Out-of-hours primary percutaneous coronary intervention for ST-elevation myocardial infarction is not associated with excess mortality: a study of 3347 patients treated in an integrated cardiac network
Rathod, Krishnaraj S. Jones, Daniel A. Gallagher, Sean M. Bromage, Dan Whitbread, Mark Archbold, Andrew Jain, Ajay K. Mathur, Anthony Wragg, Andrew Knight, Charles
Rathod, Krishnaraj S.
Jones, Daniel A.
Gallagher, Sean M.
Bromage, Dan
Whitbread, Mark
Archbold, Andrew
Jain, Ajay K.
Mathur, Anthony
Wragg, Andrew
Knight, Charles
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Abstract
OBJECTIVES:
Timely delivery of primary percutaneous coronary intervention (PPCI) is the treatment of choice for ST-segment elevation myocardial infarction (STEMI). Optimum delivery of PPCI requires an integrated network of hospitals, following a multidisciplinary, consultant-led, protocol-driven approach. We investigated whether such a strategy was effective in providing equally effective in-hospital and long-term outcomes for STEMI patients treated by PPCI within normal working hours compared with those treated out-of-hours (OOHs).
DESIGN:
Observational study.
SETTING:
Large PPCI centre in London.
PARTICIPANTS:
3347 STEMI patients were treated with PPCI between 2004 and 2012. The follow-up median was 3.3 years (IQR: 1.2-4.6 years).
PRIMARY AND SECONDARY OUTCOME MEASURES:
The primary endpoint was long-term major adverse cardiac events (MACE) with all-cause mortality a secondary endpoint.
RESULTS:
Of the 3347 STEMI patients, 1299 patients (38.8%) underwent PPCI during a weekday between 08:00 and 18:00 (routine-hours group) and 2048 (61.2%) underwent PPCI on a weekday between 18:00 and 08:00 or a weekend (OOHs group). There were no differences in baseline characteristics between the two groups with comparable door-to-balloon times (in-hours (IHs) 67.8 min vs OOHs 69.6 min, p=0.709), call-to-balloon times (IHs 116.63 vs OOHs 127.15 min, p=0.60) and procedural success. In hospital mortality rates were comparable between the two groups (IHs 3.6% vs OOHs 3.2%) with timing of presentation not predictive of outcome (HR 1.25 (95% CI 0.74 to 2.11). Over the follow-up period there were no significant differences in rates of mortality (IHs 7.4% vs OFHs 7.2%, p=0.442) or MACE (IHs 15.4% vs OFHs 14.1%, p=0.192) between the two groups. After adjustment for confounding variables using multivariate analysis, timing of presentation was not an independent predictor of mortality (HR 1.04 95% CI 0.78 to 1.39).
CONCLUSIONS:
This large registry study demonstrates that the delivery of PPCI with a multidisciplinary, consultant-led, protocol-driven approach provides safe and effective treatment for patients regardless of the time of presentation.
https://bmjopen.bmj.com/content/bmjopen/3/6/e003063.full.pdf
This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
http://dx.doi.org/10.1136/bmjopen-2013-003063