Delays in Fibrinolytic Administration for Acute ST-Segment Elevation Myocardial Infarction: Results from the Acute Coronary Treatment and Interventions Outcomes Network Registry – Get With the Guidelines (ACTION Registry®-GWTG TM ) Seth Glickman, MD 1 ; Charles Cairns, MD 1 ; Anita Chen, MS 2 ; Christopher Granger, MD 2 ; Christopher Cannon, MD 3 ; Elizabeth Fraulo, MS 2 ; Eric Peterson, MD, MPH 2 , Matthew Roe, MD 2 1. Department of Emergency Medicine, University of North Carolina-Chapel Hill 2. Duke University Medical Center, Durham, NC 3. Brigham and Women’s Hospital, Boston, MA ,
18
Embed
Delays in Fibrinolytic Administration for Acute ST-Segment Elevation Myocardial Infarction: Results from the Acute Coronary Treatment and Interventions.
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Delays in Fibrinolytic Administration for Acute ST-Segment Elevation Myocardial
Infarction: Results from the Acute Coronary Treatment and Interventions Outcomes Network Registry – Get With
the Guidelines (ACTION Registry®-GWTGTM)
Seth Glickman, MD1; Charles Cairns, MD1; Anita Chen, MS2; Christopher Granger, MD2; Christopher Cannon, MD3; Elizabeth Fraulo, MS2; Eric Peterson,
MD, MPH2, Matthew Roe, MD2
1. Department of Emergency Medicine, University of North Carolina-Chapel Hill
2. Duke University Medical Center, Durham, NC3. Brigham and Women’s Hospital, Boston, MA
,
Disclosures
• Robert Wood Johnson Foundation Physician Faculty Scholar Award (Glickman PI)
• American Heart Association PRT Outcomes Research Center Project Grant (Glickman, Granger, Co PIs)
• NCDR-American College of Cardiology
Background
• Reperfusion therapy STEMI reduces mortality in a time-dependent manner – PCI– Fibrinolytic therapy
• 2007 AHA/ACC STEMI Guidelines– “STEMI patients presenting to a hospital without PCI
capability and who cannot be transferred to undergo PCI within 90 minutes should be treated with fibrinolytic therapy within 30 minutes as a systems goal”
Background – Challenges to First medical contact to PCI in 90 minutes
• Patients in rural areas far from PCI Centers– Only 1200/5000 hospitals are PCI capable
• 4% of STEMI patients who are transferred achieve DTB <90 minutes1
– ↑ 13% with statewide regionalization efforts2
• Method of choice for primary reperfusion in these patients may be fibrinolysis
1 Nallamothu BK et al. Circulation. 20052 Jollis JG et al. JAMA. 2007
Objectives
• Assess the performance of fibrinolytic therapy within the 30 minute guideline in contemporary practice
• Evaluate patient characteristics associated with the timeliness of fibrinolysis
• Determine association of DTN times with patient outcomes
Methods – Study population
• ACTION –GWTG Registry
• January 2007-June 200830,193 patients with STEMI at 286 hospitals
• Fibrinoytic therapy - 3,219 STEMI patients in 178 hospitals
Methods – Variables• Co-variates
– Patient demographics (age, race, gender)– Medical history– Clinical characteristics on presentation
• Outcomes– Time to fibrinolysis– In-hospital events
• Physician experience and treatment preferences• Systems factors
• Sicker patients = longer treatment delays– Yet patients in shock treated as quickly
Conclusions
• Timely fibrinolytic therapy associated with better outcomes
• DTN time < 30 min seen < one-half patients– Delays in women, elderly, and after-hours presentations
• Efforts to optimize STEMI care, including regional systems, should focus on shortening reperfusion times for patients who receive primary fibrinolysis as well as those who receive primary PCI
Back up slides
Potential reasons for treatment delays• Delay in diagnosis
– Atypical signs and symptoms
– Door to ECG times, minutes• Women, median 9 (IQR 4 to 14)• Men, median 5 (IQR 2 to 12)
• System factors at small, rural hospitals– Training of emergency providers (board certification)
– Variation in protocols – e.g. CXR, cardiology consultation
• Patient factors– Variation in provider and patient risk preferences
Variable Level Median 25th % 75th% p-value
Presentation characteristics
Systolic BP (mmHg) ≥90 mmHg 34.0 22.0 54.0 0.1622
<90 mmHg 31.0 23.0 46.0
Transported by No 36.0 24.0 57.0 <.0001
Yes 28.0 19.0 45.0
Time of Presentation Weekday, day 32.0 21.0 52.0 0.0077