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Division of Cardiology, University of British Columbia, Vancouver, British Columbia, CanadaCentre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
Division of Cardiology, University of British Columbia, Vancouver, British Columbia, CanadaCentre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, CanadaVancouver Coastal Health Authority, Vancouver, British Columbia, Canada
Division of Cardiology, University of British Columbia, Vancouver, British Columbia, CanadaCentre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, CanadaVancouver Coastal Health Authority, Vancouver, British Columbia, Canada
University of British Columbia Faculty of Pharmaceutical Sciences, Vancouver, British Columbia, CanadaCentre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, CanadaSchool of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, CanadaSchool of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
Providence Health Care Research Institute, University of British Columbia, Vancouver, British Columbia, CanadaCentre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, CanadaUniversity of British Columbia School of Nursing, Vancouver, British Columbia, Canada
Corresponding author: Dr Graham C. Wong, Vancouver General Hospital, Level 9-2775, Laurel St, Vancouver, British Columbia V5Z1M9, Canada. Tel.: +1-604-875-5735; fax: +1-604-875-5736.
Division of Cardiology, University of British Columbia, Vancouver, British Columbia, CanadaCentre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, CanadaVancouver Coastal Health Authority, Vancouver, British Columbia, Canada
The Vancouver Coastal Health (VCH) ST-elevation myocardial infarction (STEMI) program aimed to increase access to primary percutaneous coronary intervention (PPCI) and reduce first-medical-contact-to-device times (FMC-DTs). We evaluated the long-term program impact on PPCI access and FMC-DT, and overall and reperfusion-specific in-hospital mortality.
Methods
We analyzed all VCH STEMI patients between June 2007 and November 2019. The primary outcome was the proportion of patients receiving PPCI over 4 program implementation phases over 12 years. We also evaluated overall changes in median FMC-DT and the proportion of patients achieving guideline-mandated FMC-DT, in addition to overall and reperfusion-specific in-hospital mortality.
Results
A total of 3138 of 4305 VCH STEMI patients were treated with PPCI. PPCI rates increased from 40.2% to 78.7% from 2007 to 2019 (P < 0.001). From phase 1 to 4, median FMC-DT improved from 118 to 93 minutes (percutaneous coronary intervention [PCI]-capable hospitals, P < 0.001) and from 174 to 118 minutes (non-PCI-capable hospitals, P < 0.001), with a concomitant increase in those achieving guideline-mandated FMC-DT (35.5% to 66.1%, P < 0.001). Overall in-hospital mortality was 9.0% (P = 0.20 across phases), with mortality differing significantly by reperfusion strategy (4.0% fibrinolysis, 5.7% PPCI, 30.6% no reperfusion therapy, P < 0.001). Mortality significantly decreased from phase 1 to phase 4 at non-PCI-capable centres (9.6% to 3.9%, P = 0.022) but not at PCI-capable centres (8.7% vs 9.9%, P = 0.27).
Conclusions
A regional STEMI program increased the proportion of patients who received PPCI and improved reperfusion times over 12 years. Although no statistically significant decrease occurred in overall regional mortality incidence, mortality incidence was decreased for patients presenting to non-PCI-capable centres.
Résumé
Contexte
Le programme sur l’infarctus du myocarde avec élévation du segment ST (STEMI) de la régie régionale de santé Vancouver Coastal Health (VCH) visait à améliorer l’accès à des interventions coronariennes percutanées primaires (ICPP) et à réduire le temps entre le premier contact médical et l’intervention. Nous avons évalué les effets à long terme du programme sur l’accès aux ICPP, sur le temps entre le premier contact médical et l’intervention, ainsi que sur le taux global de mortalité hospitalière et le taux de mortalité hospitalière lié à la reperfusion.
Méthodologie
Nous avons analysé les cas de tous les patients admis au programme STEMI de la VCH entre juin 2007 et novembre 2019. Le critère d’évaluation principal était la proportion de patients recevant une ICPP pendant les 4 phases du programme, qui se sont étalées sur 12 ans. Nous avons aussi évalué la variation totale du temps médian entre le premier contact médical et l’intervention, et de la proportion de patients chez qui le temps recommandé entre le premier contact médical et l’intervention a été respecté ainsi que la variation du taux global de mortalité hospitalière et du taux de mortalité hospitalière lié à la reperfusion.
Résultats
Au total, 3138 des 4305 patients du programme STEMI de la VCH ont été traités par une ICPP. Les taux d’ICPP sont passés de 40,2 % à 78,7 % entre 2007 et 2019 (p < 0,001). De la phase 1 à la phase 4 du programme, le temps médian entre le premier contact médical et l’intervention s’est amélioré, passant de 118 minutes à 93 minutes (hôpitaux en mesure d’effectuer une intervention coronarienne percutanée [ICP]; p < 0,001) et de 174 à 118 minutes (hôpitaux n’étant pas en mesure d’effectuer une ICP; p < 0,001), avec une augmentation du nombre de personnes pour qui le temps recommandé entre le premier contact médical et l’intervention a été respecté (35,5 % à 66,1 %; p < 0,001). Le taux global de mortalité hospitalière était de 9,0 % (p = 0,20 pour toutes les phases), et le taux de mortalité hospitalière lié à la reperfusion différait de manière significative selon la stratégie adoptée (fibrinolyse : 4,0 %; ICPP : 5,7 %; aucune reperfusion : 30,6 %; p < 0,001). Le taux de mortalité a diminué de manière significative entre la phase 1 et la phase 4 dans les centres qui n’étaient pas en mesure d’effectuer une ICP (9,6 % à 3,9 %; p = 0,022), mais pas dans les centres en mesure d’effectuer une ICP (8,7 % c. 9,9 %; p = 0,27).
Conclusions
Le programme STEMI régional a permis d’augmenter la proportion de patients qui ont reçu une ICPP et d'améliorer les temps de reperfusion sur 12 ans. Bien qu’aucune diminution statistiquement significative n’ait été observée quant au taux global de mortalité dans la région, le taux de mortalité a diminué chez les patients se présentant dans un centre qui n’était pas en mesure d’effectuer une ICP.
Reducing the time from first medical contact to initiation of reperfusion, using either fibrinolysis (first medical contact [FMC] to needle time [FMC-NT]) or primary percutaneous coronary intervention (PPCI; FMC to device time [FMC-DT]) improves clinical outcomes and reduces mortality in the management of acute ST-segment elevation myocardial infarction (STEMI).
Relationship between delay in performing direct coronary angioplasty and early clinical outcome in patients with acute myocardial infarction: results from the global use of strategies to open occluded arteries in Acute Coronary Syndromes (GUSTO-IIb) trial.
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.
Clinical characteristics and outcome of patients with early (< 2 h), intermediate (2-4 h) and late (> 4 h) presentation treated by primary coronary angioplasty or thrombolytic therapy for acute myocardial infarction.
A randomized trial of transfer for primary angioplasty versus on-site thrombolysis in patients with high-risk myocardial infarction: the Air Primary Angioplasty in Myocardial Infarction study.
Benefit of transferring ST-segment-elevation myocardial infarction patients for percutaneous coronary intervention compared with administration of onsite fibrinolytic declines as delays increase.
Prospective randomised comparison between thrombolysis, rescue PTCA, and primary PTCA in patients with extensive myocardial infarction admitted to a hospital without PTCA facilities: a safety and feasibility study.
Long distance transport for primary angioplasty vs immediate thrombolysis in acute myocardial infarction. Final results of the randomized national multicentre trial—PRAGUE-2.
Multicentre randomized trial comparing transport to primary angioplasty vs immediate thrombolysis vs combined strategy for patients with acute myocardial infarction presenting to a community hospital without a catheterization laboratory. The PRAGUE study.
geographic and resource constraints limit its widespread use. STEMI treatment guidelines have defined the maximal recommended FMC-DT for patients who either present to a percutaneous coronary intervention (PCI)-capable centre or are transferred for PPCI after initially presenting to a non-PCI-capable centre.
2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.
2019 Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology guidelines on the acute management of ST-elevation myocardial infarction: focused update on regionalization and reperfusion.
Individual strategies utilized by regional STEMI care systems to reduce reperfusion times include prehospital electrocardiograms (ECGs), geography-based algorithms for determining the optimal hospital destination for STEMI patients, and standardized inter-facility transfer protocols for primary and adjunctive PCI. However, although the use of regionalization protocols has demonstrated reductions in median FMC-DT and FMC-NT,
Emergency department bypass for ST-segment-elevation myocardial infarction patients identified with a prehospital electrocardiogram: a report from the American Heart Association Mission: Lifeline program.
The pre-hospital electrocardiogram and time to reperfusion in patients with acute myocardial infarction, 2000-2002: findings from the National Registry of Myocardial Infarction-4.
Utilization and impact of pre-hospital electrocardiograms for patients with acute ST-segment elevation myocardial infarction: data from the NCDR (National Cardiovascular Data Registry) ACTION (Acute Coronary Treatment and Intervention Outcomes Network) Registry.
Impact of pre-hospital electrocardiograms on time to treatment and one year outcome in a rural regional ST-segment elevation myocardial infarction network.
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.
Trends in door-to-balloon time and mortality in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention.
Implementation of guidelines improves the standard of care: the Viennese registry on reperfusion strategies in ST-elevation myocardial infarction (Vienna STEMI registry).
Furthermore, few regional programs have collected detailed data describing long-term temporal trends.
The Vancouver Coastal Health (VCH) STEMI Program evolved as a regional model of STEMI care. Although the program originally started as a mixed reperfusion model (fibrinolysis and PPCI), one of the original goals of the program was to move to PPCI as the preferred regional reperfusion strategy, with the hypothesis that regional mortality would decrease with greater use of timely PPCI. Thus, the program was evolved over 3 developmental phases with the aims of increasing the proportion of STEMI patient who could be treated with PPCI and reducing overall regional FMC-DT for PPCI-treated patients (see Supplemental Appendix S1).
2019 Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology guidelines on the acute management of ST-elevation myocardial infarction: focused update on regionalization and reperfusion.
The principal aim of this study was to evaluate temporal trends and the longer-term impact of the VCH Regional STEMI Program’s success at improving access to PPCI and achieving guideline-recommended PPCI reperfusion targets. Overall and reperfusion-specific in-hospital outcomes were also evaluated over the same period of time.
Methods
This retrospective analysis utilized the VCH STEMI database, which prospectively collects clinical and procedural characteristics, as well as in-hospital events for all STEMI patients treated at VCH. The patients were categorized by the mode of reperfusion they received, as well as the institution to which they first presented. Clinical outcomes of patients were analyzed according to the hospital to which they initially presented. Details of the VCH STEMI database have been published previously.
This study was approved by the University of British Columbia Clinical Research Ethics Board (H20-00127).
In this analysis, patients were included in 1 of 4 cohorts according to the phase of program implementation (Supplemental Fig. S1 and supporting text). Briefly, standardized regional reperfusion algorithms were implemented in phase 1 (June 2007 to May 2008). The use of prehospital ECGs by emergency health services (EHS) followed by direct in-field transfer to regional PCI centres was implemented in phase 2 (May 2008 to April 2011) and then VCH moved from a mixed reperfusion model to the use of regionwide PPCI in phase 3 (May 2011 to December 2015). We also evaluated the impact of the program following its complete implementation and maturation in phase 4 (January 2015 to November 2019).
Inclusion criteria
Our study cohort included all patients with a diagnosis of STEMI who presented alive to hospitals within VCH, including those with successfully resuscitated out-of-hospital cardiac arrest and those who originated from out of province (complete regional case capture). The patients were categorized by mode of reperfusion (PPCI, fibrinolysis, or no reperfusion therapy), and reperfusion times were calculated for each cohort for patients who received PPCI or fibrinolysis. PPCI-eligible patients either could be initially assessed in the emergency room of the hospital to which they initially presented or potentially could bypass the emergency room if they were identified with an infield ECG and brought directly to a PCI centre during daytime hours. Patients who died before receiving reperfusion therapy were excluded from the calculation of reperfusion times, but they were included in the final overall and reperfusion-specific mortality analyses.
Outcomes
The primary outcome was the proportion of patients who received PPCI in each of the 4 phases over the 12-year study period, in addition to the change in median FMC-DT across phases for both PCI-capable hospitals and non-PCI-capable hospitals. FMC was defined as first contact with EHS if transported by ambulance, or as first contact with an emergency physician for patients self-presenting to the emergency department (ED). Secondary outcomes were the proportions of PPCI-treated patients achieving guideline-mandated FMC-DT (< 90 minutes for PCI-capable sites; 120 minutes from the field or from non-PCI-capable sites). We also evaluated overall and reperfusion-specific regional in-hospital mortality over the 12-year study period for the entire STEMI cohort. Outcomes were described for (i) the overall VCH region by phase of regionalization and (ii) PCI-capable vs PCI-non-capable hospitals. Mortality and FMC-DT was assigned to the hospital to which the patient initially presented; mortality was assigned to the PCI-capable hospital centre for any patients initially identified in the field by EHS and then transferred for PPCI. Patients who died in the field or the hospital prior to being assigned to a specific reperfusion strategy were included in the overall mortality calculation, but they were not assigned to any particular subgroup, as their reperfusion modality (PPCI, fibrinolysis, or medical management) was not at that point determined. Patients who were intended to be treated with PCI and had a Code STEMI activated were included in the PPCI mortality group if they died prior to reaching the catheterization laboratory.
Statistical analysis
Baseline patient demographics, clinical characteristics, and in-hospital outcomes were summarized using means (± standard deviation), medians (with interquartile range), or proportions, as appropriate, and these were compared among the groups of patients between phases, using the Kruskal-Wallis test or analysis of variance for continuous variables, and the χ2 or Fisher’s exact test for categorical variables. The presence of trends in proportions over calendar years was assessed using the Cochran-Armitage test. Logistic regression was used to compare the mortality rates between groups defined by FMC-DT, after adjusting for the following clinically important baseline variables: age, sex, diabetes, hypertension, prior myocardial infarction, prior coronary artery bypass graft, prior peripheral vascular disease, heart failure on presentation, and heart rate and systolic blood pressure at the time of FMC presentation. Comparisons were presented as odds ratios (ORs); P < 0.05 was considered statistically significant. All statistical analyses were performed using SAS, version 9.4 (SAS Institute, Cary, NC).
Results
Cohort overview
Between June 2007 and November 2019, of the 4305 STEMI patients who arrived alive at VCH hospitals, 3138 received PPCI as their reperfusion strategy. A total of 529 patients were treated with fibrinolysis, and 327 received no initial reperfusion therapy. A total of 250 patients received coronary bypass grafting. Baseline characteristics of all patients who received PPCI are shown in Table 1, according to phase. Significant differences in patient characteristics across phases included the following: those presenting in later phases were older (62.5 years in phase 1 vs 65.7 in phase 4, P = 0.04), had a higher prevalence of hypertension (44.9% in phase 1 vs 57% in phase 4, P = 0.007), and had more previous stroke or transient ischemic attack (2.4% in phase 1 vs 8.0% in phase 4, P = 0.045). The proportions of all STEMI patients who presented to the hospital via EHS rather than as "walk-ins" were similar across phases 1-4, at 65%, 72%, 65%, and 62%, respectively. However, with implementation of prehospital ECGs allowing early STEMI recognition in the field, the proportion of patients presenting via EHS directly to a PCI-capable hospital increased from 82% in phase 1, to 93%, 88%, and 92%, in phases 2, 3, and 4, respectively (P = 0.002). A total of 61 patients died prior to receiving reperfusion therapy; PPCI was planned for 47 of these patients (1.5%) who died before their arrival to the catheterization laboratory.
Table 1Baseline demographics of primary percutaneous coronary intervention (PPCI)-treated ST-elevation myocardial infarction patients, stratified by protocol phase at time of presentation
Data were missing for most patients in phases 1 and 2, as they were not uniformly collected until 2012.
—
—
117/1257 (9.3)
92/1082 (8.5)
0.496
Initial median HR, bpm, median (IQR)
80 (65, 95)
75.0 (60, 90)
76 (63, 90)
76.0 (62, 91)
0.338
Initial SBP, mm Hg, mean (SD)
138.4 (30.8)
139.7 (32.9)
140.2 (32.5)
138.9 (34.4)
0.777
Initial creatinine, mmol/L, median (IQR)
96 (80, 111)
91 (78, 113)
93 (78, 111)
94 (79, 110)
0.655
Initial hemoglobin, g/L, median (IQR)
143 (135, 153)
141 (129, 151)
143 (131, 153)
143(132, 154)
0.036
Symptom onset to FMC, min, median (IQR)
85 (27, 209)
59 (26, 145)
57 (26, 139)
60 (27, 159)
0.199
Values are n (%), unless otherwise indicated. Boldface indicates significance. Data missing for up to 20 patients in total unless noted otherwise. No missing data for age, sex, or infarct type.
The proportion of patients receiving PPCI increased significantly across phases, from 44.7% in phase 1 to 80% in phase 4, as shown in Figure 1A (P < 0.001). Figure 1B shows the annualized rates of PPCI per calendar year across the region from 2007 to 2019. Rates of PPCI by type of hospital (PCI-capable vs non-PCI-capable), by phase, are shown in Supplemental Table S1.
Figure 1(A) Final reperfusion strategy received by phase of ST-elevation myocardial infarction (STEMI) program implementation. (B) Regional primary percutaneous coronary intervention (PPCI) rates by calendar year.
The overall regional median FMC-DT for patients treated with PPCI was 125 minutes in phase 1, and 98, 104, and 101 minutesfor phases 2, 3, and 4, respectively (P < 0.001; Fig. 2). The median FMC-DT was reduced from 118 minutes in phase 1, to 92, 97, and 93 minutes in phases 2-4, respectively in PCI-capable centres (P < 0.001). Non-PCI-capable hospitals saw a greater and progressive decline in FMC-DT across phases, from 174 minutes in phase 1, to 146, 123, and 118 minutes in phases 2-4 (P < 0.001). We performed an analysis looking at the impact of presentation during working hours (8 AM to 5 PM) vs non-working hours (5 PM to 8 AM) on FMC-DT. This analysis is detailed in Supplemental Table S2. During phases 1 and 2, no statistically significant difference in PPCI times occurred between groups presenting during working hours vs during non-working hours, but a significant reduction in FMC-DT occurred in phase 3 (101 minutes for working hours vs 106 minutes for non-working hours, P < 0.001) and phase 4 (99 minutes for working hours vs 104 minutes for non-working hours, P < 0.001) for those who presented during working hours.
Figure 2Median first-medical-contact (FMC)-to-device time, by phase and type of hospital. Kruskal-Wallis testing was performed to compare groups across phases. PCI, percutaneous coronary intervention.
Supplemental Table S3 shows the evolution of FMC-NT for those patients who were treated with fibinolysis during the study period; a significant reduction in median FMC-NT occurred from phase 1 to phase 4 (56 vs 40 minutes, P = 0.003).
The overall proportion of patients achieving guideline-mandated FMC-DT across the region increased significantly, from 35.5% in phase 1 to 66.1% by phase 4 (P < 0.001). PCI-capable hospitals saw an increase in the proportion of patients meeting reperfusion targets from phase 1 to phase 2, which then plateaued in phases 3 and 4. However, non-PCI-capable hospitals showed progressive increases in the proportion of patients who achieved these reperfusion targets, from a low of 20% in phase 1 up to 53.6% by phase 4 (P < 0.001; Fig. 3).
Figure 3Percentage of ST-elevation myocardial infarction patients achieving guideline-mandated reperfusion times, stratified by phase of implementation and site. χ2 testing was performed to compare groups across phases. FMC, first medical contact; PCI, percutaneous coronary intervention.
The overall in-hospital mortality incidence was 9.0% for the entire cohort of STEMI patients, irrespective of their reperfusion strategy. Between patients treated with PPCI, fibrinolysis, or no initial reperfusion therapy (medically managed), an almost 5-fold difference in mortality incidence occurred (5.7% for PPCI vs 30.6% in those treated medically without reperfusion; Fig. 4). Mortality incidence by intended treatment was 8.2%, 5.1%, and 32.2% for PCI, thrombolytic, and medical management, respectively, if patients who died prior to receiving their assigned reperfusion strategy were included. When mortality among PPCI-treated patients was analyzed by type of hospital, no significant difference in mortality incidence was seen across phases within PCI-capable centres, whereas the mortality incidence fell from 9.6% in phase 1 to 3.9% in phase 4 (P = 0.022) in non-PCI-capable hospitals (Fig. 5).
No statistically significant change in mortality incidence occurred among all STEMI patients over the 12-year study period. (P = 0.12 for trend; Supplemental Fig. S2); and no significant change in mortality incidence for PPCI-treated patients was seen across phases (Supplemental Fig. S3). No difference in mortality incidence occurred among PPCI-treated patients across any phase between those presenting during working hours vs those that did not (Supplemental Table S2), nor those who originated from local compared to remote non-PCI-capable hospitals in VCH (Supplemental Table S4).
Mortality outcomes stratified by all modalities of reperfusion across phases are shown in Supplemental Fig. S4. Compared to those who received fibrinolysis or PPCI, those who did not receive any initial reperfusion therapy were more likely to be female, older, and to have more comorbidities (Supplemental Table S5).
Finally, PPCI patients who met guideline-mandated FMC-DT (< 90 minutes at PCI-capable hospitals and < 120 minutes at non-PCI-capable hospitals or activations from the field) had s significantly lower mortality incidence, compared to that of patients who had delayed FMC-DT (4.5% vs 7.8%; unadjusted OR = 0.55 [95% confidence interval: 0.41, 0.75], P < 0.001; Fig. 6). After adjustment for potential confounders (age, sex, diabetes, hypertension, prior myocardial infarction, prior coronary artery bypass graft, prior peripheral vascular disease, and heart failure, systolic blood pressure, and heart rate on presentation), this difference remained statistically significant (adjusted OR = 0.67 [95% confidence interval: 0.48, 0.96], P = 0.026). Baseline characteristics between these 2 groups are shown in Supplemental Table S6.
Figure 6Mortality in ST-elevation myocardial infarction patients stratified by timely vs delayed first-medical-contact-to-device time.
Implementation of a regional approach to STEMI reperfusion over a 12-year period was associated with a significant increase in the proportion of patients treated with PPCI as opposed to fibrinolysis or no reperfusion therapy. This increase was accompanied by an overall reduction in regional FMC-DT, which was most marked among patients being transferred from non-PCI-capable hospitals. These findings confirm and extend current evidence that regionalization protocols and reperfusion algorithms can improve reperfusion times.
2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.
2019 Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology guidelines on the acute management of ST-elevation myocardial infarction: focused update on regionalization and reperfusion.
Emergency department bypass for ST-segment-elevation myocardial infarction patients identified with a prehospital electrocardiogram: a report from the American Heart Association Mission: Lifeline program.
The pre-hospital electrocardiogram and time to reperfusion in patients with acute myocardial infarction, 2000-2002: findings from the National Registry of Myocardial Infarction-4.
Impact of pre-hospital electrocardiograms on time to treatment and one year outcome in a rural regional ST-segment elevation myocardial infarction network.
2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.
2019 Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology guidelines on the acute management of ST-elevation myocardial infarction: focused update on regionalization and reperfusion.
significant and progressive reductions in both FMC-DTs were noted in non-PCI-capable compared to PCI-capable hospitals. This result was accompanied by a significant reduction in in-hospital mortality for patients initially presenting to non-PCI-capable hospitals. In contrast, the proportion of patients who initially presented to PCI-capable hospitals and went on to receive timely PPCI over the same period plateaued in the later phases of the study.
Although the overall mortality incidence of 9% in our population is slightly higher than that described in previous studies. In part, this may be attributable to a significant portion of patients who were ineligible for any reperfusion therapy (7% of all STEMI patients); these patients had a very high rate of in-hospital mortality (30.6% across phases 1-4). If patients who received no reperfusion therapy were excluded, our overall mortality incidence would have been 5.45%. Interestingly, patients receiving fibrinolysis had the lowest overall mortality incidence at 4%, which likely is reflective of a lower-risk population who received early reperfusion. Compared to those who received PPCI, patients treated with fibrinolysis were younger (63 vs 65 years, P < 0.001) and had fewer anterior infarcts (38.6% vs 47.5%, P < 0.001) and less heart failure on presentation (3.4% vs 5.7%, P < 0.031). Furthermore, median FMC-NT decreased from 56 to 40 minutes across phases for patients treated with fibrinolysis. Overall, our results are consistent with prior observations demonstrating excellent clinical outcomes with fibrinolysis compared to PPCI among low-to-intermediate-risk STEMI patients.
Although we originally hypothesized that increasing access to PPCI would decrease regional mortality for all STEMI patients, the overall mortality incidence did not change significantly over time and averaged 9.0 % over 12 years. Our data extend upon previous observations that overall reductions in reperfusion times do not necessarily translate to a reduction in overall mortality in a real-world population.
Trends in door-to-balloon time and mortality in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention.
Menees et al. analyzed data from 96,738 STEMI patients from the CathPCI registry between 2005 and 2009, finding a correlation of mortality outcomes with changes in reperfusion times. Mortality incidence in patients achieving FMC-DT targets was between 3.6% and 3.8%, whereas in those with delayed reperfusion ir was 6.5% to 8.9%—rates similar to those described in our cohort.
They also described a significant reduction in FMC-DT, from 83 minutes to 67 minutes, with the proportion of patients meeting the reperfusion targets increasing from 59.7% to 83.1%, and yet no change occurred in overall mortality incidence. Potential reasons for this apparent anomaly have been discussed previously; it may be associated with the complexity and changing comorbidities of patients over time, as seen in our patient population
, and with the proportion of patients who were ineligible for any reperfusion therapy and who had high rates of in-hospital mortality.
However, a significant reduction in mortality incidence was seen in patients transferred from non-PCI-capable hospitals for PPCI, which was mirrored by a significant reduction in FMC-DT in these patients. Moreover, when the data were stratified by timely vs delayed reperfusion, a significant reduction in mortality incidence was seen among those receiving timely PPCI (4.5% with timely reperfusion vs 7.8% with delayed reperfusion), and this difference remained significant after adjusting for key confounders, highlighting the ongoing importance of early reperfusion. Thus, our data extend upon and confirm the importance of reducing FMC-DTs to reduce STEMI mortality.
The results of these analyses provide an opportunity to contemplate strategies to improve system-level aspects of the care of STEMI patients. Within the VCH region, there is room for further improvement with regard to the proportion of patients receiving timely reperfusion, whether they originate from PCI-capable or non-PCI-capable sites, with a particular emphasis on avoiding transfer delays. Wenner et al. performed a detailed analysis of the causes of delays in reperfusion times among VCH STEMI patients and found that one of the largest contributors was ED delay, which averaged 82 minutes for those being transferred from non-PCI-capable sites. Strategies to reduce these ED dwell times are currently being implemented and include the implementation of a routine ED bypass protocol during daylight hours at PCI-capable hospitals and the use of regional checklists and flowcharts for ED physicians to streamline decision-making regarding transfer for PPCI.
Although our program was successful at increasing the proportion of patients who were eligible for PPCI, a substantial proportion of patients remained who did not receive any reperfusion therapy. Compared to those who received reperfusion therapy, those who did not receive any reperfusion therapy were older, and had more comorbidities, and may thus have been more frail. Previous studies have shown that frail STEMI patients tend to have worse outcomes and less often receive PPCI, compared to less-frail patients.
Frailty score for elderly patients is associated with short-term clinical outcomes in patients with ST-segment elevated myocardial infarction treated with primary percutaneous coronary intervention.
Our study has some limitations. First, as mentioned previously, our registry did not routinely collect data on cardiogenic shock and out-of-hospital cardiac arrest in phases 1 and 2, and therefore conclusions regarding these outcomes are limited. Second, we could not rule out the potential for referral bias among emergency medical services staff who might have sent lower-risk patients to non-PCI-capable hospitals, possibly explaining the difference in mortality incidence among non-PCI-capable centres compared to PCI-capable centres. Furthermore, these results are in the context of a metropolitan population with PCI centres within 1 hour of many of the referral hospitals, and thus interpretation is limited to such geographies. Our analysis focused on in-hospital mortality, and conclusions cannot be drawn regarding the impact of our program on long term clinical outcomes such as mortality, left ventricular ejection fraction or heart failure.
Finally, limitations affect the comparison of patient outcomes among reperfusion therapies, in that the choice of therapy could be related to the severity of the illness and thus correlated with the outcome. Immortal time bias also was present, as patients could die prior to receiving the reperfusion therapy. We addressed this issue by examining the mortality by the planned therapy following STEMI diagnosis as a sensitivity analysis. Nevertheless, we have been able to provide observations on in-hospital mortality and correlated these data with an evolution of regional reperfusion strategies and reperfusion times over a 12-year period in a diverse real-world population.
A strength of our study is that the data are derived from a single health authority within a government-funded healthcare system, allowing the effectiveness of reperfusion algorithms to be accurately tracked throughout implementation phases, without the confounders of varying healthcare models or differences in regional practices. Furthermore, this study is inclusive by nature, with complete case capture of all STEMI patients within the health authority, regardless of reperfusion time or site of presentation. This inclusivity is in contrast to other registry databases that are voluntary
Emergency department bypass for ST-segment-elevation myocardial infarction patients identified with a prehospital electrocardiogram: a report from the American Heart Association Mission: Lifeline program.
In summary, implementing regional reperfusion protocols in a complex, metropolitan area was associated with significant increases in the use of primary PCI, reduction in FMC-DT, and an increased proportion of patients achieving target reperfusion times over a 12-year period. The greatest benefit in terms of increasing the proportion of patients receiving timely PPCI was demonstrated among the non-PCI-capable centres in our healthcare region, including a statistically significant reduction in mortality in those presenting to non-PCI-capable centres. Furthermore, we confirmed the benefit of timely PPCI on in-hospital mortality. Although the number of patients who were not eligible for any initial reperfusion therapy did decrease over time across phases, mortality among this cohort remained very high. Future efforts to improve patient outcomes are warranted to increase the proportions of patients who can be made eligible for reperfusion therapy and who can achieve target reperfusion times for STEMI.
Acknowledgements
The authors thank the British Columbia Ambulance Service, as well as the various VCH sites involved in the STEMI system. The authors acknowledge Joanne Gamache and Kathy Lee for their assistance in data gathering.
The authors acknowledge the tremendous contributions of the late Michele Perry-Arnesen, whose efforts helped to initiate and shape the VCH STEMI Program.
Funding Sources
This study was funded by the Vancouver Coastal Research Institute.
Disclosures
The authors have no conflicts of interest to disclose.
Relationship between delay in performing direct coronary angioplasty and early clinical outcome in patients with acute myocardial infarction: results from the global use of strategies to open occluded arteries in Acute Coronary Syndromes (GUSTO-IIb) trial.
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.
Clinical characteristics and outcome of patients with early (< 2 h), intermediate (2-4 h) and late (> 4 h) presentation treated by primary coronary angioplasty or thrombolytic therapy for acute myocardial infarction.
A randomized trial of transfer for primary angioplasty versus on-site thrombolysis in patients with high-risk myocardial infarction: the Air Primary Angioplasty in Myocardial Infarction study.
Benefit of transferring ST-segment-elevation myocardial infarction patients for percutaneous coronary intervention compared with administration of onsite fibrinolytic declines as delays increase.
Prospective randomised comparison between thrombolysis, rescue PTCA, and primary PTCA in patients with extensive myocardial infarction admitted to a hospital without PTCA facilities: a safety and feasibility study.
Long distance transport for primary angioplasty vs immediate thrombolysis in acute myocardial infarction. Final results of the randomized national multicentre trial—PRAGUE-2.
Multicentre randomized trial comparing transport to primary angioplasty vs immediate thrombolysis vs combined strategy for patients with acute myocardial infarction presenting to a community hospital without a catheterization laboratory. The PRAGUE study.
2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.
2019 Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology guidelines on the acute management of ST-elevation myocardial infarction: focused update on regionalization and reperfusion.
Emergency department bypass for ST-segment-elevation myocardial infarction patients identified with a prehospital electrocardiogram: a report from the American Heart Association Mission: Lifeline program.
The pre-hospital electrocardiogram and time to reperfusion in patients with acute myocardial infarction, 2000-2002: findings from the National Registry of Myocardial Infarction-4.
Utilization and impact of pre-hospital electrocardiograms for patients with acute ST-segment elevation myocardial infarction: data from the NCDR (National Cardiovascular Data Registry) ACTION (Acute Coronary Treatment and Intervention Outcomes Network) Registry.
Impact of pre-hospital electrocardiograms on time to treatment and one year outcome in a rural regional ST-segment elevation myocardial infarction network.
Trends in door-to-balloon time and mortality in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention.
Implementation of guidelines improves the standard of care: the Viennese registry on reperfusion strategies in ST-elevation myocardial infarction (Vienna STEMI registry).
Frailty score for elderly patients is associated with short-term clinical outcomes in patients with ST-segment elevated myocardial infarction treated with primary percutaneous coronary intervention.
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