Coronary artery disease
Impact of Delay in Door-to-Needle Time on Mortality in Patients With ST-Segment Elevation Myocardial Infarction

https://doi.org/10.1016/j.amjcard.2007.05.043Get rights and content

Fibrinolytic therapy is the most common reperfusion strategy for patients with ST-segment elevation myocardial infarction (STEMI), particularly in smaller centers. Previous studies evaluated the relation between time to treatment and outcomes when few patients were treated within 30 minutes of hospital arrival and many did not receive modern adjunctive medications. To quantify the impact of a delay in door-to-needle time on mortality in a recent and representative cohort of patients with STEMI, a cohort of 62,470 patients with STEMI treated using fibrinolytic therapy at 973 hospitals that participated in the National Registry of Myocardial Infarction from 1999 to 2002 was analyzed. Hierarchical models were used to evaluate the independent effect of door-to-needle time on in-hospital mortality. In-hospital mortality was lower with shorter door-to-needle times (2.9% for ≤30 minutes, 4.1% for 31 to 45 minutes, and 6.2% for >45 minutes; p <0.001 for trend). Compared with those experiencing door-to-needle times ≤30 minutes, adjusted odd ratios (ORs) of dying were 1.17 (95% confidence interval [CI] 1.04 to 1.31) and 1.37 (95% CI 1.23 to 1.52; p for trend <0.001) for patients with door-to-needle times of 31 to 45 and >45 minutes, respectively. This relation was particularly pronounced in those presenting within 1 hour of symptom onset to presentation time (OR 1.25, 95% CI 1.01 to 1.54; OR 1.54, 95% CI 1.27 to 1.87, respectively; p for trend <0.001). In conclusion, timely administration of fibrinolytic therapy continues to significantly impact on mortality in the modern era, particularly in patients presenting early after symptom onset.

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Methods

We used the NRMI, a voluntary acute myocardial infarction (AMI) registry sponsored by Genentech, Inc. (South San Francisco, California), to define a cohort of patients with STEMI who received acute fibrinolytic reperfusion therapy. NRMI criteria13, 14 included a diagnosis of AMI according to the International Classification of Diseases, Ninth Revision, Clinical Modification (code 410.X1) and any of total creatine kinase or creatine kinase-MB ≥2 times the upper limit of the normal range or

Results

Table 1 lists demographic, clinical, and presentation characteristics of the cohort. Nearly half the patients (47%) were treated within the guideline-recommended 30 minutes (Figure 1). In unadjusted analysis, shorter door-to-needle time was associated with lower in-hospital mortality (p <0.001 for trend; Figure 2). In-hospital mortality rates were 8.2% in patients with door-to-needle times >100 minutes and 2.5% in patients treated within 15 minutes (test for trend p <0.001). Shorter

Discussion

Fibrinolytic therapy is the most common form of reperfusion therapy for patients presenting with STEMI.12 In this large, well-characterized, and recent cohort of patients with STEMI with a high rate of proven therapies, in-hospital mortality was significantly lower for patients treated within shorter door-to-needle times. This association was found regardless of time from symptom onset to hospital presentation and was particularly strong in those presenting within 1 hour of symptom onset. The

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This work was supported by Grant No. R01HL072575 from the National Heart, Lung, and Blood Institute, Bethesda, Maryland. Genentech, Inc., South San Francisco, California, approved the study and provided access to the National Registry of Myocardial Infarction database at no charge; however, Genentech did not provide direct support for the study. Dr. Peterson receives research funding from Schering Plough, Kenilworth, New Jersey, BMS/Sanofi Aventis, New York, New York, and Merck-Schering, Whitehouse Station, New Jersey. Dr. Blaney is employed by Genentech, Inc. Dr. Frederick is employed by Ovation Research Group, Seattle, Washington, which receives research funding from Genentech.

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