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Background: The systemic inflammatory response syndrome (SIRS) frequently occurs in patients with cardiogenic shock and may aggravate shock severity and organ failure. We sought to determine the association of SIRS with illness severity and survival across the spectrum of shock severity in cardiac intensive care unit (CICU) patients. Methods: We retrospectively analyzed 8995 unique patients admitted to the Mayo Clinic CICU between 2007 and 2015. Patients with ≥2/4 SIRS criteria based on admission laboratory and vital sign data were considered to have SIRS. Patients were stratified by the 2019 Society for Cardiovascular Angiography and Interventions (SCAI) shock stages using admission data. The association between SIRS and mortality was evaluated across SCAI shock stage using logistic regression and Cox proportional-hazards models for hospital and 1-year mortality, respectively. Results: The study population had a mean age of 67.5±15.2 years, including 37.2% women. SIRS was present in 33.9% of patients upon CICU admission and was more prevalent in advanced SCAI shock stages. Patients with SIRS had higher illness severity, worse shock, and more organ failure, with an increased risk of mortality during hospitalization (16.8% versus 3.8%; adjusted odds ratio, 2.1 [95% CI, 1.7–2.5]; P P P Conclusions: One-third of CICU patients meet clinical criteria for SIRS at the time of admission, and these patients have higher illness severity and worse outcomes across the spectrum of SCAI shock stages. The presence of SIRS identified CICU patients at increased risk of short-term and long-term mortality. Further study is needed to determine whether systemic inflammation truly drives SIRS in this population and whether patients with SIRS respond differently to supportive therapies for shock.

Background: Cost is frequently cited as a barrier to optimal medication use, but the extent to which copayment assistance interventions are used when available, and their impact on evidence-based medication persistence and major adverse cardiovascular events is unknown. Methods and Results: The ARTEMIS trial (Affordability and Real-World Antiplatelet Treatment Effectiveness After Myocardial Infarction Study) randomized 301 hospitals to usual care versus the ability to provide patients with vouchers that offset copayment costs when filling P2Y 12 inhibitors in the 1 year post-myocardial infarction. In the intervention group, we used multivariable logistic regression to identify patient and medication cost characteristics associated with voucher use. We then used this model to stratify both intervention and usual care patients by likelihood of voucher use, and examined the impact of the voucher intervention on 1-year P2Y 12 inhibitor persistence (no gap in pharmacy supply >30 days) and major adverse cardiovascular events (all-cause death, myocardial infarction, or stroke). Among 10 102 enrolled patients, 6135 patients were treated at hospitals randomized to the copayment intervention. Of these, 1742 (28.4%) never used the voucher, although 1729 (99.2%) voucher never-users filled at least one P2Y 12 inhibitor prescription in the 1 year post-myocardial infarction. Characteristics most associated with voucher use included: discharge on ticagrelor, planned 1-year course of P2Y 12 inhibitor treatment, white race, commercial insurance, and higher out-of-pocket medication costs (c-statistic 0.74). Applying this propensity model to stratify all enrolled patients by likelihood of voucher use, the intervention improved medication persistence the most in patients with high likelihood of voucher use (adjusted interaction P =0.03, odds ratio, 1.86 [95% CI, 1.48–2.33]). The intervention did not significantly reduce major adverse cardiovascular events in any voucher use likelihood group, although the odds ratio was lowest (0.86 [95% CI, 0.56–1.16]) among patients with high likelihood of voucher use (adjusted interaction P =0.04). Conclusions: Among patients discharged after myocardial infarction, those with higher copayments and greater out-of-pocket medication costs were more likely to use a copayment assistance voucher, but some classes of patients were less likely to use a copayment assistance voucher. Patients at low likelihood of voucher use benefitted least from copayment assistance, and other interventions may be needed to improve medication-taking behaviors and clinical outcomes in these patients. Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT02406677.

Background: For heart transplant recipients, guidelines endorse routine coronary angiography and percutaneous coronary intervention (PCI) to screen for and treat cardiac allograft vasculopathy (CAV). However, current Appropriate Use Criteria for Revascularization (AUC-R) do not recognize CAV as a unique PCI indication, and thus PCI for CAV is often labeled “rarely appropriate (RA).” The AUC-R’s omission of CAV patients, and its impact on RA PCI rates and hospital pay-for-performance reimbursement have never been described. Methods: Using NCDR CathPCI Registry data, we identified all elective PCIs from 96 Medicare-approved heart transplant centers between 2009Q3 and 2017Q2. NCDR-reported rates of RA elective PCI were compared before and after exclusion of CAV patients using paired t-tests. The annual pay-for-performance financial incentives potentially lost by heart transplant centers were estimated based on AUC-R performance thresholds published by Anthem Blue Cross and Blue Shield’s Quality-In-Sights®: Hospital Incentive Program (Q-HIP®). Results: Of 168,802 elective PCIs performed in heart transplant centers, 1,854 (1.1%) were for CAV. CAV patients, compared with non-heart transplant recipients, were more frequently asymptomatic (81.9% vs. 33.4%, pFigure ). In a sample of 16 heart transplant centers participating in Q-HIP® during the 2017 calendar year measurement period, 2 (13%) centers could have each observed reimbursement increases estimated at ~$90,000 dollars if their Q-HIP® scorecards were re-scored after excluding CAV patients. Conclusion: Two-thirds of PCI cases in CAV patients are deemed RA by the AUC-R. The failure of the AUC-R to recognize CAV as a unique PCI indication may lead to inflated RA PCI rates and has the potential for substantial negative pay-for-performance implications in heart transplant centers. The AUC-R should recognize CAV as a unique PCI indication so that heart transplant centers are not penalized for performing PCI for CAV.

Background— Among older patients with acute myocardial infarction (MI), it remains uncertain whether there is a time-dependent difference in the risk of recurrent mortality and nonfatal cardiovascular and cerebrovascular events for those with ST-segment–elevation MI (STEMI) compared with those with non–ST-segment–elevation MI. Methods and Results— Older patients ≥65 years with acute MI and significant coronary artery disease identified with coronary angiography from the ACTION Registry-GWTG (Get With the Guidelines) were linked to Medicare claims data from 2007 to 2010. We examined the unadjusted cumulative incidence of each outcome studied from hospital discharge through 2 years with log-rank tests and then performed a piece-wise proportional hazards modeling with 2 time periods: discharge to 90 days and 90 days to 2 years. Among the 46 199 patients linked with Medicare data, 17 287 (37.4%) presented with STEMI. Through 2 years, the unadjusted cumulative incidence of all-cause mortality (16.0% versus 19.8%; P P P P Conclusions— Among older acute MI patients with angiographically confirmed coronary artery disease discharged alive, STEMI patients (compared with non–ST-segment–elevation MI patients) were found to have a lower frequency of unadjusted postdischarge mortality and composite cardiovascular and cerebrovascular outcomes through 2 years after hospital discharge. This analysis provides unique insight into differential short- and long-term risks of ischemic cardiovascular and cerebrovascular outcomes by MI classification among older MI patients with confirmed coronary artery disease surviving to hospital discharge.

Background: Balancing ischemic and bleeding risk is an evolving framework. Methods and Results: Our objectives were to simulate changes in risks for adverse events and event-driven costs with use of ticagrelor or prasugrel versus clopidogrel according to varying levels of ischemic and bleeding risk. Using the validated PARIS risk functions, we estimated 1-year ischemic (myocardial infarction or stent thrombosis) and bleeding (Bleeding Academic Research Consortium types 3 or 5) event rates among PARIS study participants who underwent percutaneous coronary intervention with drug-eluting stent implantation for an acute coronary syndrome and were discharged with aspirin and clopidogrel (n=1497). Simulated changes in adverse events with ticagrelor or prasugrel were calculated by applying treatment effects from randomized trials for a 1-year time horizon. Event costs were estimated using National Inpatient Sample data. Net costs were calculated between antiplatelet therapy groups according to level of ischemic and bleeding risk. After weighting events for quality-of-life impact, we calculated event rates and costs for risk-tailored treatment versus clopidogrel under multiple drug pricing assumptions. One-year rates (per 1000 person-years) for ischemic events were 12.6, 24.1, and 66.1, respectively, among those at low (n=630), intermediate (n=536), and high (n=331) ischemic risk. Analogous bleeding rates were 11.0, 23.9, and 66.2, respectively, among low (n=728), intermediate (n=634), and high (n=135) bleeding risk patients. Mean per event costs were $22 174 (ischemic) and $12 203 (bleeding). When risks for ischemia matched or exceeded bleeding, simulated utility-weighted event rates favored ticagrelor/prasugrel, whereas clopidogrel reduced utility-weighted events when bleeding exceeded ischemic risk. One-year costs were sensitive to drug pricing assumptions, and risk-tailored treatment with either agent progressed from cost incurring to cost saving with increasing generic market share. Conclusions: Tailoring antiplatelet therapy intensity to patient risk may improve health utility and could produce cost savings in the first year after percutaneous coronary intervention. Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT00998127.

Background: Prehospital ECG-based cardiac catheterization laboratory (CCL) activation for ST-segment–elevation myocardial infarction reduces door-to-balloon times, but CCL cancellations (CCL X ) remain a challenging problem. We examined the reasons for CCL X , clinical characteristics, and outcomes of patients presenting as ST-segment–elevation myocardial infarction activations who receive emergent coronary angiography (EA) compared with CCL X . Methods and Results: We reviewed all consecutive CCL activations between January 1, 2012, and December 31, 2014 (n=1332). Data were analyzed comparing 2 groups stratified as EA (n=466) versus CCL X (n=866; 65%). Reasons for CCL X included bundle branch block (21%), poor-quality prehospital ECG (18%), non–ST-segment–elevation myocardial infarction ST changes (18%), repolarization abnormality (13%), and arrhythmia (8%). A multivariate logistic regression model using age, peak troponin, and initial ECG findings had a high discriminatory value for determining EA versus CCL X (C statistic, 0.985). CCL X subjects were older and more likely to be women, have prior coronary artery bypass grafting, or a paced rhythm ( P X ; P =0.9377). Cardiac death was higher in the EA group (11.8% versus 3.0%; P X was associated with an increased risk for all-cause mortality during the study period (hazard ratio, 1.82; 95% CI, 1.28–2.59; P =0.0009). Conclusions: In this study, prehospital ECG without overreading or transmission lead to frequent CCL X . CCL X subjects differ with regard to age, sex, risk factors, and comorbidities. However, CCL X patients represent a high-risk population, with frequently positive cardiac enzymes and similar short- and long-term mortality compared with EA. Further studies are needed to determine how quality improvement initiatives can lower the rates of CCL X and influence clinical outcomes.

Background: Prior studies suggest that low-risk ST-segment–elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention can be considered for early discharge. We describe the implementation of an STEMI risk score to decrease cost while maintaining optimal patient outcomes. Methods and Results: We determined the impact of risk-guided STEMI care on healthcare value through the retrospective application of the Zwolle Risk Score to 967 patients receiving primary percutaneous coronary intervention between 2009 and 2011. Of these patients, 540 (56%) were categorized as low risk, indicating they may be safely triaged directly to a telemetry unit rather than the intensive care unit and targeted for early discharge. We subsequently developed and implemented a modified Zwolle Risk Calculator into the electronic medical record to support application of the fast-track protocol for low-risk STEMI patients. Among 549 prospective patients with STEMI, 62% were low risk, and the fast-track protocol was followed in 75% of cases. Prospective results confirmed lower rates of complications (low risk 8.3% versus high risk 38.7%; P P P P P P P Conclusions: In our study, risk-guided triage and discharge after primary percutaneous coronary intervention for STEMI improved healthcare value by reducing costs of care without compromising quality of care or patient outcomes.

Background: Despite evidence that therapeutic hypothermia improves patient outcomes for out-of-hospital cardiac arrest, use of this therapy remains low. It is unknown if the use of therapeutic hypothermia and patient outcomes have changed following publication of a trial that supported more lenient temperature management. Methods: In the Cardiac Arrest Registry to Enhance Survival (CARES), we identified 45,935 U.S. patients who experienced out-of-hospital cardiac arrest and survived to admission at 649 hospitals between 2013 and 2016. Using segmented hierarchical logistic regression, we determined risk-adjusted trends in the use of therapeutic hypothermia overall and stratified by presenting rhythm of ventricular tachycardia or ventricular fibrillation (VT/VF) vs pulseless electrical activity or asystole (PEA/asystole). We used mediation analysis to assess the impact of temporal trends in the use of therapeutic hypothermia on risk-adjusted survival trends at a patient- and hospital-level. Results: Overall use of therapeutic hypothermia was 46.4%. In unadjusted analyses, the use of therapeutic hypothermia dropped from 52.5% in the last quarter of 2013 to 46.0% in the first quarter of 2014 after publication of a trial that supported more lenient temperature management. Use of therapeutic hypothermia remained at or below 46.5% through 2016. After risk-adjustment, these trends in use persisted (see Figure). Compared with the last quarter of 2013, the risk-adjusted odds of therapeutic hypothermia was 18% lower in the first quarter of 2014 (OR 0.82, 95% CI 0.71, 0.94, P=0.006). Similar findings were observed in analyses stratified by presenting rhythm (see Figure). Overall risk-adjusted patient survival was 36.9% in 2013, 37.5% in 2014, 34.8% in 2015, and 34.3% in 2016 (P for trend Conclusions: In a U.S. registry of out-of-hospital cardiac arrest, the use of therapeutic hypothermia decreased after publication of a study supporting more lenient temperature thresholds. Concurrent to this change, overall risk-adjusted survival of cardiac arrest decreased, but was not attributed to lower use of therapeutic hypothermia.

Background— Transfer for primary percutaneous coronary intervention (PCI) is superior to fibrinolysis if performed in a timely manner but frequently requires dislocation of patients and their families from their local community. Although patient satisfaction is increasingly viewed as an important quality indicator, there are no data on how emergent transfer for PCI affects patients with ST–segment-elevation myocardial infarction and their families. Methods and Results— The Minneapolis Heart Institute’s Level 1 Regional ST–Segment-Elevation Myocardial Infarction program is designed to facilitate emergent transfer for PCI in patients with ST–segment-elevation myocardial infarction from 31 rural and community hospitals. To determine the effect of emergent transfer, questionnaires were given to 152 patients and their families who survived to hospital discharge with a 65.8% response rate (mean age, 63.9 years; 29% women). Ninety-five percent of patients felt the reasons and process of transfer were well explained, and 97% felt transfer for care was necessary. Despite this, 15% of patients would have preferred to stay in their local hospital. The majority of the families felt the transfer process (88%) and family member’s condition (94%) were well explained. Although 99% felt it was necessary for their family member to be transferred for specialized care, 11% of families still would have preferred that their family members remain at the local community hospital. Conclusions— Our results suggest that ST–segment-elevation myocardial infarction patients and families can be informed, even in time-critical situations, about the transfer process for PCI and understand the need for specialized care. Still, a significant minority would prefer to stay at their local hospital, despite acknowledging transfer for PCI provided optimal care.

Background: It is known that women with ST-elevation myocardial infarction (STEMI) have higher mortality in comparison to men. While the reasons for this sex-based difference are not completely understood, older age, higher prevalence of risk factors and co-morbid disease and longer time to reperfusion have been implicated. To determine whether the difference in outcomes persist even with an increase in the regional breadth of STEMI systems of care, we evaluated discharge disposition patterns and medications in a mature, multi-hospital cardiovascular network. Methods and Results: Data were drawn from a regional subset of the National Cardiovascular Data Registry for 33 hospitals in and around Dallas County, Texas from 2010 to 2015 (8,725 STEMI patients). We explored the difference between men and women in discharge dispositions (to home or other facility), to cardiac rehabilitation programs, to dietary counseling, as well as prescribed discharge medications. After multivariate controls for confounding factors including age, we found that men were 1.277 times more likely be discharged home than women (92% versus 86%), while women were more likely to be sent to an additional transitional care unit, nursing facility, or other facility. Women were also less likely to be offered dietary modification counseling (71% vs. 67%). Importantly, women were also much less likely to be prescribed Class I medications at discharge, including aspirin, beta blockers, statins, GP IIb/IIA and ACE inhibitors (all p Conclusions: Women treated for STEMI have notable differences in discharge dispositions patterns following percutaneous coronary intervention discharge. The post-discharge medications and services that women are prescribed needs to be carefully considered to reduce the significant differences in discharge disposition, although more research is needed in order to fully understand the impact of these differences.

Background— National guidelines call for participation in systems to rapidly diagnose and treat ST-segment–elevation myocardial infarction (STEMI). In order to characterize currently implemented STEMI reperfusion systems and identify practices common to system organization, the American Heart Association surveyed existing systems throughout the United States. Methods and Results— A STEMI system was defined as an integrated group of separate entities focused on reperfusion therapy for STEMI within a geographic region that included at least 1 hospital that performs percutaneous coronary intervention and at least 1 emergency medical service agency. Systems meeting this definition were invited to participate in a survey of 42 questions based on expert panel opinion and knowledge of existing systems. Data were collected through the American Heart Association Mission: Lifeline website. Between April 2008 and January 2010, 381 unique systems involving 899 percutaneous coronary intervention hospitals in 47 states responded to the survey, of which 255 systems (67%) involved urban regions. The predominant funding sources for STEMI systems were percutaneous coronary intervention hospitals (n = 320, 84%) and /or cardiology practices (n = 88, 23%). Predominant system characteristics identified by the survey included: STEMI patient acceptance at percutaneous coronary intervention hospital regardless of bed availability (N = 346, 97%); single phone call activation of catheterization laboratory (N = 335, 92%); emergency department physician activation of laboratory without cardiology consultation (N = 318, 87%); data registry participation (N = 311, 84%); and prehospital activation of the laboratory through emergency department notification without cardiology notification (N = 297, 78%). The most common barriers to system implementation were hospital (n = 139, 37%) and cardiology group competition (n = 81, 21%) and emergency medical services transport and finances (n = 99, 26%). Conclusions— This survey broadly describes the organizational characteristics of collaborative efforts by hospitals and emergency medical services to provide timely reperfusion in the United States. These findings serve as a benchmark for existing systems and should help guide healthcare teams in the process of organizing care for patients with STEMI.

Background: Bleeding complications following Percutaneous Coronary Interventions (PCI) occur in 2-6% of cases. Designed to provide rapid hemostasis, vascular closure devices (VCDs) have been found to have the largest benefit in high bleed risk cases but are utilized less often in these patients. Decision support tools and real-time feedback may impact physician practice patterns and increase utilization of VCDs in cases with high bleed risk. Methods: In May 2012, a real-time decision support tool was introduced to prospectively evaluate PCI bleed risk and stratify patients into high, intermediate, and low bleeding risk based on a validated model using data from the National Cardiovascular Data Registry. In January 2014, a group goal of 50% utilization of VCDs in high-bleed risk patients was set and weekly reports to individual interventional cardiologists performing PCI were provided. Group and individual physician practice patterns before and after the goal and real-time feedback were assessed. Results: From May 2012 to August 2015, 5,285 patients received PCI, including 1,399 (26.5%) who were classified as high bleed risk. Prior to the group utilization goal and real-time feedback being implemented, VCD use in high bleed risk patients was 40.3% (292 of 725) and utilization by individual provider ranged from 7.4% (5 of 68) to 83.1% (103 of 124) of cases. After implementation of the group utilization goal and real-time feedback, 74.2% (500 of 674) high bleed risk received VCDs and utilization by individual provider ranged from 61.4% (43 of 70) to 87.9% (87 of 99) of cases. Therefore, the physician group saw a relative increase of 84.1% in VCD utilization (40.3% vs. 74.2%; p Conclusions: Implementation of real-time feedback and clearly defined group goals for the use of VCDs in high bleed risk cases significantly increased VCD use in patients known to have the greatest benefit. These interventions also reduced the variation in care for high bleed risk patients.

Background: Bivalirudin decreased bleeding and improved mortality in ST-elevation myocardial infarction (STEMI) patients undergoing percutaneous coronary intervention (PCI) in the HORIZON trial. Currently there is limited data regarding the benefits of bivalirudin in unselected STEMI patients in real-world clinical practice. Methods: We reviewed consecutive STEMI patients at a large regional STEMI referral center from June 2009 to December 2011. All patients received aspirin and P2Y12 inhibitors. In-hospital complications, length of stay (LOS), total variable costs, 1-year cardiovascular readmissions, major adverse cardiac events (MACE) and mortality were compared for: bivalirudin alone, heparin alone and either medication with IIb/IIIa inhibitors. Results: Among 759 STEMI PCI cases, 208 (27.4%) received bivalirudin, 216 (28.5%) heparin and 335 (44.1%) IIb/IIIa, including only 48 cases with bivalirudin. Bivalirudin alone had significantly lower in-hospital complications, bleeding events, mortality and 1-year MACE and mortality (p Conclusions: In an unselected population of STEMI patients, those treated with bivalirudin had lower in-hospital complications and lower 1-year MACE and mortality rates compared to patients receiving heparin or IIb/IIIa inhibitors. These results provide further support for bivalirudin use in STEMI patients.

Background: Approximately 15% of Medicare patients who undergo percutaneous coronary intervention (PCI) are readmitted to the hospital within 30 days of discharge. A risk prediction algorithm which accurately identifies PCI patients’ risk for readmission may provide an opportunity to implement strategies to optimize care transitions to reduce inpatient readmissions and hospitalization costs in higher risk patients. Methods: We retrospectively applied a published validated 30-day readmission risk prediction algorithm to all PCI cases across three high volume centers within a single health care system between July 1, 2009 and September 30, 2013. Readmission risk scores were calculated and cases were grouped by low- ( Results: Among 13,494 PCI cases, 1,237 (9.2%) were high-, 5,846 (43.3%) were intermediate- and 6,411 (47.5%) were low-risk. High-, intermediate- and low-risk groups had significantly different overall readmission rates (19.8% vs. 10.5% vs. 5.4%; p Conclusions: A risk prediction algorithm accurately identifies PCI patients at highest risk for hospital readmission. This tool may enable providers to implement targeted strategies to reduce 30-day readmissions and hospital costs through transition care conferences, registered nurse telephone contact, early clinical follow-up and care management.

Background: Compared to the common antiplatelet clopidogrel, randomized trials have shownthe novel antiplatelet prasugrel reduces ischemic events without increasing major bleeding in diabetic acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI). However, the clinical and cost implications of clopidogrel versus prasugrel in diabetic ACS patients are limited in real-world settings. Methods: Using a shared electronic medical record we reviewed all primary PCI cases at three high volume centers from July 1, 2009 to December 31, 2013. Any complication, red blood cell transfusions, bleeding Results: Among 2,165 PCI cases, 1,899 (87.7%) received clopidogrel and 266 (12.3%) received prasugrel. The only difference in baseline demographic and clinical characteristics was older age in patients who received clopidogrel (62 years vs. 60 years; p Conclusions: In diabetic ACS patients undergoing PCI in a real-world clinical setting, there was no significant difference in peri-procedural complications with prasugrel versus clopidogrel antiplatelet therapy. Prasugrel was associated with higher costs and longer LOS.

In emergency cardiovascular care, time to treat is a key system goal to improve patient outcomes. In patients experiencing ST-elevation myocardial infarction (STEMI), reducing delays requires continuous quality improvement at PCI hospitals to reduce door to balloon (D2B) times. Yet, many of the hospital operational processes are not well situated to accommodate variability in patient presentation patterns. In this study, we questioned whether the day of week influences time to treat, since this could have an effect on hospital staffing, personnel mix, and resource utilization. We analyzed the entire population of 1,247 STEMI patients that presented in all of the PCI facilities in Dallas County Texas during a 24-month period (2010-2012), to assess relationships between arrival patterns and treatment delays. Specifically, we examined the differences in D2B times of patients presenting on weekends versus weekdays. To control for confounding factors, we developed a robust generalized linear model (GLM) regression and relied on estimated marginal means analyses to assess the impact of weekday vs. weekend on hospital D2B, and controlled for a variety of confounding factors. There was a statistically significant difference in the D2B times between patients who arrived at the hospital on weekends (75 minutes) compared to those who arrived on weekdays (65 minutes) (KW=48.9; df=1; p

> Humanity's greatest advances are not in its discoveries—but in how those discoveries are applied … . > > Bill Gates, Harvard commencement on June 7, 20071 Primary percutaneous coronary intervention (PCI) is the preferred reperfusion strategy for the patient with ST-elevation myocardial infarction (STEMI) regardless of whether they present to a PCI or non–PCI-capable hospital.2,3 These recommendations, based on randomized clinical trials and subsequent meta-analysis and meta-regression of these trials,4,5 are accompanied by a caveat: PCI must be performed in a timely manner. The unfortunate reality in the United States today is that many STEMI patients who are well suited for primary PCI do not receive PCI, or, when they do, it is frequently not within guideline-recommended time standards, a problem in particular for patients who present to hospitals without PCI capability.6 Articles see pp 468, 506, and 514 Is it a reasonable goal for the majority of Americans to receive optimal care when having a STEMI? We believe it is. While acknowledging the significant barriers and challenges to the implementation of an effective PCI-based strategy,7,8 increasing evidence suggests that it is possible. Seventy-nine percent of Americans live within 60 minutes of a PCI hospital.9 Regional STEMI centers from diverse regions have provided evidence that rapid door-to-balloon times can be broadly achieved with an associated improvement in outcomes.10,–,13 The American College of Cardiology (ACC) D2B campaign has fostered major improvements in the treatment times at PCI hospitals, and now the American Heart Association (AHA) Mission:Lifeline program is focused on systems of care to increase timely access to PCI in the United States. The 2009 focused update of the ACC/AHA STEMI guidelines describes the development of regional systems for STEMI care as a “matter of the utmost importance.”2 In fact, the authors …

Objective: We sought to quantify changes in STEMI mortality and percutaneous coronary intervention (PCI) use in the United States (US) from 2002 to 2010. Methods: We used the Nationwide Inpatient Sample (NIS), an all-payer discharge database, to create estimates of STEMI, STEMI in-hospital mortality, and PCI use. The NIS includes hospitals selected to approximate 20% of all non-federal US hospitals and includes weights to create national estimates. STEMI cases were identified based on primary diagnostic code. High volume STEMI-PCI centers were defined as >36 cases/year, according to PCI guidelines. Temporal trends were evaluated with logistic regression, adjusted for patient and hospital characteristics. Discharges to other acute care facilities were excluded for outcomes analyses. Results: We identified 1,944,112 STEMI discharges in the US; mean age was 64 years, 34% were women, and 46% were Medicare insured. The absolute number of STEMI discharges declined from 299,441 in 2002 to 167,929 in 2010 (Figure). The number of hospitals performing zero STEMI-related PCIs decreased from 75% (3633/4840) to 68% (3514/5134) between 2002 and 2010. The number of high volume centers increased from 20% (949/4840) to 24% (1235/4840) over the same period. Overall, 64% (1,145,196/1,783,825) of discharges received PCI and 8.5% (151,528/1,783,825) died during hospitalization. PCI use increased and mortality decreased over time (Figure). The adjusted odds of PCI use for STEMI discharges increased over three fold during the study period (OR 3.51 in 2010 versus 2002, 95% CI 3.21 to 3.83). The adjusted odds of death decreased by one fifth (OR 0.81 in 2010 versus 2002, 95% CI 0.75 to 0.87). Inclusion of PCI in the model attenuated the effect of year on death (OR 1.06 in 2010 versus 2002, 95% CI 0.98 to 1.14). Conclusions: In this study we demonstrate favorable trends in STEMI outcomes. Between 2002 and 2010, the absolute number of STEMIs in the US decreased, while more hospitals provided PCI for STEMI. Over time, more discharges were treated with PCI and fewer died during hospitalization.

In emergency cardiovascular care, delays often equate to poor patient outcomes. In patients experiencing ST-elevation myocardial infarction (STEMI), reducing systemic delays and receiving definitive treatment is a key goal of regionalized systems of care. Prehospital emergency care has been suggested to have an impact on improving STEMI patient outcomes, but little prior evidence exists in large suburban settings to establish relationships between EMS and hospital outcomes. In this study, we analyzed the entire population of non-transfer STEMI patients that underwent primary percutaneous coronary intervention (PCI) in Dallas County Texas from October 1, 2010 through December 31, 2011. Emergency medical services data from 24 agencies and 15 receiving hospitals collected and shared common, de-identified patient data. To control for confounding factors, we developed a robust generalized linear regression and relied on estimated marginal means analyses to assess the impact of EMS transport (versus self-transport) on hospital door to balloon (D2B) and total treatment time, defined as symptom onset to arterial reperfusion, or SOAR. In our analyses, there were statistically 11.1 minute reductions in median D2B (and 64.5 minute median reductions in SOAR (both with p Based on these findings, we recommend regional quality improvement teams develop strategies for engaging EMS in STEMI treatment, to reduce both systemic delays and total coronary reperfusion times.