Presenting Off-Hours, Door-to-Balloon Time, and Clinical Results in Patients Primary Percutaneous Coronary Intervention
DOI:
https://doi.org/10.61919/jhrr.v4i1.668Keywords:
ST-segment elevation myocardial infarction, primary percutaneous coronary intervention, presentation outside of regular business hours, time from door to balloon, clinical results, door-to-balloon timeAbstract
Background: The timely management of ST-segment elevation myocardial infarction (STEMI) through primary percutaneous coronary intervention (PCI) significantly impacts patient outcomes. However, the influence of off-hours presentation (nights, weekends, and holidays) on door-to-balloon (D2B) time and clinical outcomes remains a pivotal concern, as it potentially affects the efficiency of care and patient prognosis.
Objective: This study aims to evaluate the association between off-hours presentation, D2B time, and clinical outcomes in patients undergoing primary PCI for STEMI, to identify potential disparities in treatment efficacy and to inform strategies for improving cardiovascular emergency care.
Methods: Conducting a retrospective cross-sectional analysis, this study included 90 patients admitted with STEMI who underwent primary PCI at a tertiary care center between March 2022 and March 2023. Patients were stratified into two groups based on the timing of hospital presentation: off-hours and regular hours. Primary outcomes assessed were D2B time, mortality rates, and incidences of cardiogenic shock and heart failure. Data were analyzed using descriptive statistics, t-tests, chi-square tests, and multivariable logistic regression to adjust for potential confounders.
Results: The mean D2B time for patients presenting during off-hours was significantly longer (96.4 ± 12.3 minutes) compared to those presenting during regular hours (84.6 ± 9.8 minutes, p<0.001). No statistically significant differences were observed in mortality rates (off-hours 4.4% vs. regular hours 6.7%, p=0.155), cardiogenic shock (off-hours 6.7% vs. regular hours 4.4%, p=0.351), or heart failure (off-hours 8.9% vs. regular hours 6.7%, p=0.214). Multivariable analysis confirmed off-hours presentation as an independent predictor of prolonged D2B time (coefficient 11.8, 95% CI 8.2-15.5).
Conclusion: Off-hours presentation is associated with significantly longer D2B times in STEMI patients undergoing primary PCI, underscoring the need for healthcare systems to address the disparities in care delivery during off-hours. However, no significant differences in short-term clinical outcomes were observed, suggesting that factors beyond D2B time contribute to patient prognosis. Further studies are warranted to explore comprehensive strategies to optimize care irrespective of presentation time.
Downloads
References
Sabatine MS. ST-elevation myocardial infarction: Treatment and prognosis. UpToDate. 2021. Available from: https://www.uptodate.com/contents/st-elevation-myocardial-infarction-treatment-and-prognosis
Rathore SS, Curtis JP, Chen J. Association of door-to-balloon time and mortality in patients admitted to hospital with ST elevation myocardial infarction: National cohort study. BMJ. 2009;338:b1807.
McNamara RL, Wang Y, Herrin J, et al. Effect of door-to-balloon time on mortality in patients with ST-segment elevation myocardial infarction. J Am Coll Cardiol. 2006;47(11):2180–6.
O'Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;127(4):e362–e425.
Kushner FG, Hand M, Smith SC, et al. 2009 focused updates: ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction (updating the 2004 guideline and 2007 focused update) and ACC/AHA/SCAI guidelines on percutaneous coronary intervention (updating the 2005 guideline and 2007 focused update). J Am Coll Cardiol. 2009;54(23):2205–41.
Bradley EH, Herrin J, Wang Y, et al. Door-to-drug and door-to-balloon times: Where can we improve? Time to reperfusion therapy in patients with ST-segment elevation myocardial infarction (STEMI). Am Heart J. 2006;151(6):1281–7.
Magid DJ, Wang Y, Herrin J, et al. Relationship between time of day, day of week, timeliness of reperfusion, and in-hospital mortality for patients with acute ST-segment elevation myocardial infarction. JAMA. 2005;294(7):803–12.
Menees DS, Peterson ED, Wang Y, et al. Door-to-balloon time and mortality among patients undergoing primary PCI. N Engl J Med. 2011;364(10):905–14.
Ting HH, Rihal CS, Gersh BJ, et al. Regional systems of care to optimize timeliness of reperfusion therapy for ST-elevation myocardial infarction: The Mayo Clinic STEMI Protocol. Circulation. 2007;116(7):729–36.
Genç Ö, Yıldırım A, Kurt İH, Kılıçkap M, Erol MK, Kayıkçıoğlu M, TURKMI Study Group. Relationship Between Work Mode, Time of Admission, and Mortality in St-Segment Elevation Myocardial Infarction: Results From the TURKMI Registry. Angiology. 2023 Jul;74(6):553-62.
Bajaj S, Parikh R, Gupta N, Aldehneh A, Rosenberg M, Hamdan A, Bikkina M. “Code STEMI” protocol helps in achieving reduced door-to-balloon times in patients presenting with acute ST-segment elevation myocardial infarction during off-hours. The Journal of emergency medicine. 2012 Mar 1;42(3):260-6.
Lattuca B, Kerneis M, Saib A, Nguyen LS, Payot L, Barthelemy O, Le Feuvre C, Helft G, Choussat R, Collet JP, Montalescot G. On-versus off-hours presentation and mortality of ST-segment elevation myocardial infarction patients treated with primary percutaneous coronary intervention. Cardiovascular Interventions. 2019 Nov 25;12(22):2260-8.
Kandola D. Access to cardiac catheterization services in a rural-urban setting in northern British Columbia: Examining the impact of time-delay to PCI on patient outcomes and whether the sickest go the quickest. University of Northern British Columbia; 2014.
Sorita A, Ahmed A, Starr SR, Thompson KM, Reed DA, Prokop L, Shah ND, Murad MH, Ting HH. Off-hour presentation and outcomes in patients with acute myocardial infarction: systematic review and meta-analysis. BMJ. 2014 Jan 21;348.
Ono Y, Ishida T, Iwasaki Y, Kawakami Y, Inokuchi R, Tase C, Shinohara K. The off-hour effect on trauma patients requiring subspecialty intervention at a community hospital in Japan: a retrospective cohort study. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 2015 Dec;23:1-2.
Shavadia JS, Chen AY, Fanaroff AC, de Lemos JA, Kontos MC, Wang TY. Intensive care utilization in stable patients with ST-segment elevation myocardial infarction treated with rapid reperfusion. JACC: Cardiovascular Interventions. 2019 Apr 22;12(8):709-17.
Barbato E, Gallinoro E, Abdel-Wahab M, Andreini D, Carrié D, Di Mario C, Dudek D, Escaned J, Fajadet J, Guagliumi G, Hill J. Management strategies for heavily calcified coronary stenoses: an EAPCI clinical consensus statement in collaboration with the EURO4C-PCR group. European Heart Journal. 2023 Nov 1;44(41):4340-56.
Hammad TA, Parikh M, Tashtish N, Lowry CM, Gorbey D, Forouzandeh F, Filby SJ, Wolf WM, Costa MA, Simon DI, Shishehbor MH. Impact of COVID‐19 pandemic on ST‐elevation myocardial infarction in a non‐COVID‐19 epicenter. Catheterization and Cardiovascular Interventions. 2021 Feb 1;97(2):208-14.
Chen KC, Yin WH, Young MS, Wei J. In-hospital tele-ECG triage and interventional cardiologist activation of the infarct team for STEMI patients is associated with improved late clinical outcomes. Acta Cardiologica Sinica. 2016 Jul;32(4):428.
Furmento J, CANDIELLOMTSAC A, Máscolo P, Lamelas P, Chapman I, Sigal A, TRIVIMTSAC M, BELARDIMTSAC J, COSTABELMTSAC JP. Optimization of Door-to-Balloon Time Implementing a Process Improvement Program. Results after 5 Years. Revista Argentina de Cardiología. 2023 Jun;91(2):218-22.
Alrawashdeh A, Nehme Z, Williams B, Smith K, Stephenson M, Bernard S, Bray J, Stub D. Factors influencing patient decision delay in activation of emergency medical services for suspected ST-elevation myocardial infarction. European Journal of Cardiovascular Nursing. 2021 Mar 1;20(3):243-51.
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2024 Abdul Basit, Javeria, Hameedullah, Muhammad Ishaque, Muhammad Aslam, Abdul Waris
This work is licensed under a Creative Commons Attribution 4.0 International License.
