CLINICAL RESEARCH: MYOCARDIAL INFARCTION
Hospital Improvement in Time to Reperfusion in Patients With Acute Myocardial Infarction, 1999 to 2002
Robert L. McNamara, MD, MHS, FACC*,
Jeph Herrin, PhD*, ,
Elizabeth H. Bradley, PhD ,
Edward L. Portnay, MD*,
Jeptha P. Curtis, MD*,
Yongfei Wang, MS*,
David J. Magid, MD, MPH||,¶,
Martha Blaney, PharmD#,
Harlan M. Krumholz, MD, SM, FACC*,, ,**,* for the NRMI Investigators
* Department of Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
Section of Health Policy and Administration, Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, Connecticut
Robert Wood Johnson Clinical Scholars Program, Yale University School of Medicine, New Haven, Connecticut
Flying Buttress Associates, Charlottesville, Virginia
|| Clinical Research Unit, Kaiser Permanente, Denver, Colorado
¶ Departments of Emergency Medicine and Preventive Medicine and Biometrics, University of Colorado Health Sciences Center, Denver, Colorado
# Genentech Inc., South San Francisco, California
** Center for Outcomes Research and Evaluation, Yale-New Haven Health System, New Haven, Connecticut
Manuscript received January 13, 2005;
revised manuscript received March 29, 2005,
accepted April 11, 2005.
* Reprint requests and correspondence: Dr. Harlan M. Krumholz, Yale University School of Medicine, 333 Cedar Street, PO Box 208088, New Haven, Connecticut 06520-8088. (Email: harlan.krumholz{at}yale.edu).
OBJECTIVES: The purpose of this study was to analyze recent trends in door-to-reperfusion time and to identify hospital characteristics associated with improved performance.
BACKGROUND: Rapid reperfusion improves survival for patients with acute ST-segment elevation myocardial infarction (STEMI).
METHODS: In this retrospective observational study from the National Registry of Myocardial Infarction (NRMI)-3 and -4, between 1999 and 2002, we analyzed door-to-needle and door-to-balloon times in patients admitted with STEMI and receiving fibrinolytic therapy (n = 68,439 patients in 1,015 hospitals) or percutaneous coronary intervention (n = 33,647 patients in 421 hospitals) within 6 h of hospital arrival.
RESULTS: In 1999, only 46% of the patients in the fibrinolytic therapy cohort were treated within the recommended 30-min door-to-needle time; only 35% of the patients in the percutaneous coronary intervention cohort were treated within the recommended 90-min door-to-balloon time. Improvement in these times to reperfusion over the four-year study period was not statistically significant (door-to-needle: –0.01 min/year, 95% confidence interval [CI] –0.24 to +0.23, p > 0.9; door-to-balloon: –0.57 min/year, 95% CI –1.24 to +0.10, p = 0.09). Only 33% (337 of 1,015) of hospitals improved door-to-needle time by more than one min/year, and 26% (110 of 421) improved door-to-balloon time by more than three min/year. No hospital characteristic was significantly associated with improvement in door-to-needle time. Only high annual percutaneous coronary intervention volume and location in New England were significantly associated with greater improvement in door-to-balloon time.
CONCLUSIONS: Fewer than one-half of patients with STEMI receive reperfusion in the recommended door-to-needle or door-to-balloon time, and mean time to reperfusion has not decreased significantly in recent years. Relatively few hospitals have shown substantial improvement.
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Abbreviations and Acronyms
| | AMI = acute myocardial infarction | | CI = confidence interval | | ECG = electrocardiogram | | NRMI = National Registry of Myocardial Infarction | | PCI = percutaneous coronary intervention | | STEMI = ST-segment elevation myocardial infarction |
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