Association of a Comprehensive ST-Segment-Elevation Myocardial Infarction Protocol With Key Process Metrics Among Patients Transferred for Primary Percutaneous Coronary Intervention.

BACKGROUND

Most US patients with ST-segment-elevation myocardial infarction (STEMI) transferred for percutaneous coronary intervention (PCI) do not achieve the goal door-to-balloon time (D2BT) of ≤120 minutes. We evaluated the impact of a comprehensive STEMI protocol (CSP) implemented in our health care system on STEMI process metrics in patients transferred for PCI.

METHODS AND RESULTS

The CSP is a 4-step protocol including (1) emergency department (ED) cardiac catheterization laboratory activation; (2) a STEMI Safe Handoff Checklist; (3) immediate transfer to an available cardiac catheterization laboratory; and (4) radial-first approach to PCI. We compared the use of guideline-directed medical therapy before angiography, radial-first access, and D2BT in 1274 consecutive patients with STEMI transferred to our hospital for PCI before (pre-CSP group; January 1, 2011, to July 14, 2014) and after (CSP group; July 15, 2014, to July 15, 2019) CSP implementation. The study population included 499 patients in the pre-CSP group and 775 patients in the CSP group. After CSP implementation, guideline-directed medical therapy before angiography (84.6% versus 93.9%, <0.001) and radial access (19.0% versus 77.7%, <0.001) both increased significantly. Median D2BT decreased from 114 (interquartile range, 94-146 minutes) to 97 minutes (interquartile range, 82-115 minutes; <0.001) after CSP implementation, with substantially more patients treated with D2BT of ≤120 minutes (55.7% versus 80.1%, <0.001). Achievement of D2BT <120 minutes in the CSP group was associated with a 50% relative risk reduction in the 30-day mortality rate (odds ratio, 0.50; =0.04) and an absolute risk reduction of 0.7%.

CONCLUSIONS

In patients with STEMI transferred for PCI, a standardized protocol for STEMI care was associated in improvements in key process metrics (guideline-directed medical therapy, radial access, and D2BT) with associated reduction in the 30-day mortality rate.