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AHA. ACTION GWTG-Glickman_ Fibrinolytic Administration

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									 Delays in Fibrinolytic Administration for Acute
  ST-Segment Elevation Myocardial Infarction:
  Results from the Acute Coronary Treatment
 and Interventions Outcomes Network Registry
            – Get With the Guidelines
          (ACTION Registry®-GWTGTM)
Seth Glickman, MD1; Charles Cairns, MD1; Anita
Chen, MS2; Christopher Granger, MD2; Christopher
    Cannon, MD3; Elizabeth Fraulo, MS2; Eric
     Peterson, MD, MPH2, Matthew Roe, MD2
     1. Department of Emergency Medicine, University of North Carolina-
                                Chapel Hill
              2. Duke University Medical Center, Durham, NC
               3. Brigham and Women’s Hospital, Boston, MA
 ,
                Disclosures
• Robert Wood Johnson Foundation
  Physician Faculty Scholar Award (Glickman
  PI)

• American Heart Association PRT Outcomes
  Research Center Project Grant (Glickman,
  Granger, Co PIs)

• NCDR-American College of Cardiology
                   Background
• Reperfusion therapy STEMI reduces
  mortality in a time-dependent manner
  – PCI
  – Fibrinolytic therapy


• 2007 AHA/ACC STEMI Guidelines
  – “STEMI patients presenting to a hospital without
    PCI capability and who cannot be transferred to
    undergo PCI within 90 minutes should be treated
    with fibrinolytic therapy within 30 minutes as a
    systems goal”
   Background – Challenges to First medical
          contact to PCI in 90 minutes
• Patients in rural areas far from PCI Centers
  – Only 1200/5000 hospitals are PCI capable


• 4% of STEMI patients who are transferred
  achieve DTB <90 minutes1
  – ↑ 13% with statewide regionalization efforts2

• Method of choice for primary reperfusion in
  these patients may be fibrinolysis
                      1 Nallamothu BK et al. Circulation. 2005
                      2 Jollis JG et al. JAMA. 2007
                  Objectives

• Assess the performance of fibrinolytic
  therapy within the 30 minute guideline in
  contemporary practice

• Evaluate patient characteristics associated
  with the timeliness of fibrinolysis

• Determine association of DTN times with
  patient outcomes
          Methods – Study population

• ACTION –GWTG Registry

• January 2007-June 2008
  30,193 patients with STEMI at 286 hospitals

• Fibrinoytic therapy - 3,219 STEMI patients in
  178 hospitals
                Methods – Variables
• Co-variates
  – Patient demographics (age, race, gender)
  – Medical history
  – Clinical characteristics on presentation


• Outcomes
  – Time to fibrinolysis
  – In-hospital events
     • Mortality
     • Composite outcome – Mortality, stroke, cardiogenic
       shock
        Methods – Statistical analysis
• Association of patient factors and time to
  fibrinolysis
  – Linear generalized estimating equations (GEE)


• Association of time to fibrinolysis and
  outcomes
  – GEE model
                    Patient Characteristics (n=3,219)
Demographics                                Presentation characteristics
Age (year), median, IQR     59.0 (51.0-68.0) Clinical symptoms
Gender, male                  2358 (73.3)    Signs of CHF                   299 (9.3)
Race, white                   2804 (87.1)    Heart rate >100 bpm           392 (12.2)
Insurance status, private     1835 (57.0)    Systolic BP <90 mmHg           173 (5.4)
Body mass index (kg/m2)     28.3 (25.3-32.2) Transported by EMS            988 (30.7)


Medical history                             Hospital characteristics
Hypertension                  1823 (56.6)   Non-PCI (versus PCI)           2872 (89.2)
Diabetes mellitus             614 (19.1)    Region
Current/recent smoker         1512 (47.0)    West                          432 (13.4)
Dyslipidemia                  1545 (48.0)    Northeast                      298 (9.3)
Prior MI                      589 (18.3)     Midwest                       1041 (32.2)
                                             South                         1448 (45.0)
  Results – Distribution of DTN times




Median DTN 34.0 minutes (IQR 22.0 - 54.0)
1,432/3,219, 44.5% met the ACC/AHA guideline ≤ 30 minutes
                      Variable         Adjusted    95% CI    95% CI     p-value:      p-value:
                                       Estimate*   (Lower)   (Upper)   (Individual)   (Global)
Patient demographics
Women (vs. men)                          17.8        11.9     24.1       <.0001
Age (year)
 55 to 64 (vs. <55)                       -0.3       -5.6      5.3       0.9086       0.0434
 65 to 74 (vs. <55)                       -1.1       -8.6      7.1       0.7875
 ≥75 (vs. <55)                           12.0        1.8      23.2       0.0200
White (vs. other race)                    -6.7      -14.2      1.4       0.1039
Presentation features
Transported by EMS                       -19.3      -24.5     -13.7      <.0001
Systolic blood pressure <90 mmHg         -10.8      -19.4      -1.3      0.0263
Time or presentation
 Weekday, evening (vs. Weekday, day)      4.0        -3.1     11.7       0.2756       0.0156
 Weekday, night (vs. Weekday, day)       12.0        3.8      20.9       0.0036
 Weekend, day (vs. Weekday, day)          1.1        -8.0     11.3       0.8181
 Weekend, evening (vs. Weekday, day)      2.8        -6.3     12.7       0.5605
 Weekend, night (vs. Weekday, day)       13.4        3.0      24.8       0.0104
        Association of DTN time and Outcomes:
           ≤30 minutes versus >30 minutes

Outcome                Outcome (%)    Adjusted OR p-value
                                        (95% CI)
Death                  3.1% vs 4.4%   0.79 (0.50-1.25) 0.3126


Death /shock /stroke   6.2% vs 8.8%   0.74 (0.56-0.98) 0.0356
            Potential Limitations
• Selection bias (voluntary registry)
  – Underestimates treatment delays


• Observational study
  – Unmeasured confounders
     • Physician experience and treatment preferences
     • Systems factors


• Sicker patients = longer treatment delays
  – Yet patients in shock treated as quickly
                     Conclusions

• Timely fibrinolytic therapy associated with better
  outcomes
• DTN time < 30 min seen < one-half patients
   – Delays in women, elderly, and after-hours
     presentations


• Efforts to optimize STEMI care, including
  regional systems, should focus on shortening
  reperfusion times for patients who receive
  primary fibrinolysis as well as those who receive
  primary PCI
Back up slides
    Potential reasons for treatment delays
• Delay in diagnosis
  – Atypical signs and symptoms
  – Door to ECG times, minutes
     • Women, median 9 (IQR 4 to 14)
     • Men, median 5 (IQR 2 to 12)
• System factors at small, rural hospitals
  – Training of emergency providers (board
    certification)
  – Variation in protocols – e.g. CXR, cardiology
    consultation
• Patient factors
  – Variation in provider and patient risk preferences
            Variable                     Level    Median   25th %   75th%   p-value
Presentation characteristics
Systolic BP (mmHg)             ≥90 mmHg            34.0     22.0    54.0    0.1622
                               <90 mmHg            31.0     23.0    46.0
Transported by                 No                  36.0     24.0    57.0    <.0001
                               Yes                 28.0     19.0    45.0
Time of Presentation           Weekday, day        32.0     21.0    52.0    0.0077
                               Weekday, evening    33.0     22.0    52.0
                               Weekday, night      36.0     25.0    58.0
                               Weekend, day        33.0     22.5    45.5
                               Weekend, evening    33.0     21.5    57.0
                               Weekend, night      35.0     25.0    57.0
Hospital characteristics
Region                         West                36.0     23.5    60.0    0.0005
                               Northeast           35.0     23.0    54.0
                               Midwest             35.0     24.0    55.0
                               South               32.0     21.0    51.0
Type of hospital               PCI                 27.0     17.0    52.0    <.0001
                               Non-PCI             35.0     23.0    54.0
          Variable                    Median     25th        75th      p-value
                                               Percentile Percentile   (Global)
Patient characteristics
Age (year)                <55          31.0      21.0        50.0      <.0001
                          55-64        33.0      22.0        51.0
                          65-74        35.0      24.0        55.0
                          ≥75          41.0      25.0        67.0
Gender                    Male         32.0      21.0        50.0      <.0001
                          Female       38.0      25.0        61.5
Race                      Caucasian    34.0      22.0        53.0      0.8096
                          Black        34.0      21.0        66.0
                          Asian        32.0      14.0        57.0
                          Hispanic     34.5      21.0        52.0
                          Other        35.0      21.0        60.0

								
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