Study: Time for a new focus in QI efforts for STEMI patients
Mortality rate unchanged despite improvements in door-to-balloon times
Emergency medicine providers fully understand the importance of time-to-treatment when caring for ST-elevated myocardial infarctions (STEMI) patients. That's why quality improvement efforts have focused so intently in recent years on improving door-to-balloon times for patients suffering from STEMI, the most serious type of heart attack. However, now there is evidence that while it is important to maintain these improvements, further gains on this particular metric likely have diminishing returns in terms of reducing mortality.1
The latest findings come from an analysis led by the University of Michigan Frankel Cardiovascular Center of 100,000 STEMI admissions across the country, between 2005 and 2009, a period in which there was a national effort aimed at reducing door-to-balloon times. Over the course of the study, investigators report that the percentage of STEMI patients receiving care in 90 minutes or less improved from 59.5% to 83.1%, but there was no accompanying reduction in the mortality rate. It remained unchanged at 4.8%. While door-to-balloon times are relatively easy to measure and chart, investigators suggest it may now be time to focus improvement efforts on other factors.
Consider the pre-hospital phase
As the only hospital in Illinois with an interventional cardiology team on site 24 hours a day, Loyola University Medical Center in Maywood, IL, has made exceptional strides in pushing down door-to-balloon times in STEMI patients. The average door-to-balloon time at the 50,000-visit-per-year ED was 56 minutes in 2012, and 53 minutes in the first half of 2013. This far exceeds the level of performance recommended by national guidelines, which state that hospitals should strive to provide angioplasties within 90 minutes of a patient's arrival in the ED.
However, Fred Leya, MD, the medical director of interventional cardiology at the hospital, agrees with study investigators that there is only so much tweaking that hospitals can do once patients arrive in the ED. He suggests, though, that more could be done to get patients to react more quickly to symptoms. "An average [heart attack] patient waits two hours outside the hospital, and only 60% of patients finally decide to call 911," he says. "We know that if we shorten ischemia time from the onset of chest pain, then definitely [the] mortality [rate] will be improved, so what we are trying to stress now is that the pre-hospital portion should be improved as much as we have improved the hospital response time."
This will require hospitals and public media to take ownership of the need to do a better job of educating the public about what to do in the case of chest pain, how to behave, and when to call 911, explains Leya. He stresses that there is a finite period of time to work with in preventing damage when a STEMI occurs. "On average, there is about 15 to 20 minutes of ischemia before an initial wave of necrosis starts inside the heart, and that gradually expands outward," says Leya. "That expansion process takes about two to four hours."
There is also room for improvement in the training of emergency providers to pick up on atypical symptoms of STEMI, especially in women, adds Leya. "We have seen women in their 40s and 50s come in complaining of nausea or abdominal pain. Physicians examine them and think it is stomach flu, but no one takes the time to do an EKG," he says. "There are a lot of things we need to keep in mind, but especially women need to be taken more seriously in the ED. Everyone is trained on the classic symptoms of STEMI, but we need to make doubly sure that providers are not missing signs of a heart attack in women." (Also, see "Study: Chest pain symptoms less likely in younger women with acute coronary syndrome," below)
Prepare for new challenges
While Loyola is able to maintain an interventional cardiology team on site, around the clock, thanks to a donor, not all hospitals have the financial resources or the need to maintain such resources. A better approach for many, says Leya, is for hospitals and EDs to establish a regional response system so that when paramedics have patients exhibiting signs of a STEMI, they will know to take them to hospitals that have the appropriate resources.
Leya also favors the establishment chest pain units in which physicians and nurses can maintain a high level of skill in identifying and treating STEMI and other conditions related to chest pain. Regardless of the specific setting, however, Leya emphasizes that everyone should have a process in place for measuring outcomes and taking steps to improve. "Cardiology and ED physicians, as well as program directors should sit together and mark what they are going to improve next," he says. "Take one thing at a time, but make sure you truly improve it."
Despite the clear gains in door-to-balloon times in recent years, connecting STEMI patients with appropriate care quickly is likely to become more challenging as more people gain access to health coverage, observes Mark Cichon, DO, FACEP, FACOEP, chair of the Department of Emergency Medicine at Loyola University Medical Center.
"As volumes of patients increase at EDs across the country ... we as physicians, nurses, and EDs need to work on identifying and accelerating care to those patients who present to us with time-dependent emergencies like stroke, trauma, and MIs," notes Cichon. "Rapid evaluations in triage, rapid assessment teams, point-of-care testing, hand-held ultrasound devices, and newer innovations in EKGs are going to become more important."
1. Menees D, Peterson E, Wang Y, et al. Door-to-balloon time and mortality among patients undergoing primary PCI. N Engl J Med 2013;369:901-909.
• Mark Cichon, DO, Chair, Department of Emergency Medicine, Loyola University Medical Center, Maywood, IL. E-mail: firstname.lastname@example.org.
• Fred Leya, MD, Medical Director, Interventional Cardiology, Loyola University Medical Center, Maywood, IL. Phone: 888-584-7888.
Study: Chest pain symptoms less likely in younger women with acute coronary syndrome
A study looking at presenting symptoms in younger patients diagnosed with acute coronary syndrome (ACS) found that while chest pain is the predominant symptom in both men and women, 19% of women and 13.7% of men presented without chest pain. Investigators, reporting in JAMA Internal Medicine, noted that while it is clear that chest pain should trigger diagnostic evaluation for ACS, health care practitioners should also maintain a high degree of suspicion for ACS in patients younger than age 55, especially with respect to women.1
Most of the participants in the study who presented without chest pain reported at least one other symptom such as shortness of breath, flushing, or tachycardia. Investigators report that only two factors were independently associated with presentation without chest pain: female gender and tachycardia. Still, chest pain was by far the most common symptom, reported by 86% of men and 81% of women.
The study involved an analysis of 1,015 patients, aged 55 and younger, who were hospitalized for ACS and who were enrolled in the ongoing GENESIS PRAXY study between January 2009 and September 2012; the median age was 49. Participants came from 24 centers in Canada, one center in the United States, and one in Switzerland.
1. Khan N, Daskalopoulou S, Karp I, et al. Sex differences in acute coronary syndrome symptom presentation in young patients. JAMA Internal Medicine September 16, 2013. [Epub ahead of print].