Association Between Timeliness of Reperfusion Therapy and Clinical Outcomes in ST-Elevation Myocardial Infarction

Cardiology Evaluation Unit, Agence d'évaluation des technologies et des modes d'interventions en santé, Montreal, Québec, Canada.
JAMA The Journal of the American Medical Association (Impact Factor: 35.29). 06/2010; 303(21):2148-55. DOI: 10.1001/jama.2010.712
Source: PubMed

ABSTRACT Guidelines emphasize the importance of rapid reperfusion of patients with ST-elevation myocardial infarction (STEMI) and specify a maximum delay of 30 minutes for fibrinolysis and 90 minutes for primary percutaneous coronary intervention (PPCI). However, randomized trials and selective registries are limited in their ability to assess the effect of timeliness of reperfusion on outcomes in real-world STEMI patients.
To obtain a complete interregional portrait of contemporary STEMI care and to investigate timeliness of reperfusion and outcomes.
Systematic evaluation of STEMI care for 6 months during 2006-2007 in 80 hospitals that treated more than 95% of patients with acute myocardial infarction in the province of Quebec, Canada (population, 7.8 million).
Death at 30 days and at 1 year and the combined end point of death or hospital readmission for acute myocardial infarction or congestive heart failure at 1 year by linkage to Quebec's medicoadministrative databases.
Of 1832 patients treated with reperfusion, 392 (21.4%) received fibrinolysis and 1440 (78.6%) received PPCI. Fibrinolysis was untimely (>30 minutes) in 54% and PPCI was untimely (>90 minutes) in 68%. Death or readmission for acute myocardial infarction or heart failure at 1 year occurred in 13.5% of fibrinolysis patients and 13.6% of PPCI patients. When the 2 treatment groups were combined, patients treated outside of recommended delays had an adjusted higher risk of death at 30 days (6.6% vs 3.3%; odds ratio [OR], 2.14; 95% confidence interval [CI], 1.21-3.93) and a statistically nonsignificant increase in risk of death at 1 year (9.3% vs 5.2%; OR, 1.61; 95% CI, 1.00-2.66) compared with patients who received timely treatment. Patients treated outside of recommended delays also had an adjusted higher risk for the combined outcome of death or hospital readmission for congestive heart failure or acute myocardial infarction at 1 year (15.0% vs 9.2%; OR, 1.57; 95% CI, 1.08-2.30). At the regional level, after adjustment, each 10% increase in patients treated within the recommended time was associated with a decrease in the region-level odds of overall 30-day mortality (OR, 0.80; 95% CI, 0.65-0.98).
Among patients in Quebec with STEMI, reperfusion delivered outside guideline-recommend delays was associated with significantly increased 30-day mortality, a statistically nonsignificant increase in 1-year mortality, and significantly increased risk of the composite of mortality or readmission for acute myocardial infarction or heart failure at 1 year.

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Available from: Eli Segal, Sep 26, 2015
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    • "Recently, much attention is paid to the study of risk factors in patients with ST-elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI) [7,8, etc.]. It is well known that the quality of reperfusion therapy is a risk factor of a short-term mortality in patients with STEMI patients [9] [10]. The American College of Cardiology and the American Heart Association have published in 2008 the task force on performance measures for STEMI and non-STEMI [11]. "
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    ABSTRACT: Objective We examined relationships between inpatient medical treatment, reperfusion therapy and in-hospital mortality among patients with ST-elevation myocardial infarction (STEMI) in Russia. Methods Clinical information about 25,682 patients with STEMI enrolled in the 2010–2011 registry was included retrospectively in the study. Performance of the key guideline-recommended treatment interventions was assessed. Timeliness of reperfusion therapy was evaluated with the help of the following ACC/AHA clinical measures (2008): Time to fibrinolytic therapy, Time to primary percutaneous coronary intervention (PCI) and Reperfusion therapy. Multivariate logistic and Cox's regression models were used to assess the relationship between different in-hospital treatment interventions and the risk of in-hospital death among patients with STEMI under the control of patient characteristics and comorbidities. Results The average age of patients was 63 (55–74) years. 34% of patients were female. Survived patients differed significantly from deceased ones in the majority of demographic, anamnesis, clinical presentation and treatment parameters. Hospital treatment with ACE-Is or ARBs, β-blockers and statins was significantly associated (χ2 = 482.1, P < 0.0001) with lower inpatient mortality. Prognostic value of reperfusion therapy and measures of its timeliness were not statistically significant (P ≥ 0.05 for Wald test for each factor). Conclusion STEMI treatment with ACE-Is or ARBs, β-blockers and statins during hospital stay (not necessarily at arrival) influences upon the rate of death in hospital as strong as the patient clinical status at admission. Reperfusion and its performance are additional factors that influence indirectly on the risk of in-hospital mortality in patients with STEMI.
    Cor et vasa 06/2014; 56(3). DOI:10.1016/j.crvasa.2014.03.004
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    • "In the GUSTO-IIb trial [3], the increased delays in reperfusion were associated with a decrease in the ejection fraction , an increase in mortality, and a shortened time to death. Similar results were seen in Quebec where reperfusion delivered outside guidelines-recommended delays resulted in significantly increased 30-day mortality, a trend for an increase in one-year mortality, and a significant increase in the risk of the composite of mortality and readmission for STEMI or heart failure at one year [16]. Pinto et al. [31] identified STEMI patients enrolled in the National Registry of Myocardial Infarction (NRMI) within 12 h of pain onset and admitted in centers without pPCI capability. "
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    ABSTRACT: ESC guidelines recommend a shorter (90min) delay for the use of primary percutaneous intervention (pPCI) in patients presenting within the first 2h of pain onset. Using registry data on STEMI patients in the Greater Paris Area, we assessed changes between 2003 and 2008 in the rates of pPCI, pre-hospital fibrinolytic therapy (PHF) and time delays in patients presenting within 2h of STEMI pain onset. The Greater Paris Area was divided in 3 regions: Paris, the small and large rings. Patients were divided in three groups according to their reperfusion strategy: a) PHF, b) timely pPCI (FMC to balloon inflation time<90min), and c) late pPCI (FMC to balloon inflation time>90min). Among the 5592 patients included, 1695 (39%) had PHF, 1266 (29%) had timely pPCI, and 1415 (32%) had late pPCI. Over the 6years, there was a sharp increase in timely pPCI in all regions, balanced by a decrease in PHF. The rate of late pPCI remained globally stable, with a decrease in Paris, stabilization in the small ring, and an increase in the large ring, where the density of catheterization laboratories was the lowest. By multivariate analysis, using on-time pPCI as a reference group, mortality was higher in the PHF and late pPCI groups. In areas with a low density of pPCI centers, efforts should be made to improve the timeliness of pPCI. Otherwise, PHF followed by an immediate transfer to a pPCI capable hospital may be considered.
    International journal of cardiology 08/2013; 168:5149-5155. DOI:10.1016 /j.ijcard. · 4.04 Impact Factor
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    • "Rapid coronary reperfusion is associated with improved survival among patients presenting with an ST-elevation myocardial infarction (STEMI) [1]. Previous research has demonstrated that emergency medical service (EMS) utilization can facilitate rapid revascularization [2]. "
    International journal of cardiology 07/2013; 168(5). DOI:10.1016/j.ijcard.2013.07.016 · 4.04 Impact Factor
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