Nationwide Analysis of Patients With ST-Segment–Elevation Myocardial Infarction Transferred for Primary Percutaneous Intervention

Abstract

Multiple strategies have been used to improve the safety and efficacy of regional primary percutaneous coronary intervention (PCI) for ST-segment-elevation myocardial infarction (STEMI) programs. [1][2][3] Strategies that may improve first medical contact to device times include prehospital cardiac catheterization laboratory activation and bypass of non-PCI-capable hospitals or emergency departments. 4,5 Although rerouting patients directly to PCI centers may eliminate potential delays associated with transfer of STEMI patients for primary PCI, 5 ≈50% of patients with STEMI do not arrive to an emergency department via ambulance.6 Thus, regional systems of care face the ongoing challenge of determining best practices for timely transfer of patients from STEMI referring centers to STEMI PCI hospitals.Although significant progress has been made in achieving short ischemic time intervals for patients presenting directly to PCI centers, transfer STEMI time intervals remain a challenge.7,8 Both European and US STEMI guidelines recommend first medical contact to device time of ≤120 minutes for the transfer STEMI population 9,10 : STEMI referring facilities unable to achieve this 2-hour interval should consider fibrinolytic therapy as the primary reperfusion strategy.11 Timely first door-to-device intervals have been achieved for transfer patients in selected regional programs.12,13 However, recentBackground-Current American College of Cardiology/American Heart Association guidelines recommend transfer and primary percutaneous coronary intervention (PCI) for ST-segment-elevation myocardial infarction (STEMI) patients within the time limit of first contact to device ≤120 minutes. We determined the hospital-level, patient-level, and process characteristics of timely versus delayed primary PCI for a diverse national sample of transfer patients confined to a travel distance that facilitates the process. Methods and Results-We studied 14 518 patients transferred from non-PCI-capable hospitals for primary PCI to 398 National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines hospitals between July 2008 and December 2012. Patients with estimated transfer times >60 minutes (by Google Maps driving times) were excluded from the analysis. Patients achieving first door-to-device time ≤120 minutes were compared with patients with delayed treatment; independent predictors of timely treatment were determined using generalized estimating equations logistic regression models. The median estimated transfer distance was 26.5 miles. First door-to-device ≤120 minutes was achieved in 65% of patients (n=9380); only 37% of the hospitals were high-performing hospitals (defined as risk-adjusted rate, ≥75% of transfer STEMI patients with ≤120-minute first door-to-device time). In addition to known predictors of delay (cardiogenic shock, cardiac arrest, and prolonged door-in door-out time), STEMI referral hospitals' rural location and longer estimated transfer time were identifi...

Regional “Call 911” Emergency Department Protocol to Reduce Interfacility Transfer Delay for Patients With ST‐Segment–Elevation Myocardial Infarction

“…Multiple contemporary studies suggest that <30% of patients in the United States meet this goal 10, 11, 12, 21, 22. One study, which limited transport time to within 60 minutes, reported that 65% of patients were treated within 120 minutes 13. However, these studies likely overestimate performance, given that high‐performing hospitals are more likely to submit data to the national registries 12, 23.…”

“…A recent evaluation in Korea demonstrated that timely treatment for STEMI IFTs remains a challenge and is not limited to the United States 24. Lack of regional coordination and EMS use for primary transports contribute to overall delays within a STEMI system of care,13, 24, 25 whereas a coordinated system can deliver timely care over considerable distances 6, 26…”

“…Prior studies have also associated transport time with delays 13. The median transport interval was only 9 minutes using the municipal 911 provider agency.…”

“…While steady progress has been made to reduce FMC2B time for patients who present directly to PCI‐capable centers, progress has lagged for these patients with IFT 10. National estimates for the proportion of patients with IFT receiving PPCI within 120 minutes vary widely and range from 16% to 65% 11, 12, 13. The ability to minimize time at the transferring hospital has been demonstrated to be particularly challenging and delay in door‐in‐door‐out (DIDO) is associated with increased mortality 4, 14…”

Ethnic Minorities and Coronary Heart Disease: an Update and Future Directions

“…However, it has been seen that door-to-balloon times have improved over time and narrowed (but not eliminated) disparity [55]. Most recently, in looking at a registry of 14,518 patients transferred from a non-PCI to a PCI center for primary PCI treatment, it was found that those with first door-to-device times greater than 120 min were 19 % more likely to be of non-white race [56]. …”