Missed Target Treatment Times May Increase MI Mortality
When it comes to delivering timely treatment for patients experiencing myocardial infarction (MI), many hospitals are continuing to fall short of national guidelines, new research showed.
Benchmarks for percutaneous coronary intervention, the standard of care for acute ST-elevation MI (STEMI), aren't being met in some cases. Delays in care in the key metric of the time from first contact with medical care to angioplasty with stenting resulted in worse patient outcomes and were associated with increased in-hospital mortality risk in some cases, according to the findings, published on June 11 in JAMA Cardiology .
'There are two categories of patient delays: Those that are patient-centered and those that are system-centered,' said Neal S. Kleiman, MD, Houston Methodist DeBakey Heart and Vascular Center, Houston, the senior author of the new study. 'We don't have control over patient-related factors, but there is a lot we can do in terms of hospital systems.'
For the retrospective cross-sectional study, Kleiman and his colleagues analyzed data on 73,826 patients with STEMI or STEMI equivalent from 503 sites across the United States. The goal was to determine site-level variability in patterns of treatment times and clinical outcomes from 2020 to 2022 based on an analysis of data from the American Heart Association's Get With the Guidelines — Coronary Artery Disease registry — a quality improvement program for patients with coronary artery disease, acute MI and chest pain. The authors said the study is the first large-scale analysis of treatment goals and outcomes in STEMI based on hospital performance.
The researchers found an association between failure to reach the target time from first medical contact with care to angioplasty with stenting — 90 minutes or less — and increased risk for in-hospital mortality for primary presentations and transfers (adjusted odds ratio, 2.21; 95% CI, 2.02-2.42, and 2.44; 95% CI, 1.90-3.12, respectively).
Low-performing hospitals were associated with increased risk for mortality and longer stays in the hospital than were high-performing hospitals. However, hospital location and case volume were not associated with worse outcomes.
The guidelines recommend a target time from first contact with care to angioplasty with stenting of 90 minutes or less for patients presenting directly to hospitals offering angioplasty with stenting and 120 minutes or less for patients requiring transfer to a facility offering the procedure. The study findings revealed significant variability between hospital sites in meeting the key metric of the recommendations — adherence in at least 75% of patients with STEMI. At hospitals with the capability to perform angioplasty with stenting, the target was met in 72.2% of patients at high-performing sites, 60.8% at intermediate-performing sites, and 46.0% at low-performing sites.
When patients required transfers to other facilities with the capability to perform angioplasty, a target first medical contact-to-device treatment time of 120 minutes or less was achieved in 72.3% of patients at high-performing sites, 48.8% at intermediate performing sites, and 21.9% at low-performing sites, according to the researchers. In these hospitals, treatment delays were caused primarily by longer stays in the emergency department and time from arrival in the catheterization laboratory to stenting.
Limitations of the study included the fact registry responses were provided on a voluntary basis and may not reflect the totality of STEMI care in all geographical areas, according to the researchers. The analysis also lacked data on follow-up after discharge, making it difficult to extrapolate the findings over the long term, they said.
Yasser M. Sammour, MD, MSc, cardiology fellow at Houston Methodist DeBakey Heart and Vascular Center, who led the work, said several decades of research have highlighted the importance of treating patients with STEMI efficiently. A previous registry study found fewer treatment delays were linked to reduced mortality.
'The current study tried to take that research one step further, assessing how factors such as hospital performance and location affect patient outcomes,' Sammour said.
The result, he said: 'We're still underperforming. We need to have coordinated strategies with local intervention at the hospital level to examine where significant delays in percutaneous coronary intervention time are occurring.'
The absence of uniformity in established performance measures such as time to initiate treatment in STEMI has led to calls for greater adherence to current recommendations.
In an editorial accompanying the journal article, Roxana Mehran, MD, Mount Sinai Fuster Heart Hospital in New York City, wrote: 'After two decades of data collection, national initiatives, and public accountability, the next step must involve tailored solutions addressing barriers within each institution. Bridging the gap now requires renewed efforts and commitments to prioritize timely, coordinated STEMI care. Until then, the clock will continue to tick — against our patients.'
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