Hospital Improvement in Time to Reperfusion in Patients With Acute Myocardial Infarction, 1999 to 2002

Yale University, New Haven, Connecticut, United States
Journal of the American College of Cardiology (Impact Factor: 16.5). 01/2006; 47(1):45-51. DOI: 10.1016/j.jacc.2005.04.071
Source: PubMed


The purpose of this study was to analyze recent trends in door-to-reperfusion time and to identify hospital characteristics associated with improved performance.
Rapid reperfusion improves survival for patients with acute ST-segment elevation myocardial infarction (STEMI).
In this retrospective observational study from the National Registry of Myocardial Infarction (NRMI)-3 and -4, between 1999 and 2002, we analyzed door-to-needle and door-to-balloon times in patients admitted with STEMI and receiving fibrinolytic therapy (n = 68,439 patients in 1,015 hospitals) or percutaneous coronary intervention (n = 33,647 patients in 421 hospitals) within 6 h of hospital arrival.
In 1999, only 46% of the patients in the fibrinolytic therapy cohort were treated within the recommended 30-min door-to-needle time; only 35% of the patients in the percutaneous coronary intervention cohort were treated within the recommended 90-min door-to-balloon time. Improvement in these times to reperfusion over the four-year study period was not statistically significant (door-to-needle: -0.01 min/year, 95% confidence interval [CI] -0.24 to +0.23, p > 0.9; door-to-balloon: -0.57 min/year, 95% CI -1.24 to +0.10, p = 0.09). Only 33% (337 of 1,015) of hospitals improved door-to-needle time by more than one min/year, and 26% (110 of 421) improved door-to-balloon time by more than three min/year. No hospital characteristic was significantly associated with improvement in door-to-needle time. Only high annual percutaneous coronary intervention volume and location in New England were significantly associated with greater improvement in door-to-balloon time.
Fewer than one-half of patients with STEMI receive reperfusion in the recommended door-to-needle or door-to-balloon time, and mean time to reperfusion has not decreased significantly in recent years. Relatively few hospitals have shown substantial improvement.

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    • "Only 22% in HUS-STEMI I and 25% in HUS-STEMI II were treated within 90 minutes (Table  2). The results from a US report from the National Registry of Myocardial Infarction from 1999 to 2002 were quite similar showing no substantial improvement in average treatment times: the percentage of patients with a system delay less than 90 minutes was 35% in 1999 and increased by 2% in 2002 [12]. Another study that described the delays in 30 European countries had median system delays of 60 to 177 minutes [13]. "
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    ABSTRACT: Background Treatment delay is an important prognostic factor for patients with acute ST-elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI). We aimed to determine recent trends in these delays and factors associated with longer delays. Methods We compared two datasets collected in Helsinki University Central Hospital in 2007–2008 (HUS-STEMI I) and 2011–2012 (HUS-STEMI II), a total of 500 patients treated with primary PCI within 12 hours of the onset of symptoms. Results Delays of the emergency medical system (EMS) were longer in HUS-STEMI I than II (medians 81 vs. 67 min, respectively, p < 0.001). Although door-to-balloon times were longer in the later dataset (33 vs. 48 min, p < 0.001) most of the patients (75.3% vs. 62.8%, respectively, p = 0.010) were treated within the recommendation (<60 min) of the European Society of Cardiology (ESC). In HUS-STEMI II, patient arrival at the hospital during off-hours was associated with longer door-to-balloon time (40 and 57.5 min, p = 0.001) and system delay (111 and 127 min, p = 0.009). However, in HUS-STEMI I, arrival time did not impact the delays. Longer system delay was associated with higher mortality rates. Conclusions Though the delays inside the hospital have increased they are still mostly within the ESC guidelines. Still, only about half of the patients are treated within a system delay of recommended two hours. Albeit our results are good in comparison with previous studies, further efforts for decreasing the delays particularly within the EMS should be established.
    Full-text · Article · Sep 2014 · BMC Cardiovascular Disorders
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    • "DNT is the time taken from patient's arrival to a medical facility to the time when thrombolytic therapy is administered. As a result of the importance of the timing of the thrombolysis, DNT time has emerged as an important hospital performance measure for the quality of care of patients with STEMI in the United States and Europe [6] [7] [8]. The American College of Cardiology/the American Heart Association (ACC/AHA) and the European Society of Cardiology (ESC) guidelines for STEMI recommend that the DNT for thrombolysis should be within 30 minutes of first medical system contact [6] [7]. "
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    ABSTRACT: Objective. Early restoration of coronary perfusion by thrombolysis or percutaneous coronary intervention is the main modality of treatment to salvage the ischemic myocardium. The earlier the procedure is completed, the greater the benefit is in saving myocardium and restoring its functions. The aim of the study is to compare the door-to-needle time (DNT) in acute ST elevation myocardial infarction (STEMI) in the period prior to December 2008 when the site of thrombolysis was in coronary care unit (CCU) and the period after that when the site was shifted to emergency department (ED). Methods. A retrospective, descriptive study was conducted at Al Khor Hospital, Qatar, in patients with acute STEMI who underwent thrombolysis at CCU and ED from April 2005 until December 2011, to compare the DNT, duration of hospitalization, and mortality. Results. A total of 211 patients with acute STEMI were eligible for thrombolysis; 58 patients were thrombolysed in the CCU and 153 in ED. The median DNT was reduced from 33.5 minutes in the CCU to 17 minutes in the ED representing a reduction of more than 50% with a P value of < 0.0001. Conclusion. The transfer of the thrombolysis site from CCU to the ED was associated with a dramatic and significant reduction in median door-to-needle time by more than half.
    Full-text · Article · Sep 2013
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    • "From the data in NRMI-3 and -4, fewer than one-half of patients with STEMI received reperfusion in the recommended door-to-balloon time, and the mean door-to-balloon time was 108 min (95% CI, 160.5-109.4 min) (31). The growing interest in primary PCI and easy accessibility to the large-volume hospitals capable of performing PCI, most of which participated in the KAMIR, may account for the higher performance of primary PCI in KAMIR than in those reports. "
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    ABSTRACT: As the first nationwide Korean prospective multicenter data collection registry, the Korea Acute Myocardial Infarction Registry (KAMIR) launched in November 2005. Through a number of innovative approaches, KAMIR suggested new horizons about acute myocardial infarction (AMI) which contains unique features of Asian patients from baseline characteristics to treatment strategy. Obesity paradox was existed in Korean AMI patients, whereas no gender differences among them. KAMIR score suggested new risk stratifying method with increased convenience and an enhanced accuracy for the prediction of adverse outcomes. Standard loading dose of clopidogrel was enough for Asian AMI patients. Triple antiplatelet therapy with aspirin, clopidogrel and cilostazol could improve clinical outcomes than dual antiplatelet therapy with aspirin and clopidogrel. Statin improved clinical outcomes even in AMI patients with very low LDL-C levels. The rate of percutaneous coronary intervention was higher and door-to-balloon time was shorter than the previous reports. Zotarolimus eluting stents as the 2nd generation drug-eluting stent (DES) was not superior to the 1st generation DES, in contrast to the western AMI studies. KAMIR made a cornerstone in the study of Korean AMI and expected to be new standards of care for AMI with the renewal of KAMIR design to overcome its pitfalls.
    Full-text · Article · Feb 2013 · Journal of Korean medical science
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