Study Shows Bypassing the ED Associated with Shortened Reperfusion Times in STEMI

Use of Emergency Department (ED)-bypass before percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) patients was found to be associated with “a significant reduction in reperfusion times with no adverse impact on mortality rates,” according to a study published in Circulation.

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The study looked at 12,581 patients identified with a pre-hospital electrocardiogram at 371 U.S. hospitals participating in the ACTION Registry® — GWTG™ — Mission: Lifeline® program. When comparing ED-bypass to patients undergoing ED evaluation, results showed that ED bypass only occurred in 10.5 percent of patients, occurred more frequently during working hours than off-hours (18.3 percent vs. 4.3 percent), and the rate varied significantly across hospitals (median, 3.3 percent [range, 0 percent to 71 percent]).

Further, with ED-bypass, first medical contact to device activation time was shorter (median, 68 [54, 85] vs. 88 [73, 106] minutes, p<0.0001) and achieved within 90 minutes more frequently (80.7 percent vs. 53.7 percent, p<0.0001). The unadjusted in-hospital mortality rate was lower among ED-bypass patients (2.7 percent vs. 4.1 percent, p=0.01), but the adjusted mortality risk was similar (adjusted OR=0.69, 95 percent CI: 0.45–1.03, p=0.07).

The authors note that based on these results, "more widespread evaluation and implementation of this process is warranted in the U.S."

"The emergency department remains one of the most important components of STEMI care, both in managing the 98 percent of chest pain patients who are not suffering an acute myocardial infarction, and caring for those myocardial infarction patients who present when the catheterization lab is not yet available," said James G. Jollis, MD, FACC, governor of the NC Chapter of the ACC and co-author of the study. "Our study suggests that in the ideal situation when the patient is diagnosed prior to hospital arrival and the laboratory is available upon arrival, proceeding directly to the catheterization lab is associated with the best outcomes."

"We have demonstrated that the strategy to transport STEMI patients identified pre-hospital directly from the field to the catheterization lab, thereby bypassing the emergency department is feasible, safe and effective," added Akshay Bagai, MD, ACC fellow in training and lead author of the study. "Further work is required to increase the use of pre-hospital ECGs and implement systems for pre-activation of the catheterization lab prior to hospital arrival, two fundamental requisites for bypassing the emergency department."

According to Elliot M. Antman, MD, MACC, there are several next steps needed for improving systems of care for STEMI, including comprehensive care improvement programs that address all steps between admission and discharge after STEMI to ensure that evidence-based therapies are delivered; greater coordination among the EMS systems around the U.S. that care for STEMI patients; and a reduction in total ischemic time through educational efforts to teach patients of the warning signs of heart attack symptoms.

Keywords: Myocardial Infarction, Hospital Mortality, Chest Pain, Catheterization, Electrocardiography, Myocardial Reperfusion, Percutaneous Coronary Intervention

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