Delay In Percutaneous Coronary Intervention Research Articles

Stepwise relationship between delay in percutaneous coronary intervention and long-term mortality in patients with non-ST-segment elevation myocardial infarction.

Current guidelines recommend coronary catheterization in patients with non-ST- -segment elevation myocardial infarction (NSTEMI) within 24 hours of hospital admission. However, whether there is a stepwise relationship between the time to percutaneous coronary intervention (PCI) and long-term mortality in patients with NSTEMI treated invasively within 24 hours of admission has not been established yet. The study aimed to evaluate the association between door-to-PCI time and all-cause mortality at 12 and 36 months in NSTEMI patients presenting directly to a PCI-capable center who underwent PCI within the first 24 hours of hospitalization. We analyzed data of patients hospitalized for NSTEMI between 2007-2019, included in the nationwide registry of acute coronary syndromes. Patients were stratified into twelve groups based on 2-hour intervals of door-to-PCI time. The mortality rates of patients within those groups were adjusted for 33 confounding variables by the propensity score weighting method using overlap weights. A total of 37 589 patients were included in the study. The median age of included patients was 66.7 (interquartile range [IQR], 59.0-75.8) years; 66.7% were male, and the median GRACE (Global Registry of Acute Coronary Events) score was 115 (98-133). There were increased 12-month and 36-month mortality rates in consecutive groups of patients stratified by 2-hour door-to-PCI time intervals. After adjustment for patient characteristics, there was a significant positive correlation between the time to PCI and the mortality rates (rs = 0.61; P = 0.04 and rs = 0.65; P = 0.02 for 12-month and 36-month mortality, respectively). The longer the door-to-PCI time, the higher were 12-month and 36-month all-cause mortality rates in NSTEMI patients.

Chest Radiography Should Not Be Routinely Performed Prior to Cardiac Catheterization in Patients With ST-elevation Myocardial Infarction

Acute ST-elevation myocardial infarction (STEMI) represents the most devastating form of acute coronary syndrome. Prompt reperfusion, ideally through percutaneous coronary intervention (PCI), optimizes outcomes among patients with STEMI. Delays in percutaneous coronary intervention, as measured by door-to-balloon time, are associated with a significant rise in mortality. Indeed, a recent Cochrane Review estimated that every 30-minute delay in door-to-balloon time results in a 17% relative increase in short-term mortality.

Registry-Based Monitoring of Hospital Performance Can Improve Time Delays in Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction: A Quality Initiative From the Victorian Cardiac Outcomes Registry

Registry-Based Monitoring of Hospital Performance Can Improve Time Delays in Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction: A Quality Initiative From the Victorian Cardiac Outcomes Registry

Improving Door to Needle Thrombolysis in Acute ST-Elevation Myocardial Infarction

Background: Although primary percutaneous coronary intervention is the recommended method of reperfusion for ST-segment elevation myocardial infarction patients, thrombolytic therapy should still be given to ST-segment elevation myocardial infarction patients when anticipated delay in percutaneous coronary intervention is more than 120 minutes from first medical contact.
 Objective: The aim of this study is to assess improvement of door to needle time in cases of ST-segment elevation myocardial infarction after applying new clinical pathway for cases of ST-segment elevation myocardial infarction presenting to Emergency Department at King Abdulaziz University Hospital over one year period.
 Methods: A prospective study conducted at King Abdulaziz University Hospital, Jeddah, Saudi Arabia, in patients with ST-segment elevation myocardial infarction who underwent thrombolysis from November 2012 to October 2013 to compare door to needle time obtained from this study with door to needle time from previous records during October 2010 till September 2011.
 Results: A total of 93 patients with ST-segment elevation myocardial infarction received thrombolytic in Emergency Department. Mean age 50 years. Median door to Electrocardiogram 3 minutes, median Electrocardiogram to thrombolytic 25 minutes and door to needle time 30 minutes. 54.8% of patients received thrombolytic within 30 minutes or less.
 Conclusions: Improvement in door to needle time for thrombolysis of cases of ST-segment elevation myocardial infarction has been achieved at King Abdulaziz University Hospital during the period of the study compared to previous data.

Non-ST Elevation Myocardial Infarction with Occluded Artery and its Clinical Implications

This study aimed to determine the prevalence and differences between Non-ST elevation Myocardial Infarction (NSTEMI) with an occluded culprit artery (NSTEMIOA) and NSTEMI with a patent culprit artery (NSTEMIPA). We conducted a retrospective observational study on NSTEMI patients admitted between 01/01/2010 to 30/06/2010. The inclusion criteria were diagnosis of NSTEMI and inpatient coronary angiogram. Patients were followed up for 12 months. The primary endpoints of interest were the differentiating characteristics between NSTEMIOA and NSTEMIOA. The secondary endpoints of interest were clinical outcomes in 12 months and the effect of delay in percutaneous coronary intervention on the extent of myocardial damage. Of 143 NSTEMI patients, 34 (24%) patients had NSTEMIOA. NSTEMIOA patients had higher rates of hypercholesterolaemia (85.3% vs. 64.2%, p=0.015), ST-depression abnormality on ECGs (32.4% vs. 11.9%, p=0.008), multi-vessel disease on coronary angiogram (76.5% vs. 48.6%, p=0.004) and LV dysfunction on echo (75% vs 48%, p=0.016). At 12 months post-discharge, there was a trend of higher heart failure rate in NSTEMIOA subgroup but otherwise no difference between the two cohorts in death, myocardial infarction, revascularisation, arrhythmia, and re-admission for angina. There was no correlation between the peak CK level and the timing of percutaneous revascularisation in both cohorts. A quarter of NSTEMI patients had an occluded culprit coronary artery. They were more likely to have hypercholesterolaemia, ECG abnormalities, multi-vessel disease and LV dysfunction.

Emergency Department Bypass for ST-Segment–Elevation Myocardial Infarction Patients Identified With a Prehospital Electrocardiogram

Background— For patients identified before hospital arrival with ST-segment–elevation myocardial infarction, bypassing the emergency department (ED) with direct transport to the catheterization laboratory may shorten reperfusion times. Methods and Results— We studied 12 581 ST-segment–elevation myocardial infarction patients identified with a prehospital ECG treated at 371 primary percutaneous coronary intervention–capable US hospitals participating in the Acute Coronary Treatment and Intervention Outcomes Network Registry–Get With The Guidelines, including those participating in the American Heart Association Mission: Lifeline program from 2008 to 2011. Reperfusion times with primary percutaneous coronary intervention and in-hospital mortality rates were compared between patients undergoing ED evaluation and those bypassing the ED. ED bypass occurred in 1316 patients (10.5%). These patients had a lower frequency of heart failure and shock on presentation and nonsystem reasons for delay in percutaneous coronary intervention. ED bypass occurred more frequently during working hours compared with off-hours (18.3% versus 4.3%); ED bypass rate varied significantly across hospitals (median, 3.3%; range, 0%–71%). First medical contact to device activation time was shorter (median, 68 minutes [interquartile range, 54–85 minutes] versus 88 minutes [interquartile range, 73–106 minutes]; P <0.0001) and achieved within 90 minutes more frequently (80.7% versus 53.7%; P <0.0001) with ED bypass. The unadjusted in-hospital mortality rate was lower among ED bypass patients (2.7% versus 4.1%; P =0.01), but the adjusted mortality risk was similar (adjusted odds ratio, 0.69; 95% confidence interval, 0.45–1.03; P =0.07). Conclusions— Among ST-segment–elevation myocardial infarction patients identified with a prehospital ECG, the rate of ED bypass varied significantly across US hospitals, but ED bypass occurred infrequently and was mostly isolated to working hours. Because ED bypass was associated with shorter reperfusion times and numerically lower mortality rates, further exploration of and advocacy for the implementation of this process appear warranted.

Emergency department over-crowding: a global perspective

Emergency department over-crowding: a global perspective

Overcrowding is associated with delays in percutaneous coronary intervention for acute myocardial infarction.

BackgroundRecently developed crowding measures, such as the Emergency Department (ED) Work Index (EDWIN) score, provide a quantifiable measurement of overcrowding in the ED.AimsWe sought to determine the association between overcrowding, measured with the EDWIN score, and the time required to initiate percutaneous coronary intervention (PCI) for patients presenting to the ED with acute myocardial infarction (AMI).MethodsWe retrospectively reviewed the performance improvement (PI) data on all patients presenting to the ED over a 2-month period with chest pain and whose subsequent ECG showed AMI requiring PCI. We recorded the time from patient presentation to the (1) time to first ECG, (2) time to patient arrival in the catheterization laboratory, and (3) time to catheter balloon inflation. We calculated EDWIN scores using data archived from our electronic tracking board and compared the proportion of patients who achieved our established ED goal times between patients presenting during low crowding (EDWIN < 1.5) and high crowding (EDWIN ≥ 1.5) conditions.ResultsSeventeen patients underwent emergent PCI in the study period. Patients presenting to the ED during periods of low crowding had shorter times to balloon inflation (median of 84 min, IQR 80 to 93 min) than patients presenting to the ED during periods of high crowding (median of 107 min, IQR 94 to 122 min), P = 0.008. Times to first ECG and to arrival in the catheterization laboratory were not significantly different between patients presenting during low and high crowding conditions.ConclusionOvercrowding appears to be associated with a decreased likelihood of timely treatment for acute AMI in our ED.