Therapy initiated within national treatment-time goals set a decade ago for patients with ST-segment elevated myocardial infarction (STEMI) remains associated with improved survival in recent years. But for many such patients, time from first symptoms to initiation of reperfusion therapy still fail to meet those goals, suggests a cross-sectional registry analysis.
For example, patients initially transported to centers with percutaneous coronary intervention (PCI) capability had a median treatment time of 148 minutes, in the analysis spanning the second quarter (Q2) of 2018 to the third quarter (Q3) of 2021. But the goal for centers called for treatment initiation within 90 minutes for at least 75% of such STEMI patients.
Moreover, overall STEMI treatment times and in-hospital mortality rose in tandem significantly from Q2 2018 through the first quarter (Q1) of 2021, which included the first year of the COVID-19 pandemic. Median time-to-treatment went from 86 minutes to 91 minutes during that period. Meanwhile, in-hospital mortality went from 5.6% to 8.7%, report the study authors led by James G. Jollis, MD, Duke University, Durham, North Carolina.
Their report, based on 114,871 STEMI patients at 601 US hospitals contributing to the Get With The Guidelines – Coronary Artery Disease registry, was published online November 6 in the Journal of the American Medical Association.
Of those patients, 25,085 had been transferred from non-PCI hospitals, 32,483 were walk-ins, and 57,303 arrived via emergency medical services (EMS). Their median times from symptom onset to PCI were 240, 195, and 148 minutes, respectively.
In-hospital mortality was significantly reduced in an adjusted analysis for patients treated within target times compared to those whose treatment missed the time goals, regardless of whether they were transported by EMS, walked into a hospital with on-site PCI, or were transferred from a non-PCI center (Table 1).
Table 1. STEMI In-hospital Mortality for Patients With Treatment Meeting vs Not Meeting Time Goals
|Goals by patient mode of presentation||In-hospital mortality, treatment time goals met, %||In-hospital mortality, treatment time goals not met, %||Odds ratio[a]||95% CI|
|EMS-transported to PCI center|
|First medical contact to lab activation ≤ 20 min||3.6||9.2||0.54||0.48 – 0.60|
|First medical contact to device ≤ 90 min||3.3||12.1||0.40||0.36 – 0.44|
|Walked into PCI center|
|Hospital arrival to device ≤ 90 min||1.8||4.7||0.47||0.40 – 0.55|
|Transferred from non-PCI hospital to PCI center|
|Door-in to door-out time < 30 min||2.9||6.4||0.51||0.32 – 0.78|
|First hospital arrival to device ≤ 120 min||4.3||14.2||0.44||0.26 – 0.71|
|[a]Adjusted for age, race/ethnicity, sex, cardiac arrest, cardiogenic shock, and heart failure at presentation.|
Regardless of mode of patient presentation, treatment time goals were not met most of the time, the group reports. Patients who required interhospital transfer experienced the longest system delays; only 17% were treated within 120 minutes.
Among patients who received primary PCI, 20% had a registry-defined hospital-specified reason for delay, including cardiac arrest and/or need for intubation in 6.8%, “difficulty crossing the culprit lesion” in 3.8%, and “other reasons” in 5.8%, the group reports.
“In 2020, a new reason for delay was added to the registry, ‘need for additional personal protective equipment for suspected/confirmed infectious disease.’ This reason was most commonly used in the second quarter of 2020 (6%) and then declined over time to 1% in the final 2 quarters,” they write.
“Thus, active SARS-CoV-2 infection appeared to have a smaller direct role in longer treatment times or worse outcomes.” Rather, they continue, “the pandemic potentially had a significant indirect role as hospitals were overwhelmed with patients, EMS and hospitals were challenged in maintaining paramedic and nurse staffing and intensive care bed availability, and patients experienced delayed care due to barriers to access or perceived fear of becoming entangled in an overwhelmed medical system.”
Still an Important Quality Metric
STEMI treatment times remain an important quality metric to which hospitals should continue to pay attention because shorter times improve patient care, Deepak Bhatt, MD, MPH, told theheart.org | Medscape Cardiology.
“Having said that, as with all metrics, one needs to be thoughtful and realize that a difference of a couple of minutes is probably not a crucial thing,” said Bhatt, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, who was not involved with the current study.
Interhospital transfers indeed involve longer delays, he observed, suggesting that regional integrated health systems should develop methods for optimizing STEMI care — even, for example, if they involve bypassing non-PCI centers or stopping patients briefly for stabilization followed by rapid transport to a PCI-capable facility.
“That, of course, requires cooperation among hospitals. Sometimes that requires hospitals putting aside economic considerations and just focusing on doing the right thing for that individual patient,” Bhatt said.
Transfer delays are common for patients presenting with STEMI at hospitals without PCI capability, he noted. “Having clear protocols in place that expedite that type of transfer, I think, could go a long way in reducing the time-to-treatment in patients that are presenting to the hospital without cath labs. That’s an important message that these data provide.”
The onset of COVID-19 led to widespread delays in STEMI time-to-treatment early in the pandemic. There were concerns about exposing cath lab personnel to SARS-CoV-2 and potential adverse consequences of sick personnel being unable to provide patient care in the subsequent weeks and months, Bhatt observed.
However, “All of that seems to have quieted down, and I don’t think COVID is impacting time-to-treatment right now.”
“Suboptimal Compliance“ With Standards
The current findings of “suboptimal compliance with national targets underscore why reassessing quality metrics, in light of changing practice patterns and other secular trends, is critical,” write Andrew S. Oseran, MD, MBA, and Robert W. Yeh, MD, both of Harvard Medical School, in an accompanying editorial.
“While the importance of coordinated and expeditious care for this high-risk patient population is undeniable, the specific actions that hospitals can — or should — take to further improve overall STEMI outcomes are less clear,” they say.
“As physicians contemplate the optimal path forward in managing the care of STEMI patients, they must recognize the clinical and operational nuance that exists in caring for this diverse population and acknowledge the trade-offs associated with uniform quality metrics,” write the editorialists.
“Global reductions in time-to-treatment for STEMI patients has been one of healthcare’s great success stories. As we move forward, it may be time to consider whether efforts to achieve additional improvement in target treatment times will result in substantive benefits, or whether we have reached the point of diminishing returns.”
Ashley Lyles is an award-winning medical journalist. She is a graduate of New York University’s Science, Health, and Environmental Reporting Program. Previously, she studied professional writing at Michigan State University, where she also took premedical classes. Her work has appeared in outlets like The New York Times Daily 360, PBS NewsHour, The Huffington Post, Undark, The Root, Psychology Today, Insider, and Tonic (Health by Vice), among other publications.