In the Journals

Cath lab pre-activation beneficial but not routine in STEMI

Fewer than half of patients with STEMI who were transported by emergency medical services had catheterization laboratory pre-activation before they arrived at the hospital, despite a suggestion of mortality benefit from cath lab pre-activation, according to a study published in JACC: Cardiovascular Interventions.

“Cath lab pre-activation is currently defined and measured simply by whether or not it occurred, regardless of its timing in relation to hospital arrival,” Jay S. Shavadia, MD, cardiologist and researcher from Duke University Medical Center and the Duke Clinical Research Institute, said in a press release. “Our results suggest that the amount of notification provided is very important — if the pre-activation occurs less than 10 minutes before the patient is transported, it does not offer as much benefit to the patient.”

Researchers analyzed data from 27,840 patients (mean age, 62 years; 71% men) with STEMI from the ACTION Registry who were treated with primary PCI from 2015 to March 2017. Patients were excluded if they had cardiac arrest or had PCI delays related to medical needs such as intubation.

Pre-activation

Cath lab pre-activation was defined as an alert by EMS greater than 10 minutes before arriving at a center capable of performing PCI. No cath lab pre-activation was any call that occurred 10 minutes or less before, during or after hospital arrival.

Catheterization laboratory pre-activation greater than 10 minutes occurred in 40.9% of patients. More patients with cath lab pre-activation were transported directly to the lab when they arrived at the hospital vs. those who did not have the cath lab pre-activated (23.3% vs. 5.3%; P < .001). These patients also spent less time in the ED (17 minutes vs. 28 minutes; P < .001), had shorter door-to-device time (40 minutes vs. 52 minutes; P < .001) and were more likely to achieve first medical contact-to-device time less than 90 minutes (76.6% vs. 68.6%; P < .001).

Before adjustment, cath lab pre-activation was associated with lower in-hospital mortality rate compared with no pre-activation (2.8% vs. 3.4%; P = .012), but the difference was no longer significant after risk adjustment (OR = 0.87; 95% CI, 0.75-1.01).

Variation by hospital

Compared with patients who arrived at intermediate-tertile and high-tertile hospitals, those who arrived at low-tertile hospitals had the highest unadjusted rate of in-hospital mortality (low tertile, 3.6%; intermediate tertile, 3.1%; high tertile, 2.7%; P = .005). After adjustment for risk, patients who arrived at low-tertile hospitals had higher rates of in-hospital mortality compared with those who arrived at high-tertile hospitals (OR = 1.33; 95% CI, 1.08-1.63), although the difference between low-tertile and intermediate-tertile hospitals was not significant.

Cath lab activation time had no effect on incident HF or cardiogenic shock.

“Every 10-min delay in notifying the receiving catheterization laboratory is associated with increasing door-to-device times,” Shavadia and colleagues wrote. “These findings highlight the importance of pre-activation timing relative to arrival at the receiving PCI center. Catheterization laboratory pre-activation is currently defined and measured simply by whether it occurred, regardless of its timing in relation to hospital arrival. Yet our results suggest that the amount of notification provided is important.” – by Darlene Dobkowski

Disclosures: Shavadia reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.

Fewer than half of patients with STEMI who were transported by emergency medical services had catheterization laboratory pre-activation before they arrived at the hospital, despite a suggestion of mortality benefit from cath lab pre-activation, according to a study published in JACC: Cardiovascular Interventions.

“Cath lab pre-activation is currently defined and measured simply by whether or not it occurred, regardless of its timing in relation to hospital arrival,” Jay S. Shavadia, MD, cardiologist and researcher from Duke University Medical Center and the Duke Clinical Research Institute, said in a press release. “Our results suggest that the amount of notification provided is very important — if the pre-activation occurs less than 10 minutes before the patient is transported, it does not offer as much benefit to the patient.”

Researchers analyzed data from 27,840 patients (mean age, 62 years; 71% men) with STEMI from the ACTION Registry who were treated with primary PCI from 2015 to March 2017. Patients were excluded if they had cardiac arrest or had PCI delays related to medical needs such as intubation.

Pre-activation

Cath lab pre-activation was defined as an alert by EMS greater than 10 minutes before arriving at a center capable of performing PCI. No cath lab pre-activation was any call that occurred 10 minutes or less before, during or after hospital arrival.

Catheterization laboratory pre-activation greater than 10 minutes occurred in 40.9% of patients. More patients with cath lab pre-activation were transported directly to the lab when they arrived at the hospital vs. those who did not have the cath lab pre-activated (23.3% vs. 5.3%; P < .001). These patients also spent less time in the ED (17 minutes vs. 28 minutes; P < .001), had shorter door-to-device time (40 minutes vs. 52 minutes; P < .001) and were more likely to achieve first medical contact-to-device time less than 90 minutes (76.6% vs. 68.6%; P < .001).

Before adjustment, cath lab pre-activation was associated with lower in-hospital mortality rate compared with no pre-activation (2.8% vs. 3.4%; P = .012), but the difference was no longer significant after risk adjustment (OR = 0.87; 95% CI, 0.75-1.01).

Variation by hospital

Compared with patients who arrived at intermediate-tertile and high-tertile hospitals, those who arrived at low-tertile hospitals had the highest unadjusted rate of in-hospital mortality (low tertile, 3.6%; intermediate tertile, 3.1%; high tertile, 2.7%; P = .005). After adjustment for risk, patients who arrived at low-tertile hospitals had higher rates of in-hospital mortality compared with those who arrived at high-tertile hospitals (OR = 1.33; 95% CI, 1.08-1.63), although the difference between low-tertile and intermediate-tertile hospitals was not significant.

Cath lab activation time had no effect on incident HF or cardiogenic shock.

“Every 10-min delay in notifying the receiving catheterization laboratory is associated with increasing door-to-device times,” Shavadia and colleagues wrote. “These findings highlight the importance of pre-activation timing relative to arrival at the receiving PCI center. Catheterization laboratory pre-activation is currently defined and measured simply by whether it occurred, regardless of its timing in relation to hospital arrival. Yet our results suggest that the amount of notification provided is important.” – by Darlene Dobkowski

Disclosures: Shavadia reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.