乌鸦传媒

Activating the cardiac catheterization laboratory at least 10 minutes before an ST-segment elevation MI (STEMI) patient arrived at the hospital was associated with less reperfusion delay -- and possibly better in-hospital survival, a large registry study showed.

Among patients with a pre-hospital diagnosis of STEMI who were transported by ambulance to a percutaneous coronary intervention (PCI) center, 41% had the cardiac cath lab activated more than 10 minutes before hospital arrival. Compared to cases with later cath lab activation, these patients were more likely to (P<0.001 for all):

• Be transported directly to the cath lab (23.3% versus 5.3%)
• Spend less time between hospital arrival and cath lab arrival (median 17 versus 28 min)
• Have shorter door-to-device time (40 versus 52 min)
• Achieve first medical contact-to-device times of 90 min or less (76.6% versus 68.6%)

In-hospital mortality was less common with early cath lab activation (2.8% versus 3.4%, P=0.01), though the association missed statistical significance after adjustment for other factors (adjusted OR 0.87, 95% CI 0.75-1.01).

The data generally supported earlier cath lab pre-activation in pre-identified STEMI patients, researchers led by Jay Shavadia, MD, of Duke Clinical Research Institute in Durham, North Carolina, concluded in the Sept. 24 issue of .

The study was based on ACTION registry data from 2015-2017 on 27,840 of STEMI patients seen at 744 PCI centers.

"We have known for years from the Seattle experience that pre-transport ECG's can save 1 hour of time to reperfusion. Now these investigators show that this practice can be done across the country and in fact does save lives," commented William O'Neill, MD, of Henry Ford Hospital in Detroit.

"This information will also pressure all ambulances picking up potential heart attack patients to get the capability of sending remote ECGs to PCI STEMI centers," he suggested. O'Neill was not involved in the study.

Emergency medical technicians (EMTs) should call as early as possible to give the cath team more time to get to the lab, emphasized James Blankenship, MD, of Geisinger Medical Center in Danville, Pennsylvania.

As for emergency department (ED) physicians who handle EMT calls, it is important that they develop communication strategies so that it is known when the cath team has assembled. "Even plan to route the patient directly to the cath lab a little before the cath team is ready, recognizing that it may take a few minutes to get through the halls to the cath lab, and worst case scenario is the EMTs sitting in the cath lab with just a nurse or two until the rest of the cath team gets there," Blankenship told 乌鸦传媒.

"For the entire STEMI team including EMTs, ED MDs, and cath teams – understand that direct-to-cath lab saves time and will occasionally save a life, and develop your system to maximize the number of patients that go directly to cath lab without a stop in ED," he said.

"At our hospital, pre-activation almost always results in direct-to-cath lab transfer -- and we much prefer it. It takes 7 minutes to go from ED to cath lab – a complete waste of time. It is frustrating when we only get 5 minutes warning before the ambulance reaches the hospital and then we wish the EMTs called before they got into the ambulance!"

Notably, approximately 75% of patients in the study had the cath lab activated before hospital arrival, although only 41% had at least 10 minutes elapse between the two.

"We use a 10-min notification window on the basis of clinical judgment that this would be the minimum amount of time needed to prepare a catheterization laboratory across hospital types," Shavadia and colleagues wrote. "Shorter or longer time benchmarks could be considered, depending on geographic location, time of day, and proximity or anticipated delays to a PCI-capable hospital."

In the registry, patients who did get the full 10 minutes of cath lab pre-activation were more often white and had a slightly lower risk profile.

The investigators divided the hospitals into tertiles by pre-activation rate: 19% (low), 38% (intermediate), and 58% (high). Hospitals with the lowest pre-activation rates had substantially more patients die compared to centers in the highest tertile (3.6% versus 2.7%, adjusted OR 1.33, 95% CI 1.08-1.63).

Two major caveats of the study were that the ACTION registry did not include false cath lab activations (where patients had the initial diagnosis of STEMI changed subsequently) and relied on a group of self-selecting hospitals. Bias and residual confounding therefore could not be excluded.

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