Room for improvement in reperfusion strategies in U.S. hospitals

December 12, 2014 – The DCRI’s Tracy Wang, MD, MHS, MSc, and others found that hospitals often fail to achieve guideline-recommended reperfusion targets for STEMI patients.

U.S. hospitals often fail to use available tools to achieve guideline-recommended reperfusion targets for acute ST-segment elevation myocardial infarction (STEMI) patients who require interhospital transfer, according to a new study by DCRI researchers.

The study, conducted by Amit Vora, MD, MPH; DaJuanicia Holmes, MS; Matthew Roe, MD, MHS; Christopher Granger, MD; Laine Thomas, PhD; Tracy Wang, MD, MHS, MSc; and colleagues from other institutions, was published online this week in the journal JAMA Internal Medicine.

Earlier research has established the importance of rapid reperfusion for improving outcomes for STEMI patients. Primary percutaneous coronary intervention (pPCI) is the preferred method of reperfusion for such patients, if it can be performed in a timely manner. However, only one-third of acute care hospitals in the United States have full-time PCI capability. Many patients are therefore treated with fibrinolysis, which can be administered in most centers within 30 to 60 minutes of arrival, instead of PCI. Because there are limited data on patterns of reperfusion among patients requiring transfer to a PCI-capable hospital, the researchers sought to determine how interhospital transfer times are associated with reperfusion strategies for STEMI patients in U.S. hospitals.

To do so, they examined patient data from the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry–Get With The Guidelines (ACTION Registry-GWTG), the largest ongoing quality improvement database of acute myocardial infarction in the United States. The registry contains detailed information on cardiac patients, including demographic and clinical characteristics, care processes, and in-hospital outcomes. The researchers identified 22,481 patients eligible for PCI or fibrinolysis who were transferred from 1,771 STEMI referring centers to 366 STEMI receiving centers.

Of these patients, 6,642 (29.5%) received pretransfer fibrinolytic therapy, whereas 15,839 (70.5%) were directly transferred for pPCI. The median estimated interhospital drive time was 57 minutes. In cases where the estimated drive time exceeded 30 minutes, only 42.6% of transfer patients were treated with pPCI within 120 minutes, while only 52.7% of eligible patients with a drive time exceeding 60 minutes received fibrinolysis. Of the 15,437 patients with estimated drive times of 30 to 120 minutes who were eligible for fibrinolysis or pPCI, 5296 (34.3%) received pretransfer fibrinolysis, with a median time of 34 minutes for initiation of therapy. After fibrinolysis, the median time to transfer to the STEMI receiving center was 49 minutes, and 97.1% of patients underwent follow-up angiography. There was no significant difference in mortality risk for patients treated with fibrinolysis (3.7%) versus pPCI (3.9%), but fibrinolysis patients did have a higher bleeding risk (10.7% versus 9.5%).

These results, the researchers concluded, illustrate that many U.S. hospitals are failing to utilize either pPCI or fibrinolysis optimally to achieve guideline-recommended reperfusion targets for STEMI patients. The authors recommended that hospitals consider making greater use of fibrinolysis in cases where transfer times prevent timely pPCI.