THE ASSOCIATION OF REDUCED DOOR TO BALLOON TIMES AND MORTALITY IN PATIENTS UNDERGOING PRIMARY PCI: A REPORT FROM THE NATIONAL CARDIOVASCULAR DATA REGISTRY (NCDR®)
Daniel S. MeneesEric PetersonYongfei WangJeptha CurtisJohn C. MessengerJohn RumsfeldHitinder S. Gurm
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The objectives of this study is to confirm reduction of door-to-balloon (D2B) time with single-catheter percutaneous coronary intervention (SC-PCI) method.Reduction of total ischemic time is important in the emergency treatment of ST-elevation myocardial infarction (STEMI). There have been no established methods in primary percutaneous coronary intervention (PCI) to shorten ischemic time via radial access. Ikari left curve was reported as a universal guiding catheter for left and right coronary arteries. Several procedure steps can be skipped by SC-PCI method as the advantage of a universal catheter.This study is a retrospective analysis of a total of 1,275 consecutive STEMI cases treated with primary PCI in 14 hospitals. Patients were divided into two groups, SC-PCI method (n = 298) and conventional PCI method (n = 977). Primary endpoints were door-to-balloon (D2B) time and radiation exposure dose.The mean age was 68 ± 13 years old. Radial access was used in 85% of participants. PCI success was achieved in 99.5% of participants and the SC-PCI method was successfully performed in 92.6%. The D2B time was shorter (68 ± 46 vs. 74 ± 50 min, respectively; p = .02), and the radiation exposure dose was lower (1,664 ± 970 vs. 2008 ± 1,605 mGy, respectively; p < .0001) in the SC-PCI group than in the conventional group.Primary PCI with SC-PCI method for patients with STEMI demonstrated shorter D2B time and lower radiation exposure dose.
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Background: The relationship between quality of care and cost of medical services is a popular topic. In this study, we examined whether a reduced door-to-balloon (D2B) time led to cost savings, benefitted insurance payers, and improved patient outcomes. Methods: We retrospectively enrolled consecutive patients who presented with ST-segment elevation myocardial infarction (STEMI) and received primary percutaneous coronary intervention (PCI) between Feb. 1, 2007, and Jul. 31, 2009, at a tertiary hospital in Taiwan. The patient data were collected by chart review. We utilized claims data from the hospital financial system as the proxy for insurance payer costs. We only included the claims data, regardless of whether patients were inpatients or outpatients, associated with the first three cardiovascular related ICD-9 codes. Multivariable logistic regression was used to examine the relationships between the D2B time, in-hospital mortality and one-year cardiovascular readmission. We utilized a multivariable linear regression to test the relationships between the D2B time, hospitalization cost and one-year cardiovascular-related cost. Results: The D2B time did not influence the in-hospital mortality rate, but a D2B time greater than 90 min increased the probability of one-year cardiovascular readmission (p = 0.018). The D2B time did not increase the index hospitalization cost, but patients with a D2B time above 90 min had 14.6% higher one-year cardiovascular-related costs. Conclusions: Our study shows that the D2B time in patients with STEMI could impact the one-year cardiovascular readmission and one-year cardiovascular-related health cost. These results suggest that the pursuit of high-quality care not only leads to better outcomes, but also reduces costs.
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To compare door-to-balloon times with culprit vessel percutaneous coronary intervention (PCI) as initial treatment for ST-elevation myocardial infarction (STEMI) to traditional complete coronary angiography followed by PCI for treatment of STEMI.Shorter door-to-balloon time for STEMI treatment is associated with better outcomes, and is generally achieved by shortening the door-to-vascular access time. Whether procedural improvements can shorten the vascular access-to-balloon time has not been examined.Door-to-balloon times were assessed in 50 consecutive patients who underwent initial PCI of the culprit vessel for STEMI at Wake Forest University Baptist Medical Center, and in 85 consecutive patients who underwent traditional coronary angiography followed by PCI for STEMI.Procedural success was 100% in both groups. Door-to-balloon times were 66 +/- 20 minutes for culprit PCI vs. 79 +/- 28 minutes for traditional PCI, p < 0.001, due to shorter vascular access-to-balloon time, 11 +/- 8 minutes for culprit PCI vs. 18 +/- 8 minutes for traditional PCI, p < 0.001. 92% of the culprit PCI group had a door-to-balloon time < 90 minutes, compared to 76% in the traditional group, p = 0.023. Subsequent planned revascularization procedures were infrequent and similar in both groups.In this small pilot study, performing PCI of the culprit vessel for STEMI as initial treatment resulted in a decrease in the door-to-balloon time compared to traditional coronary angiography followed by PCI without compromising subsequent cardiac care. Whether broader utilization of this strategy will result in beneficial outcomes remains to be determined.
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Background
There are increasing calls for regionalization of acute myocardial infarction (AMI) care in the United States to hospitals with the capacity to perform percutaneous coronary intervention (PCI). Whether regionalization will improve outcomes depends in part on the magnitude of existing differences in outcomes between PCI and non-PCI hospitals within the same health care region.Methods
A 100% sample of claims from Medicare fee-for-service beneficiaries 65 years or older hospitalized for AMI between January 1, 2004, and December 31, 2006, was used to calculate hospital-level, 30-day risk-standardized mortality rates (RSMRs). The RSMRs between PCI and local non-PCI hospitals were compared within local health care regions defined by hospital referral regions (HRRs).Results
A total of 523 119 AMI patients was admitted to 1382 PCI hospitals, and 194 909 AMI patients were admitted to 2491 non-PCI hospitals in 295 HRRs with at least 1 PCI and 1 non-PCI hospital. Although PCI hospitals had lower RSMRs than non-PCI hospitals (mean, 16.1% vs 16.9%;P < .001), considerable overlap was seen in RSMRs between non-PCI and PCI hospitals within the same HRR. In 80 HRRs, the RSMRs at the best-performing PCI hospital were lower than those at local non-PCI hospitals by 3% or more. Among the remaining HRRs, the RSMRs at the best-performing PCI hospital were lower by 1.5% to 3.0% in 104 HRRs and by greater than 0 to 1.5% in 74 HRRs. In 37 HRRs, the RSMRs at the best-performing PCI hospital were no better or were higher than at local non-PCI hospitals.Conclusions
The magnitude of benefit from comprehensively regionalizing AMI care to PCI hospitals appears to vary greatly across HRRs. These findings support a tailored regionalization policy that targets areas with the greatest outcome differences between PCI and local non-PCI hospitals.Cite
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Objective To measure the effect of a clinical pathway on patients with acute myocardial infarction(AMI) in emergency departments.Methods The effectiveness of a multidisciplinary clinical pathway for AMI patients over the past seventeen years in our emergency department was retrospectively analyzed.The clinical pathways used before 2004 and after 2004 were compared.The measurement involed the time to room,time of door-to-needle,time of door-to-balloon.We also compared the effect of clinical outcomes of facilitated PCI(venous thromblysis plus PCI,percutaneous coronary intervention) and primary PCI.Results A total of 1134 ST-segment elevation myocardial infarction(STEMI) patients were analyzed.The number of acute PCI patients increased while the time of door-to-needle time and door-to-balloon decreased significantly since 2004.However,time to room didn't change much.Facilitated PCI could not improve in-hospital survival compared with the primary PCI.Conclusion The clinical pathway can shorten the time of door-to-needle and door-to-balloon for AMI patients.Facilitated PCI fails to improve the clinical outcomes when compared with primary PCI.
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