Pre-activating cath labs speeds reperfusion, boosts survival for STEMI patients
ST-segment elevation myocardial infarction (STEMI) patients have better odds of survival if emergency medical services (EMS) personnel alert the hospital where the patient will be arriving ahead of time, according to a study published Sept. 17 in JACC: Cardiovascular Interventions. But catheterization labs in the U.S. are notified at least 10 minutes in advance in only 41 percent of cases, researchers found.
“Cath lab pre-activation is currently defined and measured simply by whether or not it occurred, regardless of its timing in relation to hospital arrival,” lead study author Jay S. Shavadia, MD, a cardiologist and researcher with Duke University Medical Center and Duke Clinical Research Institute, said in a press release. “But our results suggest that the amount of notification provided is very important—if the pre-activation occurs less than 10 minutes before the patient is transported, it does not offer as much benefit to the patient.”
Using a nationwide registry, Shavadia and colleagues studied 27,840 STEMI patients who were transported to 744 percutaneous coronary intervention (PCI)-capable hospitals. They used a 10-minute notification window to define cath lab pre-activation because it represented a “reasonable amount of advanced notification required to prepare the catheterization laboratory and its staff to significantly influence reperfusion timing.”
Unsurprisingly, an early notification resulted in significantly shorter reperfusion times, and hospitals with higher pre-activation rates achieved lower in-hospital mortality rates. That association remained regardless of whether patients were treated during normal work hours or “off hours,” Shavadia et al. reported.
Compared with a notification less than 10 minutes prior to arrival or not at all, EMS notification at least 10 minutes before patient arrival was associated with:
- A greater likelihood patients would be transported directly to the cath lab upon hospital arrival (23.3 percent versus 5.3 percent).
- A shorter time between hospital arrival and stent implantation (median of 40 minutes versus a median of 52 minutes).
- A greater likelihood of stent implantation occurring less than 90 minutes after the first documented EMS contact with the patient (76.6 percent versus 68.6 percent).
- A trend toward lower in-hospital mortality (2.8 percent versus 3.4 percent). Patients treated at hospitals in the lowest tertile of pre-activation rates had 33 percent greater in-hospital mortality than those in the highest tertile (3.6 percent versus 2.7 percent).
“We know that shorter door-to-device times improve patient outcomes,” JACC: Cardiovascular Interventions editor-in-chief David J. Moliterno, MD, said in the release. “These findings show that even a 10-minute delay in cath lab notification may lead to increased door-to-device times. Improving coordination between EMS and PCI hospitals is necessary to reduce the time it takes to treat STEMI patients.”
The authors said there is a popular belief that cath lab pre-activation is unnecessary during normal work hours because staff is already available onsite, but this study suggests advanced notification of a STEMI patient’s arrival is important at all hours.
“Despite pre-activation, the majority of patients with STEMI continue to be first evaluated in the emergency department for both work-hour and off-hour presentations, with low rates of direct-to-catheterization laboratory transport,” they wrote. “The necessity of processes such as patient registration, emergency department physician assessment, and repeat electrocardiography for STEMI confirmation that make an emergency department stop necessary need to be reevaluated to further reduce reperfusion delays.”
Daniel joined TriMed’s Chicago editorial team in 2017 as a Cardiovascular Business writer. He previously worked as a writer for daily newspapers in North Dakota and Indiana.