STEMI Mortality Unaffected by Weekend, Weeknight, or Holiday Admission in France

Patients with STEMI presenting to the hospital in the middle of the night or on the weekend fare just as well as those treated during regular working hours, according to results from a large French hospital.

At this high-volume center, there was no difference in the median time from first medical contact (FMC) to sheath insertion between STEMI patients presenting off-hours versus those who presented during regular working hours, nor was there any difference in the risk of death in the hospital or at 1 year.

“Our analysis demonstrates that a well-organized urban STEMI network allows [us] to bridge the gap between on-hours and off-hours management and provide the same quality of care whatever time of admission,” report Benoit Lattuca, MD (Sorbonne University/Hôpital Universitaire Pitié-Salpêtrière, Paris, France), and colleagues online October 30, 2019, in the Journal of the American College of Cardiology.  

In an accompanying editorial, Eric Bates, MD (University of Michigan, Ann Arbor), addresses one of the key questions about the new report: whether the excellent outcomes achieved at this hospital are generalizable to hospital systems in the United States and elsewhere.

He points out, for example, that there is a nationwide prehospital emergency response system in France—the Service d’Aide Médicale Urgente (SAMU)—that uses a mobile intensive care unit (MICU). The MICU includes an onboard physician, nurse, and driver trained as an emergency medical technician and provides advanced care and rapid transfer to a PCI-capable hospital. Moreover, patients in this study were treated at the Hôpital Universitaire Pitié-Salpêtrière, which is a world-class academic medical center with numerous accomplishments in the field of STEMI research, says Bates.  

“So, what about STEMI networks not in France?” asks Bates. “Ambulances are not mobile intensive care units with physicians and nurses. Prehospital EKGs are not possible in many areas. Local or regional regulations codifying EMS transfer policies for primary PCI rarely exist. In urban hospitals, traffic or competition among EMS or hospital services can be problematic. In rural hospitals, access to transport units, geographic distances, and weather can cause time delays. And not all PCI-capable hospitals can deliver 24-hour service.”

Gregg Fonarow, MD (Ronald Reagan UCLA Medical Center, Los Angeles, CA), who was not involved in the study but who has studied the “weekend effect” previously, agreed that further studies are needed to determine if the findings are generalizable to other hospitals in France, as well as other countries. He told TCTMD that the weekend/weeknight effect has been evaluated in multiple studies, with some showing that those who present off-hours are less likely to receive guideline-based medications and/or timely reperfusion and have worse clinical outcomes.

“However, there have been other studies that have not found meaningful differences in care quality based on the timing of presentation,” he said. “This may reflect the patients, healthcare systems, and regions studied.”

Although the study reflects outcomes from a renowned single center in Paris where excellent EMS and transportation networks exist, Hani Jneid, MD (Baylor College of Medicine/Michael E. DeBakey VA Medical Center, Houston, TX), said he believes that these outcomes “are achievable in the US with the improvement of the regional systems of care.” The majority of acute MI events, he said, occur after hours, so the systems of care—including the EMS, emergency department (ED), cath lab physicians, nurses, technicians, and hospital staff—need to “perform with the same high standard.”

“Examples or instances when standards of care can be compromised and the timeliness of reperfusion delayed off-hours are when some regional hospitals are understaffed during off-hours, or when they allow inexperienced physicians to moonlight in the ED without proper orientation to the existing protocols for cath lab activation,” Jneid told TCTMD.

Excellent Results in All-Comer Population

The new analysis included 2,167 consecutive patients with a confirmed STEMI admitted for primary PCI between 2003 and 2013. Of these, 1,048 patients were admitted during the weekday between 8 am and 6 pm and 1,119 patients were admitted on a weekend, weeknight, or holiday. Baseline characteristics between the two groups were well matched and included patients with out-of-hospital cardiac arrest (7.9% vs 8.8%; P = 0.55) and cardiogenic shock (12.3% vs 14.7%; P = 0.16).

In terms of treatment, there was no difference in the time from symptom onset to FMC for patients treated during the workday and those treated off-hours. The time from FMC to sheath insertion was 90 minutes for those treated during weekday hours and 93 minutes for those treated at night, on the weekend, or on holidays (P = 0.58).  

In-hospital mortality was 8.1% for patients treated during standard workday hours and 7.0% for those treated off-hours (P = 0.49). Mortality at 1 year was also no different for those treated on- and off-hours (11.0% vs 11.1%; P = 0.89). In-hospital and 1-year mortality did not differ according to admission time for patients without cardiac arrest or cardiogenic shock. Patients with cardiac arrest and cardiogenic shock had significantly higher rates of death compared with the other patients, but these rates did not differ by admission time.

While the overall 1-year mortality rate is higher than rates observed in randomized trials performed in modern STEMI networks, the researchers say the large percentage of shock and cardiac arrest patients is the likeliest explanation for the discrepancy.

The investigators acknowledge that delivering high-quality 24/7 care remains a challenge because human resources and expertise may differ during the day and night. The researchers attributed their success to the MICU system of field triage with the onboard physician and the activation of the cath lab by the emergency department/MICU physician without the need to wait for STEMI confirmation by the hospital’s cardiology team. The 24/7 PCI service includes an available senior cardiologist, a shock team with mobile extracorporeal life support for the sickest patients, and access to evidence-based medical therapy regardless of admission time, they say.

Contemporary Look at STEMI ‘Weekend Effect’

Still, despite their success, Lattuca and colleagues state that the time from first contact to reperfusion is still too long at 93 minutes, something which they plan to study further.

To TCTMD, Jneid said the observed difference in FMC to sheath insertion of 3 minutes, while not statistically significant, is clinically meaningful. “Notably, these numbers pertain to first medical contact to sheath insertion and not first medical contact to device, and I was surprised these achieved overall metrics are not better in this single center of excellence in both off and regular hours.”

Performance metrics from the American College of Cardiology/American Heart Association, published in 2017 and authored by Jneid, emphasize the importance of timely reperfusion in STEMI, recommending FMC-to-device and door-to-balloon times of 90 and 30 minutes, respectively. Most tertiary-care hospitals in the US are achieving those optimal times, said Jneid.

In 2008, Fonarow, along with Jneid, published data on 62,814 acute MI patients admitted to 379 US hospitals as part of the Get With The Guidelines-Coronary Artery Disease (GWTG-CAD) database. Between 2000 and 2005, they reported that the majority of US acute MI patients arrived off-hours and while these patients were less likely to receive primary PCI than those who presented during standard working hours—and were less likely to achieve a door-to-balloon time of less than 90 minutes—there was no discernible difference in the risk of in-hospital mortality, Fonarow told TCTMD.

The present study, said Fonarow, is more contemporary, but shows similar quality of care and mortality outcomes for patients presenting off-hours, which “suggests that this center was able to provide equal care irrespective of timing of presentation.”

Bates, in his editorial, offers congratulations to the French researchers for their excellent accomplishments, but notes that many US centers are still trying to achieve similar outcomes. “We should all be inspired by this report to continue to pursue more efficient and effective prehospital and in-hospital STEMI care,” he writes. “Access to EMS and primary PCI services, and time-to-treatment, remain the most modifiable variables in the continuing effort to further decrease morbidity and mortality from STEMI.”

To TCTMD, Jneid stressed the importance of measuring and tracking performance in acute MI care and providing feedback in order to improve all aspects of care within the network. The STEMI network “should be regionalized and tailored to the needs and available resources in the community,” he said. “As we emphasize in the guidelines, it is important for hospitals to participate in regional or national registries—it is also a performance measure—that track the timeliness of reperfusion, care processes, and outcomes, and provide feedback and comparative data with the goal to improve healthcare.”