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J Am Coll Cardiol, 2006; 47:45-51, doi:10.1016/j.jacc.2005.04.071
© 2006 by the American College of Cardiology Foundation
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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{dagger}, 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*,{dagger},{ddagger},**,* for the NRMI Investigators

* Department of Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
{dagger} Section of Health Policy and Administration, Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, Connecticut
{ddagger} 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.

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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Copyright © 2006 by the American College of Cardiology Foundation.