Off-Hours Admission Does Not Impact Outcomes in Patients Undergoing Primary Percutaneous Coronary Intervention and with a First Medical Contact-to-Device Time Within 90 Minutes
Primary percutaneous coronary intervention (PPCI) is the primary recommended reperfusion method for patients with ST-segment elevation myocardial infarction (STEMI). The first medical contact-to-device (FMC-to-device) time is a critical factor in the treatment of STEMI patients, as shorter times are associated with better outcomes. Recent guidelines from the American College of Cardiology/American Heart Association and the European Society of Cardiology recommend an FMC-to-device time of 90 minutes or less for patients presenting to a PCI-capable hospital. However, it remains unclear whether the outcomes of STEMI patients treated with PPCI during off-hours are as favorable as those treated during on-hours, especially when the FMC-to-device time is within the recommended 90-minute window. This study aimed to determine whether off-hours admission impacts late outcomes in patients undergoing PPCI with an FMC-to-device time of 90 minutes or less.
The study was a multicenter retrospective analysis conducted in Beijing, China, involving 670 STEMI patients who underwent successful PPCI with an FMC-to-device time of 90 minutes or less. The patients were recruited from 19 chest pain centers between January 2018 and December 2018. The patients were divided into two groups based on their arrival time: the on-hours group (weekdays between 08:00 and 18:00) and the off-hours group (weekdays between 18:00 and 08:00, weekends, or Chinese holidays). Baseline characteristics, clinical data, and key time intervals during treatment were collected using the “Heart and Brain Green Channel” app, which is available for smartphones and personal computers.
The study population had a median age of 58.8 years, and 19.9% of the patients were female. Of the 670 patients, 296 (44.2%) underwent PPCI during on-hours, and 374 (55.8%) underwent PPCI during off-hours. The median FMC-to-device time for all patients was 69 minutes, with 34.2% of patients achieving an FMC-to-device time of 60 minutes or less. The off-hours group had a significantly longer FMC-to-device time compared to the on-hours group (71 minutes vs. 65 minutes, p < 0.001). Additionally, fewer patients in the off-hours group achieved an FMC-to-device time of 60 minutes or less (29.1% vs. 40.7%, p = 0.002). The activation-to-catheter lab time was also longer in the off-hours group (22 minutes vs. 16 minutes, p < 0.001). However, there were no significant differences in other key time intervals, such as symptom-to-device time, symptom-to-FMC time, FMC-to-ECG time, ECG-to-activation time, or catheter lab-to-device time between the two groups.
The study followed the patients for an average of 24 months to assess major adverse cardiovascular events (MACEs), which were defined as a composite of all-cause death, non-fatal myocardial reinfarction, and target vessel revascularization (TVR). During the follow-up period, 64 (9.6%) patients experienced a MACE, with 28 (9.1%) in the on-hours group and 36 (9.6%) in the off-hours group (p > 0.05). The Kaplan-Meier curves showed no significant differences in the risks of MACE, all-cause death, reinfarction, or TVR between the two groups (p > 0.05). Cox regression analyses further confirmed that off-hours admission was not a predictor of 2-year MACEs (p = 0.788).
The study also examined the baseline characteristics and clinical outcomes of the patients. There were no significant differences in age, gender, body mass index, past medical history, admission status, or culprit vessel between the two groups. The in-hospital mortality rate was slightly higher in the off-hours group (1.9% vs. 2.4%, p = 0.653), but this difference was not statistically significant. Over the follow-up period, 6.1% of patients died from all causes, with 5.0% in the on-hours group and 6.1% in the off-hours group (p = 0.970). Reinfarctions occurred in 2.2% of patients, with 2.0% in the on-hours group and 2.4% in the off-hours group (p = 0.502). TVR was performed in 1.1% of patients, with 1.4% in the on-hours group and 1.0% in the off-hours group (p = 0.734).
The study’s findings suggest that off-hours admission does not impact the long-term outcomes of STEMI patients who undergo PPCI with an FMC-to-device time of 90 minutes or less. Although the off-hours group had a longer FMC-to-device time, the difference did not translate into worse clinical outcomes. This could be attributed to the non-significant difference in the total ischemic time (symptom-to-device time) between the two groups. The study also highlighted that advanced age and higher heart rates were independently associated with an increased risk of 2-year MACEs.
The study has several limitations. First, the findings may not be generalizable to other regions in China, as Beijing has a high concentration of high-quality medical resources. Second, the retrospective design of the study may have introduced selection bias. Third, data on stent thrombosis were missing. Fourth, the study had a relatively small sample size, and a larger randomized controlled trial is needed to validate the results.
In conclusion, this real-world, multicenter retrospective study demonstrated that off-hours admission is safe for STEMI patients who undergo PPCI with an FMC-to-device time of 90 minutes or less. There was no significant difference in the risk of 2-year MACEs between patients treated during on-hours and off-hours. The findings support the safety of PPCI performed during off-hours, provided that the guideline-recommended FMC-to-device time is achieved.
doi.org/10.1097/CM9.0000000000001621
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