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© 2008, American Heart Association. All rights reserved. Impact of Time of Presentation on the Care and Outcomes of Acute Myocardial Infarction Hani Jneid,

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Presentation on theme: "© 2008, American Heart Association. All rights reserved. Impact of Time of Presentation on the Care and Outcomes of Acute Myocardial Infarction Hani Jneid,"— Presentation transcript:

1 © 2008, American Heart Association. All rights reserved. Impact of Time of Presentation on the Care and Outcomes of Acute Myocardial Infarction Hani Jneid, Gregg C. Fonarow, Christopher P. Cannon, Igor F. Palacios, Teoman Kilic, George V. Moukarbel, Andrew O. Maree, Kenneth A LaBresh, Li Liang, L. Kristin Newby, Gerald Fletcher, Laura Wexler, Eric Peterson; for the Get With The Guidelines Steering Committee and Investigators From the Massachusetts General Hospital and Harvard Medical School, Boston, MA (Drs Jneid, Palacios, Kilic, Moukarbel, and Maree); UCLA Medical Center, Los Angeles, CA (Dr Fonarow); TIMI Group and BWH, Boston, MA (Dr Cannon); Masspro, Inc., Waltham, Massachusetts, USA (Dr. LaBresh); Duke Clinical Research Institute and Duke University Medical Center, Durham, NC (Drs Liang, Newby, and Peterson); Mayo Clinic, Jacksonville, FL (Dr. Fletcher); University of Cincinnati College of Medicine, Cincinnati, OH (Dr Wexler) Jneid, H. et al. Circulation May 2008.

2 © 2008, American Heart Association. All rights reserved. Background Acute myocardial infarction (AMI) remains a leading cause of death in the United States. Its associated mortality and morbidity can be altered however by proven, effective therapies.Acute myocardial infarction (AMI) remains a leading cause of death in the United States. Its associated mortality and morbidity can be altered however by proven, effective therapies. Healthcare providers have been working to improve the consistency and timely delivery of evidence-based treatments. Despite these efforts, studies continue to demonstrate quality gaps in AMI care in routine clinical practice.Healthcare providers have been working to improve the consistency and timely delivery of evidence-based treatments. Despite these efforts, studies continue to demonstrate quality gaps in AMI care in routine clinical practice. Jneid, H. et al. Circulation May 2008.

3 © 2008, American Heart Association. All rights reserved. Background Recently, several studies found that patients presenting on weekends or during off-hours (weekday nights, weekends, and holidays) were less likely to receive guideline-based medications and/or timely reperfusion after AMI.Recently, several studies found that patients presenting on weekends or during off-hours (weekday nights, weekends, and holidays) were less likely to receive guideline-based medications and/or timely reperfusion after AMI. However, these studies have been inconsistent in their findings and have been in part limited by reflecting non- contemporary clinical practices, regional results and selected MI patients.However, these studies have been inconsistent in their findings and have been in part limited by reflecting non- contemporary clinical practices, regional results and selected MI patients. Jneid, H. et al. Circulation May 2008.

4 © 2008, American Heart Association. All rights reserved. To conduct a comprehensive analysis of the influence of regular vs. off-hour AMI presentation on subsequent care and outcomes using the American Heart Associations Get With The Guidelines-Coronary Artery Disease (GWTG-CAD) national database.To conduct a comprehensive analysis of the influence of regular vs. off-hour AMI presentation on subsequent care and outcomes using the American Heart Associations Get With The Guidelines-Coronary Artery Disease (GWTG-CAD) national database. More specifically, we examined differences in reperfusion strategies, timeliness of reperfusion, use of invasive procedures, early medical treatments and in-hospital mortality among AMI patients admitted during regular vs. off- hours.More specifically, we examined differences in reperfusion strategies, timeliness of reperfusion, use of invasive procedures, early medical treatments and in-hospital mortality among AMI patients admitted during regular vs. off- hours. We corroborated our findings in patients with ST-segment myocardial infarction (STEMI) and non-ST-segment myocardial infarction (NSTEMI), in age and sex subgroups, and using an alternative definition for arrival time.We corroborated our findings in patients with ST-segment myocardial infarction (STEMI) and non-ST-segment myocardial infarction (NSTEMI), in age and sex subgroups, and using an alternative definition for arrival time. Aims of this Study Jneid, H. et al. Circulation May 2008.

5 © 2008, American Heart Association. All rights reserved. Methods Data Source and Study Sample The primary data source was the Get with the Guidelines- Coronary artery disease (GWTG-CAD) database, which contained data on a total of 93,595 AMI patients treated at 379 hospitals between July 2000 and September 2005 admissions.The primary data source was the Get with the Guidelines- Coronary artery disease (GWTG-CAD) database, which contained data on a total of 93,595 AMI patients treated at 379 hospitals between July 2000 and September 2005 admissions. We excluded patients with missing or invalid arrival dates/times (n= 4,568), and transfer-in patients (n= 26,213) in whom initial treatments could not be ascertained with accuracy.We excluded patients with missing or invalid arrival dates/times (n= 4,568), and transfer-in patients (n= 26,213) in whom initial treatments could not be ascertained with accuracy. The final study population included included 62,814 AMI patients.The final study population included included 62,814 AMI patients. Jneid, H. et al. Circulation May 2008.

6 © 2008, American Heart Association. All rights reserved. Methods Data Collection and Measures Arrival time (regular vs. off-hours) was the primary independent variable.Arrival time (regular vs. off-hours) was the primary independent variable. Regular hours were defined as weekdays (Monday through Friday) 7:00 AM to 7:00 PM. Off-hours were defined as weeknights (7:00 PM to 7:00 AM), weekends and holidays.Regular hours were defined as weekdays (Monday through Friday) 7:00 AM to 7:00 PM. Off-hours were defined as weeknights (7:00 PM to 7:00 AM), weekends and holidays. Holidays included: New Year (December 31 st and January 1 st ), Christmas holiday (December 24 th and 25th), Memorial day, Independence, Labor and Thanksgiving days.Holidays included: New Year (December 31 st and January 1 st ), Christmas holiday (December 24 th and 25th), Memorial day, Independence, Labor and Thanksgiving days. Jneid, H. et al. Circulation May 2008.

7 © 2008, American Heart Association. All rights reserved. Methods Data Collection and Measures The primary study outcome was in-hospital mortality.The primary study outcome was in-hospital mortality. Secondary outcomes included rates of:Secondary outcomes included rates of: a) Quality of Care measures: a) Quality of Care measures: - acute medical therapies (aspirin and beta blocker within - acute medical therapies (aspirin and beta blocker within 24 h) 24 h) - reperfusion therapies in the STEMI cohort (fibrinolytic - reperfusion therapies in the STEMI cohort (fibrinolytic therapy, PCI, any reperfusion) therapy, PCI, any reperfusion) - timeliness of reperfusion in the STEMI cohort (door-to- - timeliness of reperfusion in the STEMI cohort (door-to- balloon within 90 min, and door-to-needle within 30 balloon within 90 min, and door-to-needle within 30 min) min) b) Invasive procedures (catheterization, PCI, CABG, b) Invasive procedures (catheterization, PCI, CABG, revascularization) revascularization) Jneid, H. et al. Circulation May 2008.

8 © 2008, American Heart Association. All rights reserved. Statistical Analyses For the descriptive analysis: –patients sociodemographic –medical history variables –baseline clinical characteristics –invasive procedures –Quality of Care (QOC) are measures – in-hospital mortality were compared among patients arriving during off-hours vs. regular hours. Multivariable logistic regression analyses, using the Generalized Estimating Equations (GEE) method, were performed to determine whether off-hour arrival independently influenced each measure and outcome.Multivariable logistic regression analyses, using the Generalized Estimating Equations (GEE) method, were performed to determine whether off-hour arrival independently influenced each measure and outcome. Methods Jneid, H. et al. Circulation May 2008.

9 © 2008, American Heart Association. All rights reserved. Methods Statistical Analysis The adjusted covariates inlcuded: age, sex, race, body mass index, insurance type, systolic BP, cardiac diagnosis, initial ECG with diagnostic ST-segment elevation or LBBB, diabetes, hypertension, hyperlipidemia, smoking, renal insufficiency, COPD, heart failure, stroke, peripheral artery disease, and previous MI To assess the generalizability of our findings, we repeated the analysis using an alternative definition by re- classifing patients hospital arrival time into weekends (from 6:00 PM on Friday until 7:00 AM on Monday) and holidays vs. weekdays (from 7:00 AM on Monday until 6:00 PM on Friday). Subgroup analyses were performed by sex and age (subdivided into 3 intervals: 75 yr). Jneid, H. et al. Circulation May 2008.

10 © 2008, American Heart Association. All rights reserved. Of all AMI patients (n= 62,814), 54.1% (n= 33,982) arrived during off-hours.Of all AMI patients (n= 62,814), 54.1% (n= 33,982) arrived during off-hours. Of the overall AMI cohort, 20,279 (32.3%) patients had STEMI, defined as having an initial ECG on arrival showing diagnostic ST-segment elevation or left bundle branch block (LBBB).Of the overall AMI cohort, 20,279 (32.3%) patients had STEMI, defined as having an initial ECG on arrival showing diagnostic ST-segment elevation or left bundle branch block (LBBB). The remaining 67.7% of AMI patients constituted the NSTEMI cohort (n= 42,535).The remaining 67.7% of AMI patients constituted the NSTEMI cohort (n= 42,535). Results Jneid, H. et al. Circulation May 2008.

11 © 2008, American Heart Association. All rights reserved. Results Socio-Demographic Characteristics Description Regular hours (N= 28,832) % (n) Off-hours (N =33,982) % (n) P value Age, mean (SD), yr68.2 ± ±14.7< Male60.8 (17,524)60.3 (20,494)0.23 Caucasian75.1 (21,654)73.3 (24,921) < African American6.7 (1,934)7.4 (2,523) Asian4.0 (1,150)4.1 (1,404) Hispanic6.8 (1,945)6.9 (2,328) American Indian0.2 (46)0.2 (61) Other1.9 (541)2.3 (764) Unknown5.4 (1,562)5.8 (1,981) BMI, mean (SD), kg/m ±6.5 (25,713)28.1±6.5 (30,078) Health insurance Medicare43.4 (12,498)41.6 (14,119)< Medicaid5.7 (1,646)6.1 (2,059)0.03 No insurance/UTD6.7 (1,916)6.9 (2,333)0.16 Other insurance38.3 (11,035)38.0 (12,917)0.80 Jneid, H. et al. Circulation May 2008, Table 1..

12 © 2008, American Heart Association. All rights reserved. Results Description Regular hours (N= 28,832) % (n) Off-hours (N =33,982) % (n) P value Hypertension62.1 (17,896)61.7 (20,956)0.30 Hyperlipidemia31.3 (9,033)31.7 (10,782)0.26 Diabetes30.1 (8,670)31.5 (10,690) Previous MI19.8 (5,697)21.3 (7,226)< Angina10.4 (2,984)10.2 (3,476)0.63 Heart failure15.5 (4,472)16.8 (5,707)< Chronic renal insufficiency10.8 (3,117)11.0 (3,730)0.50 Renal dialysis2.3 (649)2.2 (755)0.81 Atrial fibrillation8.6 (2,470)8.1 (2,752)0.03 Stroke8.6 (2,472)8.5 (2,898)0.85 COPD13.1 (3,781)13.2 (4,493)0.68 PVD8.8 (2,536)8.5 (2,884)0.17 Adult history of smoking26.6 (7,667)28.8 (9,802)< Medical History Jneid, H. et al. Circulation May 2008, Table 1.

13 © 2008, American Heart Association. All rights reserved. Results Clinical Characteristics Description Regular hours (N= 28,832) % (n) Off-hours (n =33,982) % (n) P value STEMI diagnosis31.6 (9,122)32.8 (11,157)0.001 SBP, mean (SD), mmHg123± DBP, mean (SD), mmHg67±1667± Total Cholesterol, mean (SD), mg/dl175±48176± Ejection fraction, mean (SD), %47± Jneid, H. et al. Circulation May 2008, Table 1.

14 © 2008, American Heart Association. All rights reserved. Results Early Medical Therapies Regular hours % (n) Off-hours % (n) P Value Aspirin within 24h *91.2 (23,634)91.3 (27,928)0.65 Beta blocker within 24h *84.0 (20,177)84.7 (23,985)0.02 Jneid, H. et al. Circulation May 2008, Table 2.. * Overall AMI patients

15 © 2008, American Heart Association. All rights reserved. Results Reperfusion and Timeliness of Reperfusion Regular hours % (n) Off-hours % (n) P Value Reperfusion therapy * Any Reperfusion65.5 (5,970)66.2 (7,384)0.21 PCI60.5 (5,516)58.9 (6,570)0.03 Fibrinolytics9.8 (893)14.1 (1,574)< Timeliness of Reperfusion * DTN time, Median (25 th -75 th ), min40 (23-65)40 (25-65)0.59 DTB time, Median (25 th -75 th ), min85 (60-127)110 (83-157)< DTN time 30 min, % (n)35.4 (271)33.5 (485)0.36 DTB time 90 min, % (n)54.2 (1,390)30.9 (891)< DTB: Door-To-Balloon; DTN: Door-To-Needle. * STEMI Patients only Jneid, H. et al. Circulation May 2008, Table 2..

16 © 2008, American Heart Association. All rights reserved. Results Invasive Procedures Regular hours % (n) Off-hours % (n) P Value All AMI patients Cardiac catheterization52.8 (13,764)52.8 (15,972)0.8 PCI45.2 (11,800)44.4 (13,441)0.07 CABG8.0 (2,083)7.6 (2,301)0.1 Any Revascularization52.2 (13,620)51.0 (15,433)0.006 STEMI patients Cardiac catheterization60.3 (5,027)60.2 (6,046)0.9 CABG7.1 (596)7.8 (788)0.07 Any Revascularization70.2 (5,855)69.9 (7,021)0.7 NSTEMI patients Cardiac catheterization49.2 (8,737)49.1 (9,926)1.0 PCI36.1 (6,403)34.7 (7,021)0.009 CABG8.4 (1,487)7.5 (1,513)0.002 Any Revascularization43.7 (7,765)41.6 (8,412)< Jneid, H. et al. Circulation May 2008.

17 © 2008, American Heart Association. All rights reserved. Results In-hospital Mortality in the Overall AMI Cohort Jneid, H. et al. Circulation May 2008, figure 1.

18 © 2008, American Heart Association. All rights reserved. Results In-hospital Mortality in the NSTEMI Cohort In-hospital Mortality in the STEMI Cohort Jneid, H. et al. Circulation May 2008, figure 1.

19 © 2008, American Heart Association. All rights reserved. Results N OR (95% CI) Off-hours vs. Regular hours P value Aspirin within 24 h56, ( )0.28 Beta blocker within 24 h52, ( )0.03 Adjusted Odds Ratios for Early Medical Therapies in Patients Arriving during Off-hours vs. Regular hours * Overall AMI patients Jneid, H. et al. Circulation May 2008.Table 3.

20 © 2008, American Heart Association. All rights reserved. Results N OR (95% CI) Off-hours vs. Regular hours P value Reperfusion Therapy * Any Reperfusion therapy19, ( )0.25 PCI19, ( )0.004 Fibrinolytic therapy19, ( )< Timeliness of Reperfusion * Door-to-needle time 30 min2, ( )0.44 Door-to-balloon time 90 min5, ( )< Adjusted Odds Ratios for ReperfusionTherapies in Patients Arriving during Off-hours vs. Regular hours DTB: Door-To-Balloon; DTN: Door-To-Needle. * STEMI Patients only Jneid, H. et al. Circulation May Table 3.

21 © 2008, American Heart Association. All rights reserved. Results N OR (95% CI) Off-hours vs. Regular hours P value All AMI patients Cardiac catheterization54, ( )0.17 PCI54, ( )0.02 CABG54, ( )0.04 Revascularization54, ( ) STEMI patients Cardiac catheterization18, ( )0.18 CABG18, ( )0.26 Any Revascularization18, ( )0.11 NSTEMI patients Cardiac catheterization36, ( )0.71 PCI36, ( )0.18 CABG36, ( ) Any Revascularization36, ( )0.002 Adjusted Odds Ratios for InvasiveTherapies in Patients Arriving during Off-hours vs. Regular hours Jneid, H. et al. Circulation May 2008, Table 3.

22 © 2008, American Heart Association. All rights reserved. Results In-hospital Mortality (%) 2.1% (133) 2.3% (117) 5.2% (647) 4.8% (520) 12.0% (1,371) 12.2% (1,247) In-hospital Mortality across Age Subgroups with respect to Hospital Arrival Time Jneid, H. et al. Circulation May 2008, figure 2..

23 © 2008, American Heart Association. All rights reserved. Results In-Hospital Mortality in Men and Women with Respect to Arrival time In-hospital Mortality (%) 6.0% (1,094) 6.2% (968) 8.7% (1,051) 8.9% (912) Jneid, H. et al. Circulation May 2008, figure 2..

24 © 2008, American Heart Association. All rights reserved. Conclusions I n this large cohort study of 62,814 patients with AMI from the multicenter GWTG-CAD database, we found that arrival during off-hours was associated with slightly lower rates of primary PCI and revascularization during the initial hospitalization, and significantly longer Door-to-Balloon times.I n this large cohort study of 62,814 patients with AMI from the multicenter GWTG-CAD database, we found that arrival during off-hours was associated with slightly lower rates of primary PCI and revascularization during the initial hospitalization, and significantly longer Door-to-Balloon times. There were no measurable differences in in-hospital mortality in the overall AMI cohort, and in the STEMI and NSTEMI subpopulations.There were no measurable differences in in-hospital mortality in the overall AMI cohort, and in the STEMI and NSTEMI subpopulations. Similar observations were made across most age and sex subgroups and using an alternative definition for arrival time (weekends/holidays vs. weekdays).Similar observations were made across most age and sex subgroups and using an alternative definition for arrival time (weekends/holidays vs. weekdays). Jneid, H. et al. Circulation May 2008.

25 © 2008, American Heart Association. All rights reserved. Conclusions Healthcare providers should continue to work to enhance the healthcare system during regular and off-hours and reduce existing disparities in cardiac care through multifaceted initiatives aiming to improve the timely delivery of evidence- based therapies. Jneid, H. et al. Circulation May 2008.

26 © 2008, American Heart Association. All rights reserved. AUTHORS: Hani Jneid, Gregg C. Fonarow, Christopher P. Cannon, Igor F. Palacios, Teoman Kilic, George V. Moukarbel, Andrew O. Maree, Kenneth A LaBresh, Li Liang, L. Kristin Newby, Gerald Fletcher, Laura Wexler, Eric Peterson; for the Get With The Guidelines Steering Committee and Investig AUTHORS: Hani Jneid, Gregg C. Fonarow, Christopher P. Cannon, Igor F. Palacios, Teoman Kilic, George V. Moukarbel, Andrew O. Maree, Kenneth A LaBresh, Li Liang, L. Kristin Newby, Gerald Fletcher, Laura Wexler, Eric Peterson; for the Get With The Guidelines Steering Committee and Investigators From the Massachusetts General Hospital and Harvard Medical School, Boston, MA (Drs Jneid, Palacios, Kilic, Moukarbel, and Maree); UCLA Medical Center, Los Angeles, CA (Dr Fonarow); TIMI Group and BWH, Boston, MA (Dr Cannon); Masspro, Inc., Waltham, Massachusetts, USA (Dr. LaBresh); Duke Clinical Research Institute and Duke University Medical Center, Durham, NC (Drs Liang, Newby, and Peterson); Mayo Clinic, Jacksonville, FL (Dr. Fletcher); University of Cincinnati College of Medicine, Cincinnati, OH (Dr Wexler) Jneid, H. et al. Circulation May 2008

27 © 2008, American Heart Association. All rights reserved. Funding/Support This analysis and publication is supported by a grant from the Council on Clinical Cardiology of the American Heart Association. The GWTG-CAD program is funded in part by the Merck Schering Plough partnership. Data collection and management was performed by Outcome, Inc (Cambridge, MA). The analysis of registry data was preformed at Duke Clinical Research Institute (Durham, NC), which also receives funding from the American Heart Association. Jneid, H. et al. Circulation May 2008

28 © 2008, American Heart Association. All rights reserved. Disclosures Dr. Hani Jneid has received a database research seed grant from the Council on Clinical Cardiology. Dr. Gregg C. Fonarow serves as chair of the American Heart Association's Get With the Guidelines Steering Committee. Dr. Christopher Cannon serves as the chair of the American Heart Association's Get With the Guidelines Steering Science Sub- Committee. Dr. Eric Peterson is the Associated Director of the Duke Clinical Research Institute, which also receives funding from the American Heart Association. Jneid, H. et al. Circulation May 2008

29 © 2008, American Heart Association. All rights reserved. Publication ahead of Print Reference Jneid H, Fonarow GC, Cannon CP, Palacios IF, Kilic T, Moukarbel GV, Maree AO, LaBresh KA, Liang L, Newby LK, Fletcher G, Wexler L, Peterson E, for the Get With the Guidelines Steering Committee and Investigators Impact of Time of Presentation on the Care and Outcomes of Acute Myocardial Infarction. Circulation 2008: published online before print April 21, 2008, /CIRCULATIONAHA


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