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Health Care System Delay may increase risk of Death for Heart
Patients receiving Reperfusion Therapy
Newswise, August 2010 — For patients with a
certain type of heart attack, delay in the
time between first contact with emergency
medical service to initiation of therapy
such as balloon angioplasty is associated
with an increased risk of death, according
to a study in the August 18 issue of JAMA.
Timely reperfusion therapy with either
fibrinolysis (the dissolution of fibrin) or
primary percutaneous coronary intervention (PCI;
procedures such as balloon angioplasty or
stent placement used to open narrowed
coronary arteries) is recommended for
patients with ST-segment elevation
myocardial infarction (STEMI; a certain
pattern on an electrocardiogram following a
heart attack).
Door-to-balloon delay has been proposed as a
performance measure in triaging patients for
primary PCI.
“However, focusing on the time from first
contact with the health care system to the
initiation of reperfusion therapy (system
delay) may be more relevant, because it
constitutes the total time to reperfusion
modifiable by the health care system. No
previous studies have focused on the
association between system delay and outcome
in patients with STEMI treated with primary
PCI,” the authors write.
Christian Juhl Terkelsen, M.D., Ph.D., of
Aarhus University Hospital, Aarhus, Denmark,
and colleagues assessed the associations
between treatment, patient, system, and
door-to-balloon delays and mortality in a
large group of patients with STEMI treated
with primary PCI.
The study included data from Danish medical
registries of patients with STEMI
transported by emergency medical service and
treated with primary PCI from January 2002
to December 2008 at 3 high-volume PCI
centers in Western Denmark. Patients (n =
6,209) underwent primary PCI within 12 hours
of symptom onset. The median (midpoint)
follow-up time was 3.4 years.
The researchers found that when stratified
according to intervals of system delay,
long-term cumulative mortality was 15.4
percent (n = 43) in patients with system
delays of 0 through 60 minutes (n = 347),
23.3 percent (n = 380) in those with delays
of 61 through 120 minutes (n = 2,643), 28.1
percent (n = 378) in those with delays of
121 through 180 minutes (n = 2,092), and
30.8 percent (n = 275) in those with delays
of 181 through 360 minutes (n = 1,127). “In
multivariate analysis adjusted for other
predictors of mortality, system delay was
independently associated with mortality, as
was its components, prehospital system delay
and door-to-balloon delay,” the authors
write.
“We conclude that health care system delay
is valuable as a performance measure when
patients with STEMI are treated with primary
PCI, because it is associated with
mortality, it constitutes the part of
treatment delay modifiable by the health
care system in the acute phase, and it
applies to patients field-triaged directly
to the PCI center as well as to patients
transferred from local hospitals. Increased
focus on the total health care system delay
may optimize triage of patients with STEMI
and may be the key to further improving
survival of these patients.”
