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


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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    • "In acute coronary syndromes (ACS), and in particular ST elevation myocardial infarction (STEMI), prompt reopening of occluded vessels is essential in order to restore myocardial perfusion [4]. Evidence has linked longer treatment delays with increased mortality [5] [6]. Therefore, all possible measures should be undertaken to minimize the time from symptom onset to reperfusion of the ischemic area [7]. "
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    ABSTRACT: Introduction: Physician perceptions about emergency medical services (EMS) are important determinants of improving pre-hospital care for cardiac emergencies. No data exist on physician attitudes towards EMS care of patients with ST-Elevation Myocardial Infarction (STEMI) in the Emirate of Abu Dhabi. Objectives: To describe the perceptions towards EMS among physicians caring for patients with STEMI in Abu Dhabi. Methods: We surveyed a convenience sample of physicians involved in the care of patients with STEMI (emergency medicine, cardiology, cardiothoracic surgery and intensive care) in four government facilities with 24/7 Primary PCI in the Emirate of Abu Dhabi. Surveys were distributed using dedicated email links, and used 5-point Likert scales to assess perceptions and attitudes to EMS. Results: Of 106 physician respondents, most were male (82%), practicing in emergency medicine (47%) or cardiology (44%) and the majority (63%) had been in practice for >10. years. Less than half of the responders (42%) were "Somewhat Satisfied" (35%) or "Very Satisfied" (7%) with current EMS level of care for STEMI patients. Most respondents were "Very Likely" (67%) to advise a patient with a cardiac emergency to use EMS, but only 39% felt the same for themselves or their family. Most responders were supportive (i.e. "Strongly Agree") of the following steps to improve EMS care: 12-lead ECG and telemetry to ED by EMS (69%), EMS triage of STEMI to PCI facilities (65%), and activation of PCI teams by EMS (58%). Only 19% were supportive of pre-hospital fibrinolytics by EMS. There were no significant differences in the responses among the specialties. Conclusions: Most physicians involved in STEMI care in Abu Dhabi are very likely to advise patients to use EMS for a cardiac emergency, but less likely to do so for themselves or their families. Different specialties had concordant opinions regarding steps to improve pre-hospital EMS care for STEMI.
    Full-text · Article · Jun 2015 · Journal of the Saudi Heart Association
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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.
    Full-text · Article · Jun 2014 · Cor et vasa
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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.
    Full-text · Article · Aug 2013 · International journal of cardiology
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