2018-2021 年 ST 段抬高型心肌梗死患者的治疗时间和住院死亡率。
Treatment Time and In-Hospital Mortality Among Patients With ST-Segment Elevation Myocardial Infarction, 2018-2021.
机构信息
Lindner Center for Research and Education, Cincinnati, Ohio.
Duke University, Durham, North Carolina.
出版信息
JAMA. 2022 Nov 22;328(20):2033-2040. doi: 10.1001/jama.2022.20149.
IMPORTANCE
Recognizing the association between timely treatment and less myocardial injury for patients with ST-segment elevation myocardial infarction (STEMI), US national guidelines recommend specific treatment-time goals.
OBJECTIVE
To describe these process measures and outcomes for a recent cohort of patients.
DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional study of a diagnosis-based registry between the second quarter of 2018 and the third quarter of 2021 for 114 871 patients with STEMI treated at 648 hospitals in the Get With The Guidelines-Coronary Artery Disease registry.
EXPOSURES
STEMI or STEMI equivalent.
MAIN OUTCOMES AND MEASURES
Treatment times, in-hospital mortality, and adherence to system goals (75% treated ≤90 minutes of first medical contact if the first hospital is percutaneous coronary intervention [PCI]-capable and ≤120 minutes if patients require transfer to a PCI-capable hospital).
RESULTS
In the study population, median age was 63 (IQR, 54-72) years, 71% were men, and 29% were women. Median time from symptom onset to PCI was 148 minutes (IQR, 111-226) for patients presenting to PCI-capable hospitals by emergency medical service, 195 minutes (IQR, 127-349) for patients walking in, and 240 minutes (IQR, 166-402) for patients transferred from another hospital. Adjusted in-hospital mortality was lower for those treated within target times vs beyond time goals for patients transported via emergency medical services (first medical contact to laboratory activation ≤20 minutes [in-hospital mortality, 3.6 vs 9.2] adjusted OR, 0.54 [95% CI, 0.48-0.60], and first medical contact to device ≤90 minutes [in-hospital mortality, 3.3 vs 12.1] adjusted OR, 0.40 [95% CI, 0.36-0.44]), walk-in patients (hospital arrival to device ≤90 minutes [in-hospital mortality, 1.8 vs 4.7] adjusted OR, 0.47 [95% CI, 0.40-0.55]), and transferred patients (door-in to door-out time <30 minutes [in-hospital mortality, 2.9 vs 6.4] adjusted OR, 0.51 [95% CI, 0.32-0.78], and first hospital arrival to device ≤120 minutes [in-hospital mortality, 4.3 vs 14.2] adjusted OR, 0.44 [95% CI, 0.26-0.71]). Regardless of mode of presentation, system goals were not met in most quarters, with the most delayed system performance among patients requiring interhospital transfer (17% treated ≤120 minutes).
CONCLUSIONS AND RELEVANCE
This study of patients with STEMI included in a US national registry provides information on changes in process and outcomes between 2018 and 2021.
重要性
认识到及时治疗与心肌损伤程度降低之间的关联，美国国家指南推荐了特定的治疗时间目标。
目的
描述最近一组 STEMI 患者的这些过程指标和结果。
设计、设置和参与者：这是一项基于诊断的注册研究，在 2018 年第二季度至 2021 年第三季度期间，对 648 家医院治疗的 114871 名 STEMI 患者进行了研究。这些患者的诊断依据为 STEMI 或 STEMI 等效标准。
暴露
STEMI 或 STEMI 等效。
主要结果和措施
治疗时间、住院死亡率以及对系统目标的遵守情况（如果首次就诊医院具备经皮冠状动脉介入治疗 [PCI] 能力，则在首次医疗接触后 90 分钟内治疗的比例应达到 75%；如果患者需要转至具备 PCI 能力的医院，则在首次医疗接触后 120 分钟内治疗的比例应达到 75%）。
结果
在研究人群中，中位年龄为 63 岁（IQR，54-72 岁），71%为男性，29%为女性。对于通过紧急医疗服务就诊的 PCI 能力医院，从发病到 PCI 的中位时间为 148 分钟（IQR，111-226），对于自行前来就诊的患者为 195 分钟（IQR，127-349），对于从其他医院转来的患者为 240 分钟（IQR，166-402）。与超过时间目标的患者相比，在目标时间内接受治疗的患者的院内死亡率更低：通过紧急医疗服务转运的患者（首次医疗接触至实验室激活时间≤20 分钟的院内死亡率为 3.6% vs 9.2%，调整后的比值比 [OR]，0.54 [95%置信区间 [CI]，0.48-0.60]；以及首次医疗接触至设备≤90 分钟的院内死亡率为 3.3% vs 12.1%，调整后的 OR，0.40 [95% CI，0.36-0.44]）；自行前来就诊的患者（医院到达至设备≤90 分钟的院内死亡率为 1.8% vs 4.7%，调整后的 OR，0.47 [95% CI，0.40-0.55]）；以及转院的患者（门到门时间<30 分钟的院内死亡率为 2.9% vs 6.4%，调整后的 OR，0.51 [95% CI，0.32-0.78]；以及首次医院到达至设备≤120 分钟的院内死亡率为 4.3% vs 14.2%，调整后的 OR，0.44 [95% CI，0.26-0.71]）。无论就诊模式如何，大多数情况下系统目标都未达到，在需要院内转院的患者中系统表现延迟最为明显（17%的患者在 120 分钟内接受治疗）。
结论和相关性
这项对包括在美国国家注册中心的 STEMI 患者的研究提供了 2018 年至 2021 年期间过程和结果变化的信息。
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