Duke Clinical Research Institute, Durham, NC; University of Alberta, Alberta, Canada.
Harbor-UCLA Medical Center, Torrance, CA.
Am Heart J. 2018 Mar;197:9-17. doi: 10.1016/j.ahj.2017.10.017. Epub 2017 Nov 2.
Assessing hospital-related network-level primary percutaneous coronary intervention (PCI) performance for ST-segment elevation myocardial infarction (STEMI) is challenging due to differential time-to-treatment metrics based on location of diagnostic electrocardiogram (ECG) for STEMI.
STEMI patients undergoing primary PCI at 588 PCI-capable hospitals in AHA Mission: Lifeline (2008-2013) were categorized by initial STEMI identification location: PCI-capable hospitals (Group 1); pre-hospital setting (Group 2); and non-PCI-capable hospitals (Group 3). Patient-specific time-to-treatment categories were converted to minutes ahead of or behind their group-specific mean; average time-to-treatment difference for all patients at a given hospital was termed comprehensive ECG-to-device time. Hospitals were then stratified into tertiles based on their comprehensive ECG-to-device times with negative values below the mean representing shorter (faster) time intervals.
Of 117,857 patients, the proportion in Groups 1, 2, and 3 were 42%, 33%, and 25%, respectively. Lower rates of heart failure and cardiac arrest at presentation are noted within patients presenting to high-performing hospitals. Median comprehensive ECG-to-device time was shortest at -9 minutes (25th, 75th percentiles: -13, -6) for the high-performing hospital tertile, 1 minute (-1, 3) for middle-performing, and 11 minutes (7, 16) for low-performing. Unadjusted rates of in-hospital mortality were 2.3%, 2.6%, and 2.7%, respectively, but the adjusted risk of in-hospital mortality was similar across tertiles.
Comprehensive ECG-to-device time provides an integrated hospital-related network-level assessment of reperfusion timing metrics for primary PCI, regardless of the location for STEMI identification; further validation will delineate how this metric can be used to facilitate STEMI care improvements.
由于 ST 段抬高型心肌梗死（STEMI）的诊断心电图（ECG）位置不同，导致治疗时间指标存在差异，因此评估医院相关的网络层面直接经皮冠状动脉介入治疗（PCI）的表现具有挑战性。
在美国心脏协会生命线使命（2008-2013 年）期间，在 588 家有能力进行 PCI 的医院接受直接 PCI 的 STEMI 患者，根据初始 STEMI 识别位置进行分类：有能力进行 PCI 的医院（第 1 组）；院前环境（第 2 组）；以及无能力进行 PCI 的医院（第 3 组）。将患者特定的治疗时间类别转换为其所在组平均时间的提前或延迟分钟数；给定医院所有患者的平均治疗时间差异被称为综合 ECG 至设备时间。然后根据综合 ECG 至设备时间将医院分为三分位数，负值表示时间间隔更短（更快）。
在 117857 名患者中，第 1、2 和 3 组的比例分别为 42%、33%和 25%。表现良好的医院的患者就诊时心力衰竭和心脏骤停的发生率较低。表现良好的医院三分位数的中位综合 ECG 至设备时间最短为-9 分钟（25%，75%：-13，-6），中等表现的为 1 分钟（-1，3），表现不佳的为 11 分钟（7，16）。未调整的住院死亡率分别为 2.3%、2.6%和 2.7%，但各三分位数的住院死亡率调整风险相似。
综合 ECG 至设备时间为直接 PCI 的再灌注时间指标提供了一种整合的医院相关网络层面评估方法，无论 STEMI 识别的位置如何；进一步的验证将阐明如何使用该指标来促进 STEMI 护理的改善。
