Primary PCI during off-hours is not related to increased mortality

Timing of Complete Revascularization Stratified by Index Presentation During On- and Off-Hours

Recent trials suggested immediate complete revascularization (ICR) as a safe alternative to staged complete revascularization (SCR), but the impact of the respective percutaneous coronary intervention strategies between on- versus off-hours is unclear. On-hours was defined as an index revascularization performed between 8:00 a.m. and 6:00 p.m., Monday to Friday, or else the procedure was defined as performed during off-hours. The primary end point consisted of a composite of all-cause mortality, myocardial infarction, unplanned ischemia-driven revascularization, and cerebrovascular events at 1-year follow-up. We used Cox regression models to relate randomized treatment with study end points. We evaluated multiplicative and additive interactions between on- versus off-hours and randomized treatment. The BIOVASC (Percutaneous Complete Revascularization Strategies Using Sirolimus Eluting Biodegradable Polymer Coated Stents in Patients Presenting With Acute Coronary Syndromes and Multivessel Disease) trial enrolled 1,097 and 428 patients during on- and off-hours, respectively. Patients randomized during off-hours were more likely to present with ST-segment elevation myocardial infarction (66.4% vs 29.5%, p <0.001). The composite primary outcome occurred in 8.4% and 10.1% of patients randomized to ICR and SCR, respectively, during on-hours (hazard ratio 0.80, 95% confidence interval 0.54 to 1.19). During off-hours, the primary composite outcome occurred in 5.4% and 7.7% in ICR and SCR (0.69, 95% confidence interval 0.32 to 1.46) with no evidence of a differential effect (interaction pmultiplicative = 0.70, padditive = 0.56). No differential effect was found between treatment allocation and on- versus off-hours in any of the secondary outcomes. In conclusion, no differential treatment effect was found when comparing ICR versus SCR in patients presenting with acute coronary syndrome and multivessel disease during on- or off-hours.

Association between holiday and weekend admissions and mortality outcomes among patients with acute myocardial infarction receiving percutaneous coronary intervention in Taiwan

There is a lack of studies that concurrently differentiate the effect of the holiday season from the weekend effect on mortality risk in patients with acute myocardial infarction (AMI). We evaluated the mortality risk among patients admitted with AMI who underwent percutaneous coronary intervention, using data from the Taiwan National Health Insurance Research Database. Adult AMI patients admitted during January and February between 2013 and 2020 were enrolled and classified into the holiday season (using the Chinese New Year holiday seasons as an indicator) (n = 1729), weekend (n = 4725), and weekday (n = 14,583) groups according to the first day of admission. A multivariable logistic regression model was used to assess the risk. With the weekday group or the weekend group as the reference, the holiday season group did not have increased risks of in-hospital mortality (adjusted odds ratio [aOR] 1.15; 95% confidence intervals [CI] 0.93-1.42 or aOR 1.23; 95% CI 0.96-1.56) and 7-day mortality (aOR 1.20; 95% CI 0.90-1.58 or aOR 1.24; 95% CI 0.90-1.70). Stratified and subgroup analyses showed similar trends. We conclude that holiday season-initiated admissions were not associated with higher mortality risks in AMI admission cases than weekday or weekend admissions.

Impact of off-hour admission on the MACEs of patients with acute myocardial infarction

BACKGROUND

In China, on more than 100 weekends or holidays, only on-duty cardiologists are available during admissions. This study aimed to analyze the impact of admission time on major adverse cardiovascular events (MACEs) in patients with acute myocardial infarction (AMI).

METHODS

This prospective observational study enrolled patients with AMI between October 2018 and July 2019. The patients were assorted into off-hour (admitted on weekends or national holidays) and on-hour groups. The outcome was MACEs at admission and 1 year after discharge.

RESULTS

A total of 485 patients with AMI were enrolled in this study. The occurrence of MACEs was significantly higher in the off-hour group compared with the on-hour group (P < .05). Multivariate regression analysis showed that age (HR = 1.047, 95% CI: 1.021-1.073), blood glucose level (HR = 1.029, 95% CI: 1.009-1.050), multivessel disease (HR = 1.904, 95% CI: 1.074-3.375), and off-hour hospital admission (HR = 1.849, 95% CI: 1.125-3.039) were all independent risk factors for in-hospital MACEs, while percutaneous coronary intervention (HR = 0.210, 95% CI: 0.147-0.300) and on-hour admission (HR = 0.723, 95% CI: 0.532-0.984) were protective factors for MACEs 1 year after discharge.

CONCLUSION

The "off-hour effect" still existed in patients with AMI, and the risk of MACEs in the hospital and 1 year after discharge was higher for off-hour admission.

Acute Coronary Syndrome Presenting during On- and Off-Hours: Is There a Difference in a Tertiary Cardiovascular Center?

Background and Objectives: ACS presents an acute manifestation of coronary artery disease and its treatment is based on timely interventional diagnostics and PCI. It has been known that the treatment and the outcomes are not the same for all the patients with ACS during the working day, depending on the availability of the procedures and staff. The aim of the study was to explore the differences in clinical characteristics and outcomes in patients admitted for ACS during on- and off-hours. Materials and Methods: The retrospective study included 1873 consecutive ACS patients admitted to a tertiary, university hospital that underwent coronary angiography and intervention. On-hours were defined from Monday to Friday from 07:30 h to 14:30 h, while the rest was considered off-hours. Results: There were more males in the off-hours group (on-hours 475 (56%) vs. off-hours 635 (62%); p = 0.011), while previous MI was more frequent in the on-hours group (on 250 (30%) vs. off 148 (14%); p < 0.001). NSTEMI was more frequent during on-hours (on 164 (19%) vs. off 55 (5%); p < 0.001), while STEMI was more frequent during off-hours (on 585 (69%) vs. off 952 (93%); p < 0.001). Patients admitted during on-hours had more multivessel disease (MVD) (on 485 (57%) vs. off 489 (48%); p = 0.006), as well as multivessel PCI (on 187 (22%) vs. off 171 (16%); p = 0.002), while radial access was preferred in off-hours patients (on 692 (82%) vs. off 883 (86%); p = 0.004). Left main PCI was performed with similar frequency in both groups (on 37 (4%) vs. off 35 (3%); p = 0.203). Death occurred with similar frequency in both groups (on 17 (2.0%) vs. off 26 (2.54%); p = 0.404), while major adverse cardio-cerebral events (MACCEs) were more frequent in the on-hours group (on 105 (12.4%) vs. off 70 (6.8%); p = 0.039) probably due to the more frequent repeated PCI (on 49 (5.8%) vs. off 27 (2.6%); p = 0.035). Conclusions: Patients admitted for ACS during working hours in a tertiary hospital present with more complex CAD, have more demanding interventions, and experience more MACCEs during follow-up mostly due to myocardial infarctions and repeated procedures.

Effect of weekend versus weekday admission on the mortality of acute ischemic stroke patients in China: an analysis of data from the Chinese acute ischemic stroke treatment outcome registry

Background

Due to disparities in medical resources in rural and urban areas as well as in different geographic regions in China, the effect of weekend versus weekday admission on the outcomes of acute ischemic stroke (AIS) patients is unknown. Our aim was to investigate whether the outcomes of AIS patients differ according to the day of admission in China.

Methods

The data were extracted from the Chinese Acute Ischemic Stroke Treatment Outcome Registry (CASTOR), a multicenter prospective study database of patients diagnosed with AIS. The chi-square test (χ²) and logistic regression were used to assess mortality for weekday and weekend admissions among AIS patients stratified by rural or urban status and geographic region (including the eastern, northeastern, central, and western regions).

Results

In total, 9,256 patients were included in this study. Of these patients, 57.2% were classified as urban, and 42.8% were classified as rural. A total of 6,760 (73%) patients were admitted on weekdays, and 2,496 (27%) were admitted on weekends. There was no significant difference in the mortality rate among patients admitted on weekends compared with those admitted on weekdays in urban (7.5% versus 7.4%) or rural areas (8.8% versus 8.1%; p > 0.05). The mortality rate was the highest among patients admitted on weekends and weekdays (11.6% versus 10.3%) in the northeastern area, without statistical significance before and after adjusting for the patients' background characteristics (p > 0.05). In addition, regression analysis revealed that the mortality of patients admitted on weekdays was more likely to be influenced by regional subgroup, hospital level and intravenous thrombolysis than that of patients admitted on weekends.

Conclusion

The weekend effect was not observed in the mortality of patients with AIS regardless of rural-urban status or geographic region in China.

Association of Admission Time and Mortality in STEMI Patients: A Systematic Review and Meta-analysis

This systematic review and meta-analysis aimed to evaluate patients with acute ST-segment elevation myocardial infarction (STEMI) who were admitted during off-hours and treated with primary angioplasty associated with an increased risk of mortality compared with those admitted during regular working hours. We performed a systematic literature search using PubMed, SCOPUS, Europe PMC, and Cochrane CENTRAL databases that was finalized on March 15, 2021. The primary outcome was mortality comprising early (in-hospital), midterm (30 days to 1 year), and long-term mortality (>1 year). A total of 384,452 patients from 56 studies were included. The overall mortality of acute STEMI patients admitted during off-hours and regular hours were 6.1 and 6.7%, respectively. Patients admitted during off-hours had similar risk of early, midterm, and long-term mortality compared to those admitted during regular working hours ([relative risk or RR = 1.07, 95% confidence interval or CI, 1.00-1.14, p  = 0.06; I 2  = 45%, p  = 0.0009], [RR = 1.00, 95% CI, 0.95-1.05, p  = 0.92; I 2  = 13%, p  = 0.26], and [RR = 0.95, 95% CI, 0.86-1.04, p  = 0.26; I 2  = 0%, p  = 0.76], respectively). Subgroup analyses indicated that the results were consistent across all subgroups ([women vs. men], [age >65 years vs. ≤65 years], and [Killip classification II to IV vs. Killip I]). Funnel plot was asymmetrical. However, Egger's test suggests no significance of small-study effects ( p  = 0.19). This meta-analysis showed that patients with acute STEMI who were admitted during off-hours and treated with primary angioplasty had similar risk of early, midterm, and long-term mortality compared with those admitted during regular working hours.

Relationship Between Work Mode, Time of Admission, and Mortality in St-Segment Elevation Myocardial Infarction: Results From the TURKMI Registry

Treatment of acute myocardial infarction has evolved steadily. However, limited studies exist regarding the effect of all innovations on mortality. We aimed to investigate the effect of time of admission and work mode on 1-year outcomes in patients presenting with ST-segment elevation myocardial infarction (STEMI). Based on the TURKMI registry, we analyzed 735 STEMI patients recruited consecutively and prospectively from 50 PCI-capable cardiology clinics within a prespecified two-week period. Centers were categorized as "on-call" and "on-duty" according to their work mode. At 1-year follow-up, all-cause mortality and cardiovascular mortality were the primary outcomes. The secondary outcome was a composite of coronary revascularization, re-infarction/stroke, and recurrent angina. One-fifth of the participants (19.5%) were treated in the on-call group. All-cause mortality (7.9 vs 10.5%, aHR: 1.16, P = .650) and cardiovascular mortality rates (6.1 vs 9.1%, aHR: 1.35, P = .413) were similar between centers' modes of work. Likewise, both groups were equally likely to undergo coronary revascularization (P = .278), re-MI/stroke (P = .280), recurrent angina (P = .175), and the composite outcome of these components (P = .482). No significant difference was observed in primary outcomes between weekend and weekday admissions. In conclusion, we observed similar outcomes between the on-call and on-duty groups among STEMI patients.

Influence of Admission Time on Health Care Quality and Utilization in Patients with Stroke: Analysis for a Possible July Effect and Weekend Effect

(1) Purpose: Undesirable health care outcomes could conceivably increase as a result of the entry of new, less experienced health care personnel into patient care during the month of July (the July effect) or as a result of the less balanced allocation of health care resources on weekends (the weekend effect). Whether these two effects were present in Taiwan’s National Health Insurance (NHI) system was investigated. (2) Methods: The current study data were acquired from the NHI Research Database. The research sample comprised ≥18-year-old patients diagnosed as having a stroke for the first time from 1 January 2006 to 30 September 2012. The mortality rate within 30 days after hospitalization and readmission rate within 14 days after hospital discharge were used as health care quality indicators, whereas health care utilization indicators were the total length and cost of initial hospitalization. (3) Results: The results revealed no sample-wide July effect with regard to the four indicators among patients with stroke. However, an unexpected July effect was present among in-patients in regional and public hospitals, in which the total lengths and costs of initial hospitalization for non-July admissions were higher than those for July admissions. Furthermore, the total hospitalization length for weekend admissions was 1.06–1.07 times higher than that for non-weekend admissions; the total hospitalization length for weekend admissions was also higher than that for weekday admissions during non-July months. Thus, weekend admission did not affect the health care quality of patients with stroke but extended their total hospitalization length. (4) Conclusions: Consistent with the NHI’s general effectiveness in ensuring fair, universally accessible, and high-quality health care services in Taiwan, the health care quality of patients examined in this study did not vary significantly overall between July and non-July months. However, a longer hospitalization length was observed for weekend admissions, possibly due to limitations in personnel and resource allocations during weekends. These results highlight the health care efficiency of hospitals during weekends as an area for further improvement.

Percutaneous coronary intervention during on- and off-hours in patients with ST-segment elevation myocardial infarction

OBJECTIVE

There are conflicting data on the clinical outcomes of percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) based on the time of admission to the catheterization laboratory. Thus, we aimed to assess clinical outcomes in an unselected cohort of consecutive patients with STEMI treated with PCI during on-and-off hours of work.

METHODS

A total of 99,783 patients were included in the analysis. Patients were divided using the most frequently used definition: On-hours (Monday-Friday 07:00 AM-04:59 PM); off-hours (Monday-Friday 05:00 PM-06:59 AM, Saturday, Sunday, and nonworking holidays) (37,469 matched pairs). To avoid potential preselection bias, a propensity score was calculated to compare on-and-off hour groups.

RESULTS

Higher radiation doses were observed for PCIs performed during off-hours (1055.2(±1006.5) vs. 1081.6(±1003.25)[mGy] and p = 0.001). A similar prevalence of periprocedural complications was observed during on- and off-hours. However, there was a higher mortality rate during off-hours than during regular working hours (1.17% (439) vs. 1.49% (559) and p = 0.001).

CONCLUSIONS

Primary PCIs in STEMI performed during off-hours might be associated with a higher rate of periprocedural mortality and higher radiation doses than procedures conducted during regular working hours.

Association Between Off-hour Presentations and In-hospital Mortality for Patients with Acute ST-Elevation Myocardial Infarction Treated with Primary Percutaneous Coronary Intervention

Objectives

This study aimed to assess the effect of the admission time (on-hours versus off-hours) on in-hospital mortality in patients with ST-elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PPCI) in a region without STEMI network.

Methods

We analysed in-hospital the mortality among 300 consecutive ST-segment elevation myocardial infarction (STEMI) patients treated with PPCI between March 2012 and February 2017. Patients were divided according to admission time into on-hours admission (08:00 AM until 08:00 PM on weekdays) versus off-hours admission (08:00 PM until 08:00 AM on weekdays and 24 h on weekends and holidays). Demographic and clinical data as well as in-hospital mortality were compared between the two groups.

Results

One hundred and seventy eight (59.3%) patients were admitted during on-hours, and 122 (40.7%) patients were presented in off-hours. The mean door-to-balloon time was 42.3 min in the off-hours group and 34.2 min in the on-hours group with no statistically significant difference (p = 0.39). The mortality rate was 3.9% at on-hours presentation versus 4.09% in off-hours admission (p = 0.58). Multivariate logistic regression analysis showed that off-hours presentation was not associated with in-hospital mortality. [odds ratio (OR) 0.74; 95% CI, 0.21–2.61, p = 0.64].

Conclusion

Despite no efficient STEMI network in present study, off-hour presentation had no significant impact on in-hospital prognosis in patients with STEMI treated with PPCI. Larger studies are warranted in order to determine the prognostic role of off-hour presentation in patients with STEMI undergoing PPCI.

Mortality differences in acute myocardial infarction patients in the Netherlands: The weekend-effect

Objective

Several studies have shown that patients admitted with an acute myocardial infarction during the weekends have a higher mortality rate than those admitted during weekdays, possibly attributable to less trained personnel available and a lower use of medical procedures. The current study aimed to assess this ‘weekend-effect’ in a nationwide registry.

Methods

In the Netherlands, all inhabitants are, by law, obliged to have health insurance and all claim data are centrally registered. In 2012 and 2013, all national diagnose-codings of STEMI and NSTEMI patients were acquired. One-year mortality rates and treatment with percutaneous coronary intervention (PCI) were compared between weekdays and weekends (holidays included).

Results

In total, 59,534 patients (67 ± 13 years, 39,545(66%) male) were included of whom 33,904(57%) had a NSTEMI. Overall 6857(12%) patients died in the year following the acute myocardial infarction registration. In STEMI patients, no differences in one-year mortality rates were observed between admission on weekdays or weekends. In NSTEMI patients, one-year mortality was higher in those admitted during weekends (weekdays 11% versus weekends 13%, P < .001). Furthermore, STEMI patients admitted during weekends were more often treated with PCI (weekdays 77% versus weekends 81%, P < .001). Conversely, NSTEMI patients admitted during weekends were less often treated with PCI (weekdays 35% versus weekends 32%, P < .001).

Conclusion

Differences in treatment and mortality rates exist between acute myocardial infarction patients admitted during weekdays and weekends. NSTEMI patients admitted during weekends are less often treated with PCI and have a higher mortality rate than patients admitted during weekdays.

Impact of time of admission on short- and long-term mortality in the Vienna STEMI registry

BACKGROUND

Several studies have shown contradictive findings regarding mortality and hospital admission time in patients presenting with ST-elevation myocardial infarction (STEMI). The aim of this study was to assess the impact of "on-" or "off-hour" admission on short- and long-term all-cause mortality of patients in the advanced Vienna STEMI network between 2003 and 2009.

METHODS AND RESULTS

In total, 2829 patients were included into this analysis. Patients were stratified according to admission time into "on-hour" admission (07:30 until 15:00h on weekdays) and "off-hour" admission (15:00-7:30h on weekdays and 24h on weekends). As endpoint of interest, all-cause mortality was investigated after 30days and 3years of follow-up, the latter for all patients and as Landmark analysis for survivors of the index event. Mean age was 60.5±13.3years, 2048 (72.4%) patients were male and 1260 (44.5%) patients presented with anterior wall infarction. 683 (24.1%) patients were admitted "on-hours", 2146 (75.9%) patients were admitted "off-hours". All-cause death occurred in 176 (6.2%) patients after a follow-up of 30days and in 337 (11.9%) patients after 3years. For short- and long-term all-cause mortality no significant differences could be detected between "on-" and "off-hour" admission in univariate and multivariate Cox proportional hazard analyses as well as for propensity score adjusted outcome analysis.

CONCLUSION

In the Vienna STEMI network, "on-" or "off-hour" admission had no impact on short- and long-term mortality for all-comers presenting with acute STEMI. Our findings confirm the imperative need for well-structured STEMI networks of care, as previous data repeatedly demonstrated increased adverse cardiovascular outcome for "off-hour" admission.

Two-year mortality of primary angioplasty for acute myocardial infarction during regular working hours versus off-hours

BACKGROUND

Studies with short-term follow-up found higher mortality in patients with STEMI who underwent primary PCI during off-hours as compared to regular working hours. We analyzed the interaction between one and two-year survival of patients with STEMI who underwent primary PCI during regular working hours and off-hours in a tertiary care academic teaching hospital.

METHODS

A total of 1126 STEMI patients treated with primary PCI between 2008 and 2013 were analyzed. Two-years follow-up were available in 941 (83%) patients. Multivariable survival analysis was used to estimate the relationship between treatment during off-hours versus regular hours and the incidence of all-cause mortality at 2-years follow-up. Logistic regression was used to calculate interaction p-values between time of admission and time (between ≤1 year and ≤2 year).

RESULTS

At 2-years, the mortality rate of patients admitted during off-hours and regular hours was similar (15% vs. 19%; adjusted hazard ratio 0.77; 95% confidence interval 0.52-1.16). Of the 941 patients, those who admitted during off-hours (N = 717) had similar median door-to-device time (94 min vs. 91 min), final Thrombolysis In Myocardial Infarction 3 flow grade (93% vs. 91%) and use of dual antiplatelet within 24 h (96% vs. 98% respectively) as compared with regular hours admission (N = 224). There were no mortality difference observed between one year and two years (p interaction >0.05).

CONCLUSION

In this analysis, the similar mortality observed at one year between patients with STEMI treated by primary PCI during off-hour and regular hour were maintained at two years.

Off-hours presentation is associated with short-term mortality but not with long-term mortality in patients with ST-segment elevation myocardial infarction: A meta-analysis

BACKGROUND

The association between off-hours presentation and mortality in patients with ST-segment elevation myocardial infarction (STEMI) remains unclear. We performed a meta-analysis to assess the impact of off-hours presentation on short- and long-term mortality among STEMI patients.

METHODS

We searched PubMed, EMBASE, and the Cochrane Library from their inception to 10 July 2016. Studies were eligible if they evaluated the relationship of off-hours (weekend and/or night) presentation with short- and/or long-term mortality.

RESULTS

A total of 30 studies with 33 cohorts involving 192,658 STEMI patients were included. Off-hours presentation was associated with short-term mortality (odds ratio [OR] 1.07, 95% confidence interval [CI] 1.02-1.12, P = 0.004) but not with long-term mortality (OR 1.00, 95% CI 0.94-1.07, P = 0.979). No significant heterogeneity was observed. The outcomes remained the same after sensitivity analyses and trim and fill analyses. Subgroup analyses showed that STEMI patients undergoing primary percutaneous coronary intervention do not have a higher risk of short-term mortality (OR 1.061, 95% CI 0.993-1.151). In addition, higher mortality was observed only during hospitalization (OR 1.072, 95% CI 1.022-1.125), not at the 30-day, 1-year or long-term follow-ups.

CONCLUSIONS

Off-hours presentation was associated with an increase in short-term mortality, but not long-term mortality, among STEMI patients. Clinical approaches to decrease short-term mortality regardless of the time of presentation should be evaluated in future studies.

Comparison of Outcomes of ST-Elevation Myocardial Infarction Treated by Percutaneous Coronary Intervention During Off-Hours Versus On-Hours

Previous studies have reported worse outcomes and longer door-to-balloon times (DBTs) in patients presenting with ST-elevation myocardial infarction (STEMI) after normal working hours, during weekends, and on holidays (off-hours) compared with normal business hours (on-hours). Recent studies, however, have reported similar outcomes regardless of presentation time. MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were queried from January 1990 through December 2016. Only studies comparing STEMI outcomes during off-hours versus on-hours with percutaneous coronary intervention were included. A random-effects meta-analysis model was used to pool outcomes across the studies. Clinical end points included short- (<30 days of presentation), intermediate- (at 1 to 2 years), and long-term (at 3 to 4 years) stent thrombosis, mortality, recurrent myocardial infarction (MI), and major adverse cardiovascular events (MACEs). A total of 86,776 patients (62 years and 74.5% male) were identified from 39 studies. There was no significant difference between both groups with regard to mean DBT (odds ratio [OR] 0.74, 95% confidence interval [CI] -2.73 to 4.22, p = 0.67) or median DBT (p = 0.19). There was no significant difference between the 2 groups for short-term end points including mortality (OR 1.11, 95% CI 0.99 to 1.25, p = 0.08), MI (OR 1.25, 95% CI 0.90 to 1.74, p = 0.18), MACE (OR 1.06, 95% CI 0.93 to 1.20, p = 0.40), or stent thrombosis (OR 1.23, 95% CI 0.83 to 1.82, p = 0.31). Similarly, intermediate-term end points were not statistically different for mortality (OR 0.97, 95% CI 0.89 to 1.05, p = 0.46), MI (OR 0.86, 95% CI 0.73 to 1.02, p = 0.08), or MACE (OR 1.00, 95% CI 0.92 to 1.08, p = 0.98). Long-term end points did not differ statistically between groups for mortality (OR 0.95, 95% CI 0.83 to 1.09, p = 0.46), MI (OR 1.19, 95% CI 0.77 to 1.84, p = 0.44), or MACE (OR 0.98, 95% CI 0.89 to 1.08, p = 0.67). In conclusion, patients presenting with STEMI during off-hours and treated with percutaneous coronary intervention had similar short-, intermediate-, and long-term outcomes compared with patients presenting during on-hours. DBT was not affected by the time of presentation.

On versus off-hour care of patients with acute coronary syndrome and persistent ST-segment elevation in certified German chest pain units

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.

Total ischemic time and outcomes for patients with ST-elevation myocardial infarction: does time of admission make a difference?

OBJECTIVE

To investigate whether admission time was associated with the delay of reperfusion therapy and in-hospital death in patients with ST-elevation myocardial infarction (STEMI).

METHODS

All patients with STEMI who were admitted to the emergency department and underwent primary percutaneous coronary intervention at Peking University People's Hospital between April 2012 and March 2015 were included. We examined differences in clinical characteristics, total ischemic time, and in-hospital death between patients admitted during off-hours and those admitted during regular hours. Multivariate logistic regression was used to estimate the relationship between off-hours admission and clinical outcome.

RESULTS

The sample comprised 184 and 105 patients with STEMI admitted to hospital during off-hours and regular hours, respectively. Total ischemic and onset-to-door times were significantly shorter in patients admitted during off-hours than among those admitted during regular hours (all P < 0.05). Door-to-balloon (DTB) time, the rate of DTB time ≤ 90 min, and in-hospital death were comparable between groups. Multivariate logistic regression showed that age and creatinine level, but not off-hours admission, were associated independently with increased in-hospital death.

CONCLUSIONS

Off-hours admission did not result in delayed reperfusion therapy or increased in-hospital mortality in patients with STEMI. Further efforts should focus on identifying pivotal factors associated with the pre-hospital and in-hospital delay of reperfusion therapy, and implementing quality improvement initiatives for reperfusion programs.

Off-hour admission and outcomes for patients with acute myocardial infarction undergoing percutaneous coronary interventions

BACKGROUND

Prior studies have suggested that patients with acute myocardial infarction (AMI) who are admitted during off-hours (weekends, nights and holidays) have higher mortality when compared with patients admitted during regular hours.

METHODS

We analyzed consecutive patients with AMI (ST-elevation myocardial infarction [STEMI] and non-STEMI) who were treated with percutaneous coronary interventions from January 1998 to June 2010 at an academic medical center. Multivariable logistic regression models were used to estimate the association between off-hour admission and clinical outcomes adjusted for demographic and clinical variables.

RESULTS

There were 3,422 and 2,664 patients with AMI admitted during off-hours and regular hours, respectively. Patients admitted during off-hours were more likely to have STEMI (56% vs 48%, P < .001), have cardiogenic shock at presentation (6% vs 4%, P = .002), and develop shock after presentation (6% vs 5%, P = .004). After multivariable analyses, off-hour admission was not significantly associated with in-hospital mortality (odds ratio [OR] 1.12, 95% CI 0.84-1.49), 30-day mortality (OR 1.12, 0.87-1.45), or 30-day readmissions (OR 1.01, 0.84-1.20) but was significantly associated with composite major complications and any of emergent coronary artery bypass graft surgery, ventricular arrhythmia, stroke/transient ischemic attack, and gastrointestinal/retroperitoneal/intracranial bleeding (OR 1.27, 1.05-1.55, P = .015). There was no significant time trend in the adjusted mortality difference between off-hours and regular hours. The results were not different between STEMI and non-STEMI.

CONCLUSIONS

Patients who were admitted during off-hours did not have higher mortality or readmission rates as compared with ones admitted during regular hours at an academic medical center.

Quality of care in primary percutaneous coronary intervention for acute ST-segment -elevation myocardial infarction: Gulf RACE 2 experience

BACKGROUND AND OBJECTIVES

Primary percutaneous coronary intervention (pPCI) has been recognized as an effective management strategy for acute ST-segment-elevation myocardial infarction (STEMI). However, there is no first-hand information regarding the quality of pPCI procedures in the Arabian Gulf countries. This study aims to explore the quality of pPCI practice.

DESIGN AND SETTINGS

The Gulf Race II was designed as a prospective, multinational, multicentre registry of acute coronary events, focusing on the epidemiology, management practices, and outcomes of patients with acute coronary syndrome. The study recruited consecutive patients aged 18 years and above from 65 hospitals in 6 adjacent Middle Eastern countries (Bahrain, Saudi Arabia, Qatar, Oman, United Arab Emirates, and Yemen).

PATIENTS AND METHODS

We used data from the Gulf Registry of Acute Coronary Events (Gulf RACE 2). We analyzed data on patients who received pPCI to assess the guidelines-supported performance measure of door-to-balloon (D2B).

Off-hour presentation and outcomes in patients with acute myocardial infarction: systematic review and meta-analysis

OBJECTIVE

To assess the association between off-hour (weekends and nights) presentation, door to balloon times, and mortality in patients with acute myocardial infarction.

DATA SOURCES

Medline in-process and other non-indexed citations, Medline, Embase, Cochrane Database of Systematic Reviews, and Scopus through April 2013.

STUDY SELECTION

Any study that evaluated the association between time of presentation to a healthcare facility and mortality or door to balloon times among patients with acute myocardial infarction was included.

DATA EXTRACTION

Studies' characteristics and outcomes data were extracted. Quality of studies was assessed with the Newcastle-Ottawa scale. A random effect meta-analysis model was applied. Heterogeneity was assessed using the Q statistic and I(2).

RESULTS

48 studies with fair quality, enrolling 1,896,859 patients, were included in the meta-analysis. 36 studies reported mortality outcomes for 1,892,424 patients with acute myocardial infarction, and 30 studies reported door to balloon times for 70,534 patients with ST elevation myocardial infarction (STEMI). Off-hour presentation for patients with acute myocardial infarction was associated with higher short term mortality (odds ratio 1.06, 95% confidence interval 1.04 to 1.09). Patients with STEMI presenting during off-hours were less likely to receive percutaneous coronary intervention within 90 minutes (odds ratio 0.40, 0.35 to 0.45) and had longer door to balloon time by 14.8 (95% confidence interval 10.7 to 19.0) minutes. A diagnosis of STEMI and countries outside North America were associated with larger increase in mortality during off-hours. Differences in mortality between off-hours and regular hours have increased in recent years. Analyses were associated with statistical heterogeneity.

CONCLUSION

This systematic review suggests that patients with acute myocardial infarction presenting during off-hours have higher mortality, and patients with STEMI have longer door to balloon times. Clinical performance measures may need to account for differences arising from time of presentation to a healthcare facility.