. It is believed that short staffing at night hours may lead to a lapse in the delivery of effective, efficient and timely medical intervention. Methods A retrospective single-center study was performed, and a total of 436 patients were randomized into two groups. Group A had 279 patients who had the heart catheterization done during the daytime (between 6 am and 6 pm), while group B had 157 patients who had the same intervention performed at night (between 6 pm and 6 am). Results Door to balloon (DTB) time during the day was about 16 min shorter than the DTB time at night (81.29 ± 3.26 vs. 97.30 ± 8.54) with no statistical difference (P = 0.051). The mean troponin rise during the day was 1.94 ± 10.60 SEM (95% confidence interval (CI): -22.70 to 18.90) higher than night troponin levels (71.75 ± 7.18 vs. 69.80 ± 7.18), but P value was 0.85. The left ventricular ejection fraction (LVEF) fall for daytime was 0.93% vs. 0.90% for night time patients (P = 0.94). Conclusion There is no significant difference in the mean DTB time, the rise in troponin, fall in LVEF, readmission rates, or mortality, and hence no negative effects on patient outcomes based on the patient's time of presentation between the two groups.
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Affiliation(s)
- Waqas Ullah
- Abington - Jefferson Health, Abington, PA, USA
| | | | | | | | - Rehan Saeed
- Abington - Jefferson Health, Abington, PA, USA
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Enezate TH, Omran J, Al-Dadah AS, Alpert M, Mahmud E, Patel M, Aronow HD, Bhatt DL. Comparison of Outcomes of ST-Elevation Myocardial Infarction Treated by Percutaneous Coronary Intervention During Off-Hours Versus On-Hours. Am J Cardiol 2017; 120:1742-1754. [PMID: 28893379 DOI: 10.1016/j.amjcard.2017.07.082] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 07/18/2017] [Accepted: 07/24/2017] [Indexed: 11/29/2022]
Abstract
Previous studies have reported worse outcomes and longer door-to-balloon times (DBTs) in patients presenting with ST-elevation myocardial infarction (STEMI) after normal working hours, during weekends, and on holidays (off-hours) compared with normal business hours (on-hours). Recent studies, however, have reported similar outcomes regardless of presentation time. MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were queried from January 1990 through December 2016. Only studies comparing STEMI outcomes during off-hours versus on-hours with percutaneous coronary intervention were included. A random-effects meta-analysis model was used to pool outcomes across the studies. Clinical end points included short- (<30 days of presentation), intermediate- (at 1 to 2 years), and long-term (at 3 to 4 years) stent thrombosis, mortality, recurrent myocardial infarction (MI), and major adverse cardiovascular events (MACEs). A total of 86,776 patients (62 years and 74.5% male) were identified from 39 studies. There was no significant difference between both groups with regard to mean DBT (odds ratio [OR] 0.74, 95% confidence interval [CI] -2.73 to 4.22, p = 0.67) or median DBT (p = 0.19). There was no significant difference between the 2 groups for short-term end points including mortality (OR 1.11, 95% CI 0.99 to 1.25, p = 0.08), MI (OR 1.25, 95% CI 0.90 to 1.74, p = 0.18), MACE (OR 1.06, 95% CI 0.93 to 1.20, p = 0.40), or stent thrombosis (OR 1.23, 95% CI 0.83 to 1.82, p = 0.31). Similarly, intermediate-term end points were not statistically different for mortality (OR 0.97, 95% CI 0.89 to 1.05, p = 0.46), MI (OR 0.86, 95% CI 0.73 to 1.02, p = 0.08), or MACE (OR 1.00, 95% CI 0.92 to 1.08, p = 0.98). Long-term end points did not differ statistically between groups for mortality (OR 0.95, 95% CI 0.83 to 1.09, p = 0.46), MI (OR 1.19, 95% CI 0.77 to 1.84, p = 0.44), or MACE (OR 0.98, 95% CI 0.89 to 1.08, p = 0.67). In conclusion, patients presenting with STEMI during off-hours and treated with percutaneous coronary intervention had similar short-, intermediate-, and long-term outcomes compared with patients presenting during on-hours. DBT was not affected by the time of presentation.
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Affiliation(s)
| | - Jad Omran
- UC San Diego Sulpizio Cardiovascular Center, San Diego, California
| | | | | | - Ehtisham Mahmud
- UC San Diego Sulpizio Cardiovascular Center, San Diego, California
| | - Mitul Patel
- UC San Diego Sulpizio Cardiovascular Center, San Diego, California
| | - Herbert D Aronow
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, Massachusetts
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5
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Impact of in or out of office hours at admission time on outcome in out-of-hospital cardiac arrest patients. Eur J Emerg Med 2017; 24:249-254. [DOI: 10.1097/mej.0000000000000343] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Can it wait until morning? A comparison of nighttime versus daytime cholecystectomy for acute cholecystitis. Am J Surg 2014; 208:911-8; discussion 917-8. [DOI: 10.1016/j.amjsurg.2014.09.004] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2014] [Revised: 09/14/2014] [Accepted: 09/15/2014] [Indexed: 12/29/2022]
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Dasari TW, Roe MT, Chen AY, Peterson ED, Giugliano RP, Fonarow GC, Saucedo JF. Impact of Time of Presentation on Process Performance and Outcomes in ST-Segment–Elevation Myocardial Infarction. Circ Cardiovasc Qual Outcomes 2014; 7:656-63. [DOI: 10.1161/circoutcomes.113.000740] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Prior studies demonstrated that patients with ST-segment–elevation myocardial infarction presenting during off-hours (weeknights, weekends, and holidays) have slower reperfusion times. Recent nationwide initiatives have emphasized 24/7 quality care in ST-segment–elevation myocardial infarction. It remains unclear whether patients presenting off-hours versus on-hours receive similar quality care in contemporary practice.
Methods and Results—
Using Acute Coronary Treatment and Intervention Outcomes Network-Get With The Guidelines (ACTION-GWTG) database, we examined ST-segment–elevation myocardial infarction performance measures in patients presenting off-hours (n=27 270) versus on-hours (n=15 972; January 2007 to September 2010) at 447 US centers. Key quality measures assessed were aspirin use within first 24 hours, door-to-balloon time, door-to-ECG time, and door-to-needle time. In-hospital risk-adjusted all-cause mortality was calculated. Baseline demographic and clinical characteristics were similar. Aspirin use within 24 hours approached 99% in both groups. Among patients undergoing primary percutaneous coronary intervention (n=41 979; 97.1%), median door-to-balloon times were 56 versus 72 minutes (
P
<0.0001) for on-hours versus off-hours. The proportion of patients achieving door-to-balloon time ≤90 minutes was 87.8% versus 79.2% (
P
<0.0001), respectively. There were no differences attaining door-to-ECG time ≤10 minutes (73.4% versus 74.3%,
P
=0.09) and door-to-needle time ≤30 minutes (62.3% versus 58.7%;
P
=0.44) between on-hours versus off-hours. Although in-hospital all-cause mortality was similar (4.2%) in both groups, the risk-adjusted all-cause mortality was higher for patients presenting off-hours (odds ratio, 1.13; 95% confidence interval, 1.02–1.26).
Conclusions—
In contemporary community practice, achievement of quality performance measures in patients presenting with ST-segment–elevation myocardial infarction was high, regardless of time of presentation. Door-to-balloon time was, however, slightly delayed (by an average of 16 minutes), and risk-adjusted in-hospital mortality was 13% higher in patients presenting off-hours.
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Affiliation(s)
- Tarun W. Dasari
- From the University of Oklahoma Health Sciences Center, Oklahoma City (T.W.D.); Duke University Medical Center and Duke Clinical Research Institute, Durham, NC (M.T.R., A.Y.C., E.D.P.); Brigham and Women’s Hospital, Boston, MA (R.P.G.); University of California, Los Angeles (G.C.F.); and NorthShore University Health System, Evanston, IL (J.F.S.)
| | - Matthew T. Roe
- From the University of Oklahoma Health Sciences Center, Oklahoma City (T.W.D.); Duke University Medical Center and Duke Clinical Research Institute, Durham, NC (M.T.R., A.Y.C., E.D.P.); Brigham and Women’s Hospital, Boston, MA (R.P.G.); University of California, Los Angeles (G.C.F.); and NorthShore University Health System, Evanston, IL (J.F.S.)
| | - Anita Y. Chen
- From the University of Oklahoma Health Sciences Center, Oklahoma City (T.W.D.); Duke University Medical Center and Duke Clinical Research Institute, Durham, NC (M.T.R., A.Y.C., E.D.P.); Brigham and Women’s Hospital, Boston, MA (R.P.G.); University of California, Los Angeles (G.C.F.); and NorthShore University Health System, Evanston, IL (J.F.S.)
| | - Eric D. Peterson
- From the University of Oklahoma Health Sciences Center, Oklahoma City (T.W.D.); Duke University Medical Center and Duke Clinical Research Institute, Durham, NC (M.T.R., A.Y.C., E.D.P.); Brigham and Women’s Hospital, Boston, MA (R.P.G.); University of California, Los Angeles (G.C.F.); and NorthShore University Health System, Evanston, IL (J.F.S.)
| | - Robert P. Giugliano
- From the University of Oklahoma Health Sciences Center, Oklahoma City (T.W.D.); Duke University Medical Center and Duke Clinical Research Institute, Durham, NC (M.T.R., A.Y.C., E.D.P.); Brigham and Women’s Hospital, Boston, MA (R.P.G.); University of California, Los Angeles (G.C.F.); and NorthShore University Health System, Evanston, IL (J.F.S.)
| | - Gregg C. Fonarow
- From the University of Oklahoma Health Sciences Center, Oklahoma City (T.W.D.); Duke University Medical Center and Duke Clinical Research Institute, Durham, NC (M.T.R., A.Y.C., E.D.P.); Brigham and Women’s Hospital, Boston, MA (R.P.G.); University of California, Los Angeles (G.C.F.); and NorthShore University Health System, Evanston, IL (J.F.S.)
| | - Jorge F. Saucedo
- From the University of Oklahoma Health Sciences Center, Oklahoma City (T.W.D.); Duke University Medical Center and Duke Clinical Research Institute, Durham, NC (M.T.R., A.Y.C., E.D.P.); Brigham and Women’s Hospital, Boston, MA (R.P.G.); University of California, Los Angeles (G.C.F.); and NorthShore University Health System, Evanston, IL (J.F.S.)
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Wieringa WG, Lexis CPH, Mahmoud KD, Ottervanger JP, Burgerhof JGM, Pundziute G, van ‘t Hof AWJ, van Gilst WH, Lipsic E. Time of symptom onset and value of myocardial blush and infarct size on prognosis in patients with ST-elevation myocardial infarction. Chronobiol Int 2014; 31:797-806. [DOI: 10.3109/07420528.2014.908897] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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9
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de Boer SP, Oemrawsingh RM, Lenzen MJ, van Mieghem NM, Schultz C, Akkerhuis KM, van Leeuwen MA, Zijlstra F, van Domburg RT, Serruys PW, Boersma E. Primary PCI during off-hours is not related to increased mortality. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2013; 1:33-9. [PMID: 24062885 DOI: 10.1177/2048872612441581] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2012] [Accepted: 01/30/2012] [Indexed: 11/15/2022]
Abstract
AIM Previous studies have shown contradictory outcomes in ST-segment elevation myocardial infarction (STEMI) patients who underwent primary percutaneous coronary intervention (pPCI) during off-hours versus regular 'office' hours. We aimed to evaluate the relationship between pPCI timing (off-hours versus regular hours) and mortality in patients with STEMI undergoing pPCI. METHODS The study population comprised 4352 consecutive STEMI patients treated with pPCI in a high-volume centre with a 24/7 programme during 2000-2009. Descriptive statistics and multivariable survival analyses were applied to evaluate the relationship between treatment during off-hours (Monday-Friday, 6.00 pm-8.00 am and weekends) versus regular hours and the incidence of all-cause mortality at 30-day and 4-year follow-up. RESULTS A total of 2760 patients (63.4%) were treated during off-hours and 1592 patients (36.6%) during regular hours. With the exception of smoking, diabetes mellitus, use of glycoprotein IIb/IIIa antagonists and calcium antagonists, no major differences in baseline characteristics were observed between the groups. Mortality at 30-day follow-up was similar in patients treated during off-hours and those treated during regular hours (7.7% vs 7.7%; hazard ratio adjusted for potential confounders 1.03; 95% CI 0.82-1.28). Four-year mortality was similar (17.3% vs 17.3%; adjusted hazard ratio 0.95; 95% CI 0.81-1.11). CONCLUSION In STEMI patients who present during off-hours in a high-volume centre with 24/7 service, pPCI provides similar survival as patients who were treated during regular hours.
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Affiliation(s)
- Sanneke Pm de Boer
- Thoraxcenter, Department of Cardiology, Erasmus MC, Rotterdam, The Netherlands
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10
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Rathod KS, Jones DA, Gallagher SM, Bromage DI, Whitbread M, Archbold AR, Jain AK, Mathur A, Wragg A, Knight CJ. Out-of-hours primary percutaneous coronary intervention for ST-elevation myocardial infarction is not associated with excess mortality: a study of 3347 patients treated in an integrated cardiac network. BMJ Open 2013; 3:e003063. [PMID: 23811175 PMCID: PMC3696864 DOI: 10.1136/bmjopen-2013-003063] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2013] [Revised: 05/21/2013] [Accepted: 05/29/2013] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES Timely delivery of primary percutaneous coronary intervention (PPCI) is the treatment of choice for ST-segment elevation myocardial infarction (STEMI). Optimum delivery of PPCI requires an integrated network of hospitals, following a multidisciplinary, consultant-led, protocol-driven approach. We investigated whether such a strategy was effective in providing equally effective in-hospital and long-term outcomes for STEMI patients treated by PPCI within normal working hours compared with those treated out-of-hours (OOHs). DESIGN Observational study. SETTING Large PPCI centre in London. PARTICIPANTS 3347 STEMI patients were treated with PPCI between 2004 and 2012. The follow-up median was 3.3 years (IQR: 1.2-4.6 years). PRIMARY AND SECONDARY OUTCOME MEASURES The primary endpoint was long-term major adverse cardiac events (MACE) with all-cause mortality a secondary endpoint. RESULTS Of the 3347 STEMI patients, 1299 patients (38.8%) underwent PPCI during a weekday between 08:00 and 18:00 (routine-hours group) and 2048 (61.2%) underwent PPCI on a weekday between 18:00 and 08:00 or a weekend (OOHs group). There were no differences in baseline characteristics between the two groups with comparable door-to-balloon times (in-hours (IHs) 67.8 min vs OOHs 69.6 min, p=0.709), call-to-balloon times (IHs 116.63 vs OOHs 127.15 min, p=0.60) and procedural success. In hospital mortality rates were comparable between the two groups (IHs 3.6% vs OOHs 3.2%) with timing of presentation not predictive of outcome (HR 1.25 (95% CI 0.74 to 2.11). Over the follow-up period there were no significant differences in rates of mortality (IHs 7.4% vs OFHs 7.2%, p=0.442) or MACE (IHs 15.4% vs OFHs 14.1%, p=0.192) between the two groups. After adjustment for confounding variables using multivariate analysis, timing of presentation was not an independent predictor of mortality (HR 1.04 95% CI 0.78 to 1.39). CONCLUSIONS This large registry study demonstrates that the delivery of PPCI with a multidisciplinary, consultant-led, protocol-driven approach provides safe and effective treatment for patients regardless of the time of presentation.
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11
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Dreyer RP, Beltrame JF, Tavella R, Air T, Hoffmann B, Pati PK, Di Fiore D, Arstall M, Zeitz C. Evaluation of gender differences in Door-to-Balloon time in ST-elevation myocardial infarction. Heart Lung Circ 2013; 22:861-9. [PMID: 23628331 DOI: 10.1016/j.hlc.2013.03.078] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Revised: 03/17/2013] [Accepted: 03/18/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND A delayed Door-to-Balloon (DTB) time in women with ST-elevation myocardial infarction (STEMI) has been associated with an increased mortality. The objectives of this study were to (a) quantify the components of the delayed DTB time in women and (b) assess the independent effect of gender on DTB time in patients undergoing percutaneous coronary intervention (PCI) for STEMI. METHODS Clinical parameters were prospectively collected for 735 STEMI patients undergoing primary PCI from 2006 to 2010, with particular attention to the components of DTB time, including the onset of chest pain and the 'code' notification of the STEMI team by the Emergency Department. RESULTS Women were significantly older with more co-morbidity. Upon hospital arrival they also experienced delays in Door-to-Code (23 vs. 17 min, P=.012), Code-to-Balloon (63 vs. 57 min, P=.001) and thus DTB time (88 vs. 72 min, P=.001). After multivariate adjustment, independent determinants of DTB time included female gender (ratio of geometric means [RGM]=1.13; 95% CI 1.02-1.26; P=.022), hypertension (RGM=1.12, 95% CI 1.02-1.23, P=.014), maximum ST-elevation (RGM=0.97, 95% CI 0.94-0.98, P<.001), office hours (RGM=0.84, 95% CI 0.78-0.92, P<.001) and triage category (RGM=1.23, 95% CI 1.09-1.40, P=.001). CONCLUSIONS Women experience delays in identification of the STEMI diagnosis and also in the PCI process. Thus a multifaceted approach addressing both the diagnosis and management of STEMI in women is required.
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Affiliation(s)
- Rachel P Dreyer
- Cardiology Unit, The Queen Elizabeth Hospital (The Basil Hetzel Institute), Discipline of Medicine, University of Adelaide, Adelaide, South Australia, Australia
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12
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Graham MM, Ghali WA, Southern DA, Traboulsi M, Knudtson ML. Outcomes of after-hours versus regular working hours primary percutaneous coronary intervention for acute myocardial infarction. BMJ Qual Saf 2012; 20:60-7. [PMID: 21228077 PMCID: PMC3022364 DOI: 10.1136/bmjqs.2010.041137] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Background Primary percutaneous coronary intervention (PCI) is a proven therapy for acute ST-segment elevation myocardial infarction. However, outcomes associated with primary PCI may differ depending on time of day. Methods and results Using the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease, a clinical data-collection initiative capturing all cardiac catheterisation patients in Alberta, Canada, the authors described and compared crude and risk-adjusted survival for ST-segment elevation myocardial infarction patients undergoing primary PCI after-hours versus regular working hours. From 1 January 1999 to 31 March 2006, 1664 primary PCI procedures were performed (54.4% after-hours). Mortalities at 30 days were 3.6% for regular hours procedures and 5.0% for after-hours procedures (p=0.16). 1-year mortalities were 6.2% and 7.3% in the regular hours and after-hours groups, respectively (p=0.35). After adjusting for baseline risk factor differences, HRs for after-hours mortality were 1.26 (95% CI 0.78 to 2.02) for survival to 30 days and 1.08 (0.73 to 1.59) for survival to 1 year. A meta-analysis of our after-hours HR point estimate with other published risk estimates for after hours primary PCI outcomes yielded an RR of 1.23 (1.00 to 1.51) for shorter-term outcomes. Conclusions After-hours primary PCI was not associated with a statistically significant increase in mortality. However, a meta-analysis of this study with other published after-hours outcome studies yields an RR that leaves some questions about unexplored factors that may influence after-hours primary PCI care.
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Al Faleh HF, Thalib L, AlHabib KF, Ullah A, AlNemer K, AlSaif SM, Taraben AN, Malik A, Abuosa AM, Mimish LA, Hersia AS. Are acute coronary syndrome patients admitted during off-duty hours treated differently? An analysis of the Saudi Project for Assessment of Acute Coronary Syndrome (SPACE) study. Ann Saudi Med 2012; 32:366-71. [PMID: 22705606 PMCID: PMC6081017 DOI: 10.5144/0256-4947.2012.366] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND AND OBJECTIVES It is often suggested that acute coronary syndrome (ACS) patients admitted during off-duty hours (OH) have a worse clinical outcome than those admitted during regular working hours (RH). Our objective was to compare the management and hospital outcomes of ACS patients admitted during OH with those admitted during RH. DESIGN AND SETTING Prospective observational study of ACS patients enrolled in the Saudi Project for Assessment of Acute Coronary Syndrome study from December 2005 to December 2007. PATIENTS AND METHODS ACS patients with available date and admission times were included. RH were defined as weekdays, 8 AM-5 PM, and OH was defined as weekdays 5 PM-8 AM, weekends, during Eid (a period of several days marking the end of two major Islamic holidays), and national days. RESULTS Of the 2825 patients qualifying for this analysis, 1016 (36%) were admitted during RH and 1809 (64%) during OH. OH patients were more likely to present with heart failure and ST elevation myocardial infarction (STEMI) and to receive fibrinolytic therapy, but were less likely to undergo primary percutaneous coronary interventions (PCI). The median door to balloon time was significantly longer (P<.01) in OH patients (122 min) than in RH patients. No differences were observed in hospital outcomes including mortality between the two groups, except for higher heart failure rates in OH patients (11.1% vs 7.2%, P<.001). CONCLUSIONS STEMI patients admitted during OH were disadvantaged with respect to use and speed of delivery of primary PCI but not fibrinolytic therapy. Hospitals providing primary PCI during OH should aim to deliver it in a timely manner throughout the day.
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Crudu V, Sartorius J, Berger P, Scott T, Skelding K, Blankenship J. Middle-of-the-night PCI does not affect subsequent day PCI success and complication rates by the same operator. Catheter Cardiovasc Interv 2012; 80:1149-54. [DOI: 10.1002/ccd.23504] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2011] [Accepted: 11/20/2011] [Indexed: 11/09/2022]
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15
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Holmes DR, Aguirre FV, Aplin R, Lennon RJ, Nestler DM, Bell MR, Rihal CS, Ting HH. Circadian rhythms in patients with ST-elevation myocardial infarction. Circ Cardiovasc Qual Outcomes 2010; 3:382-9. [PMID: 20570918 DOI: 10.1161/circoutcomes.109.913343] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Circadian rhythms with regard to time of symptom onset for patients with acute myocardial infarction have been observed, although their relationship to outcomes has been debated. We evaluated these rhythms in patients with ST-elevation myocardial infarction as a function of the 24-hour circadian cycle. METHODS AND RESULTS The relationship between onset of symptoms during the 24-hour circadian cycle and prehospital delays from symptom onset to hospital arrival, timeliness of reperfusion, and in-hospital death was assessed in 2143 patients with ST-elevation myocardial infarction presenting from 2004-2008 at 1 of 3 tertiary-care healthcare ST-elevation myocardial infarction systems. There was a significant association between time of onset and the circadian cycle, with the greatest percentage (39%) of patients experiencing onset between 8 AM and 3 PM (P<0.001). Time of onset was associated with prehospital delay and timeliness of reperfusion. Patients with onset from 12 AM to 5:59 AM had median prehospital delays of 121 minutes versus 70 minutes from 12 PM to 5:59 PM (P<0.001). Patients with onset time from 12 AM to 5:59 AM had median door-to-balloon times of 75 minutes versus 60 minutes from 6 AM to 11:59 AM (P<0.001). Using multivariable modeling to control for baseline patient characteristics, prehospital delay, and timeliness of reperfusion, there was no significant association between time of symptom onset with in-hospital death. CONCLUSIONS Patients with ST-elevation myocardial infarction exhibit significant circadian patterns in symptom onset, prehospital delay, and timeliness of reperfusion. Patients who develop symptoms from 12 AM to 5:59 AM present with longer prehospital delays and have longer door-to-balloon times. After multivariable adjustment, there was no significant association between circadian patterns of time of onset and in-hospital death.
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16
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Relationship between time of day, day of the week and in-hospital mortality in patients undergoing emergency percutaneous coronary intervention. Arch Cardiovasc Dis 2009; 102:811-20. [DOI: 10.1016/j.acvd.2009.09.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2009] [Revised: 09/19/2009] [Accepted: 09/25/2009] [Indexed: 11/19/2022]
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17
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Glaser R, Naidu SS, Selzer F, Jacobs AK, Laskey WK, Srinivas VS, Slater JN, Wilensky RL. Factors associated with poorer prognosis for patients undergoing primary percutaneous coronary intervention during off-hours: biology or systems failure? JACC Cardiovasc Interv 2009; 1:681-8. [PMID: 19463384 DOI: 10.1016/j.jcin.2008.08.020] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2008] [Revised: 08/06/2008] [Accepted: 08/18/2008] [Indexed: 11/30/2022]
Abstract
OBJECTIVES We sought to determine whether poorer outcomes in patients undergoing primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (MI) during off-hours are related to delays in treatment, circadian changes in biology, or differences in operator-related quality of care. BACKGROUND Previous investigation has suggested that patients undergoing primary PCI during off-hours are more likely to have adverse cardiac events than routine-hours patients, but the reasons for this remain poorly defined. METHODS Clinical, angiographic, and procedural characteristics were compared in consecutive patients (n = 685) undergoing primary PCI in the National Heart, Lung, and Blood Institute Dynamic Registry between 1997 and 2006 that were classified as occurring during routine-hours (07:00 to 18:59) or off-hours (19:00 to 06:59). The primary end points were in-hospital death, MI, and target vessel revascularization. RESULTS Median time from symptom onset to PCI was similar (off-hours 3.4 h vs. routine-hours 3.3 h). Patients presenting in off-hours were more likely to present with cardiogenic shock and multivessel coronary artery disease but were equally likely to present with complete occlusion of the infarct-related artery. Procedural complications including dissection were more frequent in off-hours patients. In-hospital death, MI, and target vessel revascularization were significantly higher in off-hours patients (adjusted odds ratio [OR]: 2.66, p = 0.001), and differences in outcomes were worse even if the procedure was immediately successful (adjusted OR: 2.58, p = 0.005, adjusting for angiographic success). Patients undergoing PCI on weekends had better outcomes during the daytime than nighttime. CONCLUSIONS Patients undergoing primary PCI for acute MI during off-hours are at significantly higher risk for in-hospital death, MI, and target vessel revascularization. These findings appear related to both diurnal differences in presentation and lesion characteristics, as well as differences in procedural complication and success rates that extend beyond differences in symptom-to-balloon time.
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Affiliation(s)
- Ruchira Glaser
- Cardiology Consultants, Christiana Hospital, Newark, Delaware, USA.
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Domínguez Rodríguez A, Abreu González P, Bosa Ojeda F. Primary angioplasty and diurnal variations. Rev Esp Cardiol 2009; 62:709-10; author reply 710-1. [PMID: 19480773 DOI: 10.1016/s1885-5857(09)72242-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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19
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Domínguez Rodríguez A, Abreu González P, Bosa Ojeda F. Angioplastia primaria y variaciones diurnas. Rev Esp Cardiol (Engl Ed) 2009. [DOI: 10.1016/s0300-8932(09)71345-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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20
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Impact of day versus night as intervention time on the outcomes of primary angioplasty for acute myocardial infarction. Catheter Cardiovasc Interv 2009; 74:826-34. [DOI: 10.1002/ccd.22154] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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21
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Jneid H, Fonarow GC, Cannon CP, Palacios IF, Kilic T, Moukarbel GV, Maree AO, LaBresh KA, Liang L, Newby LK, Fletcher G, Wexler L, Peterson E. Impact of Time of Presentation on the Care and Outcomes of Acute Myocardial Infarction. Circulation 2008; 117:2502-9. [DOI: 10.1161/circulationaha.107.752113] [Citation(s) in RCA: 110] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Prior studies have demonstrated an inconsistent association between patients’ arrival time for acute myocardial infarction (AMI) and their subsequent medical care and outcomes.
Methods and Results—
Using a contemporary national clinical registry, we examined differences in medical care and in-hospital mortality among AMI patients admitted during regular hours (weekdays 7
am
to 7
pm
) versus off-hours (weekends, holidays, and 7
pm
to 7
am
weeknights). The study cohort included 62 814 AMI patients from the Get With the Guidelines–Coronary Artery Disease database admitted to 379 hospitals throughout the United States from July 2000 through September 2005. Overall, 33 982 (54.1%) patients arrived during off-hours. Compared with those arriving during regular hours, eligible off-hour patients were slightly less likely to receive primary percutaneous coronary intervention (adjusted odds ratio [OR], 0.93; 95% confidence interval [CI], 0.89 to 0.98), had longer door-to-balloon times (median, 110 versus 85 minutes;
P
<0.0001), and were less likely to achieve door-to-balloon ≤90 minutes (adjusted OR, 0.34; 95% CI, 0.29 to 0.39). Arrival during off-hours was associated with slightly lower overall revascularization rates (adjusted OR, 0.94; 95% CI, 0.90 to 0.97). No measurable differences, however, were found in in-hospital mortality between regular hours and off-hours in the overall AMI, ST-elevated MI, and non–ST-elevated MI cohorts (adjusted OR, 0.99; 95% CI, 0.93 to 1.06; adjusted OR, 1.05; 95% CI, 0.94 to 1.18; and adjusted OR, 0.97; 95% CI, 0.90 to 1.04, respectively). Similar observations were made across most age and sex subgroups and with an alternative definition for arrival time (weekends/holidays versus weekdays).
Conclusions—
Despite slightly fewer primary percutaneous coronary interventions and overall revascularizations and significantly longer door-to-balloon times, patients presenting with AMI during off-hours had in-hospital mortality similar to those presenting during regular hours.
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Affiliation(s)
- Hani Jneid
- From the Massachusetts General Hospital and Harvard Medical School, Boston (H.J., I.F.P., T.K., G.V.M., A.O.M.); UCLA Medical Center, Los Angeles, Calif (G.C.F.); TIMI Group and BWH, Boston, Mass (C.P.C.); Masspro, Inc, Waltham, Mass (K.A.L.); Duke Clinical Research Institute and Duke University Medical Center, Durham, NC (L.L., L.K.N., E.P.); Mayo Clinic, Jacksonville, Fla (G.F.); and University of Cincinnati College of Medicine, Cincinnati, Ohio (L.W.)
| | - Gregg C. Fonarow
- From the Massachusetts General Hospital and Harvard Medical School, Boston (H.J., I.F.P., T.K., G.V.M., A.O.M.); UCLA Medical Center, Los Angeles, Calif (G.C.F.); TIMI Group and BWH, Boston, Mass (C.P.C.); Masspro, Inc, Waltham, Mass (K.A.L.); Duke Clinical Research Institute and Duke University Medical Center, Durham, NC (L.L., L.K.N., E.P.); Mayo Clinic, Jacksonville, Fla (G.F.); and University of Cincinnati College of Medicine, Cincinnati, Ohio (L.W.)
| | - Christopher P. Cannon
- From the Massachusetts General Hospital and Harvard Medical School, Boston (H.J., I.F.P., T.K., G.V.M., A.O.M.); UCLA Medical Center, Los Angeles, Calif (G.C.F.); TIMI Group and BWH, Boston, Mass (C.P.C.); Masspro, Inc, Waltham, Mass (K.A.L.); Duke Clinical Research Institute and Duke University Medical Center, Durham, NC (L.L., L.K.N., E.P.); Mayo Clinic, Jacksonville, Fla (G.F.); and University of Cincinnati College of Medicine, Cincinnati, Ohio (L.W.)
| | - Igor F. Palacios
- From the Massachusetts General Hospital and Harvard Medical School, Boston (H.J., I.F.P., T.K., G.V.M., A.O.M.); UCLA Medical Center, Los Angeles, Calif (G.C.F.); TIMI Group and BWH, Boston, Mass (C.P.C.); Masspro, Inc, Waltham, Mass (K.A.L.); Duke Clinical Research Institute and Duke University Medical Center, Durham, NC (L.L., L.K.N., E.P.); Mayo Clinic, Jacksonville, Fla (G.F.); and University of Cincinnati College of Medicine, Cincinnati, Ohio (L.W.)
| | - Teoman Kilic
- From the Massachusetts General Hospital and Harvard Medical School, Boston (H.J., I.F.P., T.K., G.V.M., A.O.M.); UCLA Medical Center, Los Angeles, Calif (G.C.F.); TIMI Group and BWH, Boston, Mass (C.P.C.); Masspro, Inc, Waltham, Mass (K.A.L.); Duke Clinical Research Institute and Duke University Medical Center, Durham, NC (L.L., L.K.N., E.P.); Mayo Clinic, Jacksonville, Fla (G.F.); and University of Cincinnati College of Medicine, Cincinnati, Ohio (L.W.)
| | - George V. Moukarbel
- From the Massachusetts General Hospital and Harvard Medical School, Boston (H.J., I.F.P., T.K., G.V.M., A.O.M.); UCLA Medical Center, Los Angeles, Calif (G.C.F.); TIMI Group and BWH, Boston, Mass (C.P.C.); Masspro, Inc, Waltham, Mass (K.A.L.); Duke Clinical Research Institute and Duke University Medical Center, Durham, NC (L.L., L.K.N., E.P.); Mayo Clinic, Jacksonville, Fla (G.F.); and University of Cincinnati College of Medicine, Cincinnati, Ohio (L.W.)
| | - Andrew O. Maree
- From the Massachusetts General Hospital and Harvard Medical School, Boston (H.J., I.F.P., T.K., G.V.M., A.O.M.); UCLA Medical Center, Los Angeles, Calif (G.C.F.); TIMI Group and BWH, Boston, Mass (C.P.C.); Masspro, Inc, Waltham, Mass (K.A.L.); Duke Clinical Research Institute and Duke University Medical Center, Durham, NC (L.L., L.K.N., E.P.); Mayo Clinic, Jacksonville, Fla (G.F.); and University of Cincinnati College of Medicine, Cincinnati, Ohio (L.W.)
| | - Kenneth A. LaBresh
- From the Massachusetts General Hospital and Harvard Medical School, Boston (H.J., I.F.P., T.K., G.V.M., A.O.M.); UCLA Medical Center, Los Angeles, Calif (G.C.F.); TIMI Group and BWH, Boston, Mass (C.P.C.); Masspro, Inc, Waltham, Mass (K.A.L.); Duke Clinical Research Institute and Duke University Medical Center, Durham, NC (L.L., L.K.N., E.P.); Mayo Clinic, Jacksonville, Fla (G.F.); and University of Cincinnati College of Medicine, Cincinnati, Ohio (L.W.)
| | - Li Liang
- From the Massachusetts General Hospital and Harvard Medical School, Boston (H.J., I.F.P., T.K., G.V.M., A.O.M.); UCLA Medical Center, Los Angeles, Calif (G.C.F.); TIMI Group and BWH, Boston, Mass (C.P.C.); Masspro, Inc, Waltham, Mass (K.A.L.); Duke Clinical Research Institute and Duke University Medical Center, Durham, NC (L.L., L.K.N., E.P.); Mayo Clinic, Jacksonville, Fla (G.F.); and University of Cincinnati College of Medicine, Cincinnati, Ohio (L.W.)
| | - L. Kristin Newby
- From the Massachusetts General Hospital and Harvard Medical School, Boston (H.J., I.F.P., T.K., G.V.M., A.O.M.); UCLA Medical Center, Los Angeles, Calif (G.C.F.); TIMI Group and BWH, Boston, Mass (C.P.C.); Masspro, Inc, Waltham, Mass (K.A.L.); Duke Clinical Research Institute and Duke University Medical Center, Durham, NC (L.L., L.K.N., E.P.); Mayo Clinic, Jacksonville, Fla (G.F.); and University of Cincinnati College of Medicine, Cincinnati, Ohio (L.W.)
| | - Gerald Fletcher
- From the Massachusetts General Hospital and Harvard Medical School, Boston (H.J., I.F.P., T.K., G.V.M., A.O.M.); UCLA Medical Center, Los Angeles, Calif (G.C.F.); TIMI Group and BWH, Boston, Mass (C.P.C.); Masspro, Inc, Waltham, Mass (K.A.L.); Duke Clinical Research Institute and Duke University Medical Center, Durham, NC (L.L., L.K.N., E.P.); Mayo Clinic, Jacksonville, Fla (G.F.); and University of Cincinnati College of Medicine, Cincinnati, Ohio (L.W.)
| | - Laura Wexler
- From the Massachusetts General Hospital and Harvard Medical School, Boston (H.J., I.F.P., T.K., G.V.M., A.O.M.); UCLA Medical Center, Los Angeles, Calif (G.C.F.); TIMI Group and BWH, Boston, Mass (C.P.C.); Masspro, Inc, Waltham, Mass (K.A.L.); Duke Clinical Research Institute and Duke University Medical Center, Durham, NC (L.L., L.K.N., E.P.); Mayo Clinic, Jacksonville, Fla (G.F.); and University of Cincinnati College of Medicine, Cincinnati, Ohio (L.W.)
| | - Eric Peterson
- From the Massachusetts General Hospital and Harvard Medical School, Boston (H.J., I.F.P., T.K., G.V.M., A.O.M.); UCLA Medical Center, Los Angeles, Calif (G.C.F.); TIMI Group and BWH, Boston, Mass (C.P.C.); Masspro, Inc, Waltham, Mass (K.A.L.); Duke Clinical Research Institute and Duke University Medical Center, Durham, NC (L.L., L.K.N., E.P.); Mayo Clinic, Jacksonville, Fla (G.F.); and University of Cincinnati College of Medicine, Cincinnati, Ohio (L.W.)
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22
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Berger A, Stauffer JC, Radovanovic D, Urban P, Bertel O, Erne P. Comparison of in-hospital mortality for acute myocardial infarction in Switzerland with admission during routine duty hours versus admission during out of hours (insight into the AMIS plus registry). Am J Cardiol 2008; 101:422-7. [PMID: 18312751 DOI: 10.1016/j.amjcard.2007.09.092] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2007] [Revised: 09/10/2007] [Accepted: 09/10/2007] [Indexed: 01/30/2023]
Abstract
To improve long-term survival, prompt revascularization of the infarct-related artery should be done in patients with acute myocardial infarction (AMI); therefore, a large proportion of these patients would be hospitalized during out of hours. The clinical effects of out-of-hours AMI management were already questioned, with conflicting results. The purpose of this investigation was to compare the in-hospital outcome of patients admitted for AMI during out of hours and working hours. All patients with AMI included in the AMIS Plus Registry from January 1, 1997, to March 30, 2006, were analyzed. The working-hours group included patients admitted from 7 a.m. to 7 p.m. on weekdays, and the out-of-hours group included patients admitted from 7 p.m. to 7 a.m. on weekdays or weekends. Major cardiac events were defined as cardiovascular death, reinfarction, and stroke. The study primary end points were in-hospital death and major adverse cardiac event (MACE) rates. A total of 12,480 patients met the inclusion criteria, with 52% admitted during normal working hours, and 48%, during out of hours. Patients admitted during weekdays included more women (28.1% vs 26%; p = 0.009), older patients (65.5 +/- 13 vs 64.1 +/- 13 years; p = 0.0011), less current smokers (40.1% vs 43.5%; p <0.001), and less patients with a history of ischemic heart disease (31.5% vs 34.5%; p = 0.001). A significantly higher proportion of patients admitted during out of hours had Killip's class III and IV. No differences in terms of in-hospital survival rates between the 2 groups (91.5% vs 91.2%; p = 0.633) or MACE-free survival rates (both 88.5%; p = 1.000) were noted. In conclusion, the outcome of patients with AMI admitted out of hours was the same compared with those with a weekday admission. Of predictors for in-hospital outcome, timing of admission had no significant influence on mortality and/or MACE incidence.
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23
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Dominguez-Rodriguez A, Garcia-Gonzalez M, Abreu-Gonzalez P. Outcome of primary angioplasty for ST-segment elevation myocardial infarction during routine duty hours versus during off-hours. Results of a single-center in Spain. Int J Cardiol 2007; 119:227-9. [PMID: 17045677 DOI: 10.1016/j.ijcard.2006.07.110] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2006] [Revised: 07/18/2006] [Accepted: 07/22/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND A circadian variation in the time of onset of ST-segment elevation myocardial infarction (STEMI) with peak in the morning hours has been described. We sought to investigate the impact of circadian patterns on the practice of primary angioplasty in individuals residing in Tenerife Island (Spain). METHODS 90 consecutive patients with STEMI were treated in our hospital. All patients were admitted within 6 h from symptom onset. Patients were divided into 2 groups according to the time of treatment: routine duty hours (0800-1800) and off-hours (1800-0800). RESULTS There were no differences in baseline clinical characteristics or treatment delays between routine duty hours and off-hours patients. There is a significant higher rate of angioplasty failure and in-hospital mortality from 1800 to 0800 h compared to the time range from 0800 to 1800 h. CONCLUSIONS Circadian variations have a profound effect on the practice of primary angioplasty.
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24
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Boari B, Salmi R, Gallerani M, Malagoni AM, Manfredini F, Manfredini R. Acute myocardial infarction: Circadian, weekly, and seasonal patterns of occurrence. BIOL RHYTHM RES 2007. [DOI: 10.1080/09291010600906067] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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25
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LaBounty T, Eagle KA, Manfredini R, Fang J, Tsai T, Smith D, Rubenfire M. The impact of time and day on the presentation of acute coronary syndromes. Clin Cardiol 2007; 29:542-6. [PMID: 17190180 PMCID: PMC6653835 DOI: 10.1002/clc.22] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The frequency of acute myocardial infarction (AMI) peaks on Mondays and in the mornings. However, the distribution of the types of acute coronary syndromes (ACS), including unstable angina (UA), has not been systematically evaluated. HYPOTHESIS The distribution of the types of ACS and clinical presentations varies by time and day of admission. METHODS A retrospective cohort study was conducted in 1,946 consecutive nontransfer ACS admissions (1999-2004) to a tertiary-care academic center to assess presenting clinical variables in patients admitted on days versus nights (6 P.M.-6 A.M.) and weekdays versus weekends (Friday 6 P.M.-Monday 6 A.M.). RESULTS There were fewer ACS admissions than expected on nights and weekends (p < 0.001), but the proportion of patients with ACS presenting with ST-elevation myocardial infarction (STEMI) is 64% higher on weekends (p < 0.001) and 31% higher on nights (p = 0.022). This increased proportion with STEMI results in a greater proportion of ACS with AMI on weekends (up arrow 10%, p = 0.006) and nights (up arrow 7%, p = 0.033). Using multivariate modeling, the increase in patients with AMI on weekends was not explained by conventional risk predictors. CONCLUSIONS Although fewer patients with ACS presented on nights and weekends, patients at those times were more likely to have an AMI, driven largely by an increased proportion with STEMI at those times. Consideration should be given to these findings when developing clinical care paradigms, health care staffing needs, and when comparing new treatment outcomes in patients with ACS.
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Affiliation(s)
- Troy LaBounty
- Michigan Cardiovascular Outcomes Research and Reporting Program, Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Medical Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Kim A. Eagle
- Michigan Cardiovascular Outcomes Research and Reporting Program, Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Medical Center, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Jianming Fang
- Michigan Cardiovascular Outcomes Research and Reporting Program, Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Medical Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Thomas Tsai
- Michigan Cardiovascular Outcomes Research and Reporting Program, Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Medical Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Dean Smith
- Michigan Cardiovascular Outcomes Research and Reporting Program, Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Medical Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Melvyn Rubenfire
- Michigan Cardiovascular Outcomes Research and Reporting Program, Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Medical Center, University of Michigan, Ann Arbor, Michigan, USA
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Berger A, Meier JM, Wasserfallen JB, Graf D, Renders F, Dascotte Y, Prudent V, Eeckhout E. Out of hours percutaneous coronary interventions in acute coronary syndromes: long-term outcome. Heart 2006; 92:1157-8. [PMID: 16844875 PMCID: PMC1861073 DOI: 10.1136/hrt.2005.081281] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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27
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Ayrik C, Ergene U, Kinay O, Nazli C, Unal B, Ergene O. Factors influencing emergency department arrival time and in-hospital management of patients with acute myocardial infarction. Adv Ther 2006; 23:244-55. [PMID: 16751157 DOI: 10.1007/bf02850130] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Reperfusion of the infarct-related artery in the very first hour ("golden hour") of acute myocardial infarction (AMI) significantly reduces mortality rates. Several factors may delay the initiation of reperfusion therapy (ie, thrombolytic therapy or primary percutaneous transluminal coronary angioplasty [PCTA]), most of which are related to patients. A total of 520 patients with suspected AMI were evaluated in the emergency department of Dokuz Eylül University Hospital between March 1996 and October 1999. After inclusion criteria were applied, the study consisted of 178 patients with a history of AMI. Analyzed data that affected patients' arrival to the hospital were obtained from responses to a questionnaire. The Statistical Package for the Social Sciences (SPSS; SPSS Inc., Chicago, Ill), version 11.0, was used for all statistical analyses. The mean "symptom onset-hospital arrival time" was 188+/-325 min for the entire study group. The median delay was 110 min (approximately 2 h). Only 39 (22%) patients arrived to the hospital within the first hour. The mean time needed for late responders (n=109, 74%) (hospital arrival later than 1 h after symptom onset) to arrive was 245-/+363 min. According to the results of this study, many patients with AMI who may be eligible for reperfusion therapy miss the "golden hour" because of late hospital arrival. Some groups of patients (ie, elderly, women, those with diabetes) were especially late in arriving. To reduce such delays, training programs may be advised to focus on these groups of patients. Arrival times to the hospital during AMI can be greatly improved by efficient public education programs targeted to these groups.
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Affiliation(s)
- Cuneyt Ayrik
- Department of Emergency Medicine, Mersin University, Mersin, Turkey
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28
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Assali AR, Brosh D, Vaknin-Assa H, Fuchs S, Teplitsky I, Sela O, Kornowski R. The impact of circadian variation on outcomes in emergency acute anterior myocardial infarction percutaneous coronary intervention. Catheter Cardiovasc Interv 2006; 67:221-6. [PMID: 16404750 DOI: 10.1002/ccd.20608] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVES We investigated the impact of primary coronary angioplasty performed during night and compared to the impact of that performed during day-time on outcomes of patients with acute ST elevation anterior wall myocardial infarction (AMI). METHODS We prospectively followed 273 consecutive patients of whom 160 (58.6%) were treated during day time (8:00 a.m. to 6 p.m.) and 113 (41.4%) were treated "off hours"/at night (6 p.m. to 8 a.m.). Baseline demographics, angiographic factors, and clinical outcomes (death, recurrent AMI, and need for repeat revascularization) were compared between the groups. RESULTS Baseline clinical characteristics were similar between the two groups. Unadjusted mortality at one-month was significantly higher among patients who were treated during night compared with those treated at day-time (9.7% vs. 3.1% P = 0.03), as was adverse cardiac event rate (15.9% vs. 6.9%; P = 0.02). Multiple logistic regression analysis adjusted for the CADILLAC risk score demonstrated that this score, which includes baseline LVEF, renal failure, Killip class, final TIMI flow, age>65 years, anemia, and the number of coronary vessel diseases, is a significant predictor of one-month mortality, while the effect of time of treatment was borderline (night vs. day; odds ratio 2.7; 95% confidence interval, 0.8-9.4; P = 0.095). CONCLUSIONS The results of this study indicate that patients with anterior myocardial infarction treated during night time have worse unadjusted short-term clinical outcomes despite no delay from onset of symptoms to actual treatment. Larger studies are needed in order to identify potential contributors to this phenomenon.
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Affiliation(s)
- Abid R Assali
- The Cardiac Catheterization Laboratories, Cardiology Department, Rabin Medical Center, Petach-Tikva, Sackler School of Medicine, Tel-Aviv University, Israel
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De Luca G, Suryapranata H, Ottervanger JP, van 't Hof AWJ, Hoorntje JCA, Gosselink ATM, Dambrink JHE, Zijlstra F, de Boer MJ. Circadian variation in myocardial perfusion and mortality in patients with ST-segment elevation myocardial infarction treated by primary angioplasty. Am Heart J 2005; 150:1185-9. [PMID: 16338256 DOI: 10.1016/j.ahj.2005.01.057] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2004] [Accepted: 01/21/2005] [Indexed: 11/29/2022]
Abstract
BACKGROUND Little is known about whether the physiological factors that determine the circadian variation in ST-segment elevation myocardial infarction (STEMI) onset and thrombolysis efficacy may affect myocardial perfusion and long-term outcome of patients with STEMI treated with primary angioplasty. METHODS Our study population consisted of 1548 consecutive patients with STEMI treated by primary angioplasty between April 1997 and October 2001. All clinical, angiographic, and follow-up data were collected. RESULTS Most of the patients (65.2%) were treated at daytime (between 8 AM and 8 PM). Patients treated between 1 PM and midnight had a lower prevalence of anterior infarction and longer door-to-balloon time, whereas the shortest ischemic time and the largest use of stent were observed in patients treated between midnight and 4 AM Patients treated between 4 and 8 AM showed the worst outcome in terms of myocardial perfusion, enzymatic infarct size, and 1-year outcome, whereas patients treated between 8 AM and 4 PM had the best myocardial perfusion and lowest 1-year mortality rate. After correction for baseline confounding factors, the time of treatment (between 4 and 8 AM) was still significantly associated with 1-year mortality (relative risk 1.92, 95% CI 1.13-3.26, P = .016). CONCLUSIONS This is the first study showing a significant relationship between the time of treatment, myocardial perfusion, and long-term mortality in patients with STEMI undergoing mechanical reperfusion.
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Affiliation(s)
- Giuseppe De Luca
- Department of Cardiology, ISALA Klinieken, Hospital De Weezenlanden, Zwolle, The Netherlands
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Maioli M, Gallopin M, Leoncini M, Bellandi F, Toso A, Dabizzi RP. Facilitated primary coronary intervention with abciximab and very low dose of alteplase during off-hours compared with direct primary intervention during regular hours. Catheter Cardiovasc Interv 2005; 65:484-91. [PMID: 15973688 DOI: 10.1002/ccd.20427] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
In patients with acute myocardial infarction (AMI), the off-hour presentation is one of the major determinants of door-to-balloon delay. Moreover, the nighttime presentation is associated with increased mortality after primary coronary intervention (PCI). The prompt starting of a therapy able to start recanalization of the infarct-related artery before intervention might improve the results of off-hour primary PCI. We compared the outcome of 212 consecutive patients with AMI undergoing either direct or facilitated PCI according to the hour of presentation. Patients arriving off-hours were pretreated with alteplase (20 mg) and abciximab and underwent facilitated PCI. Patients presenting on-hours underwent direct PCI. A basal Thrombolysis in Myocardial Infarction (TIMI) flow grade 3 was observed in 1.0% of patients undergoing direct PCI and in 44% of patients undergoing facilitated PCI (P = 0.001). More patients starting PCI with a TIMI 3 flow achieved a postinterventional fast TIMI frame count (72.0% vs. 38.8% direct PCI group vs. 34.9% facilitated PCI group with basal TIMI 0-2; P = 0.001) and a TIMI perfusion grade 3 (66.0% vs. 38.8% direct PCI group vs. 39.7% facilitated PCI group with basal TIMI 0-2; P = 0.004). Preinterventional TIMI flow grade 3 was associated with a higher gain in left ventricular ejection fraction at 1 month (10.9% +/- 6.4% vs. 7.0% +/- 9.6% direct PCI group vs. 6.1% +/- 6.0% facilitated PCI group with basal TIMI 0-2; P = 0.005). No significant difference was observed in major bleedings, although there was a trend toward a higher risk in the facilitated PCI group. Patients in the facilitated PCI group achieving a basal TIMI 3 flow showed improved myocardial reperfusion and better left ventricular function recovery. Bleeding complications associated with combination therapy remained an important concern.
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Affiliation(s)
- Mauro Maioli
- Division of Cardiology, Misericordia e Dolce Hospital, Prato, Italy.
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31
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Development of Program Evaluation Indicator : Community Health Center's Health Promotion Program. HEALTH POLICY AND MANAGEMENT 2003. [DOI: 10.4332/kjhpa.2003.13.4.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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32
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Factors associated with delay in reperfusion therapy in patients with acute myocardial infarction. HEALTH POLICY AND MANAGEMENT 2003. [DOI: 10.4332/kjhpa.2003.13.4.115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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Henriques JPS, Haasdijk AP, Zijlstra F. Outcome of primary angioplasty for acute myocardial infarction during routine duty hours versus during off-hours. J Am Coll Cardiol 2003; 41:2138-42. [PMID: 12821237 DOI: 10.1016/s0735-1097(03)00461-3] [Citation(s) in RCA: 135] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES We sought to investigate the impact of circadian patterns in the onset of acute myocardial infarction (AMI) on the practice of primary angioplasty. BACKGROUND A circadian variation in the time of onset of AMI with a peak in the morning hours has been described. METHODS We studied 1,702 consecutive patients with acute ST-segment elevation myocardial infarction treated with primary angioplasty. We observed circadian variation in frequency of symptom onset, hospital admission, and first balloon inflation. Circadian patterns of symptom onset, hospital admission, and balloon inflation are similar. RESULTS A majority of patients have symptom onset (53%), hospital admission (53%), and first balloon inflation (52%) during routine duty hours (0800 to 1800 h). There were no differences in baseline clinical characteristics or treatment delays between routine duty hours and off-hours patients. Hospital admission between 0800 and 1800 was associated with an angioplasty failure rate of 3.8%, compared with 6.9% between 1800 and 0800, p < 0.01. Thirty-day mortality was 1.9% in patients with hospital admission between 0800 and 1800, compared with 4.2% in patients with hospital admission between 1800 and 0800, p < 0.01. CONCLUSIONS Circadian variations may have a profound effect on the practice of primary angioplasty. A majority of patients are treated during routine duty hours. Patients treated during off-hours have a higher incidence of failed angioplasty and consequently a worse clinical outcome than patients treated during routine duty hours.
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Affiliation(s)
- Jose P S Henriques
- Isala Klinieken, Hospital De Weezenlanden, Department of Cardiology, Zwolle, Netherlands
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Spencer FA, Becker RC. Circadian variations in acute myocardial infarction: patients or health care delivery? J Am Coll Cardiol 2003; 41:2143-6. [PMID: 12821238 DOI: 10.1016/s0735-1097(03)00462-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Angeja BG, Gibson CM, Chin R, Frederick PD, Every NR, Ross AM, Stone GW, Barron HV. Predictors of door-to-balloon delay in primary angioplasty. Am J Cardiol 2002; 89:1156-61. [PMID: 12008167 DOI: 10.1016/s0002-9149(02)02296-8] [Citation(s) in RCA: 125] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
In the treatment of acute myocardial infarction, delayed reperfusion therapy is associated with increased mortality. Predictors of delay have been described for fibrinolysis but not for primary percutaneous transluminal coronary angioplasty (pPTCA). Therefore, we studied 40,017 consecutive patients with acute myocardial infarction who underwent pPTCA in the National Registry of Myocardial Infarction between June 1994 and April 2000. Median door-to-balloon times were calculated, and factors independently associated with a delay of >120 minutes were determined by logistic regression. The median door-to-balloon time among all patients was 111 minutes (interquartile range 84 to 152). The proportion of patients with a delay of >2 hours was greater among those aged > or = 65 years (49% vs 41%), women (50% vs 42%), patients with contraindications to fibrinolysis (60% vs 41%), and those without chest pain on admission (61% vs 43%, all p <0.0001). Delay was also more common with transfer from another hospital (87% vs 38%), with presentation outside the hours of 8 A.M. to 4 P.M. (51% vs 38%), and in hospitals performing <49 pPTCAs/year (47% vs 41%, all p <0.0001). The strongest independent predictor of delay was hospital transfer, along with non-daytime presentation and low-volume centers. Older age, female sex, and non-white race were weaker predictors. Both patient and hospital factors are associated with delay in pPTCA after presentation. These findings may help design treatment algorithms to minimize delay, thus improving the survival benefit of pPTCA. These results may also help design trials of combination reperfusion strategies.
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Affiliation(s)
- Brad G Angeja
- Cardiovascular Division, Department of Medicine, the University of California, San Francisco, San Francisco, California 94143, USA.
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Ajluni SC, O'Neill WW. Primary intervention in acute myocardial infarction: Do bankers' hours suffice, or should we invest our resources elsewhere? Am Heart J 1999; 138:1012-3. [PMID: 10577427 DOI: 10.1016/s0002-8703(99)70062-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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