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Price J, Rudman J, Schoenfeld D, Thomas SA, Rees P, Bloom B, McCartin M, Blumen I, Thomas SH. Survivorship With Incrementally Faster Times to Primary Percutaneous Coronary Intervention (SWIFT-PPCI): A Systematic Review and Meta-Analysis. Am J Cardiol 2023; 207:356-362. [PMID: 37776583 DOI: 10.1016/j.amjcard.2023.08.178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 08/27/2023] [Accepted: 08/27/2023] [Indexed: 10/02/2023]
Abstract
In the United States, there are approximately 750,000 ST-elevation myocardial infarction cases each year. Streamlined care and rapid delivery for primary percutaneous coronary intervention (PPCI) is associated with improved survival. This systematic review and meta-analysis aimed to generate a practical estimate of mortality savings for every notional 30-minute decrease in the time to achieving PPCI. Included studies were those that provided a specific absolute risk reduction for a specific reduction in pre-PPCI time. The eligible studies evaluated the survival benefit from pre-PPCI time savings measured in any interval ending with PPCI and commencing with objectively recorded timing, such as initial emergency call, first medical contact, or hospital arrival. Study planning called for the reporting of data as individual study results, with a pooled effect estimate of relative risk calculated with random-effects meta-analysis. A total of 1,088 records were eligible for review; 52 were reviewed in full text, with 4 studies (total patient n = 235,814, overall mortality 4.7% to 7.8%) included in the final analysis. All 4 studies reported significant time-related survival benefit over the study focus window of 60 to 180 minutes pre-PPCI. The number of lives saved per 100 cases for each 30-minute pre-PPCI time savings ranged from 0.8 to 1.9. The overall effect estimate generated was 0.753 (95% confidence interval 0.712 to 0.796), with acceptable heterogeneity (I2 = 36%). In conclusion, a pooled effect calculation estimated a 24.7% relative risk reduction for each 30 minutes of time savings. For cases that underwent PPCI within 60 to 180 minutes of initial presentation with known baseline mortality risk, the time savings in 30-minute epochs can be leveraged to estimate a specific number of lives saved; this may be useful for those involved in the organization of medical care who make systemwide plans and individual patient triage decisions.
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Affiliation(s)
- James Price
- Department of Emergency Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom; Department of Research, Audit, Innovation & Development, East Anglian Air Ambulance, Norwich, United Kingdom.
| | - Jordan Rudman
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center & Harvard Medical School, Boston, Massachusetts
| | - David Schoenfeld
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center & Harvard Medical School, Boston, Massachusetts
| | - Sarah Alice Thomas
- Department of Molecular Microbiology & Immunology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Paul Rees
- Department of Research, Audit, Innovation & Development, East Anglian Air Ambulance, Norwich, United Kingdom; Blizard Institute for Neuroscience, Surgery, & Trauma, Barts & the London School of Medicine, London, United Kingdom; Department of Cardiology, St Bartholomew's Hospital and Barts Health NHS Trust, London, United Kingdom
| | - Ben Bloom
- Blizard Institute for Neuroscience, Surgery, & Trauma, Barts & the London School of Medicine, London, United Kingdom; Department of Emergency Medicine, The Royal London Hospital and Barts Health NHS Trust, London, United Kingdom
| | - Michael McCartin
- Section of Emergency Medicine, University of Chicago, Chicago, Illinois
| | - Ira Blumen
- Section of Emergency Medicine, University of Chicago, Chicago, Illinois
| | - Stephen H Thomas
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center & Harvard Medical School, Boston, Massachusetts; Blizard Institute for Neuroscience, Surgery, & Trauma, Barts & the London School of Medicine, London, United Kingdom
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Saito Y, Inohara T, Kohsaka S, Ando H, Ishii H, Yamaji K, Amano T, Kobayashi Y, Kozuma K. Volume-Outcome Relations of Percutaneous Coronary Intervention in Patients Presenting With Acute Myocardial Infarction (from the J-PCI Registry). Am J Cardiol 2023; 192:182-189. [PMID: 36812702 DOI: 10.1016/j.amjcard.2023.01.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 01/05/2023] [Accepted: 01/13/2023] [Indexed: 02/23/2023]
Abstract
A lower institutional primary percutaneous coronary intervention (PCI) volume is associated with a higher risk of postprocedural poor outcomes, particularly in urgent or emergent settings (e.g., PCI for acute myocardial infarction [MI]). However, the individual prognostic impact of PCI volume stratified by indication and the relative ratio remains unclear. Using the Japanese nationwide PCI database, we investigated 450,607 patients from 937 institutions who underwent either primary PCI for acute MI or elective PCI. The primary end point was the observed/predicted in-hospital mortality ratio. The predicted mortality per patient was calculated using the baseline variables and averaged for each institution. The relation between the annual primary, elective, and total PCI volumes and institutional in-hospital mortality after acute MI was evaluated. The association between the primary-to-total PCI volume per hospital and mortality was also investigated. Of the 450,607 patients, 117,430 (26.1%) underwent primary PCI for acute MI, of whom 7,047 (6.0%) died during hospitalization. The median total PCI volume and primary-to-total PCI volume ratio were 198 (interquartile range 115 to 311) and 0.27 (0.20 to 0.36). Overall, the observed in-hospital mortality and observed/predicted mortality ratio in patients with acute MI were higher in institutions with lower primary, elective, and total PCI volumes. The observed/predicted mortality ratio was also higher in institutions with lower primary-to-total PCI volume ratios, even in high-PCI volume hospitals. In conclusion, in this nationwide registry-based analysis, lower institutional PCI volumes, regardless of setting, were associated with higher in-hospital mortality after acute MI. The primary-to-total PCI volume ratio provided independent prognostic information.
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Affiliation(s)
- Yuichi Saito
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan.
| | - Taku Inohara
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Hirohiko Ando
- Department of Cardiology, Aichi Medical University, Nagakute, Japan
| | - Hideki Ishii
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Kyohei Yamaji
- Department of Cardiology, Kyoto University, Kyoto, Japan
| | - Tetsuya Amano
- Department of Cardiology, Aichi Medical University, Nagakute, Japan
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Ken Kozuma
- Department of Cardiology, Teikyo University Hospital, Tokyo, Japan
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Saito Y, Tateishi K, Kanda M, Shiko Y, Kawasaki Y, Kobayashi Y, Inoue T. Volume-Outcome Relationships for Percutaneous Coronary Intervention in Acute Myocardial Infarction. J Am Heart Assoc 2022; 11:e023805. [PMID: 35261284 PMCID: PMC9075272 DOI: 10.1161/jaha.121.023805] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Lower primary percutaneous coronary intervention (PCI) volume is known to be associated with worse outcomes in patients with acute myocardial infarction (MI) at hospital level. The present study aimed to evaluate the relations of primary, elective, and total PCI volume and primary/total PCI volume ratio per hospital to in-hospital mortality in patients with acute MI undergoing primary PCI. Methods and Results Using a large nationwide administrative database, we included a total of 83 076 patients from 154 hospitals in Japan undergoing PCI for either acute MI or elective cases. Relations of annual procedural volumes for primary, elective, and total PCI to in-hospital mortality after acute MI at hospital level were evaluated. The ratio of primary to total PCI volume per hospital was also assessed. The primary end point was the ratio of observed to predicted mortality. Of 83 076 patients, 26 913 (32.4%) underwent primary PCI for acute MI, among whom 1561 (5.8%) died during hospitalization. Overall, observed in-hospital mortality after acute MI and observed/predicted mortality ratio were higher in hospitals with lower primary, elective, and total PCI volumes. Observed/predicted in-hospital mortality ratio was higher in hospitals with low primary/total PCI volume ratio, even in those with high total PCI volume. Conclusions Primary, elective, and total PCI volume at hospitals were inversely associated with in-hospital mortality in patients with acute MI undergoing primary PCI. Lower ratio of primary to total PCI volume were related to higher in-hospital mortality, suggesting primary/total PCI volume ratio as an institutional indicator of quality of care for acute MI.
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Affiliation(s)
- Yuichi Saito
- Department of Cardiovascular Medicine Chiba University Graduate School of Medicine Chiba Japan
| | - Kazuya Tateishi
- Department of Cardiovascular Medicine Chiba University Graduate School of Medicine Chiba Japan
| | - Masato Kanda
- Department of Cardiovascular Medicine Chiba University Graduate School of Medicine Chiba Japan
| | - Yuki Shiko
- Biostatistics Section Clinical Research Center Chiba University Hospital Chiba Japan
| | - Yohei Kawasaki
- Biostatistics Section Clinical Research Center Chiba University Hospital Chiba Japan
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine Chiba University Graduate School of Medicine Chiba Japan
| | - Takahiro Inoue
- Healthcare Management Research Center Chiba University Hospital Chiba Japan
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4
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German chest pain unit registry: data review after the first decade of certification. Herz 2020; 46:24-32. [PMID: 32232516 DOI: 10.1007/s00059-020-04912-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 01/24/2020] [Accepted: 03/03/2020] [Indexed: 01/12/2023]
Abstract
In 2008, the German Cardiac Society (GCS) introduced a certification program for specialized chest pain units (CPUs). In order to benchmark the performance of the certified CPUs, a nationwide German CPU registry was established. Since then, data for more than 34,000 patients have been included. The concept of certified CPUs in Germany has been widely accepted and its success is underlined by its recent inclusion in national and international guidelines. As of December 2019, 286 CPUs have been successfully certified or recertified by the GCS. This review focuses on the data retrieved from the CPU registry during the first decade of certification. As demonstrated by 16 manuscripts stemming from the registry, certified German CPUs demonstrate high quality of care in acute coronary syndrome and beyond. It is also noted that the German CPU registry allowed for further analysis of the gap in guideline adherence. With the current update of the CPU certification criteria, central data collection as a best-practice criterion will be abandoned, and after some productive years the registry has temporarily been stopped.
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Cicolo EA, Nishi FA, Peres HHC, Cruz DDALMD. Effectiveness of the Manchester Triage System on time to treatment in the emergency department: a systematic review. JBI Evid Synth 2019; 18:56-73. [PMID: 31453842 DOI: 10.11124/jbisrir-2017-003825] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVE The objective of this review was to synthesize the best available evidence on the effectiveness of the Manchester Triage System (MTS) on time to treatment (TtT) for patients who visit the emergency department (ED). INTRODUCTION The objectives of the MTS are to define a safe wait time for medical attention. Triage systems, such as the MTS, use criteria to ensure patient safety by determining appropriate wait times for each individual who visits the ED. The TtT is the time interval between arrival at the ED to initiation of therapeutic interventions. A short TtT is important in different clinical situations and may reduce infections and mortality. The MTS may have an impact on the TtT. INCLUSION CRITERIA This review considered studies that included any patients visiting the ED with any complaints or medical diagnoses who were triaged using the MTS by nurses or doctors, and the TtT was measured. This review considered randomized controlled trials, as well as quasi-experimental, before-and-after, case-control and analytical cross-sectional studies. Studies published after 1994 in English, Spanish, Portuguese, French and German were considered for inclusion. METHOD This systematic review was conducted in accordance with JBI methodology. The search strategy aimed to find both published and unpublished studies in MEDLINE, CINAHL, Lilacs, Web of Science, Embase, Scopus, Cochrane Central Register of Controlled Trials, Google Scholar, Banco de Teses - CAPES, and Digital Dissertations. The results of this search were assessed by one reviewer who excluded duplicate results. Titles and abstracts were screened by two independent reviewers for assessment against the inclusion criteria. The full texts of potentially eligible papers were retrieved and independently assessed by two reviewers using a standardized critical appraisal instrument from JBI. Data were extracted from studies included in the review and were presented using a narrative form. Tables were used to summarize the characteristics and findings of the studies. RESULTS The review included two before-and-after studies, with a total of 2265 participants. One study was of moderate quality, and the other was of high quality. One study included only patients with acute ischemic stroke, while the other included patients with any complaint. Both studies were performed with consecutive samples. The median TtT was 10 minutes before implementing the MTS and 12 minutes after implementing the MTS in the study that included patients with any complaints. In the study including patients with acute ischemic stroke, the median TtT decreased by 15 minutes after implementing the MTS (from 75 to 60 minutes). Because of the heterogeneity in the characteristics of the populations of the two studies, the results could not be pooled. CONCLUSIONS The MTS reduced the median TtT for patients triaged at the highest priority levels (orange and yellow), but it did not decrease the median TtT in all patients. The existing evidence base regarding the effectiveness of the MTS comes from two studies with methodological limitations that could not be pooled. The evidence indicates the MTS may confer benefit to some patients who visit the ED by reducing TtT, but not for all patients. Further research is needed before firm conclusions can be made.
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Affiliation(s)
| | - Fernanda Ayache Nishi
- University Hospital, University of São Paulo, São Paulo, Brazil.,The Brazilian Centre for Evidence-based Healthcare: a Joanna Briggs Institute Centre of Excellence
| | | | - Diná de Almeida Lopes Monteiro da Cruz
- The Brazilian Centre for Evidence-based Healthcare: a Joanna Briggs Institute Centre of Excellence.,School of Nursing, University of São Paulo, São Paulo, Brazil
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6
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Foo CY, Bonsu KO, Nallamothu BK, Reid CM, Dhippayom T, Reidpath DD, Chaiyakunapruk N. Coronary intervention door-to-balloon time and outcomes in ST-elevation myocardial infarction: a meta-analysis. Heart 2018; 104:1362-1369. [PMID: 29437704 DOI: 10.1136/heartjnl-2017-312517] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2017] [Revised: 12/27/2017] [Accepted: 01/05/2018] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE This study aims to determine the relationship between door-to-balloon delay in primary percutaneous coronary intervention and ST-elevation myocardial infarction (MI) outcomes and examine for potential effect modifiers. METHODS We conducted a systematic review and meta-analysis of prospective observational studies that have investigated the relationship of door-to-balloon delay and clinical outcomes. The main outcomes include mortality and heart failure. RESULTS 32 studies involving 299 320 patients contained adequate data for quantitative reporting. Patients with ST-elevation MI who experienced longer (>90 min) door-to-balloon delay had a higher risk of short-term mortality (pooled OR 1.52, 95% CI 1.40 to 1.65) and medium-term to long-term mortality (pooled OR 1.53, 95% CI 1.13 to 2.06). A non-linear time-risk relation was observed (P=0.004 for non-linearity). The association between longer door-to-balloon delay and short-term mortality differed between those presented early and late after symptom onset (Cochran's Q 3.88, P value 0.049) with a stronger relationship among those with shorter prehospital delays. CONCLUSION Longer door-to-balloon delay in primary percutaneous coronary intervention for ST-elevation MI is related to higher risk of adverse outcomes. Prehospital delays modified this effect. The non-linearity of the time-risk relation might explain the lack of population effect despite an improved door-to-balloon time in the USA. CLINICAL TRIAL REGISTRATION PROSPERO (CRD42015026069).
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Affiliation(s)
- Chee Yoong Foo
- National Clinical Research Centre, Kuala Lumpur, Malaysia.,School of Pharmacy, Monash University Malaysia, Bandar Sunway, Subang Jaya, Selangor, Malaysia.,Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway, Subang Jaya, Selangor, Malaysia
| | - Kwadwo Osei Bonsu
- Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway, Subang Jaya, Selangor, Malaysia.,Pharmacy Department, Accident and Emergency Directorate, Komfo Anokye Teaching Hospital, Kumasi, Ghana.,Department of Pharmacy Practice Faculty of Pharmacy and Pharmaceutical Sciences, College of Health Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Brahmajee K Nallamothu
- VA Health Services Research and Development Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA.,Department of Internal Medicine, Michigan Integrated Center for Health Analytics and Medical Prediction (MiCHAMP), University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Christopher M Reid
- School of Public Health, Curtin University, Perth, Western Australia, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Teerapon Dhippayom
- Faculty of Pharmaceutical Sciences, Naresuan University, Tha Pho, Muang Phitsanulok, Thailand
| | - Daniel D Reidpath
- Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway, Subang Jaya, Selangor, Malaysia.,School of Population Health, Curtin University, Perth, Western Australia, Australia.,Molecular, Genetic & Population Health Sciences, University of Edinburgh, Edinburgh, UK.,Asian Centre for Evidence Synthesis in Population, Implementation and Clinical Outcomes (PICO), Health and Well-being Cluster, Global Asia in the 21st Century (GA21) Platform, Monash University Malaysia, Bandar Sunway, Selangor, Malaysia
| | - Nathorn Chaiyakunapruk
- School of Pharmacy, Monash University Malaysia, Bandar Sunway, Subang Jaya, Selangor, Malaysia.,Asian Centre for Evidence Synthesis in Population, Implementation and Clinical Outcomes (PICO), Health and Well-being Cluster, Global Asia in the 21st Century (GA21) Platform, Monash University Malaysia, Bandar Sunway, Selangor, Malaysia.,School of Pharmacy, University of Wisconsin, Madison, Wisconsin, USA.,Center of Pharmaceutical Outcomes Research (CPOR), Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand
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Breuckmann F, Hochadel M, Voigtländer T, Haude M, Schmitt C, Münzel T, Giannitsis E, Mudra H, Heusch G, Schumacher B, Barth S, Schuler G, Hailer B, Walther D, Senges J. On versus off-hour care of patients with acute coronary syndrome and persistent ST-segment elevation in certified German chest pain units. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2016; 6:3-9. [PMID: 26714975 DOI: 10.1177/2048872615624845] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Regional healthcare projects improve the off-hour care of patients with acute coronary syndromes and persistent ST-segment elevation myocardial infarction (STEMI). To analyse differences in quality of care between on and off-hour care of STEMI patients admitted to certified German chest pain units. METHODS A total of 1107 STEMI patients from the German chest pain unit registry were enrolled. Analyses comprised critical time intervals (symptoms to first medical contact (FMC), FMC to admission, symptoms to admission, symptoms to balloon, FMC to balloon, door to balloon times) and major adverse cardiac and cerebrovascular events at follow-up. RESULTS 54.8% of patients were admitted off-hours. Symptoms to admission (2:28 (1:28-5:20 h) vs. 3:16 h (1:35-8:06 h), P<0.001), symptoms to FMC (1:15 h (0:33-3:00 h) vs. 2:00 h (0:40-6:46 h), P<0.001) and FMC to admission intervals (0:45 h (0:30-1:20 h) vs. 0:52 h (0:32-1:35 h), P=0.09) were shorter during off-hours. Percutaneous revascularisation rates were high and without difference between on and off-hours (95.5% vs. 96.8%, P=0.30). Door to balloon times were significantly less during on-hours (0:32 h (0:18-1:06 h) vs. 0:44 h (0:23-1:20 h), P<0.01) without negative impact on the proportion of patients with a door to balloon time of <60 min (72.6% vs. 68.4%, P=0.19), symptoms to balloon (3:49 h (2:12-10:46 h) vs. 3:30 h (2:04-7:41 h), P=0.08) or FMC to balloon times (1:26 h (0:56-2:22 h) vs. 1:30 h (1:03-2:29 h), P=0.14). Major adverse cardiac and cerebrovascular event rates did not differ significantly between on and off-hours (log-rank test P=0.36). CONCLUSIONS The German chest pain unit network ensures rapid and structured preclinical and in-hospital care independent from the circadian variation of admission. Slower door to balloon times off-hours are compensated by faster symptoms to admission or symptoms to FMC intervals. Further efforts should focus on patient awareness programmes on-hours and STEMI alarming tracks off-hours.
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Affiliation(s)
| | | | | | | | - Claus Schmitt
- 5 Clinic for Cardiology and Angiology, Municipal Hospital Karlsruhe, Germany
| | - Thomas Münzel
- 6 2nd Department of Medicine, Johannes Gutenberg-University Mainz, Germany
| | | | - Harald Mudra
- 8 Department of Cardiology, Pneumology, Internal Intensive Care Medicine, Städtisches Klinikum München GmbH, Germany
| | - Gerd Heusch
- 9 Institute for Pathophysiology, University Duisburg-Essen, Germany
| | | | - Sebastian Barth
- 11 Department of Cardiology, Herz- und Gefäß-Klinik GmbH, Germany
| | | | - Birgit Hailer
- 13 Department of Cardiology, Catholic Clinics Essen-Northwest, Germany
| | - Dirk Walther
- 14 2nd Department of Medicine, HELIOS Kreiskrankenhaus Gotha/Ohrdruf, Germany
| | - Jochen Senges
- 2 Institute for Myocardial Infarction Research, Germany
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Tarantini G, D’Amico G, Brener SJ, Tellaroli P, Basile M, Schiavo A, Mojoli M, Fraccaro C, Marchese A, Musumeci G, Stone GW. Survival After Varying Revascularization Strategies in Patients With ST-Segment Elevation Myocardial Infarction and Multivessel Coronary Artery Disease. JACC Cardiovasc Interv 2016; 9:1765-76. [DOI: 10.1016/j.jcin.2016.06.012] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 05/17/2016] [Accepted: 06/05/2016] [Indexed: 01/12/2023]
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Varcoe RW, Clayton TC, Gray HH, de Belder MA, Ludman PF, Henderson RA. Impact of call-to-balloon time on 30-day mortality in contemporary practice. Heart 2016; 103:117-124. [PMID: 27411838 DOI: 10.1136/heartjnl-2016-309658] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 05/27/2016] [Accepted: 06/16/2016] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE Studies reporting an association between treatment delay and outcome for patients with ST segment elevation myocardial infarction (STEMI) have generally not included patients treated by a primary percutaneous coronary intervention (PPCI) service that systematically delivers reperfusion therapy to all eligible patients. We set out to determine the association of call-to-balloon (CTB) time with 30-day mortality after PPCI in a contemporary series of patients treated within a national reperfusion service. METHODS We analysed data on 16 907 consecutive patients with STEMI treated by PPCI in England and Wales in 2011 with CTB time of ≤6 hours. RESULTS The median CTB and door-to-balloon times were 111 and 41 min, respectively, with 80.9% of patients treated within 150 min of the call for help. An out-of-hours call time (58.2% of patients) was associated with a 10 min increase in CTB time, whereas inter-hospital transfer for PPCI (18.5% of patients) was associated with a 49 min increase in CTB time. CTB time was independently associated with 30-day mortality (p<0.0001) with a HR of 1.95 (95% CI 1.54 to 2.47) for a CTB time of >180-240 min compared with ≤90 min. The relationship between CTB time and 30-day mortality was influenced by patient risk profile with a greater absolute impact of increasing CTB time on mortality in high-risk patients. CONCLUSION CTB time is a useful metric to assess the overall performance of a PPCI service. Delays to reperfusion remain important even in the era of organised national PPCI services with rapid treatment times and efforts should continue to minimise treatment delays.
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Affiliation(s)
- Richard W Varcoe
- Trent Cardiac Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Tim C Clayton
- London School of Hygiene and Tropical Medicine, London, UK
| | - Huon H Gray
- Wessex Cardiac Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | - Peter F Ludman
- Queen Elizabeth Hospital, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Robert A Henderson
- Trent Cardiac Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
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López-Sendón J, González-Juanatey JR, Pinto F, Cuenca Castillo J, Badimón L, Dalmau R, González Torrecilla E, López-Mínguez JR, Maceira AM, Pascual-Figal D, Pomar Moya-Prats JL, Sionis A, Zamorano JL. Indicadores de calidad en cardiología. Principales indicadores para medir la calidad de los resultados (indicadores de resultados) y parámetros de calidad relacionados con mejores resultados en la práctica clínica (indicadores de práctica asistencial). INCARDIO (Indicadores de Calidad en Unidades Asistenciales del Área del Corazón): Declaración de posicionamiento de consenso de SEC/SECTCV. CIRUGIA CARDIOVASCULAR 2015. [DOI: 10.1016/j.circv.2015.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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11
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López-Sendón J, González-Juanatey JR, Pinto F, Cuenca Castillo J, Badimón L, Dalmau R, González Torrecilla E, López-Mínguez JR, Maceira AM, Pascual-Figal D, Pomar Moya-Prats JL, Sionis A, Zamorano JL. Indicadores de calidad en cardiología. Principales indicadores para medir la calidad de los resultados (indicadores de resultados) y parámetros de calidad relacionados con mejores resultados en la práctica clínica (indicadores de práctica asistencial). INCARDIO (Indicadores de Calidad en Unidades Asistenciales del Área del Corazón): Declaración de posicionamiento de consenso de SEC/SECTCV. Rev Esp Cardiol 2015. [DOI: 10.1016/j.recesp.2015.07.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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12
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López-Sendón J, González-Juanatey JR, Pinto F, Cuenca Castillo J, Badimón L, Dalmau R, González Torrecilla E, López-Mínguez JR, Maceira AM, Pascual-Figal D, Pomar Moya-Prats JL, Sionis A, Zamorano JL. Quality Markers in Cardiology. Main Markers to Measure Quality of Results (Outcomes) and Quality Measures Related to Better Results in Clinical Practice (Performance Metrics). INCARDIO (Indicadores de Calidad en Unidades Asistenciales del Área del Corazón): A SEC/SECTCV Consensus Position Paper. ACTA ACUST UNITED AC 2015; 68:976-995.e10. [PMID: 26315766 DOI: 10.1016/j.rec.2015.07.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 07/21/2015] [Indexed: 02/06/2023]
Abstract
Cardiology practice requires complex organization that impacts overall outcomes and may differ substantially among hospitals and communities. The aim of this consensus document is to define quality markers in cardiology, including markers to measure the quality of results (outcomes metrics) and quality measures related to better results in clinical practice (performance metrics). The document is mainly intended for the Spanish health care system and may serve as a basis for similar documents in other countries.
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Affiliation(s)
- José López-Sendón
- Servicio de Cardiología, Hospital Universitario La Paz, IdiPaz, Madrid, Spain.
| | - José Ramón González-Juanatey
- Sociedad Española de Cardiología, Madrid, Spain; Servicio de Cardiología, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain
| | - Fausto Pinto
- European Society of Cardiology; Department of Cardiology, University Hospital Santa Maria, Lisbon, Portugal
| | - José Cuenca Castillo
- Sociedad Española de Cirugía Torácica-Cardiovascular; Servicio de Cirugía Cardiaca, Complexo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | - Lina Badimón
- Centro de Investigación Cardiovascular (CSIC-ICCC), Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Regina Dalmau
- Unidad de Rehabilitación Cardiaca, Servicio de Cardiología, Hospital Universitario La Paz, IdiPaz, Madrid, Spain
| | - Esteban González Torrecilla
- Unidad de Electrofisiología y Arritmias, Servicio de Cardiología, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - José Ramón López-Mínguez
- Unidad de Cardiología intervencionista, Servicio de Cardiología, Hospital Infanta Crsitina, Badajoz, Spain
| | - Alicia M Maceira
- Unidad de Imagen Cardiaca, Servicio de Cardiología, ERESA Medical Center, Valencia, Spain
| | - Domingo Pascual-Figal
- Servicio de Cardiología, Hospital Universitario Virgen de la Arrixaca, El Palmar, Murcia, Spain
| | | | - Alessandro Sionis
- Unidad de Cuidados Intensivos Cardiológicos, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - José Luis Zamorano
- Servicio de Cardiología, Hospital Universitario Ramón y Cajal, Madrid, Spain
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Kuno T, Kohsaka S, Numasawa Y, Ueda I, Suzuki M, Nakamura I, Negishi K, Ishikawa S, Maekawa Y, Kawamura A, Miyata H, Fukuda K. Location of the culprit coronary lesion and its association with delay in door-to-balloon time (from a multicenter registry of primary percutaneous coronary intervention). Am J Cardiol 2015; 115:581-6. [PMID: 25577426 DOI: 10.1016/j.amjcard.2014.12.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2014] [Revised: 12/11/2014] [Accepted: 12/11/2014] [Indexed: 11/18/2022]
Abstract
Current guidelines recommend shorter door-to-balloon times (DBTs) (<90 minutes) for patients with ST-elevation myocardial infarction (STEMI). Clinical factors, including patient or hospital characteristics, associated with prolonged DBT have been identified, but angiographic variables such as culprit lesion location have not been thoroughly investigated. We aimed to evaluate the effect of culprit artery location on DBT of patients with STEMI who underwent percutaneous coronary intervention (PCI). Data were analyzed from 1,725 patients with STEMI who underwent PCI from August 2008 to March 2014 at 16 Japanese hospitals. Patients were divided into 3 groups according to culprit artery location, right coronary artery (RCA), left anterior descending artery (LAD), and left circumflex artery (LC), and associations with DBT were assessed. The LC group had a trend toward a longer DBT among the 3 groups (97.1 [RCA] vs 98.1 [LAD] vs 105.1 [LC] minutes; p = 0.058). In-hospital mortality was also significantly higher in patients with a left coronary artery lesion (3.5% [RCA] vs 6.3% [LAD] vs 5.4% [LC]; p = 0.041). In-hospital mortality for patients with DBT >90 minutes was significantly higher compared with patients with DBT ≤90 minutes (6.5% vs 3.6%; p = 0.006). Multivariate logistic regression analysis revealed that the LC location was an independent predictor for DBT >90 minutes (odds ratio, 1.45; 95% confidence interval, 1.04 to 2.01; p = 0.028). In conclusion, LC location was an independent predictor of longer DBT. The difficulties in diagnosing LC-related STEMI need further evaluation.
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Affiliation(s)
- Toshiki Kuno
- Department of Cardiology, Ashikaga Red Cross Hospital, Tochigi, Japan
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan.
| | - Yohei Numasawa
- Department of Cardiology, Ashikaga Red Cross Hospital, Tochigi, Japan
| | - Ikuko Ueda
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Masahiro Suzuki
- Department of Cardiology, Saitama National Hospital, Saitama, Japan
| | - Iwao Nakamura
- Department of Cardiology, Hino City Hospital, Tokyo, Japan
| | - Koji Negishi
- Department of Cardiology, Yokohama Municipal Hospital, Kanagawa, Japan
| | - Shiro Ishikawa
- Department of Cardiology, Saitama City Hospital, Saitama, Japan
| | - Yuichiro Maekawa
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Akio Kawamura
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Hiroaki Miyata
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Keiichi Fukuda
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
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14
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De Luca G, Parodi G, Sciagrà R, Venditti F, Bellandi B, Vergara R, Migliorini A, Valenti R, Antoniucci D. Preprocedural TIMI flow and infarct size in STEMI undergoing primary angioplasty. J Thromb Thrombolysis 2015; 38:81-6. [PMID: 23928869 DOI: 10.1007/s11239-013-0977-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Despite optimal epicardial recanalization, primary angioplasty for STEMI is still associated with suboptimal reperfusion in a relatively large proportion of patients. The aim the current study was to evaluate the impact of preprocedural TIMI flow on myocardial scintigraphic infarct size among STEMI undergoing primary angioplasty. Our population is represented by 793 STEMI patients undergoing primary PCI. Infarct size was evaluated at 30 days by technetium-99m-sestamibi. Poor preprocedural TIMI flow (TIMI 0-1) was observed in 645 patients (81.3%). Poor preprocedural TIMI flow was associated with more hypercholesterolemia (p = 0.012), and a trend in lower prevalence of diabetes (p = 0.081). Preprocedural TIMI flow significantly affected scintigraphic and enzymatic infarct size. Similar findings were observed in the analysis restricted to patients with postprocedural TIMI 3 flow. The impact of preprocedural TIMI flow on scintigraphic infarct size was confirmed when the analysis was performed according to the percentage of patients above the median (p < 0.001) and after adjustment for baseline confounding factors (Hypercholesterolemia and diabetes) [adjusted OR (95% CI) for pre preprocedural TIMI 3 flow = 0.59 (0.46-0.75), p < 0.001]. This study shows that among patients with STEMI undergoing primary angioplasty, poor preprocedural TIMI flow is independently associated with larger infarct size.
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Affiliation(s)
- Giuseppe De Luca
- Division of Cardiology, "Maggiore della Carità" Hospital, Eastern Piedmont University, Novara, Italy,
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15
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Maier S, Thiele H, Zahn R, Sefrin P, Naber C, Scholz K, von Scheidt W. Empfehlungen zur Organisation von Herzinfarktnetzwerken. DER KARDIOLOGE 2014. [DOI: 10.1007/s12181-013-0540-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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16
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Jakl M, Stasek J, Kala P, Rokyta R, Kanovsky J, Ondrus T, Hromadka M, Widimsky P. Acute myocardial infarction complicated by shock: outcome analysis based on initial electrocardiogram. SCAND CARDIOVASC J 2013; 48:13-9. [PMID: 24228641 DOI: 10.3109/14017431.2013.865074] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES To assess the relation between initial ECG findings, presence of risk factors, coronary angiography findings, and clinical outcomes in patients with acute myocardial infarction complicated by cardiogenic shock (CS). DESIGN Data from a total of 5572 acute myocardial infarction patients admitted to the four tertiary hospitals during a period of 3 years were analyzed. CS on admission was present in 358 patients (6.4%). They were divided into four groups based on the admission ECG: ST-segment elevation (STEMI), ST-segment depression (STDMI), bundle branch block (BBBMI), and other ECG acute myocardial infarction. RESULTS CS developed most frequently among BBBMI patients (in 12.1% of all BBBMIs, p < 0.001 vs. STEMI), followed by STEMI (6.7%), STDMI (4.4%), and other ECG acute myocardial infarction (2.3%). The risk of CS development was similar in patients with left bundle branch block (LBBB) (13.3%) and right bundle branch block (RBBB) (11.2%). The one-year mortality was highest among RBBBMI patients (66.7%, p < 0.001), followed by LBBBMI (48.6%), other ECG (47.1%), STEMI (41.7%), and STDMI patients (38.1%). CONCLUSIONS RBBB on admission ECG is associated with the highest risk of CS development, frequent left main coronary artery affection, and unsuccessful revascularization. It is also an independent predictor of one-year mortality.
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Affiliation(s)
- Martin Jakl
- 1st Department of Internal Medicine - Cardioangiology, University Hospital Hradec Kralove , Czech Republic
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17
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Efficacy and limitations of a STEMI network: 3 years of experience within the myocardial infarction network of the region of Augsburg - HERA. Clin Res Cardiol 2013; 102:905-14. [PMID: 24061282 DOI: 10.1007/s00392-013-0608-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2013] [Accepted: 08/14/2013] [Indexed: 01/20/2023]
Abstract
AIMS The HERA Registry investigates logistics, adherence to standards, time intervals, and mortality in a regional network for primary percutaneous coronary intervention (PPCI) in ST-elevation myocardial infarction (STEMI) in a mixed urban and rural area. METHODS AND RESULTS We included 826 consecutive patients (pts) within the HERA network with its dedicated PPCI strategy (female n = 243, mean age 64 years, range 25-98 years) with acute STEMI (May 2007 until January 2010). 680 pts (82 %) received PPCI and 45 (5.4 %) acute bypass surgery. Of 512 pts seen by an emergency physician (EP) as first medical contact (FMC) 87 % received on-scene 12-lead ECG. ECG transmission rate to the PPCI center was 29 %. Median FMC-to-balloon time (CBT) was 135 min and door-to-balloon time (DBT) 70 min. With EP FMC DBT was 38 min with direct transfer to cath lab (n = 70), 69 min via ICU (n = 240), and 132 min via ER (n = 91, p < 0.01). Out of 826 pts, 143(17.3 %) presented in cardiogenic shock. In-hospital mortality was 8.8 % (n = 73), 35.7 % for shock pts versus 3.2 % for non-shock pts (p < 0.01). For pts receiving PPCI, in-hospital mortality was 6.2 %, for shock pts (n = 107) 28.0 %, and for non-shock pts (n = 573) 2.1 % (p < 0.01). CONCLUSION Prehospital management, CBT and DBT compare favourably to data from studies and registries, but do not yet fulfill strict guideline requirements. Real world mortality in non-shock pts is very low. Direct transfer to cath lab reduces DBTs by 49 %. For this crucial improvement, transmission of a 12-lead ECG to the PPCI center is mandatory.
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18
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Harold JG, Bass TA, Bashore TM, Brindiss RG, Brush JE, Burke JA, Dehmers GJ, Deychak YA, Jneids H, Jolliss JG, Landzberg JS, Levine GN, McClurken JB, Messengers JC, Moussas ID, Muhlestein JB, Pomerantz RM, Sanborn TA, Sivaram CA, Whites CJ, Williamss ES, Halperin JL, Beckman JA, Bolger A, Byrne JG, Lester SJ, Merli GJ, Muhlestein JB, Pina IL, Wang A, Weitz HH. ACCF/AHA/SCAI 2013 Update of the Clinical Competence Statement on Coronary Artery Interventional Procedures. Catheter Cardiovasc Interv 2013; 82:E69-111. [DOI: 10.1002/ccd.24985] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
| | - John G. Harold
- American College of Cardiology Foundation representative
| | - Theodore A. Bass
- Society for Cardiovascular Angiography and Interventions representative
| | | | | | | | | | | | | | | | | | | | | | | | | | - Issam D. Moussas
- Society for Cardiovascular Angiography and Interventions representative
| | | | | | | | | | | | | | | | - Joshua A. Beckman
- Former Task Force member during the writing effort; Authors with no symbol by their name were included to provide additional content expertise
| | | | | | | | | | | | - Ileana L. Pina
- Former Task Force member during the writing effort; Authors with no symbol by their name were included to provide additional content expertise
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19
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ACCF/AHA/SCAI 2013 Update of the Clinical Competence Statement on Coronary Artery Interventional Procedures. J Am Coll Cardiol 2013; 62:357-96. [DOI: 10.1016/j.jacc.2013.05.002] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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20
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Out-of-hospital cardiac arrest and percutaneous coronary intervention for ST-elevation myocardial infarction: Long-term survival and neurological outcome. Int J Cardiol 2013; 166:236-41. [DOI: 10.1016/j.ijcard.2011.11.029] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2011] [Revised: 10/21/2011] [Accepted: 11/24/2011] [Indexed: 11/18/2022]
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21
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Harold JG, Bass TA, Bashore TM, Brindis RG, Brush JE, Burke JA, Dehmer GJ, Deychak YA, Jneid H, Jollis JG, Landzberg JS, Levine GN, McClurken JB, Messenger JC, Moussa ID, Muhlestein JB, Pomerantz RM, Sanborn TA, Sivaram CA, White CJ, Williams ES. ACCF/AHA/SCAI 2013 update of the clinical competence statement on coronary artery interventional procedures: a report of the American College of Cardiology Foundation/American Heart Association/American College of Physicians Task Force on Clinical Competence and Training (writing committee to revise the 2007 clinical competence statement on cardiac interventional procedures). Circulation 2013; 128:436-72. [PMID: 23658439 DOI: 10.1161/cir.0b013e318299cd8a] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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22
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Scholz KH, Maier SKG, Jung J, Fleischmann C, Werner GS, Olbrich HG, Ahlersmann D, Keating FK, Jacobshagen C, Moehlis H, Hilgers R, Maier LS. Reduction in treatment times through formalized data feedback: results from a prospective multicenter study of ST-segment elevation myocardial infarction. JACC Cardiovasc Interv 2013; 5:848-57. [PMID: 22917457 DOI: 10.1016/j.jcin.2012.04.012] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2012] [Revised: 04/05/2012] [Accepted: 04/12/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVES This study sought to evaluate the effect of systematic data analysis and standardized feedback on treatment times and outcome in a prospective multicenter trial. BACKGROUND Formalized data feedback may reduce treatment times in ST-segment elevation myocardial infarction (STEMI). METHODS Over a 15-month period, 1,183 patients presenting with STEMI were enrolled. Six primary percutaneous coronary intervention hospitals in Germany and 29 associated nonpercutaneous coronary intervention hospitals participated. Data from patient contact to balloon inflation were collected and analyzed. Pre-defined quality indicators, including the percentage of patients with pre-announced STEMI, direct handoff in the catheterization laboratory, contact-to-balloon time <90 min, door-to-balloon time <60 min, and door-to-balloon time <30 min were discussed with staff on a quarterly basis. RESULTS Median door-to-balloon time decreased from 71 to 58 min and contact-to-balloon time from 129 to 103 min between the first and the fifth quarter (p < 0.05 for both). Contributing were shorter stays in the emergency department, more direct handoffs from ambulances to the catheterization laboratory (from 22% to 38%, p < 0.05), and a slight increase in the number of patients transported directly to the percutaneous coronary intervention facility (primary transport). One-year mortality was reduced in the total group of patients and in the subgroup of patients with primary transport (p < 0.05). The sharpest fall in mortality was observed in patients with primary transport and TIMI (Thrombolysis In Myocardial Infarction) risk score ≥ 3 (n = 521) with a decrease in 30-day mortality from 23.1% to 13.3% (p < 0.05) and in 1-year mortality from 25.6% to 16.7% (p < 0.05). CONCLUSIONS Formalized data feedback is associated with a reduction in treatment times for STEMI and with an improved prognosis, which is most pronounced in high-risk patients. (Feedback Intervention and Treatment Times in ST-Elevation Myocardial Infarction [FITT-STEMI]; NCT00794001).
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23
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A systematic review of factors predicting door to balloon time in ST-segment elevation myocardial infarction treated with percutaneous intervention. Int J Cardiol 2012; 157:8-23. [DOI: 10.1016/j.ijcard.2011.06.042] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2011] [Revised: 03/17/2011] [Accepted: 06/06/2011] [Indexed: 11/22/2022]
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24
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von Scheidt W, Thilo C. As time goes by?: the fallacy of thrombolysis in STEMI networks. Clin Res Cardiol 2011; 100:867-77. [PMID: 21717207 DOI: 10.1007/s00392-011-0332-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2010] [Accepted: 06/08/2011] [Indexed: 11/25/2022]
Abstract
Primary percutaneous coronary intervention (PPCI) is superior to thrombolysis (TL) as reperfusion therapy in ST-elevation myocardial infarction (STEMI). TL is a rapidly available, but semi-effective therapy (effective reperfusion in 50% of patients only), whereas PPCI is a potentially delayed, but highly effective therapy (effective reperfusion in >90%). Since TL loses its efficacy beyond 2-3 h after symptom onset, it is a significant reperfusion alternative to PPCI in early presenters only. The individual decision to treat an early presenter with PPCI or TL requires the evaluation of the time delay between potential start of TL or PPCI, the PCI-related delay (PRD). PRD is greatest, if TL is given in the prehospital setting. Until now, prehospital TL as the most rapidly available reperfusion strategy has failed to demonstrate any prognostic or even any other relevant benefit compared to PPCI in any subgroup of patients, even with time delays for PPCI of up to several hours. On average, a median PRD of at least 90-120 min can be considered a time corridor of prognostic superiority of PPCI over TL. This is already achieved in contemporary registries and myocardial infarction networks.Therefore, the efforts should not focus on the implementation of a dual reperfusion strategy (PPCI, and prehospital TL in selected cases) in established or upcoming myocardial infarction networks, but concentrate on the availability of PPCI in less than 2 h. TL, as rapid as possible, i.e. prehospital, is a vital treatment option in case of non-existing PPCI facilities within a median time limit of 2 h or even more, a scenario not existing or easily to eliminate in European countries by implementing well organized myocardial infarction networks. This is the mission to be accomplished.
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Affiliation(s)
- Wolfgang von Scheidt
- Department of Internal Medicine I, Klinikum Augsburg, Heart Center Augsburg-Swabia, Germany.
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25
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Bossaert L, O'Connor RE, Arntz HR, Brooks SC, Diercks D, Feitosa-Filho G, Nolan JP, Hoek TLV, Walters DL, Wong A, Welsford M, Woolfrey K. Part 9: Acute coronary syndromes: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 2011; 81 Suppl 1:e175-212. [PMID: 20959169 DOI: 10.1016/j.resuscitation.2010.09.001] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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26
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27
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Towae F, Juenger C, Mudra H, Glunz HG, Hauptmann E, Grube E, Voigtländer T, Bauer T, Zeymer U, Senges J, Gitt AK, Zahn R. The development of door-to-angiography time in the last 14 years for patients with acute ST-elevation myocardial infarction treated with primary coronary intervention: Determinants and outcome. Results from the MITRAplus and OPTAMI registry. ACTA ACUST UNITED AC 2011; 13:35-9. [DOI: 10.3109/17482941.2010.551133] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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28
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Naegeli B, Radovanovic D, Rickli H, Erne P, Seifert B, Duvoisin N, Pedrazzini G, Urban P, Bertel O. Impact of a nationwide public campaign on delays and outcome in Swiss patients with acute coronary syndrome. ACTA ACUST UNITED AC 2011; 18:297-304. [DOI: 10.1177/1741826710389386] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
| | - Dragana Radovanovic
- AMIS Plus Data Center, Institute of Social and Preventive Medicine, Zürich University, Switzerland
| | - Hans Rickli
- Division of Cardiology, Kantonsspital, St.Gallen, Switzerland
| | - Paul Erne
- Division of Cardiology, Luzerner Kantonsspital, Switzerland
| | - Burkhardt Seifert
- Biostatistics Unit, Institute of Social and Preventive Medicine, Zürich University, Switzerland
| | - Nicole Duvoisin
- AMIS Plus Data Center, Institute of Social and Preventive Medicine, Zürich University, Switzerland
| | | | - Philip Urban
- Cardiovascular Department, Hopital de la Tour, Switzerland
| | - Osmund Bertel
- HerzGefässZentrum, Klinik Im Park, Zürich, Switzerland
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29
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O'Connor RE, Bossaert L, Arntz HR, Brooks SC, Diercks D, Feitosa-Filho G, Nolan JP, Vanden Hoek TL, Walters DL, Wong A, Welsford M, Woolfrey K. Part 9: Acute coronary syndromes: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2010; 122:S422-65. [PMID: 20956257 DOI: 10.1161/circulationaha.110.985549] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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30
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Minutello RM, Kim L, Aggarwal S, Cuomo LJ, Feldman DN, Wong SC. Door-to-balloon time in primary percutaneous coronary intervention predicts degree of myocardial necrosis as measured using cardiac biomarkers. Tex Heart Inst J 2010; 37:161-165. [PMID: 20401287 PMCID: PMC2851434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
Reduced door-to-balloon time in primary percutaneous coronary intervention for the treatment of ST-elevation myocardial infarction has been associated with lower cardiac mortality rates. However, it remains unclear whether door-to-balloon time is predominantly a surrogate for overall peri-myocardial infarction care and is not independently predictive of outcomes, particularly when differences in door-to-balloon time have narrowed and previous studies have contained myocardial infarction-selection bias.We analyzed 179 consecutive patients who presented emergently at our cardiac catheterization laboratory with ST-elevation myocardial infarction within 12 hours of symptom onset and who underwent primary percutaneous coronary intervention within 3 hours of presentation. Our curve estimation regression model used the natural logarithm (ln) of area under the curve (AUC) of creatine kinase to evaluate the effect of door-to-balloon time on cardiac biomarker levels. We correlated ln (AUC-creatine kinase) with improvement of left ventricular ejection fraction at follow-up and with the intermediate-term mortality rate.Median door-to-balloon time was 87 minutes (interquartile range, 65-113 min). The ln (AUC-creatine kinase) correlated significantly with door-to-balloon time (r=0.2, P=0.02). Upon propensity-score analysis, door-to-balloon time remained a significant independent predictor of ln (AUC-creatine kinase) (beta=0.15, P=0.03). Upon use of a Cox regression model, ln (AUC-creatine kinase) independently predicted death (P=0.04) and recovery of left ventricular function (P=0.001) at follow-up (mean, 14 mo).Longer door-to-balloon time independently predicts increased myocardial cell damage, and ln (AUC-creatine kinase) predicts improvement in left ventricular systolic function and intermediate-term death after ST-elevation myocardial infarction.
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Affiliation(s)
- Robert M Minutello
- Department of Medicine, Division of Cardiology, Weill Cornell Medical College, New York, New York 10065, USA.
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31
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Leurent G, Fougerou C, Pennec PY, Filippi E, Moquet B, Druelles P, Hacot JP, Rialan A, Rouault G, Gervais R, Bedossa M, Boulmier D, Boulanger B, Hamon C, Treuil J, Coudert I, Courcoux H, Le Breton H. Door-to-balloon delays before primary angioplasty in the Regional Acute Myocardial Infarction Registry of Brittany. An analysis of the Observatoire Régional Breton sur l'Infarctus du myocarde (ORBI). Arch Cardiovasc Dis 2009; 102:777-84. [PMID: 19944394 DOI: 10.1016/j.acvd.2009.08.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2009] [Revised: 08/21/2009] [Accepted: 08/24/2009] [Indexed: 11/24/2022]
Abstract
BACKGROUND Minimizing delays to coronary reperfusion is critical in the management of acute myocardial infarction (AMI). AIMS To determine delays in in-hospital management and factors associated with delays of over 45min. METHODS We analysed data from the Observatoire Régional Breton sur l'Infarctus, a registry of AMI patients admitted within 24h of symptom onset (July 2007 to December 2008) to an interventional cardiology centre in Brittany. Prehospital delay was defined as time between first responder arrival at the patient and patient arrival at an interventional cardiovascular centre. In-hospital delay was defined as time between admission to the interventional cardiovascular centre and first balloon inflation. Patients were grouped according to duration of in-hospital delay (>45 vs <or=45min). Predictors of short in-hospital delay (<or=45min) were examined by logistic regression analysis. RESULTS The analysis included 560 patients (mean age 60.7+/-13 years; 443 men). Median delay between symptom onset and call for medical assistance was 50min (mean 115+/-180). Two-thirds (n=371) of patients were admitted to hospital during working hours (08:00-20:00h); 383 (68%) patients were managed by emergency medical services before admission. In-hospital delay was less than or equal to 45min for 296 (53%) patients. The mean overall (pre- and in-hospital) delay was 140 (median 109) min. Direct admission to a catheterization laboratory and admission during working hours were independently correlated with short in-hospital delay (odds ratios 20.8 [p<0.001] and 2.37 [p=0.004], respectively). CONCLUSIONS In Brittany, median in-hospital delay before treatment of AMI by primary angioplasty was over 45min in 50% of patients. Overall, delays were longer than recommended, due to excessively long prehospital delays. Patient admission during working hours and direct admission to a catheterization laboratory were associated with short in-hospital delay.
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Affiliation(s)
- Guillaume Leurent
- Service de cardiologie et maladies vasculaires, CHU de Rennes, Rennes, France.
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Short-term prognosis of contemporary interventional therapy of ST-elevation myocardial infarction: does gender matter? Clin Res Cardiol 2009; 98:709-15. [PMID: 19690904 DOI: 10.1007/s00392-009-0055-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2008] [Accepted: 07/30/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND A higher mortality risk for women with acute ST-elevation myocardial infarction (STEMI) has been a common finding in the past, even after acute percutaneous coronary intervention (PCI). We set out to analyze whether there are gender differences in real-world contemporary treatment and outcomes of STEMI. PATIENTS AND METHODS A retrospective analysis of all consecutive patients with STEMI and acute coronary angiography with the intention of performing a PCI at our center 6/1999-6/2006 was carried out (n = 566). Data were examined for gender-specific differences regarding patients' characteristics, referral patterns, timing of acute symptoms, angiographic findings, procedural details, and adverse events at 30 days after PCI. RESULTS Women (n = 161) were on average 8 years older than men (n = 405), had higher co-morbidity, were more often transported to the hospital by ambulance and presented less often to the emergency room on their own (4.2% vs. 12.6% in men, P = 0.02). The pre-hospital delay from symptom onset to admission was significantly longer for women (median 185 vs. 135 min, P < 0.02). There was no gender difference in time from admission to PCI (median 46 min vs. 48 min, P = 0.42). Both genders received PCI with similar frequency (88.8% vs. 92.4%, P = 0.19), with similar success rates (83.2% vs. 85.3%, P = 0.68). Thirty-day overall mortality for women was not significantly higher than for men (8.7% vs. 7.2%, P = 0.6). Re-infarction or stroke within 30 days were rare for both genders without gender-specific differences whereas bleeding necessitating blood replacement was significantly more frequent in women (16.8% vs. 5.9%, P < 0.001). In multivariate analysis, female gender was not independently associated with a higher risk of 30-day mortality (OR 0.964, P = 0.93). CONCLUSIONS Women underwent PCI therapy for STEMI with the same frequency and the same angiographic success as men. Despite their more advanced age and the higher prevalence of co-morbidities, they did not have a significantly higher 30-day mortality rate than men. Female gender was not an independent risk factor of 30-day mortality. Longer pre-hospital delays before hospital admission in women indicate that awareness of risk from coronary artery disease should be further raised in women.
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Zahn R, Zeymer U. [Acute myocardial infarction: acute coronary intervention at any hospital versus acute coronary intervention at specialized centers only]. Herz 2009; 34:211-7. [PMID: 19444405 DOI: 10.1007/s00059-009-3230-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The acute coronary syndromes (ACS) are currently divided into those with ST elevation (STE-ACS = ST elevation myocardial infarction [STEMI]) and those without ST elevation (NSTE-ACS). The latter are further divided into NSTE-ACS with risk factors and NSTE-ACS without risk factors. For NSTE-ACS patients with risk factors an invasive strategy within 72 h after presentation is recommended, whereas NSTE-ACS patients without risk factors can be treated conservatively, without a routine invasive diagnosis. In patients with STE-ACS, primary angioplasty is the reperfusion therapy of choice. These recommendations concerning the invasive strategies are valid only under three conditions: (1) primary angioplasty has to be performed within 2 h after diagnosis of an STE-ACS; (2) door-to-balloon times for STE-ACS have to be < 60 min; (3) the invasive procedures have to be performed by experienced investigators at hospitals with a sufficient annual PCI (percutaneous coronary intervention) volume. The last point is based on studies which showed a volume-outcome relationship for PCIs in ACS patients and hospital mortality. In Germany, a nationwide supply with such an invasive strategy for ACS patients is currently possible, even within the recommended time frames. Therefore, local networks have to be established to achieve this goal. However, at least in regions with a high density of invasive centers, such networks should take the investigators' experience and the annual interventional volumes of the participating hospitals into account.
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Affiliation(s)
- Ralf Zahn
- Chefarzt der Medizinischen Klinik B, Kardiologie/Pneumologie/Angiologie/Internistische Intensivmedizin, Herzzentrum Ludwigshafen, Bremserstrasse 79, 67063 Ludwigshafen.
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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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Peels J, Hautvast R, de Swart J, Huybregts M, Umans V, Arnold A, Jessurun G, Zijlstra F. Percutaneous coronary intervention without on site surgical back-up; two-years registry of a large Dutch community hospital. Int J Cardiol 2009; 132:59-65. [DOI: 10.1016/j.ijcard.2007.10.037] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2007] [Revised: 07/18/2007] [Accepted: 10/27/2007] [Indexed: 10/22/2022]
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Gibson CM, Pride YB, Frederick PD, Pollack CV, Canto JG, Tiefenbrunn AJ, Weaver WD, Lambrew CT, French WJ, Peterson ED, Rogers WJ. Trends in reperfusion strategies, door-to-needle and door-to-balloon times, and in-hospital mortality among patients with ST-segment elevation myocardial infarction enrolled in the National Registry of Myocardial Infarction from 1990 to 2006. Am Heart J 2008; 156:1035-44. [PMID: 19032997 DOI: 10.1016/j.ahj.2008.07.029] [Citation(s) in RCA: 200] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2008] [Accepted: 07/09/2008] [Indexed: 11/30/2022]
Abstract
BACKGROUND Among patients with ST-segment elevation myocardial infarction (STEMI), rapid reperfusion is associated with improved mortality. As such, door-to-needle (D2N) and door-to-balloon (D2B) times have become metrics of quality of care and targets for intense quality improvement. METHODS The National Registry of Myocardial Infarction (NRMI) collected data regarding reperfusion therapy, its timing and in-hospital mortality among STEMI patients from 1990 through 2006. RESULTS Since 1990, NRMI has enrolled 1,374,232 STEMI patients at 2,157 hospitals. Among those, 774,279 (56.3%) were eligible for reperfusion upon arrival. The proportion receiving fibrinolytic therapy fell from 52.5% in 1990 to 27.6% in 2006 (P < .001), while the proportion undergoing primary percutaneous coronary intervention (pPCI) increased from 2.6% to 43.2%. Among reperfusion-eligible patients who received fibrinolytic therapy, there was a nearly linear decline in median D2N time from 59 minutes in 1990 to 29 minutes in 2006 (P < .001 for trend) as well as a decrease in mortality from 7.0% in 1994 to 6.0% in 2006 (P < .001). Among those undergoing pPCI, D2B time among nontransfer patients declined linearly from 111 minutes in 1994 to 79 minutes in 2006 (P < .001) with a decline in mortality from 8.6% to 3.1% (P < .001). The relative improvement in mortality attributable to improvements in D2N time was 16.3% and to D2B time was 7.5%. CONCLUSIONS Since 1990, there has been a progressive decline in D2N and D2B time among reperfusion-eligible STEMI patients. These improvements have contributed, at least in part, to a progressive decline in mortality.
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Affiliation(s)
- C Michael Gibson
- Cardiovascular Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
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Association of Previous Coronary Artery Bypass Graft Surgery With Door-to-Balloon Time and In-Hospital Outcomes: A Report From the National Cardiovascular Data Registry (NCDR). J Am Coll Cardiol 2008; 52:1665-70. [DOI: 10.1016/j.jacc.2008.08.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2008] [Revised: 07/24/2008] [Accepted: 08/04/2008] [Indexed: 11/17/2022]
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Flesch M, Hagemeister J, Berger HJ, Schiefer A, Schynkowski S, Klein M, Sahebdjami S, vom Dahl S, Fehske W, Mies R, von Eiff M, Pfaff H, Frommolt P, Hoepp HW. Implementation of Guidelines for the Treatment of Acute ST-Elevation Myocardial Infarction. Circ Cardiovasc Interv 2008; 1:95-102. [DOI: 10.1161/circinterventions.108.768176] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
The aim of the Köln (Cologne) Infarction Model is to examine the feasibility of obligatory treatment of ST-segment–elevation myocardial infarction (STEMI) by first-line percutaneous coronary intervention.
Methods and Results—
The study was performed in Cologne with >1 million citizens, 5 coronary intervention centers, and 11 primary care hospitals. Twelve-lead ECG was available for all emergency medical service (EMS) teams. Partners guaranteed direct transfer of STEMI patients to a catheterization laboratory. A total of 519 patients treated within KIM in 2006 were included in the study. Of these, 24% presented at a primary care hospital, 11% presented directly at a coronary intervention center, 5% were transferred by EMS to primary care hospitals, and 60% were directly transferred by EMS to a catheterization laboratory. In 91% of cases, the catheterization laboratory was notified of the patient’s arrival in advance. False-positive ECG diagnosis of STEMI by EMS accounted for 6%. Median treatment times were as follows: from the start of symptoms to first medical contact, 120 minutes; phone to balloon, 70 minutes; and door to balloon, 49 minutes. Of all patients, 93% underwent angiography; 409 patients were treated by coronary intervention, and 24 underwent emergency coronary artery bypass graft. Thrombolysis in Myocardial Infarction grade 3 flow was obtained in 89%. In the hospitals, deaths and new myocardial infarctions were observed in 12.1% and in 1.9% of all patients, respectively.
Conclusion—
The Cologne Infarction Model provides evidence for the feasibility of obligatory treatment of STEMI by primary coronary intervention in a metropolitan setting. Acceptance of treatment pathways allowed nearly all STEMI patients to undergo coronary angiography. ECG competence of EMS was excellent. Treatment times were within postulated limits. Results, including mortality, were within a high quality range.
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Affiliation(s)
- Markus Flesch
- From the Klinik III für Innere Medizin (M.F., J.H., S.S., M.K., H.-W.H.) and Krankenhaus Merheim, Lehrstuhl II für Innere Medizin (H.-J.B.), Universitaet zu Koeln, Cologne, Germany; St. Franziskus-Hospital, Cologne, Germany (A.S., S.S., S.v.D.); St. Vinzenz-Hospital, Cologne, Germany (W.F.); St. Antonius-Krankenhaus, Cologne, Germany (R.M.); Malteser-Krankenhaus St. Hildegardis, Cologne, Germany (M.v.E.); Zentrum für Versorgungsforschung der Universitaet zu Koeln, Cologne, Germany (H.P.)
| | - Jens Hagemeister
- From the Klinik III für Innere Medizin (M.F., J.H., S.S., M.K., H.-W.H.) and Krankenhaus Merheim, Lehrstuhl II für Innere Medizin (H.-J.B.), Universitaet zu Koeln, Cologne, Germany; St. Franziskus-Hospital, Cologne, Germany (A.S., S.S., S.v.D.); St. Vinzenz-Hospital, Cologne, Germany (W.F.); St. Antonius-Krankenhaus, Cologne, Germany (R.M.); Malteser-Krankenhaus St. Hildegardis, Cologne, Germany (M.v.E.); Zentrum für Versorgungsforschung der Universitaet zu Koeln, Cologne, Germany (H.P.)
| | - Hans-Joerg Berger
- From the Klinik III für Innere Medizin (M.F., J.H., S.S., M.K., H.-W.H.) and Krankenhaus Merheim, Lehrstuhl II für Innere Medizin (H.-J.B.), Universitaet zu Koeln, Cologne, Germany; St. Franziskus-Hospital, Cologne, Germany (A.S., S.S., S.v.D.); St. Vinzenz-Hospital, Cologne, Germany (W.F.); St. Antonius-Krankenhaus, Cologne, Germany (R.M.); Malteser-Krankenhaus St. Hildegardis, Cologne, Germany (M.v.E.); Zentrum für Versorgungsforschung der Universitaet zu Koeln, Cologne, Germany (H.P.)
| | - Annett Schiefer
- From the Klinik III für Innere Medizin (M.F., J.H., S.S., M.K., H.-W.H.) and Krankenhaus Merheim, Lehrstuhl II für Innere Medizin (H.-J.B.), Universitaet zu Koeln, Cologne, Germany; St. Franziskus-Hospital, Cologne, Germany (A.S., S.S., S.v.D.); St. Vinzenz-Hospital, Cologne, Germany (W.F.); St. Antonius-Krankenhaus, Cologne, Germany (R.M.); Malteser-Krankenhaus St. Hildegardis, Cologne, Germany (M.v.E.); Zentrum für Versorgungsforschung der Universitaet zu Koeln, Cologne, Germany (H.P.)
| | - Sylke Schynkowski
- From the Klinik III für Innere Medizin (M.F., J.H., S.S., M.K., H.-W.H.) and Krankenhaus Merheim, Lehrstuhl II für Innere Medizin (H.-J.B.), Universitaet zu Koeln, Cologne, Germany; St. Franziskus-Hospital, Cologne, Germany (A.S., S.S., S.v.D.); St. Vinzenz-Hospital, Cologne, Germany (W.F.); St. Antonius-Krankenhaus, Cologne, Germany (R.M.); Malteser-Krankenhaus St. Hildegardis, Cologne, Germany (M.v.E.); Zentrum für Versorgungsforschung der Universitaet zu Koeln, Cologne, Germany (H.P.)
| | - Martin Klein
- From the Klinik III für Innere Medizin (M.F., J.H., S.S., M.K., H.-W.H.) and Krankenhaus Merheim, Lehrstuhl II für Innere Medizin (H.-J.B.), Universitaet zu Koeln, Cologne, Germany; St. Franziskus-Hospital, Cologne, Germany (A.S., S.S., S.v.D.); St. Vinzenz-Hospital, Cologne, Germany (W.F.); St. Antonius-Krankenhaus, Cologne, Germany (R.M.); Malteser-Krankenhaus St. Hildegardis, Cologne, Germany (M.v.E.); Zentrum für Versorgungsforschung der Universitaet zu Koeln, Cologne, Germany (H.P.)
| | - Sassan Sahebdjami
- From the Klinik III für Innere Medizin (M.F., J.H., S.S., M.K., H.-W.H.) and Krankenhaus Merheim, Lehrstuhl II für Innere Medizin (H.-J.B.), Universitaet zu Koeln, Cologne, Germany; St. Franziskus-Hospital, Cologne, Germany (A.S., S.S., S.v.D.); St. Vinzenz-Hospital, Cologne, Germany (W.F.); St. Antonius-Krankenhaus, Cologne, Germany (R.M.); Malteser-Krankenhaus St. Hildegardis, Cologne, Germany (M.v.E.); Zentrum für Versorgungsforschung der Universitaet zu Koeln, Cologne, Germany (H.P.)
| | - Stephan vom Dahl
- From the Klinik III für Innere Medizin (M.F., J.H., S.S., M.K., H.-W.H.) and Krankenhaus Merheim, Lehrstuhl II für Innere Medizin (H.-J.B.), Universitaet zu Koeln, Cologne, Germany; St. Franziskus-Hospital, Cologne, Germany (A.S., S.S., S.v.D.); St. Vinzenz-Hospital, Cologne, Germany (W.F.); St. Antonius-Krankenhaus, Cologne, Germany (R.M.); Malteser-Krankenhaus St. Hildegardis, Cologne, Germany (M.v.E.); Zentrum für Versorgungsforschung der Universitaet zu Koeln, Cologne, Germany (H.P.)
| | - Wolfgang Fehske
- From the Klinik III für Innere Medizin (M.F., J.H., S.S., M.K., H.-W.H.) and Krankenhaus Merheim, Lehrstuhl II für Innere Medizin (H.-J.B.), Universitaet zu Koeln, Cologne, Germany; St. Franziskus-Hospital, Cologne, Germany (A.S., S.S., S.v.D.); St. Vinzenz-Hospital, Cologne, Germany (W.F.); St. Antonius-Krankenhaus, Cologne, Germany (R.M.); Malteser-Krankenhaus St. Hildegardis, Cologne, Germany (M.v.E.); Zentrum für Versorgungsforschung der Universitaet zu Koeln, Cologne, Germany (H.P.)
| | - Rudolf Mies
- From the Klinik III für Innere Medizin (M.F., J.H., S.S., M.K., H.-W.H.) and Krankenhaus Merheim, Lehrstuhl II für Innere Medizin (H.-J.B.), Universitaet zu Koeln, Cologne, Germany; St. Franziskus-Hospital, Cologne, Germany (A.S., S.S., S.v.D.); St. Vinzenz-Hospital, Cologne, Germany (W.F.); St. Antonius-Krankenhaus, Cologne, Germany (R.M.); Malteser-Krankenhaus St. Hildegardis, Cologne, Germany (M.v.E.); Zentrum für Versorgungsforschung der Universitaet zu Koeln, Cologne, Germany (H.P.)
| | - Michael von Eiff
- From the Klinik III für Innere Medizin (M.F., J.H., S.S., M.K., H.-W.H.) and Krankenhaus Merheim, Lehrstuhl II für Innere Medizin (H.-J.B.), Universitaet zu Koeln, Cologne, Germany; St. Franziskus-Hospital, Cologne, Germany (A.S., S.S., S.v.D.); St. Vinzenz-Hospital, Cologne, Germany (W.F.); St. Antonius-Krankenhaus, Cologne, Germany (R.M.); Malteser-Krankenhaus St. Hildegardis, Cologne, Germany (M.v.E.); Zentrum für Versorgungsforschung der Universitaet zu Koeln, Cologne, Germany (H.P.)
| | - Holger Pfaff
- From the Klinik III für Innere Medizin (M.F., J.H., S.S., M.K., H.-W.H.) and Krankenhaus Merheim, Lehrstuhl II für Innere Medizin (H.-J.B.), Universitaet zu Koeln, Cologne, Germany; St. Franziskus-Hospital, Cologne, Germany (A.S., S.S., S.v.D.); St. Vinzenz-Hospital, Cologne, Germany (W.F.); St. Antonius-Krankenhaus, Cologne, Germany (R.M.); Malteser-Krankenhaus St. Hildegardis, Cologne, Germany (M.v.E.); Zentrum für Versorgungsforschung der Universitaet zu Koeln, Cologne, Germany (H.P.)
| | - Peter Frommolt
- From the Klinik III für Innere Medizin (M.F., J.H., S.S., M.K., H.-W.H.) and Krankenhaus Merheim, Lehrstuhl II für Innere Medizin (H.-J.B.), Universitaet zu Koeln, Cologne, Germany; St. Franziskus-Hospital, Cologne, Germany (A.S., S.S., S.v.D.); St. Vinzenz-Hospital, Cologne, Germany (W.F.); St. Antonius-Krankenhaus, Cologne, Germany (R.M.); Malteser-Krankenhaus St. Hildegardis, Cologne, Germany (M.v.E.); Zentrum für Versorgungsforschung der Universitaet zu Koeln, Cologne, Germany (H.P.)
| | - Hans-Wilhelm Hoepp
- From the Klinik III für Innere Medizin (M.F., J.H., S.S., M.K., H.-W.H.) and Krankenhaus Merheim, Lehrstuhl II für Innere Medizin (H.-J.B.), Universitaet zu Koeln, Cologne, Germany; St. Franziskus-Hospital, Cologne, Germany (A.S., S.S., S.v.D.); St. Vinzenz-Hospital, Cologne, Germany (W.F.); St. Antonius-Krankenhaus, Cologne, Germany (R.M.); Malteser-Krankenhaus St. Hildegardis, Cologne, Germany (M.v.E.); Zentrum für Versorgungsforschung der Universitaet zu Koeln, Cologne, Germany (H.P.)
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Suessenbacher A, Doerler J, Alber H, Aichinger J, Altenberger J, Benzer W, Christ G, Globits S, Huber K, Karnik R, Norman G, Siostrzonek P, Zenker G, Pachinger O, Weidinger F. Gender-related outcome following percutaneous coronary intervention for ST-elevation myocardial infarction: data from the Austrian acute PCI registry. EUROINTERVENTION 2008; 4:271-6. [DOI: 10.4244/eijv4i2a47] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Mehta RH, Bufalino VJ, Pan W, Hernandez AF, Cannon CP, Fonarow GC, Peterson ED. Achieving rapid reperfusion with primary percutaneous coronary intervention remains a challenge: insights from American Heart Association's Get With the Guidelines program. Am Heart J 2008; 155:1059-67. [PMID: 18513520 DOI: 10.1016/j.ahj.2008.01.010] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2007] [Accepted: 01/17/2008] [Indexed: 11/19/2022]
Abstract
BACKGROUND The speed of reperfusion (door-to-balloon [D2B] time) is a well established performance metric for patients with ST-elevation myocardial infarction. Although preferably D2B times should be <or=90 minutes, it is unclear how consistently this is achieved in community practice, particularly in women, elderly people, and minorities. METHODS We used the American Heart Association Get With the Guidelines database to study D2B times at 254 participating United States sites (2002-2006). Median D2B time and percentage of compliance with goal (percutaneous coronary interventions [PCI] <or=90 minutes) were assessed overall, over time, and among patient subgroups associated with the greatest delay in this time (older patients, women, and minorities). Standard generalized estimating equation was used to assess continuous trend, percentage of compliance (PCI <or=90 minutes) over time, and disparities in care based on race, sex, and age. RESULTS Over the study period, 10965 patients with ST-elevation myocardial infarction who met eligibility criteria received primary PCI (36% aged >or=65 years, 27% female, and 17% nonwhite). The overall median D2B time was 96 minutes (interquartile range [IQR] 69-140 minutes). Only 44.8% of cases had D2B <or=90 minutes. Median D2B time improved over the study period (108 minutes at baseline [fourth quarter of 2002] to 82 minutes by the last study quarter [third quarter of 2006], adjusted P = .001). The percentage achieving D2B <or=90 minutes also improved (36.2%-58.8%, adjusted P = .003). Relative to their peers, patients aged >or=65 years (103 [IQR 74-153] vs 93 [IQR 67-133] minutes), women (103 [IQR 73-154] vs 94 [IQR 68-135] minutes), and minorities (108 [IQR 77-162] vs 95 [IQR 68-136] minutes) had significantly longer median D2B times. These subgroup disparities in the D2B persisted over the study period as compared with their peers. CONCLUSION The median D2B times with primary PCI have improved modestly in hospitals participating in the American Heart Association Get With the Guidelines program over the last few years but remain below ideal levels. The D2B times are particularly delayed in the elderly people, women, and minority populations; an issue that has persisted over time. These results highlight the ongoing need for national myocardial infarction quality improvement initiatives.
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Affiliation(s)
- Rajendra H Mehta
- Duke Clinical Research Institute and Duke University Medical Center, Durham, NC, USA
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Ellis SG, Tendera M, de Belder MA, van Boven AJ, Widimsky P, Janssens L, Andersen HR, Betriu A, Savonitto S, Adamus J, Peruga JZ, Kosmider M, Katz O, Neunteufl T, Jorgova J, Dorobantu M, Grinfeld L, Armstrong P, Brodie BR, Herrmann HC, Montalescot G, Neumann FJ, Effron MB, Barnathan ES, Topol EJ. Facilitated PCI in patients with ST-elevation myocardial infarction. N Engl J Med 2008; 358:2205-17. [PMID: 18499565 DOI: 10.1056/nejmoa0706816] [Citation(s) in RCA: 419] [Impact Index Per Article: 26.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND We hypothesized that percutaneous coronary intervention (PCI) preceded by early treatment with abciximab plus half-dose reteplase (combination-facilitated PCI) or with abciximab alone (abciximab-facilitated PCI) would improve outcomes in patients with acute ST-segment elevation myocardial infarction, as compared with abciximab administered immediately before the procedure (primary PCI). METHODS In this international, double-blind, placebo-controlled study, we randomly assigned patients with ST-segment elevation myocardial infarction who presented 6 hours or less after the onset of symptoms to receive combination-facilitated PCI, abciximab-facilitated PCI, or primary PCI. All patients received unfractionated heparin or enoxaparin before PCI and a 12-hour infusion of abciximab after PCI. The primary end point was the composite of death from all causes, ventricular fibrillation occurring more than 48 hours after randomization, cardiogenic shock, and congestive heart failure during the first 90 days after randomization. RESULTS A total of 2452 patients were randomly assigned to a treatment group. Significantly more patients had early ST-segment resolution with combination-facilitated PCI (43.9%) than with abciximab-facilitated PCI (33.1%) or primary PCI (31.0%; P=0.01 and P=0.003, respectively). The primary end point occurred in 9.8%, 10.5%, and 10.7% of the patients in the combination-facilitated PCI group, abciximab-facilitated PCI group, and primary-PCI group, respectively (P=0.55); 90-day mortality rates were 5.2%, 5.5%, and 4.5%, respectively (P=0.49). CONCLUSIONS Neither facilitation of PCI with reteplase plus abciximab nor facilitation with abciximab alone significantly improved the clinical outcomes, as compared with abciximab given at the time of PCI, in patients with ST-segment elevation myocardial infarction. (ClinicalTrials.gov number, NCT00046228 [ClinicalTrials.gov].)
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Affiliation(s)
- Stephen G Ellis
- Department of Cardiovascular Medicine, the Cleveland Clinic, F25, 9500 Euclid Ave., Cleveland, OH 44195, USA.
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Krüth P, Zeymer U, Gitt A, Jünger C, Wienbergen H, Niedermeier F, Glunz HG, Senges J, Zahn R. Influence of presentation at the weekend on treatment and outcome in ST-elevation myocardial infarction in hospitals with catheterization laboratories. Clin Res Cardiol 2008; 97:742-7. [PMID: 18465106 DOI: 10.1007/s00392-008-0671-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2007] [Accepted: 04/04/2008] [Indexed: 11/26/2022]
Abstract
BACKGROUND Studies about the influence of various factors on clinical therapy and course in acute coronary syndromes have shown that the outcome is related to admission time to the hospital, with an impaired prognosis in patients admitted out of regular working hours. However little is known about the impact of admission on weekend in hospitals with catheterisation laboratories. METHODS We analyzed data of the prospective MITRA-PLUS registry of 11,516 patients with ST-elevation myocardial infarction (STEMI) admitted to hospitals with catheterization facilities for differences of in-hospital mortality between patients admitted during regular working hours, at night and on weekends. RESULTS The prehospital delay and "door-to-balloon"-time were significantly longer on weekends and at nights than at regular working hours (median 196 Vs. 240 Vs. 155 min; P < 0.0001; 60 Vs. 84 min at weekends, resp. 75 min at nights; P < 0.0001). Reperfusion therapy was performed in 72.8% (8,248/11,332) patients, and there were less patients treated on weekend versus "on"-hours (69.7 Vs. 77 %, P < 0.0001). On weekends we found a significant higher in-hospital mortality (11.1 Vs. 9.4%, P = 0.01) and at night there was a trend to higher in-hospital mortality when compared with regular working hours (10.6 Vs. 9.4%, P = 0.07). CONCLUSION In patients with STEMI admitted to hospitals with catheterization facilities, admission during the "off"-hours is associated with higher in-hospital mortality. This may be due to lower rates of revascularization therapy and longer prehospital and in-hospital delays as compared to "on"-hours.
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Affiliation(s)
- Patricia Krüth
- Herzzentrum, Med Klinik B, Klinikum Ludwigshafen, Ludwigshafen, Germany.
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Singer AJ, Shembekar A, Visram F, Schiller J, Russo V, Lawson W, Gomes CA, Santora C, Maliszewski M, Wilbert L, Dowdy E, Viccellio P, Henry MC. Emergency Department Activation of an Interventional Cardiology Team Reduces Door-to-Balloon Times in ST-Segment-Elevation Myocardial Infarction. Ann Emerg Med 2007; 50:538-44. [DOI: 10.1016/j.annemergmed.2007.06.480] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2007] [Revised: 04/17/2007] [Accepted: 06/04/2007] [Indexed: 01/24/2023]
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Pérez-Vizcayno MJ, Hernández-Antolín RA, Alfonso F, Bañuelos de Lucas C, Escaned J, Jiménez P, Fernández-Ortiz A, Fernández C, Macaya C. Evolución en los últimos 20 años en el perfil demográfico, epidemiológico y clínico, técnica y resultados de los procedimientos coronarios percutáneos. Rev Esp Cardiol 2007; 60:932-42. [PMID: 17915149 DOI: 10.1157/13109646] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
INTRODUCTION AND OBJECTIVES The aim of this study was to describe the changes observed in clinical practice in our interventional cardiology unit over the last 20 years. METHODS Between January 1, 1986 and December 31, 2005, >or=17,204 percutaneous transluminal coronary angioplasties (PTCAs) were performed at our center. They were analyzed in four periods of 5 years each. After each procedure, prospective data on patient, procedural, and outcome variables were recorded. The data were analyzed with regard to when the procedure was performed, and the patients' sex and age (i.e., < or >or=75 years). Data from 2006 were used as a reference, but were not included in the analysis. RESULTS The number of PTCAs increased significantly. Over the time period, mean patient age increased (from 57[10] years to 62[12] years for males and from 66[10] years to 70[11] years for females), and there were significant increases in the proportions of women (from 16% to 22%) and patients aged >75 years (from 7% to 22%). Among men, the incidence of smoking decreased while that of hypertension, diabetes and hyperlipemia increased. Among women, however, there was no change in risk factors. The numbers of urgent and emergent procedures (17% of PTCAs were for acute myocardial infarction in 2006) increased in both sexes and age groups, more ad hoc procedures were carried out, and more lesions were treated, usually with a stent. Over time, the success rate increased and the complication rate decreased in both sexes and age groups. In-hospital mortality for all procedures, except those for acute myocardial infarction, was 0.7% in males and 1.4% in females (P=.012). CONCLUSIONS Significant changes were observed over the last 20 years in the baseline characteristics of, the techniques used in, and the outcomes obtained in patients undergoing percutaneous coronary intervention.
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Affiliation(s)
- María J Pérez-Vizcayno
- Unidad de Hemodinámica, Instituto Cardiovascular, Hospital Clínico San Carlos, Madrid, España
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Recio-Mayoral A, Chaparro M, Prado B, Cózar R, Méndez I, Banerjee D, Kaski JC, Cubero J, Cruz JM. The reno-protective effect of hydration with sodium bicarbonate plus N-acetylcysteine in patients undergoing emergency percutaneous coronary intervention: the RENO Study. J Am Coll Cardiol 2007; 49:1283-8. [PMID: 17394959 DOI: 10.1016/j.jacc.2006.11.034] [Citation(s) in RCA: 188] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2006] [Revised: 11/01/2006] [Accepted: 11/16/2006] [Indexed: 02/06/2023]
Abstract
OBJECTIVES This study was designed to determine the effectiveness of a protocol for rapid intravenous hydration to prevent contrast-induced nephropathy (CIN) in patients undergoing emergency percutaneous coronary intervention (PCI). BACKGROUND Contrast-induced nephropathy frequently complicates PCI, resulting in prolonged hospitalization and increased in-hospital and long-term morbidity and mortality. Little is known regarding prevention of CIN in patients undergoing urgent PCI. METHODS We conducted a prospective, controlled, randomized, single-center trial in 111 consecutive patients with acute coronary syndrome undergoing emergency PCI. As part of the hydration therapy, 56 patients (group A) received an infusion of sodium bicarbonate plus N-acetylcysteine (N-AC) started just before contrast injection and continued for 12 h after PCI. The remaining 55 patients (group B) received the standard hydration protocol consisting of intravenous isotonic saline for 12 h after PCI. In both groups, 2 doses of oral N-AC were administered the next day. RESULTS The 2 groups were similar with respect to age, gender, diabetes mellitus, and baseline serum creatinine. A serum creatinine concentration >0.5 mg/dl from baseline after emergency PCI was observed in 1 patient in group A (1.8%) and in 12 patients in group B (21.8%; p < 0.001). Acute anuric renal failure was observed in 1 patient (1.8%) in group A and in 7 patients (12.7%) in group B (p = 0.032). CONCLUSIONS Rapid intravenous hydration with sodium bicarbonate plus N-AC before contrast injection is effective and safe in the prevention of CIN in patients undergoing emergency PCI.
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Pinto DS, Kirtane AJ, Nallamothu BK, Murphy SA, Cohen DJ, Laham RJ, Cutlip DE, Bates ER, Frederick PD, Miller DP, Carrozza JP, Antman EM, Cannon CP, Gibson CM. Hospital Delays in Reperfusion for ST-Elevation Myocardial Infarction. Circulation 2006; 114:2019-25. [PMID: 17075010 DOI: 10.1161/circulationaha.106.638353] [Citation(s) in RCA: 332] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
It has been suggested that the survival benefit associated with primary percutaneous coronary intervention (PPCI) in ST-segment elevation myocardial infarction may be attenuated if door-to-balloon (DB) time is delayed by >1 hour beyond door-to-needle (DN) times for fibrinolytic therapy. Whereas DB times are rapid in randomized trials, they are often prolonged in routine practice. We hypothesized that in clinical practice, longer DB-DN times would be associated with higher mortality rates and reduced PPCI survival advantage. We also hypothesized that in addition to PPCI delays, patient risk factors would significantly modulate the relative survival advantage of PPCI over fibrinolysis.
Methods and Results—
DB-DN times were calculated by subtracting median DN time from median DB time at a hospital using data from 192 509 patients at 645 National Registry of Myocardial Infarction hospitals. Hierarchical models that adjusted simultaneously for both patient-level risk factors and hospital-level covariates were used to evaluate the relationship between PCI-related delay, patient risk factors, and in-hospital mortality. Longer DB-DN times were associated with increased mortality (
P
<0.0001). The DB-DN time at which mortality rates with PPCI were no better than that of fibrinolysis varied considerably depending on patient age, symptom duration, and infarct location.
Conclusions—
As DB-DN times increase, the mortality advantage of PPCI over fibrinolysis declines, and this advantage varies considerably depending on patient characteristics. As indicated in the American College of Cardiology/American Heart Association guidelines, both the hospital-based PPCI-related delay (DB-DN time) and patient characteristics should be considered when a reperfusion strategy is selected.
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Affiliation(s)
- Duane S Pinto
- TIMI Study Group and the Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, 185 Pilgrim Rd, Boston, MA 02115, USA
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Aguiar-Souto P, Valero-González S, Domínguez JFO. N-acetylcysteine and contrast-induced nephropathy. N Engl J Med 2006; 355:1497-8; author reply 1499-500. [PMID: 17021328 DOI: 10.1056/nejmc061983] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Marenzi G, Assanelli E, Marana I, Lauri G, Campodonico J, Grazi M, De Metrio M, Galli S, Fabbiocchi F, Montorsi P, Veglia F, Bartorelli AL. N-acetylcysteine and contrast-induced nephropathy in primary angioplasty. N Engl J Med 2006; 354:2773-82. [PMID: 16807414 DOI: 10.1056/nejmoa054209] [Citation(s) in RCA: 394] [Impact Index Per Article: 21.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Patients with acute myocardial infarction undergoing primary angioplasty are at high risk for contrast-medium-induced nephropathy because of hemodynamic instability, the need for a high volume of contrast medium, and the lack of effective prophylaxis. We investigated the antioxidant N-acetylcysteine for the prevention of contrast-medium-induced nephropathy in patients undergoing primary angioplasty. METHODS We randomly assigned 354 consecutive patients undergoing primary angioplasty to one of three groups: 116 patients were assigned to a standard dose of N-acetylcysteine (a 600-mg intravenous bolus before primary angioplasty and 600 mg orally twice daily for the 48 hours after angioplasty), 119 patients to a double dose of N-acetylcysteine (a 1200-mg intravenous bolus and 1200 mg orally twice daily for the 48 hours after intervention), and 119 patients to placebo. RESULTS The serum creatinine concentration increased 25 percent or more from baseline after primary angioplasty in 39 of the control patients (33 percent), 17 of the patients receiving standard-dose N-acetylcysteine (15 percent), and 10 patients receiving high-dose N-acetylcysteine (8 percent, P<0.001). Overall in-hospital mortality was higher in patients with contrast-medium-induced nephropathy than in those without such nephropathy (26 percent vs. 1 percent, P<0.001). Thirteen patients (11 percent) in the control group died, as did five (4 percent) in the standard-dose N-acetylcysteine group and three (3 percent) in the high-dose N-acetylcysteine group (P=0.02). The rate for the composite end point of death, acute renal failure requiring temporary renal-replacement therapy, or the need for mechanical ventilation was 21 (18 percent), 8 (7 percent), and 6 (5 percent) in the three groups, respectively (P=0.002). CONCLUSIONS Intravenous and oral N-acetylcysteine may prevent contrast-medium-induced nephropathy with a dose-dependent effect in patients treated with primary angioplasty and may improve hospital outcome. (ClinicalTrials.gov number, NCT00237614[ClinicalTrials.gov]).
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Affiliation(s)
- Giancarlo Marenzi
- Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico, Institute of Cardiology, University of Milan, Milan, Italy.
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Affiliation(s)
- Gregg W Stone
- Columbia University Medical Center and the Cardiovascular Research Foundation, New York, NY 10032, USA.
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Steg PG, Juliard JM. Primary percutaneous coronary intervention in acute myocardial infarction: time, time, and time! Heart 2005; 91:993-4. [PMID: 16020578 PMCID: PMC1769058 DOI: 10.1136/hrt.2004.050625] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Longer door-to-balloon times, total duration of ischaemia, and time of presentation relative to symptom onset all have an impact on outcome following primary percutaneous coronary intervention.
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