On- versus off-hour care for patients with non-ST-segment elevation myocardial infarction in Germany

Breuckmann, Frank; Remberg, Friederike; Böse, Dirk; Waltenberger, Johannes; Fischer, Dieter; Rassaf, Tienush

doi:10.1007/s00059-016-4425-5

Cited by 6 publications

(6 citation statements)

References 23 publications

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“…Patients hospitalised at weekends were more likely to receive angiography after more than 24 h. Although this is a well-known phenomenon, this was not seen in other registries [ 22 , 29 ] and is probably related to logistics and planning of angiography.…”

Section: Discussionmentioning

confidence: 82%

Use, timing and outcome of coronary angiography in patients with high-risk non-ST-segment elevation acute coronary syndrome in daily clinical practice: insights from a ‘real world’ prospective registry

et al. 2018

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BackgroundAn early invasive strategy (EIS) is recommended in high-risk patients with non-ST-elevation acute coronary syndrome (NSTE-ACS), defined as coronary angiography (CAG), within 24 h of admission. The aim of the present study is to investigate guideline adherence, patient characteristics associated with timing of the intervention and clinical outcome.MethodsIn a prospective registry, the use and timing of CAG and the characteristics and clinical outcome associated with timing were evaluated in high-risk ACS patients. The outcome of early versus delayed invasive strategy (DIS) was compared.ResultsBetween 2006 and 2014, 2,299 high-risk NSTE-ACS patients were included. The use of CAG increased from 77% in 2006 to 90% in 2014 (p trend <0.001) together with a decrease of median time to CAG from 23.3 to 14.5 h (p trend <0.001) and an increase of patients undergoing EIS from 50 to 60% (p trend = 0.002). Patient factors independently related to DIS were higher GRACE risk score, higher age and the presence of comorbidities. No difference was found in incidence of mortality, reinfarction or bleeding at 30-day follow-up. All-cause mortality at 1‑year follow-up was 4.1% vs 7.0% in EIS and DIS respectively (hazard ratio 1.67, 95% confidence interval 1.12–2.49) but was comparable after adjustment for confounding factors.ConclusionThe percentage of high-risk NSTE-ACS patients undergoing CAG and EIS has increased in the last decade. In contrast to the guidelines, patients with a higher risk profile are less likely to undergo EIS. However, no difference in outcome after 30 days and 1 year was found after multivariate adjustment for this higher risk.

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Section: Discussionmentioning

confidence: 82%

Use, timing and outcome of coronary angiography in patients with high-risk non-ST-segment elevation acute coronary syndrome in daily clinical practice: insights from a ‘real world’ prospective registry

et al. 2018

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“…A total of 384,452 patients from 56 studies were included. 2 3 4 5 6 7 8 9 10 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 Baseline characteristics are presented in Table 1 .…”

Section: Resultsmentioning

confidence: 99%

Association of Admission Time and Mortality in STEMI Patients: A Systematic Review and Meta-analysis

2022

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This systematic review and meta-analysis aimed to evaluate patients with acute ST-segment elevation myocardial infarction (STEMI) who were admitted during off-hours and treated with primary angioplasty associated with an increased risk of mortality compared with those admitted during regular working hours. We performed a systematic literature search using PubMed, SCOPUS, Europe PMC, and Cochrane CENTRAL databases that was finalized on March 15, 2021. The primary outcome was mortality comprising early (in-hospital), midterm (30 days to 1 year), and long-term mortality (>1 year). A total of 384,452 patients from 56 studies were included. The overall mortality of acute STEMI patients admitted during off-hours and regular hours were 6.1 and 6.7%, respectively. Patients admitted during off-hours had similar risk of early, midterm, and long-term mortality compared to those admitted during regular working hours ([relative risk or RR = 1.07, 95% confidence interval or CI, 1.00–1.14, p = 0.06; I 2 = 45%, p = 0.0009], [RR = 1.00, 95% CI, 0.95–1.05, p = 0.92; I 2 = 13%, p = 0.26], and [RR = 0.95, 95% CI, 0.86–1.04, p = 0.26; I 2 = 0%, p = 0.76], respectively). Subgroup analyses indicated that the results were consistent across all subgroups ([women vs. men], [age >65 years vs. ≤65 years], and [Killip classification II to IV vs. Killip I]). Funnel plot was asymmetrical. However, Egger's test suggests no significance of small-study effects (p = 0.19). This meta-analysis showed that patients with acute STEMI who were admitted during off-hours and treated with primary angioplasty had similar risk of early, midterm, and long-term mortality compared with those admitted during regular working hours.

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“…A number of factors that may underlie a worse prognosis in patients with ACS presenting off-hours compared with patients presenting on-hours have been suggested. Thus, walk-in or self-transported patients with ACS [ 19 , 20 ], absence of digital prehospital ECG transfer [ 21 ], insufficient centralized EMS networking [ 22 ], lack of patient awareness programs [ 23 ], resource constrained hospitals [ 24 ], slow initial triage, absence of dedicated in-hospital pathways [ 25 ], major complications such as those related to emergency CABG surgery, ventricular tachyarrhythmias, stroke or transient ischemic attack, bleedings from gastrointestinal, retroperitoneal, or intracranial origin [ 18 ], higher amount of contrast use and associated contrast-induced nephropathy [ 26 ], socioeconomic differences in between the countries and regions [ 6 ], fatigue of medical staff and varying expertise of the individual PCI operators, and circadian variation in myocardial perfusion and increased reperfusion times have been suggested.…”

Section: Discussionmentioning

confidence: 99%

“…In Germany, there is a widespread standardized and well-established emergency network to optimally supply patients with ACS. The dedicated German chest pain unit network has been reported to ensure rapid and structured prehospital and in-hospital care and may compensate for longer door-to-balloon times during off-hour presentation by shortening symptom-to-admission or symptom-to-first medical contact time intervals [ 23 , 25 ]. Likewise, in Italy, efficient networks to guarantee efficient reperfusion therapies for patients with ACS have shown comparable clinical effectiveness both during off-hours and regular hours [ 27 ].…”

Section: Discussionmentioning

confidence: 99%

Ticagrelor or prasugrel in patients with acute coronary syndrome with off-hour versus on-hour presentation: a subgroup analysis of the ISAR-REACT 5 trial

et al. 2022

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Objectives To assess the efficacy and safety of ticagrelor versus prasugrel in patients with acute coronary syndrome (ACS) presenting during off- and on-hours. Background The efficacy and safety of ticagrelor versus prasugrel in patients with ACS according to time of hospital presentation remain unknown. Methods This post hoc analysis of the ISAR-REACT 5 trial included 1565 patients with ACS presenting off-hours and 2453 patients presenting on-hours, randomized to ticagrelor or prasugrel. The primary endpoint was a composite of death, myocardial infarction, or stroke; the safety endpoint was Bleeding Academic Research Consortium (BARC) type 3–5 bleeding, both at 12 months. Results The primary endpoint occurred in 80 patients (10.4%) in the ticagrelor group and 57 patients (7.3%) in the prasugrel group in patients presenting off-hours (hazard ratio [HR] = 1.45; 95% confidence interval [CI] 1.03–2.03; P = 0.033), and 104 patients (8.5%) in the ticagrelor group and 80 patients (6.7%) in the prasugrel group in patients presenting on-hours (HR = 1.29 [0.97–1.73]; P = 0.085), without significant treatment arm-by-presentation time interaction (Pint = 0.62). BARC type 3 to 5 bleeding occurred in 35 patients (5.1%) in the ticagrelor group and 37 patients (5.3%) in the prasugrel group (P = 0.84) in patients presenting off-hours, and 60 patients (5.9%) in the ticagrelor group and 43 patients (4.6%) in the prasugrel group in patients presenting on-hours (P = 0.17). Conclusions In patients with ACS planned to undergo an invasive treatment strategy, time of presentation (off-hours vs. on-hours) does not interact significantly with the relative efficacy and safety of ticagrelor vs. prasugrel. Clinical trial registration. NCT01944800. Graphical abstract

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On- versus off-hour care for patients with non-ST-segment elevation myocardial infarction in Germany

Abstract: Our exemplary experience in two different German CPUs demonstrates adequate timing of coronary catheterization in over 75 % of cases, irrespective of admission during on- or off-hours. Nationwide validation of our findings by the German CPU registry is mandatory.

Cited by 6 publications

References 23 publications

Use, timing and outcome of coronary angiography in patients with high-risk non-ST-segment elevation acute coronary syndrome in daily clinical practice: insights from a ‘real world’ prospective registry

Use, timing and outcome of coronary angiography in patients with high-risk non-ST-segment elevation acute coronary syndrome in daily clinical practice: insights from a ‘real world’ prospective registry

Association of Admission Time and Mortality in STEMI Patients: A Systematic Review and Meta-analysis

Ticagrelor or prasugrel in patients with acute coronary syndrome with off-hour versus on-hour presentation: a subgroup analysis of the ISAR-REACT 5 trial

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