Temporal changes in patient characteristics and outcomes in ST-segment elevation myocardial infarction 2003-2018.
acute myocardial infarction
outcomes
trends
Journal
Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions
ISSN: 1522-726X
Titre abrégé: Catheter Cardiovasc Interv
Pays: United States
ID NLM: 100884139
Informations de publication
Date de publication:
01 05 2021
01 05 2021
Historique:
received:
24
03
2020
accepted:
29
03
2020
pubmed:
16
4
2020
medline:
12
10
2021
entrez:
16
4
2020
Statut:
ppublish
Résumé
We sought to describe changes in demographic variables, process of care measures, and outcomes of patients treated in a regional ST-segment elevation myocardial infarction (STEMI) program over the last 15 years. We describe demographic variables, process of care measures, and outcomes of patients treated in the program in various 5-year time periods: 2003-2007 (n = 1,821), 2008-2012 (n = 1,968), and 2013-2018 (n = 2,223). The primary outcome measures were in-hospital and 30-day mortality. Among 6,012 STEMI patients treated from 2003 to 2018 we observed a significant increase in mean age at presentation (62 ± 14 to 64 ± 13 years) and diabetes (14-22%, p < .01). The proportion of patients with cardiogenic shock (CS) and cardiac arrest (CA) pre-PCI increased significantly from 9.5% to 11.1% and 8.5% to 12.7% (p < .05), respectively. The median door-to-balloon (D2B) times decreased from 98 to 93 min and total ischemic time decreased from 202 to 185 min (all p < .05). Despite increased patient complexity, the proportion of nontransfer and transfer patients achieving D2B times consistent with guideline recommendations remained unchanged (for nontransfer patients 79-82%, p = .45 and for transfer patients 65-64%, p = .34). Among all STEMI patients, in-hospital mortality increased during the study period from 4.9 to 6.9% (p = .007) but remained stable (<2%) when CA and CS patients were excluded. Over the last 15 years, short-term STEMI mortality has increased despite improvements in care delivery metrics. Patients with CA and/or CS now represent 10% of STEMI patients and are responsible for 80% of deaths. Therefore, efforts to improve STEMI mortality, and metrics for assessing STEMI programs, should focus on these patients.
Sections du résumé
BACKGROUND
We sought to describe changes in demographic variables, process of care measures, and outcomes of patients treated in a regional ST-segment elevation myocardial infarction (STEMI) program over the last 15 years.
METHODS
We describe demographic variables, process of care measures, and outcomes of patients treated in the program in various 5-year time periods: 2003-2007 (n = 1,821), 2008-2012 (n = 1,968), and 2013-2018 (n = 2,223). The primary outcome measures were in-hospital and 30-day mortality.
RESULTS
Among 6,012 STEMI patients treated from 2003 to 2018 we observed a significant increase in mean age at presentation (62 ± 14 to 64 ± 13 years) and diabetes (14-22%, p < .01). The proportion of patients with cardiogenic shock (CS) and cardiac arrest (CA) pre-PCI increased significantly from 9.5% to 11.1% and 8.5% to 12.7% (p < .05), respectively. The median door-to-balloon (D2B) times decreased from 98 to 93 min and total ischemic time decreased from 202 to 185 min (all p < .05). Despite increased patient complexity, the proportion of nontransfer and transfer patients achieving D2B times consistent with guideline recommendations remained unchanged (for nontransfer patients 79-82%, p = .45 and for transfer patients 65-64%, p = .34). Among all STEMI patients, in-hospital mortality increased during the study period from 4.9 to 6.9% (p = .007) but remained stable (<2%) when CA and CS patients were excluded.
CONCLUSIONS
Over the last 15 years, short-term STEMI mortality has increased despite improvements in care delivery metrics. Patients with CA and/or CS now represent 10% of STEMI patients and are responsible for 80% of deaths. Therefore, efforts to improve STEMI mortality, and metrics for assessing STEMI programs, should focus on these patients.
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
1109-1117Commentaires et corrections
Type : CommentIn
Informations de copyright
© 2020 Wiley Periodicals LLC.
Références
Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials. Lancet. 2003;361(9351):13-20.
Weaver WD, Simes RJ, Betriu A, et al. Comparison of primary coronary angioplasty and intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review. Jama. 1997;278(23):2093-2098.
Grines CL, Browne KF, Marco J, et al. A comparison of immediate angioplasty with thrombolytic therapy for acute myocardial infarction. The primary angioplasty in myocardial infarction study group. N Engl J Med. 1993;328(10):673-679.
Langabeer JR, Henry TD, Kereiakes DJ, et al. Growth in percutaneous coronary intervention capacity relative to population and disease prevalence. J Am Heart Assoc. 2013;2(6):e000370.
Nallamothu BK, Bates ER, Wang Y, Bradley EH, Krumholz HM. Driving times and distances to hospitals with percutaneous coronary intervention in the United States: implications for prehospital triage of patients with ST-elevation myocardial infarction. Circulation. 2006;113(9):1189-1195.
Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction; a report of the American College of Cardiology/American Heart Association task force on practice guidelines (committee to revise the 1999 guidelines for the management of patients with acute myocardial infarction). J Am Coll Cardiol. 2004;44(3):E1-E211.
Henry TD, Sharkey SW, Burke MN, et al. A regional system to provide timely access to percutaneous coronary intervention for ST-elevation myocardial infarction. Circulation. 2007;116(7):721-728.
Graham KJ, Strauss CE, Boland LL, et al. Has the time come for a national cardiovascular emergency care system? Circulation. 2012;125(16):2035-2044.
Miedema MD, Newell MC, Duval S, et al. Causes of delay and associated mortality in patients transferred with ST-segment-elevation myocardial infarction. Circulation. 2011;124(15):1636-1644.
Larson DM, Duval S, Sharkey SW, et al. Safety and efficacy of a pharmaco-invasive reperfusion strategy in rural ST-elevation myocardial infarction patients with expected delays due to long-distance transfers. Eur Heart J. 2012;33(10):1232-1240.
Jacobs AK, Antman EM, Ellrodt G, et al. Recommendation to develop strategies to increase the number of ST-segment-elevation myocardial infarction patients with timely access to primary percutaneous coronary intervention. Circulation. 2006;113(17):2152-2163.
Bradley EH, Nallamothu BK, Stern AF, et al. The door-to-balloon alliance for quality: who joins national collaborative efforts and why? Jt Comm J Qual Patient Saf. 2009;35(2):93-99.
Menees DS, Peterson ED, Wang Y, et al. Door-to-balloon time and mortality among patients undergoing primary PCI. N Engl J Med. 2013;369(10):901-909.
Vora AN, Dai D, Gurm H, et al. Temporal trends in the risk profile of patients undergoing outpatient percutaneous coronary intervention: a report from the National Cardiovascular Data Registry's CathPCI Registry. Circ Cardiovasc Interv. 2016;9(3):e003070.
Waldo SW, Gokhale M, O'Donnell CI, et al. Temporal trends in coronary angiography and percutaneous coronary intervention: insights from the VA clinical assessment, reporting, and tracking program. JACC Cardiovasc Interv. 2018;11(9):879-888.
Mooney MR, Unger BT, Boland LL, et al. Therapeutic hypothermia after out-of-hospital cardiac arrest: evaluation of a regional system to increase access to cooling. Circulation. 2011;124(2):206-214.
Klein LW, Harjai KJ, Resnic F, et al. 2016 revision of the SCAI position statement on public reporting. Catheter Cardiovasc Interv. 2017;89(2):269-279.
Cavender MA, Joynt KE, Parzynski CS, et al. State mandated public reporting and outcomes of percutaneous coronary intervention in the United States. Am J Cardiol. 2015;115(11):1494-1501.
Joynt KE, Blumenthal DM, Orav EJ, Resnic FS, Jha AK. Association of public reporting for percutaneous coronary intervention with utilization and outcomes among Medicare beneficiaries with acute myocardial infarction. Jama. 2012;308(14):1460-1468.
Waldo SW, McCabe JM, O'Brien C, Kennedy KF, Joynt KE, Yeh RW. Association between public reporting of outcomes with procedural management and mortality for patients with acute myocardial infarction. J Am Coll Cardiol. 2015;65(11):1119-1126.
Bangalore S, Guo Y, Xu J, et al. Rates of invasive Management of Cardiogenic Shock in New York before and after exclusion from public reporting. JAMA Cardiol. 2016;1(6):640-647.
Hochman JS, Sleeper LA, Webb JG, et al. Early revascularization in acute myocardial infarction complicated by cardiogenic SHOCK. SHOCK Investigators. Should we emergently Revascularize occluded coronaries for cardiogenic shock. N Engl J Med. 1999;341(9):625-634.
Hochman JS, Sleeper LA, Webb JG, et al. Early revascularization and long-term survival in cardiogenic shock complicating acute myocardial infarction. Jama. 2006;295(21):2511-2515.
Van de Werf F, Ardissino D, Betriu A, et al. Management of acute myocardial infarction in patients presenting with ST-segment elevation. The task force on the Management of Acute Myocardial Infarction of the European Society of Cardiology. Eur Heart J. 2003;24(1):28-66.
Thiele H, Zeymer U, Neumann FJ, et al. Intraaortic balloon support for myocardial infarction with cardiogenic shock. N Engl J Med. 2012;367(14):1287-1296.
Sandhu A, McCoy LA, Negi SI, et al. Use of mechanical circulatory support in patients undergoing percutaneous coronary intervention: insights from the National Cardiovascular Data Registry. Circulation. 2015;132(13):1243-1251.
Thiele H, Ohman EM, de Waha-Thiele S, Zeymer U, Desch S. Management of cardiogenic shock complicating myocardial infarction: an update 2019. Eur Heart J. 2019;40(32):2671-2683.
Rab T, Ratanapo S, Kern KB, et al. Cardiac shock care centers: JACC review topic of the week. J Am Coll Cardiol. 2018;72(16):1972-1980.