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Impact of socioeconomic status on guideline-recommended care for ST-elevation myocardial infarction in the United States
International Journal of Cardiology 143 (2010) 424 – 450 www.elsevier.com/locate/ijcard
Letters to the Editor
Impact of socioeconomic status on guideline-recommended care for ST-elevation myocardial infarction in the United States Samip Vasaiwala, Mladen Vidovich ⁎ University of Illinois Hospital, Chicago, Illinois, United States Received 4 November 2008; accepted 9 November 2008 Available online 7 January 2009
Keywords: Primary PCI; Fibrinolysis; STEMI
Dr. Terkelsen and colleagues from Denmark address the idea of “system-delay” in the management of patients with STElevation myocardial infarction (STEMI) with primary PCI. Their recommendations are directed at pre-hospital diagnosis, rerouting of STEMI patients to PPCI-centers (STEMIcenters), pre-hospital activation of catheterization laboratories, and establishment of large-volume PCI centers available 24 h/ day 7 days/week with a goal D2B time of 30 min or less [1]. We support their opinion of restricting management of STEMI patients with PCI at centers providing full-time, highly skilled, and efficient care. We wish to report some of our analysis on the D2B and D2N times in the United States, which we recently presented at the European Society of Cardiology Congress in Munich, Germany. We analyzed over 4400 hospitals in the US from the year 2006 for 2 hospital process of care measures: the proportion of patients with AMI meeting the D2B time of 90 min or less for PPCI and D2N time of 30 min or less for fibrinolytics, respectively. Available data on the proportion of patients receiving fibrinolytic and PPCI therapies were obtained from Hospital Compare, a quality initiative tool created by the Centers for Medicare and Medicaid Services, the Department of Health and Human Services, and the Hospital Quality Alliance. Data on MHI for each hospital ZIP code were obtained from the US Census Bureau. MHI was grouped in tertiles; Groups: 1, lowest, b $34,560; 2, middle, $34,560–$47,500; 3, highest, N $47,500). Kruskal–Wallis test was used due to a non-normal distribution of MHI with a P value of b 0.001 and 0.005 for
⁎ Corresponding author. E-mail address: [email protected] (M. Vidovich).
fibrinolytic and PPCI therapies, respectively. Group differences were determined by the Mann–Whitney test. Primary results are summarized in Table 1. Such a trend correlating neighborhood income to the quality of care of STEMI patients as it relates to D2B and D2N times is of great concern. Moreover, the rates of timely therapy both for fibrinolytics and PPCI are poor in general. Based on the meta-analysis from Nallmothu et al., the American College of Cardiology/American Heart Association (ACC/AHA) Guidelines allow a maximum of 60 min PCI-related delay, after which fibrinolytics would result in a greater benefit [2–4]. Further meta-analyses have suggested that even greater PCIrelated delay may be acceptable [5,6]. These meta-analyses take into account a 30 min D2N time. Our analysis reveals that many hospitals fail to meet this guideline-recommended standard. We feel that a closer look at the D2N times for each hospital is warranted before an automatic strategy for utilizing fibrinolytics can be applied in a setting of prohibitive PCIrelated delays. The benefit of fibrinolytics administered with a D2N time greater than 30 min in a situation where the PCIrelated delay is more than 40 min as recommended by the 2007 Focused Update of the ACC/AHA STEMI guidelines for patients living in the catchment area of non-PCI capable hospitals has never been studied. This truly represents a very complex situation that needs to be addressed in future updates. The need for reduction in PPCI-related delay is unmistakable. In their commentary, Terkelsen, et al. suggest the institution of STEMI-centers participating in a STEMI network that perform high volume PPCI. It is clear that higher volume centers have lower D2B times [6] and centers performing 500–700 PPCIs/year report D2B times of 30 min or less [7]. D2B times in this range would allow increased
Letters to the Editor Table 1 Groups
Number of hospitals
Mean (95% CI)
Proportion of patients receiving fibrinolytics within 30 min 1 1362 0.2317 (0.2115–0.2519) 2 1430 0.2990 (0.2776–0.3204) 3 1312 0.2895 (0.2679–0.3111) Overall 4104 0.2736 (0.2614–0.2858) Group 1 vs. Group 2: P b 0.001 Group 1 vs. Group 3: P b 0.001 Group 2 vs. Group 3: P = 0.118 Proportion of patients receiving PCI within 90 min 1 1360 0.2999 (0.2804–0.3194) 2 1438 0.3182 (0.2984–0.3381) 3 1337 0.3409 (0.3216–0.3602) Overall 4135 0.3195 (0.3082–0.3308) Group 1 vs. Group 2: P = 0.601 Group 1 vs. Group 3: P = 0.001 Group 2 vs. Group 3: P = 0.018
transfer times to STEMI-centers and thereby expand the catchment area for that particular center. Or analysis suggests that as a group, hospitals are nowhere close to achieving these D2B times. In fact, only 32% of hospitals were able to attain a D2B time of 90 min or less. Therefore, it is imperative that hospitals that chose not to participate in the concept of a STEMI network employ the system-based approach presented by Terkelsen et al. in order to improve their D2B times. The other less attractive option is to have a fully staffed interventional team on site 24 h/day 7 days/week. It is only after these major obstacles are overcome, that we can begin to address the secondary issues of disparity in D2B times for PPCI.
425
The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology [8]. References [1] Terkelsen CJ, Sorensen JT, Nielsen TT. Is there any time left for primary percutaneous coronary intervention according to the 2007 Updated American College of Cardiology/American Heart Association ST-Segment Elevation Myocardial Infarction Guidelines and the D2B Alliance? J Am Coll Cardiol 2008;52:1211–5. [2] Nallmothu BK, Bates ER. Percutaneous coronary intervention versus fibrinolytic therapy in acute myocardial infarction: is timing (almost) everything? Am J Cardiol 2003;92:824–6. [3] Nallamothu BK, Antman EM, Bates ER. Primary percutaneous coronary intervention versus fibrinolytic therapy in acute myocardial infarction: does the choice of fibrinolytic agent impact on the importance of time-to-treatment? Am J Cardiol 2004;94:772–4. [4] Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction — executive summary: a report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 199 Guidelines for the Management of Patients With Acute Myocardial Infarction). J Am Coll Cardiol 2004;44:671–719. [5] Boersma E. The primary coronary angioplasty vs. thrombolysis group. Does time matter? A pooled analysis of randomized clinical trials comparing primary percutaneous coronary intervention and in-hospital fibrinolysis in acute myocardial infarction patients. Eur Heart J 2006;27:779–88. [6] Pinto DS, Kirtane AJ, Nallamothu BK, et al. Hospital delays in reperfusion for ST-elevation myocardial infarction: implications when selecting a reperfusion strategy. Circulation 2006;114:2019–25. [7] Kaltoft A, Bottcher M, Nielsen SS, et al. Routine thrombectomy in percutaneous coronary intervention for acute ST-segment elevation myocardial infarction: a randomized, controlled trial. Circulation 2006;114:40–7. [8] Coats AJ. Ethical authorship and publishing. Int J Cardiol 2009;131: 149–50.
0167-5273/$ - see front matter © 2008 Published by Elsevier Ireland Ltd. doi:10.1016/j.ijcard.2008.11.032
Integrated area of desaturation index in patients with myocardial infarction Noriaki Takama a,b,⁎, Yae Matsuo a,b , Hiroshi Arai a , Takahiro Yamagishi a,b , Hiromi Eguma a , Masahiko Kurabayashi b a
b
Division of Cardiology, Isesaki Municipal Hospital, Isesaki, Japan Department of Cardiovascular Medicine, Gunma University School of Medicine, Maebashi, Japan Received 2 December 2008; accepted 3 December 2008 Available online 20 January 2009
Keywords: IAD index; Sleep-disordered breathing; Myocardial infarction
⁎ Corresponding author. Division of Cardiology, Isesaki Municipal Hospital, 12-1 Tsunatorihonmachi, Isesaki City, Gunma 372-0817, Japan. Tel.: +81 270 25 5022; fax: +81 270 25 5023. E-mail address: [email protected] (N. Takama).
The apnea–hypopnea index (AHI) is one of the most common criteria used to diagnose sleep apnea. However, it has an important limitation in that severe nocturnal oxygen desaturation is estimated as being equivalent to a mild or
Letters to the Editor
Impact of socioeconomic status on guideline-recommended care for ST-elevation myocardial infarction in the United States Samip Vasaiwala, Mladen Vidovich ⁎ University of Illinois Hospital, Chicago, Illinois, United States Received 4 November 2008; accepted 9 November 2008 Available online 7 January 2009
Keywords: Primary PCI; Fibrinolysis; STEMI
Dr. Terkelsen and colleagues from Denmark address the idea of “system-delay” in the management of patients with STElevation myocardial infarction (STEMI) with primary PCI. Their recommendations are directed at pre-hospital diagnosis, rerouting of STEMI patients to PPCI-centers (STEMIcenters), pre-hospital activation of catheterization laboratories, and establishment of large-volume PCI centers available 24 h/ day 7 days/week with a goal D2B time of 30 min or less [1]. We support their opinion of restricting management of STEMI patients with PCI at centers providing full-time, highly skilled, and efficient care. We wish to report some of our analysis on the D2B and D2N times in the United States, which we recently presented at the European Society of Cardiology Congress in Munich, Germany. We analyzed over 4400 hospitals in the US from the year 2006 for 2 hospital process of care measures: the proportion of patients with AMI meeting the D2B time of 90 min or less for PPCI and D2N time of 30 min or less for fibrinolytics, respectively. Available data on the proportion of patients receiving fibrinolytic and PPCI therapies were obtained from Hospital Compare, a quality initiative tool created by the Centers for Medicare and Medicaid Services, the Department of Health and Human Services, and the Hospital Quality Alliance. Data on MHI for each hospital ZIP code were obtained from the US Census Bureau. MHI was grouped in tertiles; Groups: 1, lowest, b $34,560; 2, middle, $34,560–$47,500; 3, highest, N $47,500). Kruskal–Wallis test was used due to a non-normal distribution of MHI with a P value of b 0.001 and 0.005 for
⁎ Corresponding author. E-mail address: [email protected] (M. Vidovich).
fibrinolytic and PPCI therapies, respectively. Group differences were determined by the Mann–Whitney test. Primary results are summarized in Table 1. Such a trend correlating neighborhood income to the quality of care of STEMI patients as it relates to D2B and D2N times is of great concern. Moreover, the rates of timely therapy both for fibrinolytics and PPCI are poor in general. Based on the meta-analysis from Nallmothu et al., the American College of Cardiology/American Heart Association (ACC/AHA) Guidelines allow a maximum of 60 min PCI-related delay, after which fibrinolytics would result in a greater benefit [2–4]. Further meta-analyses have suggested that even greater PCIrelated delay may be acceptable [5,6]. These meta-analyses take into account a 30 min D2N time. Our analysis reveals that many hospitals fail to meet this guideline-recommended standard. We feel that a closer look at the D2N times for each hospital is warranted before an automatic strategy for utilizing fibrinolytics can be applied in a setting of prohibitive PCIrelated delays. The benefit of fibrinolytics administered with a D2N time greater than 30 min in a situation where the PCIrelated delay is more than 40 min as recommended by the 2007 Focused Update of the ACC/AHA STEMI guidelines for patients living in the catchment area of non-PCI capable hospitals has never been studied. This truly represents a very complex situation that needs to be addressed in future updates. The need for reduction in PPCI-related delay is unmistakable. In their commentary, Terkelsen, et al. suggest the institution of STEMI-centers participating in a STEMI network that perform high volume PPCI. It is clear that higher volume centers have lower D2B times [6] and centers performing 500–700 PPCIs/year report D2B times of 30 min or less [7]. D2B times in this range would allow increased
Letters to the Editor Table 1 Groups
Number of hospitals
Mean (95% CI)
Proportion of patients receiving fibrinolytics within 30 min 1 1362 0.2317 (0.2115–0.2519) 2 1430 0.2990 (0.2776–0.3204) 3 1312 0.2895 (0.2679–0.3111) Overall 4104 0.2736 (0.2614–0.2858) Group 1 vs. Group 2: P b 0.001 Group 1 vs. Group 3: P b 0.001 Group 2 vs. Group 3: P = 0.118 Proportion of patients receiving PCI within 90 min 1 1360 0.2999 (0.2804–0.3194) 2 1438 0.3182 (0.2984–0.3381) 3 1337 0.3409 (0.3216–0.3602) Overall 4135 0.3195 (0.3082–0.3308) Group 1 vs. Group 2: P = 0.601 Group 1 vs. Group 3: P = 0.001 Group 2 vs. Group 3: P = 0.018
transfer times to STEMI-centers and thereby expand the catchment area for that particular center. Or analysis suggests that as a group, hospitals are nowhere close to achieving these D2B times. In fact, only 32% of hospitals were able to attain a D2B time of 90 min or less. Therefore, it is imperative that hospitals that chose not to participate in the concept of a STEMI network employ the system-based approach presented by Terkelsen et al. in order to improve their D2B times. The other less attractive option is to have a fully staffed interventional team on site 24 h/day 7 days/week. It is only after these major obstacles are overcome, that we can begin to address the secondary issues of disparity in D2B times for PPCI.
425
The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology [8]. References [1] Terkelsen CJ, Sorensen JT, Nielsen TT. Is there any time left for primary percutaneous coronary intervention according to the 2007 Updated American College of Cardiology/American Heart Association ST-Segment Elevation Myocardial Infarction Guidelines and the D2B Alliance? J Am Coll Cardiol 2008;52:1211–5. [2] Nallmothu BK, Bates ER. Percutaneous coronary intervention versus fibrinolytic therapy in acute myocardial infarction: is timing (almost) everything? Am J Cardiol 2003;92:824–6. [3] Nallamothu BK, Antman EM, Bates ER. Primary percutaneous coronary intervention versus fibrinolytic therapy in acute myocardial infarction: does the choice of fibrinolytic agent impact on the importance of time-to-treatment? Am J Cardiol 2004;94:772–4. [4] Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction — executive summary: a report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 199 Guidelines for the Management of Patients With Acute Myocardial Infarction). J Am Coll Cardiol 2004;44:671–719. [5] Boersma E. The primary coronary angioplasty vs. thrombolysis group. Does time matter? A pooled analysis of randomized clinical trials comparing primary percutaneous coronary intervention and in-hospital fibrinolysis in acute myocardial infarction patients. Eur Heart J 2006;27:779–88. [6] Pinto DS, Kirtane AJ, Nallamothu BK, et al. Hospital delays in reperfusion for ST-elevation myocardial infarction: implications when selecting a reperfusion strategy. Circulation 2006;114:2019–25. [7] Kaltoft A, Bottcher M, Nielsen SS, et al. Routine thrombectomy in percutaneous coronary intervention for acute ST-segment elevation myocardial infarction: a randomized, controlled trial. Circulation 2006;114:40–7. [8] Coats AJ. Ethical authorship and publishing. Int J Cardiol 2009;131: 149–50.
0167-5273/$ - see front matter © 2008 Published by Elsevier Ireland Ltd. doi:10.1016/j.ijcard.2008.11.032
Integrated area of desaturation index in patients with myocardial infarction Noriaki Takama a,b,⁎, Yae Matsuo a,b , Hiroshi Arai a , Takahiro Yamagishi a,b , Hiromi Eguma a , Masahiko Kurabayashi b a
b
Division of Cardiology, Isesaki Municipal Hospital, Isesaki, Japan Department of Cardiovascular Medicine, Gunma University School of Medicine, Maebashi, Japan Received 2 December 2008; accepted 3 December 2008 Available online 20 January 2009
Keywords: IAD index; Sleep-disordered breathing; Myocardial infarction
⁎ Corresponding author. Division of Cardiology, Isesaki Municipal Hospital, 12-1 Tsunatorihonmachi, Isesaki City, Gunma 372-0817, Japan. Tel.: +81 270 25 5022; fax: +81 270 25 5023. E-mail address: [email protected] (N. Takama).
The apnea–hypopnea index (AHI) is one of the most common criteria used to diagnose sleep apnea. However, it has an important limitation in that severe nocturnal oxygen desaturation is estimated as being equivalent to a mild or