STEMI Patients Not Achieving Recommended Transfer Times for PCI

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Few patients with ST-segment elevation myocardial infarction (STEMI) who present to hospitals unable to perform percutaneous coronary intervention (PCI) are transferred to PCI-capable facilities within 30 minutes, according to a study published in the November 28, 2011, issue of Archives of Internal Medicine.

Researchers led by Harlan M. Krumholz, MD, SM, of the Yale School of Medicine (New Haven, CT), examined national door-in to door-out times for 13,776 STEMI patients who presented at an emergency department and subsequently required transfer to another hospital for PCI between January 1 and December 31, 2009. All data came from the Centers for Medicare and Medicaid Services outpatient payment system.

Focused updates on the management of patients with STEMI by the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines 2009 recommend that primary PCI be performed within 90 minutes for patients taken to PCI-capable facilities or within 120 minutes for patients requiring transfer. But door-in to door-out delays often can impede access and worsen outcomes. In a recent study (Wang TY, et al. JAMA. 2011;305:2540-2547), door-in to door-out times of more than 30 minutes were associated with a 56% increase in risk of in-hospital mortality.

Few Meeting Goals

Dr. Krumholz and colleagues found that the mean door-in to door-out time for the cohort was 64 minutes. The majority of patients (~ 60%) had door-in to door-out times of 30 to 90 minutes, with 31% exceeding 90 minutes, meaning just under 10% had times within a 30-minute window.

After adjusting for patient and hospital characteristics, women had longer mean times than men (73 min. vs. 60 min.; P < 0.001). In addition, African-Americans had an estimated time 9.1 minutes longer than patients reported as white, while patients age 18 to 35 had an estimated time significantly longer than all other patients except those older than 75 years of age. Meanwhile, patients with contraindications to fibrinolytic therapy had an estimated time 6.9 minutes longer than those without contraindications.

When the researchers looked at individual hospital characteristics, rural hospitals had estimated door-in to door-out times 15 minutes longer than those of urban hospitals, and hospitals in the East and West North Central regions had significantly shorter times than those in the New England region.

The median door-in to door-out times also varied significantly by state, with the top 10 performing states having median times no greater than 52 minutes:

  • New Hampshire
  • Kansas
  • Minnesota
  • Utah
  • North Carolina
  • Oregon
  • Arizona
  • Washington
  • Indiana
  • Maine

Meanwhile, the bottom 10 states had median times greater than 78 minutes:

  • Wyoming
  • Hawaii
  • West Virginia
  • New Mexico
  • Montana
  • Louisiana
  • District of Columbia
  • New Jersey
  • Idaho
  • New York

Transfers Do Not Make Big Enough Dent

In a research letter accompanying the study, Eric A. Secemsky, MD, of San Francisco General Hospital (San Francisco, CA), and colleagues conclude that transfer patients do not achieve national revascularization benchmarks even when PCI-capable hospitals are nearby.

Consecutive STEMI patients transferred to 1 of 4 PCI-capable hospitals within a 5-mile radius were compared with patients revascularized at the same center after establishment of onsite 24-hour PCI services with emergency physicians responsible for activation of the cath lab.

Among the transfer patients, none were revascularized within 90 minutes. However, the median door-to-catheterization and door-to-balloon times for patients treated after the on-site PCI services were added decreased to 50 minutes and 84 minutes, respectively, with 65% of patients revascularized in less than 90 minutes.

“More than 90% survived to hospital discharge with no significant difference between groups,” Dr. Secemsky and colleagues write.

Time to Rethink Relocating for Revascularization?

In an editorial accompanying both papers, Rita F. Redberg, MD, MSc, of the University of California, San Francisco (San Francisco, CA), argues that they are evidence of “slower than benchmark” door-in to door-out times. She suggests it is time to reconsider whether transferring patients with STEMI for primary PCI is a good idea.

“For low- and intermediate-risk patients, there is no mortality advantage to [primary PCI] over thrombolytic therapy,” Dr. Redberg writes. “Even for high-risk patients with STEMI, the mortality benefit of [primary PCI] is frequently lost due to routine delays of 1 to 3 hours by transfer.”

Dr. Redberg suggests that the best alternative for these patients may be timely reperfusion with thrombolytics.

Going Forward, Not Backward Is the Answer

But Timothy D. Henry, MD, of the Minneapolis Heart Institute (Minneapolis, MN), disagreed with that assessment.

“I think we are faced with 2 options,” he told TCTMD in a telephone interview. “Do we retreat and go back to the past or do we develop ways to meet the challenges? Going back to the old way of doing things [ie, thrombolytics] is not the answer.”

In a recent study (Miedema MD, et al. Circulation. 2011;124:1636-1644), Dr. Henry’s group found that in a regional STEMI system, patients can meet guideline-recommended door-in to door-out times even when they require transfer as far as 210 miles.

“Improving door-in to door-out times is an incredibly important thing and it is a tremendous challenge and we need to focus on strategies which we know are successful,” Dr. Henry said. “We know from experience that developing regional STEMI systems is successful. Our focus needs to be on increasing timely access to PCI, not criticizing and trying to show it doesn’t work. The current guidelines are not only reasonable, they are achievable.”

As far as Dr. Secemsky’s study, Dr. Henry pointed out that no data other than percentages are included. In fact, there is no indication of how many patients were enrolled, only that most were male with a mean age of 57 years, making it virtually impossible to extrapolate much from the data, he said.

 


Sources:
1. Herrin J, Miller LE, Turkmani D, et al. National performance on door-in to door-out time among patients transferred for primary percutaneous coronary intervention. Arch Intern Med. 2011;171:1879-1886.

2. Redberg R. Reconsidering transfer for percutaneous coronary intervention strategy. Arch Intern Med. 2011;Epub ahead of print.

3. Secemsky E, Lange D, Ho J, et al. Improvement in revascularization time after creation of a coronary catheterization laboratory at a public hospital [research letter]. Arch Intern Med. 2011;Epub ahead of print.

 

 

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Disclosures
  • Dr. Krumholz reports serving as chair of a Cardiac Scientific Advisory Board for United Healthcare and receiving a research grant from Medtronic.
  • Drs. Secemsky, Redberg, and Henry report no relevant conflicts of interest.

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