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Comprehensive care may improve outcomes in STEMI
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A comprehensive focus on STEMI care that includes transradial primary PCI, prompt guideline-directed medical therapy and door-to-balloon time improved the care of patients with STEMI, according to a study published in Circulation: Cardiovascular Interventions.
“From a clinical standpoint, what we need people to do is to think more broadly in terms of the metrics they focus on for STEMI rather than just time to reperfusion, which has been a very big focus,” Umesh N. Khot, MD, vice chairman of the Suzanne and Robert Tomsich Department of Cardiovascular Medicine, staff cardiologist in the section of clinical cardiology at the Sydell and Arnold Miller Family Heart and Vascular Institute of the Cleveland Clinic, told Cardiology Today’s Intervention. “We need to make sure that we have systems that make sure that patients receive the medications promptly, that we use transradial access when possible and that we have rapid time to reperfusion. The goal is to have all three of those things in a system.”
Data on patients with STEMI
Chetan P. Huded, MD, MSC, of the Center for Healthcare Delivery Information at the Heart and Vascular Institute at the Cleveland Clinic, and colleagues analyzed data from 1,272 patients with STEMI who were treated with PCI between 2011 and 2016.
All patients received care through a strategy that focused on the use of transradial access for primary PCI, prompt guideline-directed medical therapy before sheath insertion and door-to-balloon time.
“Everybody has been focused on door-to-balloon time and ST-elevation myocardial infarction,” Khot said in an interview. “There have recently been some additional work looking at radial access and also medications, but nobody has brought together all three into one analysis to see whether they are complementary or not from that standpoint. That was the question we wanted to ask, is that what is the role of the three key STEMI metrics, which is medication administration, transradial access and door-to-balloon time on outcomes.”
Improvements in door-to-balloon times were made by authorizing the ED physician to activate the catherization lab and to immediately bring the patient to the lab. Guideline-directed medical therapy was standardized before sheath insertion for PCI with a checklist that aided in clinical decision-making for medications and dosing. Transradial access was used as the first approach compared with one that was dependent on the operator.
The outcome of interest was in-hospital adverse events after PCI and mortality at 30 days, both of which were retrieved from medical records.
Achieving STEMI metrics
Of the patients in this study, 7.1% achieved no STEMI care metrics, 24.1% achieved one metric, 43.8% achieved two metrics and three metrics were achieved by 25.1%. In addition, mortality at 30 days occurred in 15.6% of patients who achieved zero metrics, 8.6% of those who achieved one metric, 3.6% of patients who achieved two metrics and 3.2% of those who achieved all three metrics (P for log-rank < .001).
Patients who achieved at least two STEMI metrics had a significant reduction in in-hospital mortality after adjusting for clinical predictors of STEMI in-hospital mortality (OR = 0.39; 95% CI, 0.16-0.96).
The achievement of each STEMI metric contributed to an incremental prognostic value when they were modeled in a stepwise order of the occurrence in clinical practice (C-statistic = 0.677; P < .001).
“Most of this is fairly simple in the sense that it is a change in how care is provided,” Khot told Cardiology Today’s Intervention. “It does not have any additional cost and it is not particularly high technology. It is something that requires a change in thinking in terms of how you are going to deliver care for your STEMI patients.” – by Darlene Dobkowski
For more information:
Umesh N. Khot, MD, can be reached at Cleveland Clinic, Desk J2-4, 9500 Euclid Ave., Cleveland, OH 44195; email: khotu@ccf.org; Twitter: @UmeshKhotMD.
Disclosures: Khot reports he served as a consultant for AstraZeneca. Huded reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
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