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Off-hours STEMI presentation associated with higher mortality rate
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Patients with STEMI who presented at hospitals during weeknights, weekends and holidays had a 13% higher risk-adjusted all-cause mortality rate compared with patients who presented during weekdays, according to results of a new study.
STEMI presentation during off hours was also associated with longer door-to-balloon times compared with presentation during normal business hours on weekdays. However, researchers found that presentation time had no effect on several other metrics, including aspirin use within 24 hours, door-to-ECG time and door-to-needle time.
“Slower door-to-balloon times for people who arrived at the hospital during off hours is likely due to staffing,” Jorge F. Saucedo, MD, chief of cardiology and co-director of the Cardiovascular Institute at Northshore University Health System, Evanston, Ill., said in a press release. “In the middle of the night, the hospital catheterization lab … is closed. When a heart attack patient comes to the [ED] at 1 a.m., the emergency staff activate the pagers. Doctors need to drive to the hospital, get things set up in the cath lab, and it takes time.”
National improvements
Saucedo and colleagues investigated whether national quality improvement initiatives such as Get With The Guidelines and Mission: Lifeline, both from the American Heart Association, have led to an improvement in STEMI quality measures.
They reviewed the Acute Coronary Treatment and Intervention Outcomes Network-Get With The Guidelines (ACTION-GWTG) database to compare STEMI performance measures for patients who presented off hours (n=27,270) vs. on hours (n=15.972) from January 2007 to September 2010 at 447 centers.
According to the results, the rate aspirin use within 24 hours of admission was 99.1% in the on-hours group and 98.9% in the off-hours group (P=.05).
Median door-to-ECG time was 6 minutes in both groups, and there was no difference between groups in rate of door-to-ECG time under 10 minutes (on-hours group, 73.4%; 95% CI, 72.6-74.3; off-hours group, 74.3%; 95% CI, 73.7-74.9; P=.09), according to the researchers.
In the 97.1% of patients who underwent PCI, median door-to-balloon time was longer in patients who presented during off hours (56 minutes (interquartile range, 44-73) vs. 72 minutes (interquartile range, 59-86); P<.0001), and those who presented during off hours were less likely to have a door-to-balloon time of 90 minutes or less (87.8% vs. 79.2%; P<.0001), Saucedo and colleagues wrote.
Among patients who received fibrinolytic therapy, there was no difference between the groups in door-to-needle time (on-hours group, 23 minutes; interquartile range, 13-42; off-hours group, 25 minutes; interquartile range, 16-42; P=.06) and no difference in the rate of door-to-needle time of 30 minutes or less (on-hours group, 62.3%; 95% CI, 57.3-67.3; off-hours group, 58.7%; 95% CI, 55.3-62.1; P=.44).
In-hospital mortality
The unadjusted in-hospital mortality rate for both groups was 4.2%, according to the researchers. However, after adjustment for initial serum creatinine, age, systolic BP at presentation, initial troponin, HF, shock at admission, heart rate at presentation and prior peripheral arterial disease, in-hospital all-cause mortality was 13% more likely in patients who presented during off hours (OR=1.13; 95% CI, 1.02-1.26).
“The fact that treatments were similar in both groups and that only door-to-balloon time lagged slightly is a credit to continually raising awareness and educating providers about the Mission: Lifeline guidelines,” Saucedo said in the press release. “Over the past decade, these emergency cardiac protocols carried out by multiple institutions across the country have made a huge impact in saving lives. Yes, there is opportunity for improvement, but this is really a huge success.”
Disclosure: One researcher reports financial ties with the American College of Cardiology, the AHA, Amgen, AstraZeneca, Daiichi Sankyo, Eli Lilly, Elsevier Publishers, the Familial Hypercholesterolemia Foundation, Janssen Pharmaceuticals, Merck and Sanofi-Aventis.
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