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

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.

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.

Long-term outcomes in ST-elevation myocardial infarction patients treated according to hospital visit time

BACKGROUND/AIMS

Rapid percutaneous coronary intervention (PCI) is the cornerstone of treatment for ST-elevation myocardial infarction (STEMI). However, there have been conflicting results regarding the differences in clinical outcomes between on-hours and off-hours presentation in STEMI patients. We aimed to examine the difference in long-term outcomes between off-hours and on-hours PCI in patients with STEMI.

METHODS

The characteristics and clinical outcomes of 5,364 STEMI patients between November 2011 and June 2015 from the Korea Acute Myocardial Infarction Registry-National Institutes of Health (KAMIR-NIH) registry were analyzed. Patients were divided into two groups: the off-hours group (weekdays from 6:01 PM to 7:59 AM, weekends, and legal holidays) and the on-hours group (weekdays from 8:00 AM to 6:00 PM). Major adverse cardiac and cerebrovascular events (MACCEs) were defined as a composite of allcause mortality, non-fatal myocardial infarction, any revascularization, cerebrovascular accident, and stent thrombosis. The primary endpoint was the occurrence of MACCEs, and all other clinical outcomes were analyzed.

RESULTS

A total of 3,119 patients (58.1%) underwent primary PCI due to STEMI during off-hours and 2,245 patients (41.9%) during on-hours. At 36 months, the clinical outcomes of the off-hours group were similar to those of the on-hours group in both the unadjusted and propensity score weighting-adjusted analyses.

CONCLUSION

Our analysis revealed that the long-term outcomes in STEMI patients admitted to hospitals during off-hours were similar to outcomes of those admitted during on-hours.

Off-hours admission does not impact outcomes in patients undergoing primary percutaneous coronary intervention and with a first medical contact-to-device time within 90 min

Background:

It remains unclear whether the outcomes of ST-elevation myocardial infarction (STEMI) patients treated with primary percutaneous coronary intervention (PPCI) during off-hours are as favorable as those treated during on-hours, especially those with a first medical contact-to-device (FMC-to-device) time within 90 min. We aimed to determine whether off-hours admission impacted late outcomes in patients undergoing PPCI and with an FMC-to-device time ≤90 min.

Methods:

This multicenter retrospective study included 670 STEMI patients who underwent successful PPCI and had an FMC-to-device time ≤90 min from 19 chest pain centers in Beijing from January 2018 to December 2018. Patients were divided into on-hours group and off-hours group based on their arrival time. Baseline characteristics, clinical data, and key time intervals during treatment were collected from the Quality Control & Improvement Center of Cardiovascular Intervention of Beijing by the “Heart and Brain Green Channel” app.

Results:

Overall, the median age of the patients was 58.8 years and 19.9% (133/670) were female. Of these, 296 (44.2%) patients underwent PPCI during on-hours and 374 (55.8%) patients underwent PPCI during off-hours. Compared with the on-hours group, the off-hours group had a longer FMC-to-device time and fewer patients with FMC-to-device time ≤60 min (P < 0.05). During the mean follow-up period of 24 months, a total of 64 (9.6%) participants experienced a major adverse cardiovascular event (MACE), with 28 (9.1%) in the on-hours group and 36 (9.6%) in the off-hours group (P > 0.05). According to the Cox regression analyses, off-hours admission was not a predictor of 2-year MACEs (P = 0.788). Similarly, the Kaplan-Meier curves showed that the risks of a MACE, all-cause death, reinfarction, and target vessel revascularization were not significantly different between the two groups (P > 0.05).

Conclusions:

This real-world, multicenter retrospective study demonstrated that for STEMI patients who underwent PPCI within 90 min, off-hours admission was safe, with no difference in the risk of 2-year MACEs compared with those with on-hours admission.

Impact of admission hours on each stage of care and total reperfusion delays in patients with ST elevation myocardial infarction

BACKGROUND

ST segment elevation myocardial infarction (STEMI) is preferably treated by prompt primary percutaneous coronary intervention (pPCI). Delays in initial stages of care of STEMI patients admitted off versus routine hours are controversial. The aim of this study was to evaluate time periods in each stage of care of STEMI patients submitted to pPCI in a private tertiary hospital during on- vs. off-hours, and the adherence to current guidelines recommended times.

METHODS

consecutive STEMI patients admitted 2013-2019 who underwent pPCI were enrolled in this cohort study. Time periods were prospectively registered and other variables retrieved from electronic medical records. Primary outcomes were the time periods of each stage of care, since patient arrival in the emergency room (ER) until reperfusion of the culprit artery, performed during on-hours (weekdays, from 08:00 AM to 07:59 PM) or off-hours (all other days and time periods, or holidays).

RESULTS

218 patients were included, 131 (60%) presented off-hours, with longer time periods between calling the catheterization laboratory staff until reperfusion, [55 min × 72 min; P < 0.001] and ER door-to-reperfusion [73 min × 98 min; P < 0.001]. Exploratory analysis by year suggested a decreasing reperfusion delay during on-hours admissions. In most years, total time for reperfusion exceeded the sixty minutes frame recommended in current North American guidelines, for both on- and off-hours admissions. Considering the ninety minutes recommendation of the European guideline, only on-hour admissions were in accordance during most years.

CONCLUSIONS

STEMI patients, particularly when admitted off-hours, have lags in some stages of care, culminating in delayed myocardial reperfusion greater than recommended in current guidelines.