Disclosures: Zeitouni reports he received research grants from Federation Française de Cardiologie, Institut Servier and lecture fees from Bristol-Myers Squibb/Pfizer. Please see the study for all other authors’ relevant financial disclosures.
July 06, 2020
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In STEMI transfers, time to reperfusion improved with speedy cath lab activation

Disclosures: Zeitouni reports he received research grants from Federation Française de Cardiologie, Institut Servier and lecture fees from Bristol-Myers Squibb/Pfizer. Please see the study for all other authors’ relevant financial disclosures.
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Among patients who required interhospital transfer for STEMI, nearly 40% had cath lab activation times of less than 20 minutes, which were linked to prompt PCI, researchers reported.

Among those with quick cath lab activations, more than 80% had primary PCI within the 120-minute national benchmark, whereas among those with delayed cath lab activations, less than 40% had PCI within that time frame.

catheter stent, shutterstock
Source: Adobe Stock.

Factors that contributed to delayed activation included prior CVD, hypotension and race.

Michel Zeitouni

“More than half of STEMI patients who present in non-PCI capable hospitals and require transfer receive primary PCI beyond the recommended goal of 120 minutes,” Michel Zeitouni, MD, MSc, second-year fellow in the Duke Clinical Research Institute at Duke University, told Healio. “The implementation of cath lab activation by the first facility below 20 minutes to direct fast STEMI care has the potential to significantly improve reperfusion time. This quality metric requires an active and strong coordination between transferring and receiving centers with prespecified and dedicated protocols and procedures, such as single call activations and routine feedback on patient outcomes.”

For this analysis of the American Heart Association’s Mission: Lifeline STEMI Accelerator-2 project, that was published in Circulation: Cardiovascular Quality and Outcomes, researchers assessed treatment times of patients with STEMI who required interhospital transfer for primary PCI to determine whether faster activation was associated with improved reperfusion time and outcomes.

Researchers found that the cath lab was activated within 20 minutes in 39.8% of the cohort. Among the entire cohort, approximately half received primary PCI beyond the recommended goal of 120 minutes (median first door-in to device activation time, 116 minutes). Transport, whether by ambulance, self or a family member, accounted for approximately 20% of the overall time to reperfusion (median, 26 minutes).

In addition, timely activation was associated with shorter door-in door-out times (40 vs. 68 minutes) and shorter reperfusion times (98 vs. 135 minutes). In the timely activation group, 80.1% of patients received primary PCI within 120 minutes vs. 39% in the delayed activation group.

“These findings highlight the crucial weight of diagnostic procedures performed in the first receiving facility to achieve reperfusion within 120 minutes,” Zeitouni said in an interview.

Characteristics of delayed activation

Moreover, factors associated with delayed cath lab activation included:

  • prior cerebrovascular disease (adjusted OR = 1.63; 95% CI, 1.13-2.35);
  • prior PCI (aOR = 1.65; 95% CI, 1.09-2.5);
  • Black or Latino race/ethnicity compared with white race (aOR = 1.34; 95% CI, 1.07-1.69); and
  • each 10 mm Hg decrease in systolic BP at admission (aOR = 1.04; 95% CI, 1.01-1.07).

“We also realized that cath lab was more frequently delayed in Black or Hispanic patients. This highlights the need for more efforts and education to provide consistent quality care for all the population,” Zeitouni told Healio. “Similarly, patients with complex presentations such as shock were more likely to receive delayed activation — probably related to the intensive care they required.”

In other findings, in-hospital MACE was more prevalent in the delayed activation cohort (11.2% vs. 8.1%), but researchers observed no significant difference in the risk for death, stroke, cardiac arrest or shock (aOR = 1.12; 95% CI, 0.77-1.62) between groups.

‘Considerable progress’

“A considerable amount of progress has been made in STEMI coordination and care through the Mission: Lifeline STEMI Accelerator-2 project,” Zeitouni said in an interview. “This relies on the hard work of local and regional coordinators, physicians, nurses and EMS agencies involved in the program to improve the outcomes of STEMI patients.

“Under the direction of senior researchers James Jollis, MD, professor of medicine and radiology, and Christopher Granger, MD, professor of medicine and professor in the School of Nursing at Duke, in collaboration with AHA, there is an interest in deploying protocols between non-PCI capable hospitals and PCI centers to implement cath lab activation within 20 minutes in patients requiring interhospital transfers,” Zeitouni told Healio. “Successful ‘transferring – receiving pairs’ are being analyzed to find the key to success for timely activation.”