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Treatment delays confer excess deaths in STEMI, cardiogenic shock
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For every 10-minute treatment delay in patients with STEMI and cardiogenic shock who undergo PCI, more than three additional deaths per 100 patients result, according to findings published in the European Heart Journal.
The researchers analyzed 12,675 patients (mean age, 64 years; 74% men) from the prospective, multicenter FITT-STEMI trial who had STEMI, were transported by emergency medical services and were treated with PCI.
Karl Heinrich Scholz, MD, head of the department of cardiology at St. Bernward Hospital, Hildesheim, Germany, and colleagues assessed whether the time from first medical contact to balloon affected outcomes. Patients were stratified by whether they had cardiogenic shock and whether they had out-of-hospital cardiac arrest.
Time predicts survival
Regardless of cardiogenic shock or out-of-hospital cardiac arrest status, longer contact-to-balloon time was associated with increased risk for mortality in a linear manner, and contact-to-balloon time of 90 minutes or less independently predicted survival (OR = 0.57; 95% CI, 0.47-0.7), even when TIMI risk score was included as an independent variable, according to the researchers.
Among patients with cardiogenic shock but not out-of-hospital cardiac arrest, every 10 minutes treatment was delayed resulted in 3.31 additional deaths per 100 patients, Scholz and colleagues wrote. This figure was higher than for patients with out-of-hospital cardiac arrest and cardiogenic shock (2.09 additional deaths per 100 patients), patients with out-of-hospital cardiac arrest but no cardiogenic shock (1.34 additional deaths per 100 patients) and patients with neither out-of-hospital cardiac arrest nor cardiogenic shock (0.34 additional deaths per 100 patients; P < .0001).
“The most important finding of our study is that STEMI patients presenting with cardiogenic shock are more likely to survive if they receive rapid percutaneous coronary intervention,” Scholz said in a press release. “In this high-risk patient group, every 10-minute delay was accompanied by 3.3 additional deaths, and this treatment-delay-related increase in mortality was 10-fold higher as compared to STEMI patients presenting with more stable conditions. That means that, especially in shock patients and in patients with cardiac arrest, maximum efforts are necessary to optimize processes of care to shorten the time to treatment and improve their outcome.”
Immediate treatment
“The importance of this work cannot be overemphasized,” William Wijns, MD, PhD, from the Lambe Institute for Translational Medicine and Curam at the National University of Ireland, Galway, and Christoph K. Naber, MD, PhD, from Contila Heart and Vascular Center, department of cardiology and angiology, University Hospital Essen, Germany, wrote in a related editorial. “The current study supports the recommendation to keep the [first medical contact]-to-treatment delay as short as possible, in any case below 120 min. In addition, the study by Scholz et al provides, for the first time, impressive data on the strong impact of [contact-to-balloon] time on in-hospital mortality in patients with [cardiogenic shock and/or out-of-hospital cardiac arrest], and shows that 90 min should be the appropriate time target in high-risk cases.
“The present work demonstrates that time matters even more than we used to think, especially in high-risk patients who still have poor outcomes, and that there are ways to expedite the process,” they concluded. – by Erik Swain
Disclosures: Naber, Scholz and Wijns report no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
Editor’s Note: This article was updated on Feb. 26, 2018 to clarify the number of deaths mentioned in Dr. O’Neill’s perspective.
Perspective
Back to TopWilliam W. O’Neill, MD, FACC, FSCAI
The findings show that cardiogenic shock makes up a huge part of the mortality from MI. In this national study, there were 289 deaths in people who were not in shock and 645 deaths in people with cardiogenic shock. The mortality in cardiogenic shock is substantially higher. The vast majority of deaths in STEMI care right now are related to cardiogenic shock.
A very important observation is that the time from first medical contact to angioplasty plays a huge role in cardiogenic shock mortality, which goes from 20% at 1 hour to 80% at 5 hours. There is an enormous imperative to get people in shock treated early. That will be a big problem because, at least in the United States, 60% of these patients are presenting to small hospitals that are not capable of treating cardiogenic shock. We are going to have to come up with transfer protocols that will allow rapid transfer of patients once we have identified shock to a center that can treat and support them.
The first step is to identify these patients early when they arrive at the hospital. The second step is to develop processes to facilitate transfer. Most major hospitals have satellite facilities. In my view, the biggest problem we have with acute MI/shock care in the U.S. is transferring patients from one facility to another; anywhere from 2 to 4 hours of time can be lost. With this German study, we see that patients treated after 6 hours are not likely to survive. So, we need a big push to identify patients with cardiogenic shock and develop transfer protocols to enable quick transfers in the U.S.
Of note, 18% of patients with cardiogenic shock were treated with balloon pumps; in the U.S., that figure is closer to 40%.
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