Abstract 999: Delays in Fibrinolytic Administration for Acute ST-Segment Elevation Myocardial Infarction: Results From the National Cardiovascular Data Registry (ACTION-GWTG)
Background: Guidelines state that STEMI patients presenting to a hospital without percutaneous coronary intervention (PCI) capability and who cannot be transferred to undergo PCI within 90 minutes should be treated with fibrinolytic (lytic) therapy within 30 minutes. Yet in contemporary practice, the degree to which lytic therapy is administered in a timely fashion and its association with outcomes is not well known.
Objective: To assess the performance of lytic therapy within the recommended 30 minute timeframe of arrival for STEMI patients presenting to the emergency department (ED) at non-PCI centers.
Methods: Patient characteristics associated with the timeliness of lytics were evaluated. In addition, we examined the association of timely lytics with key patient outcomes, including inpatient mortality, stroke, and cardiogenic shock. Logistic generalized estimating equations were used to account for baseline clinical factors and within-hospital clustering.
Results: Between 1/07 and 6/08, 3,219 STEMI patients in 178 hospitals received lytics in the ED. Median door-to-needle time was 34.0 minutes (IQR 22.0 –54.0 min). However, only 44.5% met the ACC/AHA guideline door-to-needle time of ≤30 min. Patient characteristics associated with longer lytic times included female gender (+17.7% longer, CI95% 11.8 –23.9) and age >75 (+11.8% longer vs age <55, CI95% 1.5–23.2). Timely (vs delayed) lytics were associated with a decreased risk of a composite outcome of death, shock, or stroke (6.2% vs 8.8%, adjusted OR 0.74, CI95% 0.56 – 0.98).
Conclusions: Timely lytic therapy in the ED was associated with lower risk of shock, death, and stroke, yet DTN times of ≤30 min were achieved in less than half of the patients in contemporary practice. Thus, efforts to optimize regional systems of care for STEMI patients should focus on shortening reperfusion times for patients who receive lytics, as well as those who receive primary PCI.