Implementing a comprehensive STEMI protocol to improve care metrics and outcomes in patients with in-hospital STEMI: an observational cohort study

BACKGROUND

Patients who experience in-hospital ST-segment elevation myocardial infarction (iSTEMI) represent a uniquely high-risk cohort owing to delays in diagnosis, prolonged time to reperfusion and increased mortality. Quality initiatives aimed at improving the care of this vulnerable, yet understudied population are needed.

METHODS

This study included consecutive patients with iSTEMI treated with percutaneous coronary intervention (PCI) between 1 January 2011 and 15 July 2019 at a single, tertiary referral centre. A comprehensive iSTEMI protocol (CSP) was implemented on 15 July 2014, incorporating: (1) cardiology fellow activation of the catheterisation lab using standardised criteria, (2) nursing chest pain protocol, (3) improved electronic access to electrocardiographic studies, (4) checklist for initial triage and management, (5) 24/7/365 catheterisation lab readiness and (6) radial-first PCI approach. Key metrics and clinical outcomes were compared before and after CSP implementation.

RESULTS

Among 125 total subjects, the post-CSP cohort (n=81) was younger, had more males and were more likely to be hospitalised for cardiac-related reasons relative to the pre-CSP cohort (n=44) who were more likely hospitalised for operative-related aetiologies. After CSP adoption, median ECG-to-first-device-activation time decreased from 113 min to 64 min (p<0.001), goal ECG-to-first-device-activation time increased from 36% to 76% of patients (p<0.001), administration of guideline-directed medical therapy prior to PCI increased from 27.3% to 65.4% (p<0.001), trans-radial access increased from 16% to 70% (p<0.001) and rates of discharge home increased from 56.8% to 76.5% (p=0.04). Statistically insignificant numerical reductions were observed post-CSP in in-hospital mortality (18.2% vs 9.9%, p=0.30), 30-day mortality (15.9% vs 12.3%, p=0.78) and 1-year mortality (27.3% vs 21.0%, p=0.57).

CONCLUSIONS

The implementation of a CSP was associated with marked enhancements in key care metrics among patients with iSTEMI. Among a larger cohort, the use of a CSP yielded a significant reduction in ECG-to-first-device-activation time in a particularly vulnerable population at high risk of death.

Relationship of Neighborhood Deprivation and Outcomes of a Comprehensive ST Elevation Myocardial Infarction Protocol

Background

We evaluated whether a comprehensive ST‐segment–elevation myocardial infarction protocol (CSP) focusing on guideline‐directed medical therapy, transradial percutaneous coronary intervention, and rapid door‐to‐balloon time improves process and outcome metrics in patients with moderate or high socioeconomic deprivation.

Methods and Results

A total of 1761 patients with ST‐segment–elevation myocardial infarction treated with percutaneous coronary intervention at a single hospital before (January 1, 2011–July 14, 2014) and after (July 15, 2014– July 15, 2019) CSP implementation were included in an observational cohort study. Neighborhood deprivation was assessed by the Area Deprivation Index and was categorized as low (≤50th percentile; 29.0%), moderate (51st –90th percentile; 40.8%), and high (>90th percentile; 30.2%). The primary process outcome was door‐to‐balloon time. Achievement of guideline‐recommend door‐to‐balloon time goals improved in all deprivation groups after CSP implementation (low, 67.8% before CSP versus 88.5% after CSP; moderate, 50.7% before CSP versus 77.6% after CSP; high, 65.5% before CSP versus 85.6% after CSP; all P<0.001). Median door‐to‐balloon time among emergency department/in‐hospital patients was significantly noninferior in higher versus lower deprivation groups after CSP (noninferiority limit=5 minutes; P_{noninferiority} high versus moderate = 0.002, high versus low <0.001, moderate versus low = 0.02). In‐hospital mortality, the primary clinical outcome, was significantly lower after CSP in patients with moderate/high deprivation in unadjusted (before CSP 7.0% versus after CSP 3.1%; odds ratio [OR], 0.42 [95% CI, 0.25–0.72]; P=0.002) and risk‐adjusted (OR, 0.42 [95% CI, 0.23–0.77]; P=0.005) models.

Conclusions

A CSP was associated with improved ST‐segment–elevation myocardial infarction care across all deprivation groups and reduced mortality in those from moderate or high deprivation neighborhoods. Standardized initiatives to reduce care variability may mitigate social determinants of health in time‐sensitive conditions such as ST‐segment–elevation myocardial infarction.

Five years of a comprehensive ST-elevation myocardial infarction protocol and its association with sex disparities

Aims

To determine whether a comprehensive ST-elevation myocardial infarction (STEMI) protocol is associated with reduced sex disparities over 5 years.

Methods and results

This was an observational cohort study of 1833 consecutive STEMI patients treated with percutaneous coronary intervention (PCI) before (1 January 2011-14 July 2014, control group) and after (15 July 2014-15 July 2019, protocol group) implementation of a protocol for early guideline-directed medical therapy (GDMT), rapid door to balloon time (D2BT), and use of trans-radial PCI. In the control group, females had less GDMT (77.1% vs. 68.1%, P = 0.03), similarly low trans-radial PCI (19.0% vs. 17.6%, P = 0.73), and longer D2BT [104 min (79, 133) vs. 112 min (85, 147), P = 0.02] corresponding to higher in-hospital mortality [4.5% vs. 10.3%, odds ratio (OR) 2.44 (1.34-4.46), P = 0.004], major adverse cardiac and cerebrovascular events [MACCE, 9.8% vs. 16.3%, OR 1.79 (1.14-2.84), P = 0.01], and net adverse clinical events [NACE, 16.1% vs. 28.3%, OR 2.06 (1.42-2.99), P < 0.001]. In the protocol group, no significant sex differences were observed in GDMT (87.2% vs. 86.4%, P = 0.81) or D2BT [85 min (64-106) vs. 89 min (65-111), P = 0.06], but trans-radial PCI was used less in females (77.6% vs. 71.2%, P = 0.03). In-hospital mortality [2.5% vs. 4.4%, OR 1.78 (0.91-3.51), P = 0.09] and MACCE [9.0% vs. 11.1%, OR 1.27 (0.83-1.92), P = 0.26] were similar between sexes, but higher NACE in females approached significance [14.8% vs. 19.4%, OR 1.38 (0.99-1.92), P = 0.05] due to higher bleeding risk [7.2% vs. 11.1%, OR 1.60 (1.04-2.46), P = 0.03].

Conclusions

A comprehensive STEMI protocol was associated with sustained reductions for in-hospital ischaemic outcomes over 5 years, but higher bleeding rates in females persisted.

Characteristics and Outcomes of Early Recurrent Myocardial Infarction After Acute Myocardial Infarction

Background We aimed to understand the characteristics and outcomes of patients readmitted with a recurrent myocardial infarction (RMI) within 90 days of discharge after an acute myocardial infarction (early RMI). Methods and Results We analyzed the timing of reinfarction, etiology, and outcome for all patients admitted with an early RMI within 90 days of discharge after an acute myocardial infarction between January 1, 2010 and January 1, 2017. We identified 6626 admissions for acute myocardial infarction (index myocardial infarction) which led to 168 cases of RMI within 90 days of discharge. The mean patient age was 65.1±13.1 years, and 37% were women. The 90-day probability of readmission with an early RMI was 2.5%. Black race, medical management, higher troponin T, and shorter length of stay were independent predictors of early RMI. Medically managed group had a higher risk for early RMI compared with percutaneous coronary intervention (P=0.04) or coronary artery bypass grafting (P=0.2). Predominant mechanisms for reinfarction were stent thrombosis (17%), disease progression (12%), and unchanged coronary artery disease (11%). At 5 years, the all-cause mortality rate for patients with an early RMI was 49% (95% CI, 40%-57%) compared with 22% (95% CI, 21%-23%) for patients without an early RMI (P<0.0001). Conclusions Early RMI is a life-threatening condition with nearly 50% mortality within 5 years. Stent-related events and progression in coronary artery disease account for most early RMI. Medication compliance, aggressive risk factor management, and care transitions should be the cornerstone in preventing early RMI.

Association of adoption of transradial access for percutaneous coronary intervention in ST elevation myocardial infarction with door-to-balloon time

Objectives

We aimed to study adoption of transradial primary percutaneous coronary intervention (TR‐PPCI) for ST elevation myocardial infarction (STEMI) (“radial first” approach) and its association with door‐to‐balloon time (D2BT).

Background

TR‐PPCI for STEMI is underutilized in the United States due to concerns about prolonging D2BT. Whether operators and hospitals adopting a radial first approach in STEMI incur prolonged D2BT is unknown.

Methods

In 1,272 consecutive cases of STEMI with PPCI at our hospital from January 1, 2011, to December 31, 2016, we studied TR‐PPCI adoption and its association with D2BT including a propensity matched analysis of similar risk TR‐PPCI and trans‐femoral primary PCI (TF‐PPCI) patients.

Results

With major increases in hospital‐level TR‐PPCI (hospital TR‐PPCI rate: 2.6% in 2011 to 79.4% in 2016, p‐trend<.001) and operator‐level TR‐PPCI (mean operator TR‐PPCI rate: 2.9% in 2011 to 81.1% in 2016, p‐trend = .005), median hospital level D2BT decreased from 102 min [81, 142] in 2011 to 84 min [60, 105] in 2016 (p‐trend<.001). TF crossover (10.3%; n = 57) was not associated with unadjusted D2BT (TR‐PPCI success 91 min [72, 112] vs. TF crossover 99 min [70, 115], p = .432) or D2BT adjusted for study year and presenting location (7.2% longer D2BT with TF crossover, 95% CI: −4.0% to +18.5%, p = .208). Among 273 propensity‐matched pairs, unadjusted D2BT (TR‐PPCI 98 [78, 117] min vs. TF‐PPCI 101 [76, 132] min, p = .304), and D2BT adjusted for study year and presenting location (5.0% shorter D2BT with TR‐PPCI, 95% CI: −12.4% to +2.4%, p = .188) were similar.

Conclusions

TR‐PPCI can be successfully implemented without compromising D2BT performance.

Abstract 28: Electronic Medical Record-Based Appointment Order Improves Cardiology Follow Up After Discharge

Background: Outpatient follow up after hospital discharge improves transitions in care, reduces readmissions, and may improve mortality. However, there is no convincing evidence that electronic medical record (EMR)-based tools increase rates of post-discharge follow up. We implemented an EMR-based appointment scheduling order to secure cardiology follow up appointments at the time of hospital discharge and measured the impact on outpatient follow up rates.

Methods: We performed an analysis of 39,211 discharges from the cardiology services within an academic center between 2012 and 2017. In the pre-implementation era, scheduling of follow up was at the discretion of clinical team (2012-2013). The EMR-based order ensured patients had scheduled follow up at time of discharge (2014-2017). We monitored follow up rates for six years and compared pre- (2012-2013, n=12,853) and post-implementation (2014-2017, n=26,358) era rates of follow up using chi square analysis. Multivariate logistic regression analysis was used to adjust for patient demographics and payor status.

Results: The average age of our patients was 69.3 ± 14.7 and 60.7% were male. A majority of our patients were white (75.7%) and on Medicare (62.8%). The average rate of follow up within 90 days in the pre-implementation era was 56.7% (7,286 of 12,854) and increased to 67.6% (17,816 of 26,357, P < 0.0001) in the post-implementation era. Annualized rates of 90 day follow up increased from 57% in 2012 to 70% in 2017 (2012: 57% (3,598 of 6,349), 2013: 57% (3,688 of 6,505), 2014: 66% (4,267 of 6,445), 2015: 67% (4,441 of 6,650), 2016: 68% (4,465 of 6,642), 2017: 70% (4,643 of 6,620, P<0.0001). Use of the EMR-based follow up order was independently associated with increased outpatient follow-up within 90 days after adjusting for patient demographics and payor status (OR 3.28, 95% CI 3.103 to 3.467, P<0.0001).

Conclusion: An EMR-based order for follow up appointment scheduling is successful in improving cardiovascular medicine follow up independent of patient demographics or payor status. This benefit was sustained over four years post-implementation. EMR-based tools are an attractive solution to improve patient follow-up after hospital discharge.

Incremental Prognostic Value of Guideline-Directed Medical Therapy, Transradial Access, and Door-to-Balloon Time on Outcomes in ST-Segment-Elevation Myocardial Infarction

BACKGROUND

Systems to improve ST-segment-elevation myocardial infarction (STEMI) care have traditionally focused on improving door-to-balloon time. However, prompt guideline-directed medical therapy and transradial primary percutaneous coronary intervention (PCI) are also associated with reduced STEMI mortality. The incremental prognostic value of each facet of STEMI care on clinical outcomes within a STEMI system of care is unknown.

METHODS AND RESULTS

We implemented systems-based strategies at our hospital to improve 3 STEMI care metrics: (1) prompt guideline-directed medical therapy before sheath insertion for PCI, (2) use of transradial primary PCI, and (3) door-to-balloon time. We assessed the incremental association of metrics achieved with in-hospital adverse events and 30-day mortality. Of 1272 consecutive patients with STEMI treated with PCI at our hospital (January 1, 2011, to December 31, 2016), the percentage with achievement of zero, 1, 2, or 3 STEMI care metrics was 7.1%, 24.1%, 43.8%, and 25.1%; and 30-day mortality was 15.6%, 8.6%, 3.6%, and 3.2%, respectively (log-rank P<0.001). After adjusting for known clinical predictors of STEMI in-hospital mortality, achievement of at least 2 STEMI care metrics was associated with significantly reduced in-hospital mortality (odds ratio, 0.39; 95% CI, 0.16-0.96; P=0.041). Each metric provided incremental prognostic value when modeled in stepwise order of their occurrence in clinical practice (final model C statistic, 0.677; P<0.001).

CONCLUSIONS

Prompt guideline-directed medical therapy before sheath insertion for PCI, transradial primary PCI, and door-to-balloon time add incremental prognostic value in STEMI care. Expanding STEMI systems of care from a singular focus on door-to-balloon time to a comprehensive focus on multifaceted STEMI care offers an opportunity to further improve STEMI outcomes.

Abstract 116: Independent Prognostic Value of Guideline-Directed Medical Therapy, Radial Access, and Door-to-Balloon Time in Predicting STEMI In-Hospital Mortality

Background: Systems-based strategies to improve STEMI care have traditionally focused on improving door to balloon time (D2BT) performance. However, prompt guideline-directed medical therapy (GDMT) and use of radial access for PCI are also associated with reduced mortality in patients with STEMI. The incremental value of each facet of STEMI care on mortality is unknown.

Methods: On 7/15/14 we implemented a comprehensive four-step STEMI protocol at our institution: (1) ED physician cath lab activation (2) Safe STEMI Handoff Checklist with GDMT decision support (3) immediate transfer to an immediately available cath lab and (4) radial access for PCI. The protocol was intended to minimize care variability in GDMT (aspirin, P2Y12 inhibitor, and anticoagulant) prior to PCI, use of radial access for PCI, and D2BT. We studied consecutive patients with STEMI treated with PCI at our center (1/1/11-12/31/16) to assess the incremental prognostic value of these STEMI care processes using logistic regression models.

Results: Of 1272 participants mean age was 61+/-12 years and 68% were men. STEMI presenting location was 25% primary ED, 69% inter-hospital transfer, and 6% in-hospital. The rates of GDMT prior to PCI (74% vs 83%, P<0.001) and radial access for PCI (19% vs. 67%, P<0.001) improved and median D2BT (106 [81-140] vs. 90 [68-109], P<0.001) decreased after implementation of the comprehensive four-step STEMI protocol. In a multivariable model, GDMT prior to PCI (OR 0.42, 95% CI 0.25-0.71, P=0.001), radial access for PCI (OR 0.44, 95% CI 0.23-0.82, P=0.002), and decreasing D2BT (10min decrease: OR 0.96, 95% CI 0.94-0.99, P=0.007) were each independently associated with reduced odds of in-hospital mortality. Step-wise modeling of the risk of in-hospital mortality demonstrated that GDMT prior to PCI, radial access for PCI, and D2BT performance provided incremental prognostic value when added in stepwise order of the occurrence of these care processes in clinical practice (Figure).

Conclusions: Prompt GDMT administration, radial access for PCI, and D2BT performance add incremental prognostic value. Expanding STEMI systems of care from a singular focus on D2BT to a comprehensive focus on multi-faceted STEMI care offers an opportunity to further improve STEMI outcomes.

Abstract 257: Improving Digital ECG Acquisition-to-Visualization Time Using EMR and Institutional Standard Operating Procedures

Introduction: Integration of electrocardiogram (ECG) tracings into the electronic medical record (EMR) is a challenge in the modern era. Delays in EMR-based ECG visualization negatively impact the care of patients with suspected cardiac disease. We aimed to measure the impact of a standardized process for acquiring and uploading ECG to the EMR on ECG acquisition-to-visualization time (AtV).

Methods: We studied all ECG obtained at our hospital system from 1/1/13-12/31/16, and we stratified the study into baseline (1/1/13-1/31/14), transition (2/1/14-2/28/15), and full implementation (3/1/15-12/31/16) groups. In the baseline group, an ECG was only viewable in the EMR after it was formally read by a cardiologist. In the transition group, technical modifications made it possible for a preliminary ECG to immediately upload into the EMR after acquisition without a cardiologist’s interpretation. In the full implementation group, a standardized process encouraged timely upload to the EMR by setting a 30 minute AtV goal and establishing individual and inpatient unit performance tracking. The primary outcome of AtV was compared across groups with one-way analysis of variance.

Results: During the study period, 628,322 ECGs were obtained (45% baseline, 47% transition, 8% full implementation). Mean AtV was 379 hours in the baseline group, 235 hours in the transition group, and 4 hours in the full implementation group. Compared to baseline, the transition group was associated with a 144 hour decrease in AtV (95%CI 137 - 151 hours, P<0.001) and the full implementation group was associated with 375 hour decrease in AtV (95% CI 362 - 388 hours, P<0.001) (Figure).

Conclusion: A standardized process for ECG acquisition and EMR upload dramatically reduces AtV time allowing for rapid EMR viewing of ECGs. The stepwise improvement in AtV observed in our study stresses the importance of both technical and operational components to this process.

4-Step Protocol for Disparities in STEMI Care and Outcomes in Women

BACKGROUND

Women with ST-segment elevation myocardial infarction (STEMI) receive suboptimal care and have worse outcomes than men. Whether strategies to reduce STEMI care variability impact disparities in the care and outcomes of women with STEMI is unknown.

OBJECTIVES

The study assessed the care and outcomes of men versus women with STEMI before and after implementation of a comprehensive STEMI protocol.

METHODS

On July 15, 2014, the authors implemented: 1) emergency department catheterization lab activation; 2) STEMI Safe Handoff Checklist; 3) immediate transfer to an immediately available catheterization lab; and 4) radial first approach to percutaneous coronary intervention (PCI). The authors prospectively studied consecutive patients with STEMI and assessed guideline-directed medical therapy (GDMT) before PCI, median door-to-balloon time (D2BT), in-hospital adverse events, and 30-day mortality stratified by sex before (January 1, 2011 to July 14, 2014; control group) and after (July 15, 2014 to December 31, 2016) implementation of the STEMI protocol.

RESULTS

Of 1,272 participants (68% men, 32% women), women were older with more comorbidities than men. In the control group, women had less GDMT (77% vs. 69%; p = 0.019) and longer D2BT (median 104 min; [interquartile range (IQR): 79 to 133] min vs. 112 [IQR: 85 to 147] min; p = 0.023). Women had more in-hospital stroke, vascular complications, bleeding, transfusion, and death. In the comprehensive 4-step STEMI protocol, sex disparities in GDMT (84% vs. 80%; p = 0.32), D2BT (89 [IQR: 68 to 106] min vs. 91 [IQR: 68 to 114] min; p = 0.15), and in-hospital adverse events resolved. The absolute sex difference in 30-day mortality decreased from the control group (6.1% higher in women; p = 0.002) to the comprehensive 4-step STEMI protocol (3.2% higher in women; p = 0.090).

CONCLUSIONS

A systems-based approach to STEMI care reduces sex disparities and improves STEMI care and outcomes in women.

Abstract 074: Door to Balloon Time in Patients With ST Elevation Myocardial Infarction With and Without Cardiopulmonary Arrest: is Exclusion From Public Reporting Justified?

Background: Since 2006 the Center for Medicare and Medicaid Services has allowed hospitals to exclude public reporting of door to balloon (D2B) time data for STEMI patients with cardiopulmonary arrest (CPA) within 90 minutes after hospital arrival, a high risk group with 30% in-hospital mortality. In July 2014, we implemented a high reliability STEMI process with rapid reperfusion goals for all STEMI patients treated with primary PCI at our center with no patient exclusions (figure). We studied D2B times for patients with and without in-hospital CPA before and after implementation of our high reliability STEMI process to clarify whether exclusion from public reporting on the basis of CPA is justified.

Methods: We compared consecutive cases of STEMI treated with primary PCI at our center before (January 2013 to July 15 th , 2014) and after (July 16 th , 2014 to October 2016) implementation of a high reliability STEMI process, and we assessed D2B times in patients with and without in-hospital CPA prior to primary PCI. The primary endpoint was the % of patients treated within guideline D2B times ( < 90 minutes for ED presenting patients or < 120 minutes for inter-hospital transfer patients).

Results: Over the study period 795 cases of STEMI were treated with primary PCI at our center. The control group constituted 37.4% (297/795) of patients who were treated prior to July 15 th , 2014, and the high reliability group constituted 62.6% (498/795) of patients treated after July 15 th , 2014. Patients presenting to our primary ED were 27.3% (217/795), inter-hospital transfer patients were 69.1% (549/795), and in-hospital STEMI patients were 3.6% (29/795). CPA within 90 minutes of hospital arrival occurred in 6.3% (50/795) of patients overall, and CPA was more prevalent in the control group vs the high reliability group (8.8% [26/297] vs 4.8% [24/498], P=0.027). In the control group patients with CPA were less likely to achieve goal D2B times compared to patients without CPA (30.8% [8/26] vs 60.5% [164/271], P=0.003), whereas in the high reliability group there was no difference in the rate of achievement of goal D2B times in patients with vs without CPA (75.0% [18/24] vs 81.6% [387/474], P=0.418).

Conclusion: High reliability STEMI processes can improve delivery of care for the most vulnerable and highest risk patients.

Study of the normal and insufficient velopharyngeal valve by the "Forced Sucking Test"

A thorough assessment of the velopharyngeal (VP) closure dynamics is important for therapeutic planning in patients with nasal speech. An additional diagnostic tool to the standard endoscopic examination of the VP valve, the "Forced Sucking Test" (FST) is presented. In this study, 110 patients with a normal VP valve and 40 patients with VP insufficiency were subjected to a comprehensive endoscopic examination. When existent, Passavant's ridge clearly appears in 80% of these cases during the FST. This is advantageous, since the ridge is often unseen during routine nasendoscopy. Passavant's ridge appears indistinguishable in shape and level during speech and FST. During FST, the bulge of the uvular ridge is clearly seen on the flat or concave nasal surface of the velum. In cases of diastasis of the velar musculature, the midline V-defect of the velum is clearly seen. The test is particularly important in children with concomitant adenoid hypertrophy. The findings are discussed in terms of their implications for the anatomy and physiology of the VP valve. FST is recommended as an additional and complementary part of the endoscopic examination of the VP valve.

Genetic linkage between hereditary hemochromatosis and HLA

A large Mormon pedigree of a proband with hemochromatosis was studied, using transferrin saturation as the quantitative phenotypic trait. The analysis indicated that the inheritance of hemochromatosis was recessive, with partial expression in some heterozygotes. The lod score of 6.88 (theta = .0) was strongly indicative of linkage between the hemochromatosis locus and the human major histocompatibility (HLA) loci.

Hereditary hemochromatosis. Phenotypic expression of the disease

Previous studies have shown that hemochromatosis is an inherited, autosomal-recessive disease and that the gene is closely linked to the HLA locus on chromosome 6. We obtained a lod score for linkage of +9.8 for a recombination fraction of 0.0 and a gene frequency of 0.056, the frequency estimated in this population. We studied the phenotypic expression of the disease in 261 members of 10 pedigrees. In heterozygotes over 20 years of age, there was an intermediate increase in transferrin saturation and a limited increase in hepatic iron but no clinical manifestations. In male heterozygotes, the average amount of iron in the liver increased from about 0.2 to 1.3 g. Abnormal homozygotes accumulated iron progressively with time, with men accumulating about 18 g in the liver. All measurements of iron status were increased in abnormal homozygotes. Hemochromatosis is inherited as an autosomal-recessive disease, with partial biochemical expression in heterozygotes.