Off-hours presentation may explain continuing fibrinolytic therapy in STEMI
MedWire News: A substantial number of ST-segment elevation myocardial infarction (STEMI) patients still receive fibrinolytic therapy at hospitals with capability to perform percutaneous coronary intervention (PCI) in the USA, report researchers.
Day and time of hospital arrival was the single strongest factor associated with the use of primary PCI, with presentation at weekends and evenings associated with around a 70% lower chance of undergoing primary PCI compared with during working hours on week days.
Despite increasing use of PCI, it is still not universally performed at PCI-capable centers, with more than one third such hospitals reporting use of fibrinolytic therapy.
To explore how clinical indications related to current PCI use, Reza Fazel (Emory University, Atlanta, Georgia, USA) and team analyzed data from the US National Registry of Myocardial Infarction (NRMI) on STEMI patients who presented at PCI-capable hospitals between 2000 and 2006.
They identified 25,579 patients who received primary PCI and 14,332 patients who received fibrinolytic therapy at 444 PCI-capable hospitals.
The rate of PCI varied widely across hospitals, from 40% to 86% (median 64%), but increased significantly each year, rising from 54% of patients in 2000 to 86% in 2006 (p for trend <0.001).
Of strong clinical indications for primary PCI, cardiogenic shock and delayed presentation were both associated with greater use of primary PCI, at adjusted odds ratios of 2.14 and 1.18, respectively, but Thrombolysis in MI risk score ≥5 was not.
Advanced age, female gender, and non-White race (risk factors for intracranial hemorrhage after fibrinolytic therapy) were not associated with increased use of PCI – in fact older (aged 85 years or more) and non-White patients were less likely to undergo primary PCI than their younger and White counterparts, at odds ratios of 0.69 and 0.90, respectively.
Overall, the most striking factor associated with reduced likelihood of primary PCI was arrival at the hospital during off-hours (odds ratio=0.27, p<0.0001).
Interaction analysis indicated that use of primary PCI during off-hours was not being reserved for the PCI-preferred group, despite a much lower overall use during off-hours.
In a related editorial, Farhan Khawaja and Henry Ting (Mayo Clinic, Rochester, Minnesota, USA) comment that the study “exposes the gap between what guidelines recommend as the ideal reperfusion therapy for STEMI patients who present to PCI hospitals versus the routine, usual care that is provided every day and night.”
They note the inferred limitation in resources during off-hours “highlights an important opportunity to improve patient outcomes at PCI-capable hospitals and regional STEMI-receiving centers.”
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By Caroline Price