Department of Cardiology Saint Luke's Mid-America Heart Institute Kansas City MO.
Department of Quantitative Health Sciences Lerner Research InstituteCleveland Clinic Cleveland OH.
J Am Heart Assoc. 2021 Dec 21;10(24):e024540. doi: 10.1161/JAHA.121.024540. Epub 2021 Nov 15.
Background We evaluated whether a comprehensive ST-segment-elevation myocardial infarction protocol (CSP) focusing on guideline-directed medical therapy, transradial percutaneous coronary intervention, and rapid door-to-balloon time improves process and outcome metrics in patients with moderate or high socioeconomic deprivation. Methods and Results A total of 1761 patients with ST-segment-elevation myocardial infarction treated with percutaneous coronary intervention at a single hospital before (January 1, 2011-July 14, 2014) and after (July 15, 2014- July 15, 2019) CSP implementation were included in an observational cohort study. Neighborhood deprivation was assessed by the Area Deprivation Index and was categorized as low (≤50th percentile; 29.0%), moderate (51st -90th percentile; 40.8%), and high (>90th percentile; 30.2%). The primary process outcome was door-to-balloon time. Achievement of guideline-recommend door-to-balloon time goals improved in all deprivation groups after CSP implementation (low, 67.8% before CSP versus 88.5% after CSP; moderate, 50.7% before CSP versus 77.6% after CSP; high, 65.5% before CSP versus 85.6% after CSP; all <0.001). Median door-to-balloon time among emergency department/in-hospital patients was significantly noninferior in higher versus lower deprivation groups after CSP (noninferiority limit=5 minutes; high versus moderate = 0.002, high versus low <0.001, moderate versus low = 0.02). In-hospital mortality, the primary clinical outcome, was significantly lower after CSP in patients with moderate/high deprivation in unadjusted (before CSP 7.0% versus after CSP 3.1%; odds ratio [OR], 0.42 [95% CI, 0.25-0.72]; =0.002) and risk-adjusted (OR, 0.42 [95% CI, 0.23-0.77]; =0.005) models. Conclusions A CSP was associated with improved ST-segment-elevation myocardial infarction care across all deprivation groups and reduced mortality in those from moderate or high deprivation neighborhoods. Standardized initiatives to reduce care variability may mitigate social determinants of health in time-sensitive conditions such as ST-segment-elevation myocardial infarction.
背景 我们评估了一个综合的 ST 段抬高型心肌梗死方案（CSP），该方案侧重于指南指导的药物治疗、经桡动脉经皮冠状动脉介入治疗和快速门球时间，是否能改善中高社会经济剥夺程度的患者的治疗过程和结局指标。
方法和结果 在单家医院接受经皮冠状动脉介入治疗的 1761 例 ST 段抬高型心肌梗死患者纳入了一项观察性队列研究，这些患者在 CSP 实施前（2011 年 1 月 1 日至 2014 年 7 月 14 日）和后（2014 年 7 月 15 日至 2019 年 7 月 15 日）。通过区域剥夺指数评估邻里剥夺程度，并分为低（≤50 百分位；29.0%）、中（51-90 百分位；40.8%）和高（>90 百分位；30.2%）。主要治疗过程结果为门球时间。在 CSP 实施后，所有剥夺程度的组的门球时间目标都得到了改善（低：CSP 前为 67.8%，CSP 后为 88.5%；中：CSP 前为 50.7%，CSP 后为 77.6%；高：CSP 前为 65.5%，CSP 后为 85.6%；均<0.001）。在 CSP 实施后，急诊室/院内患者的中位门球时间在较高与较低剥夺组之间具有显著的非劣效性（非劣效性界值=5 分钟；高 vs. 中=0.002，高 vs. 低<0.001，中 vs. 低=0.02）。主要临床结局院内死亡率在中/高剥夺程度的患者中，在未调整（CSP 前为 7.0%，CSP 后为 3.1%；优势比[OR]，0.42[95%置信区间，0.25-0.72]；=0.002）和风险调整（OR，0.42[95%置信区间，0.23-0.77]；=0.005）模型中均显著降低。
结论 CSP 与所有剥夺组的 ST 段抬高型心肌梗死治疗效果改善相关，并降低了中/高剥夺社区患者的死亡率。减少治疗变异性的标准化举措可能会减轻时间敏感型疾病（如 ST 段抬高型心肌梗死）的健康社会决定因素。
