Abstract
Background
Studies with short-term follow-up found higher mortality in patients with STEMI who underwent primary PCI during off-hours as compared to regular working hours. We analyzed the interaction between one and two-year survival of patients with STEMI who underwent primary PCI during regular working hours and off-hours in a tertiary care academic teaching hospital.
Methods
A total of 1126 STEMI patients treated with primary PCI between 2008 and 2013 were analyzed. Two-years follow-up were available in 941 (83%) patients. Multivariable survival analysis was used to estimate the relationship between treatment during off-hours versus regular hours and the incidence of all-cause mortality at 2-years follow-up. Logistic regression was used to calculate interaction p -values between time of admission and time (between ≤1 year and ≤2 year).
Results
At 2-years, the mortality rate of patients admitted during off-hours and regular hours was similar (15% vs. 19%; adjusted hazard ratio 0.77; 95% confidence interval 0.52–1.16). Of the 941 patients, those who admitted during off-hours ( N = 717) had similar median door-to-device time (94 min vs. 91 min), final Thrombolysis In Myocardial Infarction 3 flow grade (93% vs. 91%) and use of dual antiplatelet within 24 h (96% vs. 98% respectively) as compared with regular hours admission ( N = 224). There were no mortality difference observed between one year and two years (p interaction >0.05).
Conclusion
In this analysis, the similar mortality observed at one year between patients with STEMI treated by primary PCI during off-hour and regular hour were maintained at two years.
1
Introduction
There has been concern as to whether admission times may affect the outcome of patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). This concern has been associated with different performance of the hospital in treating patients with STEMI during off-hours and regular working hours [ ]. Several studies found higher short-term mortality (in-hospital or 30 days) in patients with STEMI who underwent primary PCI during off-hours as compared to regular working hours. However the studies had limited clinical impact due to the short-term outcome considered [ ], while long-term follow up studies are very limited [ ]. We reported the two years mortality and analyzed the interaction between one and two-year survival of patients with STEMI who underwent primary PCI during regular working hours and off-hours in a tertiary care academic teaching hospital.
2
Methods
2.1
Study design
A retrospective analysis of the Jakarta Acute Coronary Syndrome (JAC) registry was performed. The JAC registry was conducted in the emergency department of a primary PCI center that recorded consecutive patients with acute coronary syndrome admitted to the hospital. The PCI center is a tertiary care academic hospital and hosting the regional STEMI network (Jakarta Cardiovascular Care Unit Network System). The primary PCI center has nearly 600 primary PCI procedures during 2015–2016.
As previously reported [ ], the basis classification used in this study was admission time (off-hours and regular working hours). Off-hours arrival time was defined as weeknights (Monday through Thursday; 4 PM to 7.30 AM and Friday; 4.30 PM to 7.30 AM), weekends, and holidays. Regular hours arrival was defined as weekdays/regular office hours (Monday through Thursday; 7.30 AM to 4 PM and Friday; 7.30 AM to 4.30 PM).
2.2
Study sample
Out of 5237 patients with STEMI admitted to the emergency department, 1126 patients who underwent primary PCI between 2008 and 2013 were analyzed. Before primary PCI all patients received 160–320 mg acetylsalicylic acid and 600 mg clopidogrel followed by daily administration of 75 mg clopidogrel for six to 12 months after discharge and 80–100 mg acetylsalicylic acid indefinitely. Bolus unfractionated heparin was given at the catheterization laboratory before primary PCI in all patients. Dual antiplatelet therapy was defined as use of acetylsalicylic acid and clopidogrel.
2.3
Study endpoints and follow-up
The primary endpoint was all-cause mortality at two years. The mortality at two years was collected from the medical records or phone calls.
2.4
Statistical methods
Patients were compared according to time of admission (off-hours or regular hours). Categorical variables were compared by the chi-square or Fisher’s exact test. Continuous variables presented as mean ± SD or median (interquartile range) and compared by t -test or Mann-Whitney U test. Kaplan-Meier survival curves were obtained to evaluate the cumulative survival at two years between off-hours and regular hours group and compared by log-rank test. Hazard ratios and their 95% confidence intervals were calculated using off-hours as a reference with test for interaction. Logistic regression was used to calculate interaction p -values between admission time and time (between ≤1 year and ≤2 year). The mortality was also assessed in pre-specified subgroups using logistic regression with tests for interaction. All statistical analyses were performed with SPSS version 17.0 (SPSS Inc., Chicago, IL, USA).
2
Methods
2.1
Study design
A retrospective analysis of the Jakarta Acute Coronary Syndrome (JAC) registry was performed. The JAC registry was conducted in the emergency department of a primary PCI center that recorded consecutive patients with acute coronary syndrome admitted to the hospital. The PCI center is a tertiary care academic hospital and hosting the regional STEMI network (Jakarta Cardiovascular Care Unit Network System). The primary PCI center has nearly 600 primary PCI procedures during 2015–2016.
As previously reported [ ], the basis classification used in this study was admission time (off-hours and regular working hours). Off-hours arrival time was defined as weeknights (Monday through Thursday; 4 PM to 7.30 AM and Friday; 4.30 PM to 7.30 AM), weekends, and holidays. Regular hours arrival was defined as weekdays/regular office hours (Monday through Thursday; 7.30 AM to 4 PM and Friday; 7.30 AM to 4.30 PM).
2.2
Study sample
Out of 5237 patients with STEMI admitted to the emergency department, 1126 patients who underwent primary PCI between 2008 and 2013 were analyzed. Before primary PCI all patients received 160–320 mg acetylsalicylic acid and 600 mg clopidogrel followed by daily administration of 75 mg clopidogrel for six to 12 months after discharge and 80–100 mg acetylsalicylic acid indefinitely. Bolus unfractionated heparin was given at the catheterization laboratory before primary PCI in all patients. Dual antiplatelet therapy was defined as use of acetylsalicylic acid and clopidogrel.
2.3
Study endpoints and follow-up
The primary endpoint was all-cause mortality at two years. The mortality at two years was collected from the medical records or phone calls.
2.4
Statistical methods
Patients were compared according to time of admission (off-hours or regular hours). Categorical variables were compared by the chi-square or Fisher’s exact test. Continuous variables presented as mean ± SD or median (interquartile range) and compared by t -test or Mann-Whitney U test. Kaplan-Meier survival curves were obtained to evaluate the cumulative survival at two years between off-hours and regular hours group and compared by log-rank test. Hazard ratios and their 95% confidence intervals were calculated using off-hours as a reference with test for interaction. Logistic regression was used to calculate interaction p -values between admission time and time (between ≤1 year and ≤2 year). The mortality was also assessed in pre-specified subgroups using logistic regression with tests for interaction. All statistical analyses were performed with SPSS version 17.0 (SPSS Inc., Chicago, IL, USA).
3
Results
3.1
Patients
Out of 1126 patients presenting with STEMI and undergoing PPCI at our institution, 857 (76%) presented during off-hours. Clinical characteristics of patients were well matched between the two admission times. Discharge treatment was similar in both groups. In general, the patient baseline characteristics were similar between off-hours and regular hours admission ( Table 1 ). The proportion of patients receiving antiplatelet within 24 h, the angiographic achievement of final TIMI 3 flow and door-to-device time (DTD) were also similar between the two admission times ( Tables 1 and 2 ).
| Off-hours ( N = 857) | Regular hours ( N = 269) | P value | |
|---|---|---|---|
| Clinical characteristics | |||
| Age, years | 55.44 ± 9.73 | 56.4 ± 9.94 | 0.15 |
| Male gender, N (%) | 753 (87%) | 224 (83%) | 0.052 |
| Source of referral, N (%) | |||
| Walk-in/ambulance | 250 (29.1%) | 74 (27.5%) | 0.59 |
| Inter-hospital | 580 (67.6%) | 171 (63.5%) | 0.21 |
| Anterior wall MI, N (%) | 484 (56.5%) | 152 (56%) | 0.99 |
| Blood pressure, mm Hg | |||
| Systolic BP | 131 (56–220) | 130 (18–240) | 0.77 |
| Diastolic BP | 80 (33–153) | 77 (43–131) | 0.16 |
| Heart rate, bpm | 78 (16–166) | 76 (20–142) | 0.23 |
| Risk stratification, N (%) | |||
| Killip class 2–4 | 234 (27.3%) | 62 (23%) | 0.16 |
| TIMI score >4 | 310 (36.2%) | 88 (32.7%) | 0.30 |
| Risk factor, N (%) | |||
| Hypertension | 472 (55%) | 154 (57.2%) | 0.53 |
| Diabetes mellitus | 256 (29.8%) | 74 (27.5%) | 0.45 |
| Dyslipidemia | 385 (44.9%) | 130 (48.3%) | 0.33 |
| Smoker | 570 (66.5%) | 163 (60.6%) | 0.07 |
| Family history | 189 (22%) | 57 (21.2%) | 0.76 |
| Onset of infarction, hours | |||
| 2–6 h | 463 (54%) | 150 (55.7%) | 0.61 |
| 6–12 h | 310 (36.2%) | 80 (29.7%) | 0.053 |
| Antiplatelet within the first 24 h, N (%) | |||
| Aspirin | 836 (97%) | 264 (98%) | 0.57 |
| Clopidogrel | 829 (97%) | 263 (98%) | 0.38 |
| Medication at discharged, N (%) | |||
| Aspirin | 788 (92%) | 249 (92%) | 0.74 |
| Clopidogrel | 786 (91%) | 246 (91%) | 0.89 |
| Ace inhibitor | 656 (76%) | 190 (71%) | 0.12 |
| Statin | 789 (92%) | 240 (89%) | 0.14 |
| Beta-blocker | 646 (75%) | 185 (69%) | 0.08 |
| Length of stay, days | 5.86 ± 4.63 | 6.45 ± 4.91 | 0.07 |
| Primary PCI characteristics | |||
| Door-to-device, minutes | 114 ± 89.32 | 111 ± 66.65 | 0.58 |
| Manual thrombus aspiration, N (%) | 425 (49.6%) | 112 (41.6%) | 0.009 |
| Final TIMI 3 flow, N (%) | 801 (93%) | 245 (91%) | 0.18 |
| Use of GPI, N (%) | 574 (67%) | 172 (64%) | 0.35 |
| Culprit vessel, N (%) | |||
| LAD | 394 (46%) | 117 (43.5%) | 0.45 |
| LCX | 37 (4.3%) | 15 (5.6%) | 0.38 |
| RCA | 288 (33.6%) | 89 (33.1%) | 0.47 |
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