Author + information
- Received January 22, 2018
- Revision received June 14, 2018
- Accepted June 19, 2018
- Published online September 17, 2018.
- Ajar Kochar, MDa,∗ (, )
- Hussein R. Al-Khalidi, PhDa,
- Steen M. Hansen, PhDa,
- Jay S. Shavadia, MDa,
- Mayme L. Roettig, RN, MSNa,
- Christopher B. Fordyce, MD, MHS, MScb,
- Shannon Doerfler, PhDa,
- Bernard J. Gersh, MBChB, DPhilc,
- Timothy D. Henry, MDd,
- Peter B. Berger, MDe,
- James G. Jollis, MDa and
- Christopher B. Granger, MDa
- aDuke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- bDivision of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
- cDivision of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
- dDivision of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California
- eNew York, New York
- ↵∗Address for correspondence:
Dr. Ajar Kochar, Duke University Medical Center, Box 3126, Durham, North Carolina 27710.
Objectives This study sought to examine whether quality improvement initiatives across multiple ST-segment elevation myocardial infarction (STEMI) systems translated to faster first medical contact (FMC)-to-device times for patients presenting with cardiogenic shock (CS).
Background There are limited data describing contemporary rates of achieving guideline-directed FMC-to-device times for STEMI patients with CS.
Methods From 2012 to 2014, the American Heart Association Mission: Lifeline STEMI Systems Accelerator project established a protocol-guided approach to STEMI reperfusion systems in 484 U.S. hospitals. The study was stratified by CS versus no CS at presentation and performed Cochrane-Armitage tests to evaluate trends of achieving FMC-to-device time targets. A multivariable logistic regression model assessed the association between achieving guideline-directed FMC-to-device times and mortality.
Results Among 23,785 STEMI patients, 1,993 (8.4%) experienced CS at presentation. For direct presenters, patients with CS were less likely to achieve the 90-min FMC-to-device time compared with no-CS patients (37% vs. 54%; p < 0.001). For transferred patients, CS patients were even less likely to reach the 120-min FMC-to-device time compared with no-CS patients (34% vs. 47%; p < 0.0001). The Accelerator intervention did not result in improvements in the FMC-to-device times for direct-presenting CS patients (p for trend = 0.53), although there was an improvement for transferred patients (p for trend = 0.04). Direct-presenting patients arriving within 90 min had lower mortality rates compared with patients who reached after 90 min (20.49% vs. 39.12%; p < 0.001).
Conclusions Fewer than 40% of STEMI patients presenting with CS achieved guideline-directed FMC-to-device targets; delays in reperfusion for direct-presenting patients were associated with higher mortality.
- cardiac arrest
- cardiogenic shock
- first-medical-contact to device
- regional systems of care
- treatment delays
The Regional Systems of Care Demonstration Project: Mission: Lifeline STEMI Systems Accelerator is supported by the AR-G (Acute Coronary Treatment and Intervention Outcomes Network Registry–Get With The Guidelines) registry and grants by Abiomed, AstraZeneca, Philips Healthcare, and The Medicines Company. Dr. Hansen has received research grants from the Danish Foundation Trygfonden, the Danish Heart Foundation, and the Laerdal Foundation; and received travel support to a conference from AstraZeneca. Dr. Fordyce has served on the advisory board for Bayer, Novo Nordisk, and Boehringer Ingelheim. Dr. Berger has served on the executive steering committee for research trials funded by Janssen and Medicure. Dr. Granger has received research grant support from Bristol-Myers Squibb, Daiichi-Sankyo Bayer, The Medicines Company, AstraZeneca, Rho, Sirtez, Verseon, Novartis, Merck, Medtronic Foundation, Medtronic, GlaxoSmithKline, Gilead Science, Daiichi-Sankyo, Boston Scientific, Boehringer Ingelheim, Armetheon, Abbvie, and Janssen. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received January 22, 2018.
- Revision received June 14, 2018.
- Accepted June 19, 2018.
- 2018 American College of Cardiology Foundation
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