Delays in STEMI Treatment Remain Common, Tied to Worse PCI Outcomes

Despite substantial variability in meeting time-to-treatment targets for STEMI patients across US hospitals, many continue to face delays, which are associated with poorer outcomes, according to an analysis of the American Heart Association Get With The Guidelines Coronary Artery Disease (GWTG-CAD) registry.

Low-performing hospitals that failed to treat at least 75% of their patients within time goals saw increases in in-hospital mortality and length of stay, particularly for patients who presented directly to a PCI-capable center, lead author Yasser Sammour, MD (Houston Methodist DeBakey Heart and Vascular Center, TX), and colleagues report.

The results, published online this week in JAMA Cardiology, “suggest that despite extensive evidence supporting timely STEMI treatment and established national standards, coordinated strategies are needed to enhance the adoption of these benchmarks with targeted local interventions to address system-based challenges.”

Indeed, commented Harold Dauerman, MD (University of Vermont Medical Center, Burlington), these findings form “a very sobering picture of STEMI care in the United States.”

He pointed to the odds ratios for in-hospital mortality associated with not treating patients within the recommended time windows laid out by the AHA and the American College of Cardiology (ACC)—OR 2.21 (95% CI 2.02-2.42) for patients presenting to a PCI-capable center who were not treated within 90 minutes and 2.44 (95% CI 1.90-3.12) for transferred patients who were not treated within 120 minutes.

“This is a dramatically increased risk of death, and if the adjustments are accurate and it doesn’t reflect comorbidities, this is a call to action for us to see continuous improvement in these areas,” Dauerman said. “Getting that to happen is going to require a massive national educational program with a focus on key operational metrics like door-in/door-out time and first medical contact-to-ECG transmission time. They are all doable, but it is sobering to see how far we still have to go on this and the possibility that this is leading to excess death.”

Gaps in Care and Targets for Improvement

The time from first medical contact to use of an interventional device meant to restore blood flow (FMC-to-device time) is an established quality metric for STEMI care, but research has shown that achieving those goals can be difficult for some centers. A 2015 study by Dauerman and his colleagues showed that even in STEMI patients with a transfer time shorter than 1 hour, about one-third were not treated within the 120-minute goal. A more recent study revealed that time-to-treatment goals were not met for many patients, with interhospital delays the leading culprit.

In the current study, the investigators delved into issues around timely treatment by examining data from the GWTG-CAD registry. The analysis included 73,826 patients (median age 62 years; 27.6% women) with STEMI or a STEMI equivalent who underwent primary PCI across 503 hospitals in the US between 2020 and 2022. Most (81.4%) presented directly to a PCI-capable center and the rest required a transfer.

Overall, just 59.5% of patients presenting to a PCI-capable center were treated with an FMC-to-device time of 90 minutes or less and 50.3% of transferred patients were treated in 120 minutes or less.

Those proportions varied widely across centers, with a median rate of 60.8% of patients being treated within recommended time windows when presenting directly to PCI-capable centers and 50.0% of transferred patients. However, only 11.1% of hospitals met the goals for at least 75% of their patients directly presenting to a PCI center—as recommended by the AHA and ACC—and only 13.9% exceeded that bar for transferred patients.

High-performing centers consistently did better than low-performing centers across metrics, mostly due to longer emergency department (ED) stays, longer times from cath lab arrival to PCI, and transfer delays in the latter group.

Failing to achieve FMC-to-device time goals was associated not only with higher odds of in-hospital death, but also longer hospital stays for patients who presented to a PCI-capable center (adjusted OR 1.35; 95% CI 1.30-1.41) and those who were transferred (adjusted OR 1.35; 95% CI 1.24-1.47).

Low hospital performance also was associated with greater odds of in-hospital mortality and a longer length of stay in direct presenters; only the relationship with length of stay was significant among transferred patients.

Of note, geographic location (rural versus urban) and PCI volume did not significantly influence mortality or length of stay.

“These insights reveal gaps in care and specific targets for quality improvement to reduce treatment delays and meet early reperfusion goals in STEMI,” Sammour et al write. “Although some of these delays may stem from logistical challenges such as prehospital coordination, resource constraints, and procedural complexities, disparities in treatment based on patient demographics and hospital performance may also play a role. Consequently, targeted interventions like standardized transfer protocols, improved efficiency in the ED, and strategies to mitigate disparities are important.”

Overcoming Hurdles

Though the findings seem to indicate a backsliding from his 2015 paper, Dauerman said a change in methodology could be at play. For their paper, he and his colleagues excluded patients who had a transfer time greater than 1 hour, something that was not done in the current paper.

“If a patient has more than a 60-minute transfer time, which may be found in rural centers, it’s almost impossible to achieve this metric,” Dauerman said, referring to the 120-minute goal, which consists of a 30-minute door-in/door-out time, a 60-minute transfer, and a 30-minute time from arrival at the PCI hospital to revascularization.

Patients with prolonged transfer times were excluded from the prior analysis because the thinking was that they should get fibrinolytic therapy and then get transferred as part of a pharmacoinvasive approach. “For those patients, I don’t think they should be included in any primary PCI program,” Dauerman said. “They should be getting lytics first unless they’re lytic-ineligible.”

A second difference between the earlier report and the current study, he pointed out, is that the definition of the quality metric has changed somewhat. For transferred patients, the earlier standard was 120 minutes from first hospital presentation to PCI but now it is defined as 120 minutes from FMC to PCI, which incorporates additional time in the prehospital setting.

“Because of that, it’s very hard for me to compare our two studies on the transfer population,” Dauerman said.

Even so, “I found this analysis very sobering,” he added. “The lack of progress seen since 2015 in the transfer group is disturbing, but is also partly due to the methodology of this study.”

As for how to improve treatment times in STEMI overall, Dauerman pointed to three operational issues that should be addressed:

• Centers need to have a strategy to be either a primary PCI hospital or a transfer center at all times. “It needs to be an automatic decision at every center, and it needs to not vary by time of day or day of week.”
• Processes within EDs for identifying STEMI patients and triaging them appropriately need to be automated and cannot rely on consultations with cardiologists. EDs should make the call on STEMI and the cath labs should respond. "Sometimes it’ll be a false call, but if we stop and wait for consultations and phone calls, we’re guaranteeing a prolongation of the process before the patient gets either transferred or, in the PCI center, [taken] to the cath lab.”
• Every ambulance needs to have a 12-lead ECG and the ability to transmit that information to the ED quickly so the cath lab can be activated.

Overall, Dauerman said, “it’s what comes upstream of arrival to the cath lab that’ll determine success here.”

In an accompanying editor’s note,  Roxana Mehran, MD (Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, NY), associate editor of JAMA Cardiology, says “this analysis must not only highlight persistent gaps but also compel action.

“After two decades of data collection, national initiatives, and public accountability, the next step must involve tailored solutions addressing barriers within each institution,” she continues. “Bridging the gap now requires renewed efforts and commitments to prioritize timely, coordinated STEMI care. Until then, the clock will continue to tick—against our patients.”

Note: Mehran is a faculty member of the Cardiovascular Research Foundation, the publisher of TCTMD.