“Door-In to Door-Out” Delay in Patients with Acute ST-Segment Elevation Myocardial Infarction Transferred for Primary Percutaneous Coronary Intervention in a Metropolitan STEMI Network of a Developing Country

Abstract

Background

Routine performance measures of primary percutaneous coronary intervention (PCI) within an ST-segment elevation myocardial infarction (STEMI) network are needed to improve care.

Objective

We evaluated the door-in to door-out (DI–DO) delays at the initial hospitals in STEMI patients as a routine performance measure of the metropolitan STEMI network.

Patients and Methods

We retrospectively analyzed the DI–DO time from 1,076 patients with acute STEMI who were transferred by ground ambulance to a primary PCI center for primary PCI between 4 October 2014 and 1 April 2019. Correlation analysis between DI–DO times and total ischemia time was performed using Spearman's test. Logistic regression analyses were used to find variables associated with a longer DI–DO time.

Results

Median DI–DO time was 180 minutes (25th percentile to 75th percentile: 120–252 minutes). DI–DO time showed a positive correlation with total ischemia time (r = 0.4, p < 0.001). The median door-to-device time at the PCI center was 70 minutes (25th percentile to 75th percentile: 58–88 minutes). Multivariate analysis showed that women patients were independently associated with DI–DO time > 120 minutes (odds ratio 1.55, 95% confidence interval 1.03 to 2.33, p = 0.03).

Conclusion

The DI–DO time reported in this study has not reached the guideline recommendation. To improve the overall performance of primary PCI in the region, interventions aimed at improving the DI–DO time at the initial hospitals and specific threat for women patients with STEMI are possibly the best efforts in improving the total ischemia time.

Keywords

DI–DO - STEMI care - primary PCI

Financial Support

None.

• References

• 1 Mumma BE, Kontos MC, Peng SA, Diercks DB. Association between prehospital electrocardiogram use and patient home distance from the percutaneous coronary intervention center on total reperfusion time in ST-segment-elevation myocardial infarction patients: a retrospective analysis from the national cardiovascular data registry. Am Heart J 2014; 167 (06) 915-920
• 2 Rasmussen MB, Frost L, Stengaard C. , et al. Diagnostic performance and system delay using telemedicine for prehospital diagnosis in triaging and treatment of STEMI. Heart 2014; 100 (09) 711-715
• 3 Anderson LL, French WJ, Peng SA. , et al. Direct transfer from the referring hospitals to the catheterization laboratory to minimize reperfusion delays for primary percutaneous coronary intervention: Insights from the National Cardiovascular Data Registry. Circ Cardiovasc Interv 2015. Circ Cardiovasc Interv 2015; 8 (09) e002477
• 4 Smith FGD, Brogan RA, Alabas O. , et al. Comparative care and outcomes for acute coronary syndromes in Central and Eastern European Transitional countries: a review of the literature. Eur Heart J Acute Cardiovasc Care 2015; 4 (06) 537-554
• 5 Nallamothu BK, Krumholz HM, Ko DT. , et al. Development of systems of care for ST-elevation myocardial infarction patients: gaps, barriers, and implications. Circulation 2007; 116 (02) e68-e72
• 6 Dharma S, Andriantoro H, Dakota I. , et al. Organisation of reperfusion therapy for STEMI in a developing country. Open Heart 2015; 2 (01) e000240
• 7 Dharma S, Andriantoro H, Purnawan I. , et al. Characteristics, treatment and in-hospital outcomes of patients with STEMI in a metropolitan area of a developing country: an initial report of the extended Jakarta Acute Coronary Syndrome registry. BMJ Open 2016; 6 (08) e012193
• 8 Tarkin J, Malhotra A, Apps A. , et al. Inter-hospital transfer for primary angioplasty: delays are often due to diagnostic uncertainty rather than systems failure and universal time metrics may not be appropriate. EuroIntervention 2015; 11 (05) 511-517
• 9 Jneid H, Addison D, Bhatt DL. , et al. 2017 AHA/ACC clinical performance and quality measures for adults with ST-elevation and Non-ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures. Circ Cardiovasc Qual Outcomes 2017; 10 (10) 10 Doi.org/10.1161/HCQ.0000000000000032
• 10 Wang TY, Nallamothu BK, Krumholz HM. , et al. Association of door-in to door-out time with reperfusion delays and outcomes among patients transferred for primary percutaneous coronary intervention. JAMA 2011; 305 (24) 2540-2547
• 11 Dharma S, Juzar DA, Firdaus I, Soerianata S, Wardeh AJ, Jukema JW. Acute myocardial infarction system of care in the third world. Neth Heart J 2012; 20 (06) 254-259
• 12 Dharma S, Siswanto BB, Firdaus I. , et al. Temporal trends of system of care for STEMI: insights from the Jakarta Cardiovascular Care Unit Network System. PLoS One 2014; 9 (02) e86665
• 13 Dharma S, Sukmawan R, Siswanto BB, Andriantoro H, Dakota I, Rao SV. One-year mortality of primary angioplasty for acute myocardial infarction during regular working hours versus off-hours. Asia Intervention 2015; 1: 109-115
• 14 O'Gara PT, Kushner FG, Ascheim DD. , et al; CF/AHA Task Force. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2013; 127 (04) 529-555
• 15 Ibanez B, James S, Agewall S. , et al. ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the Management of Acute Myocardial Infarction in Patients Presenting With ST-Segment Elevation of the European Society of Cardiology (ESC). Eur Heart J 2017; 2017 (Aug): 26 ; [Epub ahead of print]
• 16 Kawecki D, Gierlotka M, Morawiec B. , et al. Direct admission versus interhospital transfer for primary percutaneous coronary intervention in ST-segment elevation myocardial infarction. JACC Cardiovasc Interv 2017; 10 (05) 438-447
• 17 Thylén I, Ericsson M, Hellström Ängerud K, Isaksson RM, Sederholm Lawesson S. ; SymTime study group. First medical contact in patients with STEMI and its impact on time to diagnosis; an explorative cross-sectional study. BMJ Open 2015; 5 (04) e007059
• 18 Lawesson SS, Alfredsson J, Fredrikson M, Swahn E. Time trends in STEMI--improved treatment and outcome but still a gender gap: a prospective observational cohort study from the SWEDEHEART register. BMJ Open 2012; 2 (02) e000726
• 19 Hanssen M, Cottin Y, Khalife K. , et al; FAST-MI 2010 Investigators. French Registry on acute ST-elevation and non ST-elevation myocardial infarction 2010. FAST-MI 2010. Heart 2012; 98 (09) 699-705
• 20 Fox KA, Goodman SG, Anderson Jr FA. , et al. GRACE Investigators. From guidelines to clinical practice: the impact of hospital and geographical characteristics on temporal trends in the management of acute coronary syndromes. The Global Registry of Acute Coronary Events (GRACE). Eur Heart J 2003; 24 (15) 1414-1424
• 21 Kalla K, Christ G, Karnik R. , et al; Vienna STEMI Registry Group. Implementation of guidelines improves the standard of care: the Viennese registry on reperfusion strategies in ST-elevation myocardial infarction (Vienna STEMI registry). Circulation 2006; 113 (20) 2398-2405