September 20th, 2011

Slow Spots in Transfer of Primary PCI Patients

In recent years great progress has been made in speeding the delivery of primary PCI to STEMI patients, but lingering problems remain, especially involving the transfer of patients from centers without primary PCI capability. A new study published in Circulation helps to identify the precise causes for delays with these patients.

Michael Miedema and colleagues analyzed data from 2034 patients transferred to the Minneapolis Heart Institute from March 2003 to December 2009. Some 30.4% of patients received treatment within 90 minutes and 65.7% within 2 hours.

Of the patients, 64.0% experienced delays at the referral hospital. Other major occasions of delay were at the primary PCI center (15.7% of patients) and during transfer (12.6% of patients). Delays were most frequently caused by lack of transportation (26.4%) and delays in the ED (14.3%). The longest mean delays were caused by diagnostic dilemmas (95.5 minutes) and nondiagnostic initial ECGs (81 minutes).

In their discussion, the researchers point out that “the cause of the delay may be more important than the actual length of delay” and emphasize that “clinical outcomes vary significantly according to the reason for the delay, and that not all delays are STEMI system dependent.” Most cases of cardiogenic shock or cardiac arrest, for instance, are not a result of a delay but more likely are the cause of a delay, they write. In a press release from the AHA, senior study author Timothy Henry points out that higher-risk patients have the worst outcome and that this phenomenon is related to their advanced disease state and may not be related to a delay in treatment.

The authors write that their study supports a goal for total door-to-balloon time of 120 minutes for transferred STEMI patients.

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