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Time to Treatment and Mortality Among STEMI Patients, 2018-2021
Quick Takes
- Among the 114,871 registry patients with STEMI, the median time to treatment in the second quarter of 2018 was 86 minutes and 91 minutes in the first quarter of 2021, which was statistically significantly different.
- Only 17% of patients presenting at noncapable PCI hospitals met national time-to-treatment goals of being transferred to PCI-capable hospitals. Consistent with previous research, risk-adjusted in-patient deaths were significantly lower among patients who received STEMI treatment within guideline-based target times.
Study Questions:
What were the treatment times and in-hospital mortality among US patients with ST-segment elevation myocardial infarction (STEMI) between 2018 and 2021?
Methods:
A cross-sectional registry study was conducted using the American Heart Association’s Get With The Guidelines (GWTG) voluntary hospital registry program. A total of 114,871 patients from 601 participating registry hospitals were included in the analysis. Outcome measures included treatment times, in-hospital mortality, and system goals achievement.
The first medical contact was defined according to the setting in which patients presented. For patients who presented to percutaneous coronary intervention (PCI)-capable hospitals via emergency medical service (EMS), first medical contact was defined as the time patients were evaluated by paramedics; for patients who walked into a PCI-capable hospital, it was defined as hospital arrival time. For patients who arrived at one hospital and needed to be transferred to another hospital, the first medical contact was the time they arrived at the first hospital. Other time processes allowed, depending on mode of arrival, included 20-minute cardiac catheterization laboratory activation for EMS arrivals, 10-minute electrocardiogram for walk-ins, and 30-minute first hospital arrival to transfer (door-in door-out).
Beginning in 2020, the coronavirus disease 2019 (COVID-19) variable was added to the analysis, including the need for personal protective equipment as a reason for delay. Data were modeled using logistic regression to calculate odds ratios (ORs), adjusting for demographic variables (age, race, and ethnicity) on admission and illness acuity variables (cardiac arrest, shock, and heart failure) on presentation.
Results:
Of the 601 hospitals included in this study, 505 were PCI-capable hospitals. Among the 114,871 registry patients with STEMI, the median time to treatment in the second quarter of 2018 was 86 minutes and 91 minutes in the first quarter of 2021. In-patient mortality increased from 5.6% in the second quarter of 2018 to 8.7% in the first quarter of 2021. Both the treatment time and mortality differences between 2018 and 2021 were statistically significant. Overall, adjusted in-patient mortality was significantly greater among patients treated in the second and fourth quarters of 2020 and the first and second quarters of 2021 (adjusted OR, 1.22 [95% CI, 1.01-1.47]); adjusted OR, 1.29 [95% CI, 1.08-1.55]; adjusted OR, 1.38 [95% CI, 1.15-1.65]; and adjusted OR, 1.26 [95% CI, 1.05-1.51]) compared to patients treated in the second quarter of 2018.
Conclusions:
This study confirms previous work that time to treatment for STEMI is a crucial factor in reducing death and disability in patients with acute coronary syndrome. In this study, mortality was significantly lower in patients whose treatment times were within the established guidelines after adjusting for patient characteristics most associated with mortality. Findings indicate the most pressing opportunities might be for transferring patients from a PCI noncapable hospital to a PCI-capable hospital, as only 17% of patients were treated within 120 minutes of arrival at the first hospital.
Perspective:
Time to treatment continues to be an important factor in STEMI care. The COVID-19 pandemic overwhelmed hospitals, and as such, might have had an indirect impact on treatment times; however, no discernible differences were attributed directly to the pandemic. Changes between processes and outcomes identified from 2018 and 2021 warrant further investigation using more rigorous prospective approaches, given the limitations for chart review and previously collected registry data. Nonetheless, the findings hold important opportunities for continuing to reduce treatment time and improve outcomes.
Clinical Topics: Acute Coronary Syndromes, Arrhythmias and Clinical EP, Cardiovascular Care Team, COVID-19 Hub, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Prevention, Stable Ischemic Heart Disease, Vascular Medicine, Implantable Devices, SCD/Ventricular Arrhythmias, Acute Heart Failure, Interventions and ACS, Interventions and Vascular Medicine, Chronic Angina
Keywords: Acute Coronary Syndrome, Allied Health Personnel, Cardiac Catheterization, Coronavirus, COVID-19, Electrocardiography, Emergency Medical Services, Heart Arrest, Heart Failure, Hospital Mortality, Myocardial Infarction, Outcome Assessment, Health Care, Patient Care Team, Percutaneous Coronary Intervention, Personal Protective Equipment, Secondary Prevention, ST Elevation Myocardial Infarction, Time-to-Treatment
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