J. Lee Garvey

Bedside Multimarker Testing for Risk Stratification in Chest Pain Units

Background—Earlier, rapid evaluation in chest pain units may make patient care more efficient. A multimarker strategy (MMS) testing for several markers of myocardial necrosis with different time-to...BackgroundEarlier, rapid evaluation in chest pain units may make patient care more efficient. A multimarker strategy (MMS) testing for several markers of myocardial necrosis with different time-to-positivity profiles also may offer clinical advantages. Methods and ResultsWe prospectively compared bedside quantitative multimarker testing versus local laboratory results (LL) in 1005 patients in 6 chest pain units. Myoglobin, creatine kinase-MB, and troponin I were measured at 0, 3, 6, 9 to 12, and 16 to 24 hours after admission. Two MMS were defined: MMS-1 (all 3 markers) and MMS-2 (creatine kinase-MB and troponin I only). The primary assessment was to relate marker status with 30-day death or infarction. More patients were positive by 24 hours with MMS than with LL (MMS-1, 23.9%; MMS-2, 18.8%; LL, 8.8%;P =0.001, all comparisons), and they became positive sooner with MMS-1 (2.5 hours, P =0.023 versus LL) versus MMS-2 (2.8 hours, P =0.026 versus LL) or LL (3.4 hours). The relation between baseline MMS status and 30-day death or infarction was stronger (MMS-1: positive, 18.8% event rate versus negative, 3.0%, P =0.001; MMS-2: 21.9% versus 3.2%, P =0.001) than that for LL (13.6% versus 5.5%, P =0.038). MMS-1 discriminated 30-day death better (positive, 2.0% versus negative, 0.0%, P =0.007) than MMS-2 (positive, 1.8% versus negative, 0.2%;P =0.055) or LL (positive, 0.0% versus negative, 0.5%;P =1.000). ConclusionsRapid multimarker analysis identifies positive patients earlier and provides better risk stratification for mortality than a local laboratory-based, single-marker approach.

The Impact of a Statewide Pre-Hospital STEMI Strategy to Bypass Hospitals Without Percutaneous Coronary Intervention Capability on Treatment Times

Background— The ultimate treatment goal for ST-segment elevation myocardial infarction (STEMI) is rapid reperfusion via primary percutaneous intervention (PCI). North Carolina has adopted a statewide STEMI referral strategy that advises paramedics to bypass local hospitals and transport STEMI patients directly to a PCI-capable hospital, even if a non-PCI-capable hospital is closer. Methods and Results— We assessed the adherence of emergency medical services to this STEMI protocol, as well as subsequent associations with patient treatment times and outcomes by linking data from the Acute Coronary Treatment and Intervention Outcomes Network Registry®—Get With the Guidelines™ and a statewide emergency medical services data system from June 2008 to September 2010 for all patients with STEMI. Patients were divided into those (1) transported directly to a PCI hospital, thereby bypassing a closer non-PCI hospital and (2) first taken to a closer non-PCI center and later transferred to a PCI hospital. Among 6010 patients with STEMI, 1288 were eligible and included in our study cohort. Of these, 826 (64%) were transported directly to a PCI facility, whereas 462 (36%) were first taken to a non-PCI hospital and later transferred. In a multivariable model, increase in differential driving time and cardiac arrest were associated with a lesser likelihood of being taken directly to a PCI center, whereas a history of PCI was associated with a higher likelihood of being taken directly to a PCI center. Patients sent directly to a PCI center were more likely to have times between first medical contact and PCI within guideline recommendations. Conclusions— We found that patients who were sent directly to a PCI center had significantly shorter time to reperfusion.

Pretest probability assessment derived from attribute matching

BackgroundPretest probability (PTP) assessment plays a central role in diagnosis. This report compares a novel attribute-matching method to generate a PTP for acute coronary syndrome (ACS). We compare the new method with a validated logistic regression equation (LRE).MethodsEight clinical variables (attributes) were chosen by classification and regression tree analysis of a prospectively collected reference database of 14,796 emergency department (ED) patients evaluated for possible ACS. For attribute matching, a computer program identifies patients within the database who have the exact profile defined by clinician input of the eight attributes. The novel method was compared with the LRE for ability to produce PTP estimation <2% in a validation set of 8,120 patients evaluated for possible ACS and did not have ST segment elevation on ECG. 1,061 patients were excluded prior to validation analysis because of ST-segment elevation (713), missing data (77) or being lost to follow-up (271).ResultsIn the validation set, attribute matching produced 267 unique PTP estimates [median PTP value 6%, 1st–3rd quartile 1–10%] compared with the LRE, which produced 96 unique PTP estimates [median 24%, 1st–3rd quartile 10–30%]. The areas under the receiver operating characteristic curves were 0.74 (95% CI 0.65 to 0.82) for the attribute matching curve and 0.68 (95% CI 0.62 to 0.77) for LRE.The attribute matching system categorized 1,670 (24%, 95% CI = 23–25%) patients as having a PTP < 2.0%; 28 developed ACS (1.7% 95% CI = 1.1–2.4%). The LRE categorized 244 (4%, 95% CI = 3–4%) with PTP < 2.0%; four developed ACS (1.6%, 95% CI = 0.4–4.1%).ConclusionAttribute matching estimated a very low PTP for ACS in a significantly larger proportion of ED patients compared with a validated LRE.

Expansion of a Regional ST-Segment Elevation Myocardial Infarction System to an Entire State

Background— Despite national guidelines calling for timely coronary artery reperfusion, treatment is often delayed, particularly for patients requiring interhospital transfer. Methods and Results— One hundred nineteen North Carolina hospitals developed coordinated plans to rapidly treat patients with ST-segment–elevation myocardial infarction according to presentation: walk-in, ambulance, or hospital transfer. A total of 6841 patients with ST-segment–elevation myocardial infarction (3907 directly presenting to 21 percutaneous coronary intervention hospitals, 2933 transferred from 98 non–percutaneous coronary intervention hospitals) were treated between July 2008 and December 2009 (age, 59 years; 30% women; 19% uninsured; chest pain duration, 91 minutes; shock, 9.2%). The rate of patients not receiving reperfusion fell from 5.4% to 4.0% (P=0.04). Treatment times for hospital transfer patients substantially improved. First-hospital-door-to-device time for hospitals that adopted a “transfer for percutaneous coronary intervention” reperfusion strategy fell from 117 to 103 minutes (P=0.0008), whereas times at hospitals with a mixed strategy of transfer or fibrinolysis fell from 195 to 138 minutes (P=0.002). Median door-to-device times for patients presenting directly to PCI hospitals fell from 64 to 59 minutes (P<0.001). Emergency medical services–transported patients were most likely to reach door-to-device goals, with 91% treated within 90 minutes and 52% being treated with 60 minutes. Patients treated within guideline goals had a mortality of 2.2% compared with 5.7% for those exceeding guideline recommendations (P<0.001). Conclusion— Through extension of regional coordination to an entire state, rapid diagnosis and treatment of ST-segment–elevation myocardial infarction has become an established standard of care independently of healthcare setting or geographic location.

Impact of a Statewide ST-Segment–Elevation Myocardial Infarction Regionalization Program on Treatment Times for Women, Minorities, and the Elderly

Background—Prior studies have demonstrated differences in time to reperfusion for ST-segment–elevation myocardial infarction (STEMI) in women, minorities, and the elderly, relative to their counterparts. Regionalization has been shown to improve overall STEMI treatment times, but its impact on care differences among these important patient subgroups is unknown. The objective of this analysis was to assess the impact of a statewide system of STEMI care (The Reperfusion of Acute Myocardial Infarction in North Carolina Emergency Departments) on treatment times according to patient sex, race, and age. Methods and Results—STEMI treatment times were determined before (July 2005 to September 2005) and after (January 2007 to March 2007) a year-long implementation of coordinated regional treatment protocols. Times in the pre- and postintervention periods were compared by mixed-effects models. A total of 2063 STEMI patients were analyzed: 1140 at percutaneous coronary intervention hospitals and 923 at non–percutaneous coronary intervention hospitals. The Reperfusion of Acute Myocardial Infarction in North Carolina Emergency Departments was associated with significant improvements in treatment times in women and the elderly, including door-to-ECG, door-to-device, door-in–door-out, and door-to-needle times (all P<0.05). Temporal improvements in treatment times at percutaneous coronary intervention hospitals were not significantly different in blacks than in whites. There was a reduction in baseline treatment disparities in door-to-ECG times in women versus men (4.4-minute reduction in difference; 95% CI, −8.1 to −0.4; P=0.03). After Reperfusion of Acute Myocardial Infarction in North Carolina Emergency Departments, an age–treatment time gap persisted in the elderly, relative to younger patients. Conclusions—A statewide STEMI regionalization program was associated with comparable improvement in treatment times for female, black, and elderly patients compared with middle-aged, white male patients. Nevertheless, there remain opportunities to further narrow treatment differences, particularly among the elderly.

Care Processes Associated With Quicker Door-In–Door-Out Times for Patients With ST-Elevation–Myocardial Infarction Requiring Transfer Results From a Statewide Regionalization Program

Background—The ability to rapidly identify patients with ST-segment elevation–myocardial infarction (STEMI) at hospitals without percutaneous coronary intervention (PCI) and transfer them to hospitals with PCI capability is critical to STEMI regionalization efforts. Our objective was to assess the association of prehospital, emergency department (ED), and hospital processes of care implemented as part of a statewide STEMI regionalization program with door-in–door-out times at non-PCI hospitals. Methods and Results—Door-in–door-out times for 436 STEMI patients at 55 non-PCI hospitals were determined before (July 2005 to September 2005) and after (January 2007 to March 2007) a year-long implementation of standardized protocols as part of a statewide regionalization program (Reperfusion of Acute Myocardial Infarction in North Carolina Emergency Departments, RACE). The association of 8 system care processes (encompassing emergency medical services [EMS], ED, and hospital settings) with door-in–door-out times was determined using multivariable linear regression. Median door-in–door-out times improved significantly with the intervention (before: 97.0 minutes, interquartile range, 56.0 to 160.0 minutes; after: 58.0 minutes, interquartile range, 35.0 to 90.0 minutes; P<0.0001). Hospital, ED, and EMS care processes were each independently associated with shorter door-in–door-out times (−17.7 [95% confidence interval, −27.5 to −7.9]; −10.1 [95% confidence interval, −19.0 to −1.1], and −7.3 [95% confidence interval, −13.0 to −1.5] minutes for each additional hospital, ED, and EMS process, respectively). Combined, adoption of EMS processes was associated with the shortest median treatment times (44 versus 138 minutes for hospitals that adopted all EMS processes versus none). Conclusions—Prehospital, ED, and hospital processes of care were independently associated with shorter door-in–door-out times for STEMI patients requiring transfer. Adoption of several EMS processes was associated with the largest reduction in treatment times. These findings highlight the need for an integrated, system-based approach to improving STEMI care.

Chest Pain Center Accreditation Is Associated With Better Performance of Centers for Medicare and Medicaid Services Core Measures for Acute Myocardial Infarction

The aim of this study was determine whether hospitals accredited by the Society of Chest Pain Centers hospitals (accredited chest pain centers [ACPCs]) are associated with better performance regarding Centers for Medicare and Medicaid Services core measures for acute myocardial infarction (AMI) than nonaccredited hospitals. The study was a retrospective, observational cohort study of hospitals reporting Centers for Medicare and Medicaid Services core measures for AMI from January 1, 2005, to December 31, 2005, on the basis of the presence or absence of Society of Chest Pain Centers accreditation. Data were obtained from the Web sites of the Centers for Medicare and Medicaid Services (Hospital Compare), Society of Chest Pain Centers listings, and the American Hospital Directory. Groups were compared in terms of demographics and mean percentage compliance with all 8 AMI core measures. Students t test, chi-square analysis, and logistic regression were used to analyze bivariate relations. Multivariate logistic regression models used a propensity-score adjustment factor. Of the 4,197 hospitals that reported core measures for AMI, 178 (4%) were accredited and 4,019 (96%) were not. ACPCs had been accredited for an average of 12 months and were larger (378 vs 204 beds), more often teaching hospitals (52% vs 30%), and more often urban (95% vs 69%) (all p <0.0001). There were 395,250 patients with AMIs, of whom 55,418 (14%) presented to ACPCs and 339,832 (86%) presented to nonaccredited hospitals. There was significantly greater compliance with all 8 AMI core measures at ACPCs (p <0.0001), except for lytic therapy <30 minutes after arrival (p = 0.04), for which unadjusted performance was the same. In conclusion, ACPCs were associated with better compliance with Centers for Medicare and Medicaid Services core measures and saw a greater proportion of patients with AMIs.

Association of neighborhood characteristics with incidence of out-of-hospital cardiac arrest and rates of bystander-initiated CPR: Implications for community-based education intervention

OBJECTIVE A 10-fold regional variation in survival after out-of-hospital cardiac arrest (OHCA) has been reported in the United States, which partly relates to variability in bystander cardiopulmonary resuscitation (CPR) rates. In order for resources to be focused on areas of greatest need, we conducted a geospatial analysis of variation of CPR rates. METHODS Using 2010-2011 data from Durham, Mecklenburg, and Wake counties in North Carolina participating in the Cardiac Arrest Registry to Enhance Survival (CARES) program, we included all patients with OHCA for whom resuscitation was attempted. Geocoded data and logistic regression modeling were used to assess incidence of OHCA and patterns of bystander CPR according to census tracts and factors associated herewith. RESULTS In total, 1466 patients were included (median age, 65 years [interquartile range 25]; 63.4% men). Bystander CPR by a layperson was initiated in 37.9% of these patients. High-incidence OHCA areas were characterized partly by higher population densities and higher percentages of black race as well as lower levels of education and income. Low rates of bystander CPR were associated with population composition (percent black: OR, 3.73; 95% CI, 2.00-6.97 per 1% increment in black patients; percent elderly: 3.25; 1.41-7.48 per 1% increment in elderly patients; percent living in poverty: 1.77, 1.16-2.71 per 1% increase in patients living in poverty). CONCLUSIONS In 3 counties in North Carolina, areas with low rates of bystander CPR can be identified using geospatial data, and education efforts can be targeted to improve recognition of cardiac arrest and to augment bystander CPR rates.

Nationwide Analysis of Patients With ST-Segment–Elevation Myocardial Infarction Transferred for Primary Percutaneous Intervention: Findings From the American Heart Association Mission: Lifeline Program

Background—Current American College of Cardiology/American Heart Association guidelines recommend transfer and primary percutaneous coronary intervention (PCI) for ST-segment–elevation myocardial infarction (STEMI) patients within the time limit of first contact to device ⩽120 minutes. We determined the hospital-level, patient-level, and process characteristics of timely versus delayed primary PCI for a diverse national sample of transfer patients confined to a travel distance that facilitates the process. Methods and Results—We studied 14 518 patients transferred from non–PCI-capable hospitals for primary PCI to 398 National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines hospitals between July 2008 and December 2012. Patients with estimated transfer times >60 minutes (by Google Maps driving times) were excluded from the analysis. Patients achieving first door-to-device time ⩽120 minutes were compared with patients with delayed treatment; independent predictors of timely treatment were determined using generalized estimating equations logistic regression models. The median estimated transfer distance was 26.5 miles. First door-to-device ⩽120 minutes was achieved in 65% of patients (n=9380); only 37% of the hospitals were high-performing hospitals (defined as risk-adjusted rate, ≥75% of transfer STEMI patients with ⩽120-minute first door-to-device time). In addition to known predictors of delay (cardiogenic shock, cardiac arrest, and prolonged door-in door-out time), STEMI referral hospitals’ rural location and longer estimated transfer time were identified as predictors of delay. In this diverse national sample, regional and racial variations in care were observed. Finally, lower PCI hospital annual STEMI volume was a potent predictor of delay. Conclusions—More than one third of US STEMI patients transferred for primary PCI fail to achieve first door-to-device time ⩽120 minutes, despite estimated transfer times <60 minutes. Delays are related to process variables, comorbidities, and lower annual PCI hospital STEMI volumes.

Regional Systems of Care Demonstration Project: American Heart Association Mission: Lifeline STEMI Systems Accelerator.

Background: Up to 50% of patients fail to meet ST-segment–elevation myocardial infarction (STEMI) guideline goals recommending a first medical contact–to–device time of <90 minutes for patients directly presenting to percutaneous coronary intervention–capable hospitals and <120 minutes for transferred patients. We sought to increase the proportion of patients treated within guideline goals by organizing coordinated regional reperfusion plans. Methods: We established leadership teams, coordinated protocols, and provided regular feedback for 484 hospitals and 1253 emergency medical services (EMS) agencies in 16 regions across the United States. Results: Between July 2012 and December 2013, 23 809 patients presented with acute STEMI (direct to percutaneous coronary intervention hospital: 11 765 EMS transported and 6502 self-transported; 5542 transferred). EMS-transported patients differed from self-transported patients in symptom onset to first medical contact time (median, 47 versus 114 minutes), incidence of cardiac arrest (10% versus 3%), shock on admission (11% versus 3%), and in-hospital mortality (8% versus 3%; P <0.001 for all comparisons). There was a significant increase in the proportion of patients meeting guideline goals of first medical contact–to–device time, including those directly presenting via EMS (50% to 55%; P <0.001) and transferred patients (44%−48%; P =0.002). Despite regional variability, the greatest gains occurred among patients in the 5 most improved regions, increasing from 45% to 57% (direct EMS; P <0.001) and 38% to 50% (transfers; P <0.001). Conclusions: This Mission: Lifeline STEMI Systems Accelerator demonstration project represents the largest national effort to organize regional STEMI care. By focusing on first medical contact–to–device time, coordinated treatment protocols, and regional data collection and reporting, we were able to increase significantly the proportion of patients treated within guideline goals. # Clinical Perspective {#article-title-31}Background: Up to 50% of patients fail to meet ST-segment–elevation myocardial infarction (STEMI) guideline goals recommending a first medical contact–to–device time of <90 minutes for patients directly presenting to percutaneous coronary intervention–capable hospitals and <120 minutes for transferred patients. We sought to increase the proportion of patients treated within guideline goals by organizing coordinated regional reperfusion plans. Methods: We established leadership teams, coordinated protocols, and provided regular feedback for 484 hospitals and 1253 emergency medical services (EMS) agencies in 16 regions across the United States. Results: Between July 2012 and December 2013, 23 809 patients presented with acute STEMI (direct to percutaneous coronary intervention hospital: 11 765 EMS transported and 6502 self-transported; 5542 transferred). EMS-transported patients differed from self-transported patients in symptom onset to first medical contact time (median, 47 versus 114 minutes), incidence of cardiac arrest (10% versus 3%), shock on admission (11% versus 3%), and in-hospital mortality (8% versus 3%; P<0.001 for all comparisons). There was a significant increase in the proportion of patients meeting guideline goals of first medical contact–to–device time, including those directly presenting via EMS (50% to 55%; P<0.001) and transferred patients (44%−48%; P=0.002). Despite regional variability, the greatest gains occurred among patients in the 5 most improved regions, increasing from 45% to 57% (direct EMS; P<0.001) and 38% to 50% (transfers; P<0.001). Conclusions: This Mission: Lifeline STEMI Systems Accelerator demonstration project represents the largest national effort to organize regional STEMI care. By focusing on first medical contact–to–device time, coordinated treatment protocols, and regional data collection and reporting, we were able to increase significantly the proportion of patients treated within guideline goals.