Does Time of Presentation Impact STEMI Patient Care?

The achievement of quality measures in ST-segment-elevation myocardial infarction (STEMI) patient care is high, regardless of time of presentation. However, patients presenting during off-hours are still subject to slower door-to-balloon (D2B) times and a risk-adjusted in-hospital mortality rate that is higher than that of STEMI patients presenting during on-hours, according to a study published July 29 in Circulation: Cardiovascular Quality and Outcomes.

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The study, led by Tarun W. Dasari, MD, MPH, FACC, used the ACTION Registry-GWTG to collect and analyze STEMI performance measures in patients presenting off-hours versus on-hours. The team’s research included 43,242 STEMI patients from 447 centers in the U.S. who underwent percutaneous coronary intervention (PCI) between January 2007 and September 2010.

The key STEMI performance variables monitored during the study were aspirin use within the first 24 hours, a door-to-balloon (D2B) time of 90 minutes or less, door-to-ECG time of 10 minutes or less, and a door-to-needle (D2N) time of 30 minutes or less. The study found high quality achievements for each of these variables regardless of time of presentation, but also noted that D2B times in off-hours were slightly delayed by an average of 16 minutes and that risk-adjusted in-hospital mortality was 13 percent higher in patients presenting during off-hours.

The median D2B time for STEMI patients presenting during off-hours was 72 minutes, which was consistently slower than the median time of 56 minutes for a STEMI patient presenting during on-hours. Additionally, 79.2 percent of patients presenting during off-hours received a D2B time within the target of 90 minutes, while 87.8 percent of STEMI patients presenting during on-hours reached D2B in 90-minutes or less.

Despite these findings, the authors note that previous studies have shown "an overall significant reduction in D2B time, regardless of time of presentation." In addition, the in-hospital mortality rate in patients with STEMI both on- and off-hours has decreased, proving that contemporary cardiovascular quality initiatives are headed in the right direction. They credit the D2B Alliance, Mission Lifeline and the Centers for Medicare and Medicaid Services’ STEMI performance measures whose efforts emphasize short D2B times and early invasive strategies to reduce cardiovascular risks in patients presenting with STEMI.

However, they add that there is still work to be done. "Quality improvement initiatives should continue to focus on attainment of quality measures and improving awareness of STEMI in the general public and early presentation to reduce symptom onset to door times." Further, "concerted efforts to reduce the disparities will pave the way for improved quality of care and outcomes in STEMI."

Keywords: Quality Improvement, Registries, Myocardial Infarction, Patient Care, Hospital Mortality, Medicaid, Centers for Medicare and Medicaid Services, U.S., Risk Factors, Electrocardiography, Medicare, Percutaneous Coronary Intervention

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