What is the clinical evidence from this study?

Study design: Cohort. Population: ST-segment elevation myocardial infarction (STEMI) (n=3608). Intervention: Travel time from home to hospital above the median vs. Travel time below or equal to the median. Primary outcome: 30-day all-cause mortality (OR 2.46, 95% CI 1.25-4.86, p=0.009).

June 23, 2016Open Access

The Tradeoff between Travel Time from Home to Hospital and Door to Balloon Time in Determining Mortality among STEMI Patients Undergoing PCI

RDRiccardo Di DomenicantonioASL Roma GCGiovanna CappaiRegione Campania PSPaolo SciattellaUniversity of Rome Tor Vergata

Key Result

Among STEMI patients with a system delay of 90 minutes or less, travel time to the hospital above the median was associated with a significantly higher risk of 30-day mortality (OR 2.46).

Study Design

Type

Cohort (n=3,608)

Multicenter

Yes

Structured PICO

Does travel time from home to hospital affect 30-day mortality in STEMI patients undergoing PCI with door-to-balloon times within 120 minutes?

Population

3,608 patients aged 35 to 100 years with STEMI who underwent percutaneous coronary intervention within a 120-minute door-to-balloon time, evaluated for 30-day mortality.

Exposure

Travel time from home to hospital above the median

Comparator

Travel time from home to hospital below the median

Outcome

Death (all-cause mortality) within 30-days from the date of the PCIhard clinical

Longer travel time from home to hospital significantly increases 30-day mortality in STEMI patients undergoing PCI, even when door-to-balloon times are within guideline-recommended targets.

Main Result

Odds Ratio: 2.46 (95% CI 1.25–4.86)

p-value: p=0.009

Limitations

Travel times adjusted for traffic effects may differ from actual travel times, especially in metropolitan areas.
Possible misclassification of travel times since not all patients are at their place of residence when STEMI occurs.
Use of travel time for patients transported by EMS, who may have worse clinical status.
Lack of clinical information such as presence of anterior STEMI, culprit artery, and timing of antiplatelets.
Potential survival bias as the study only includes patients who survived the pre-hospital phase.

Abstract

BACKGROUND: In ST-segment elevation myocardial infarction (STEMI), even in presence of short door to balloon time (DTBT), timely reperfusion with percutaneous coronary intervention (PCI) is hampered by pre-hospital delays. Travel time (TT) constitutes a relevant part of these delays and may contribute to worse outcomes. OBJECTIVE: To evaluate the relationship between TT from home to hospital and DTBT on 30-day mortality after PCI among patients with STEMI. METHODS: We enrolled a cohort of 3,608 STEMI patients with a DTBT within 120 minutes who underwent PCI between years 2009 and 2013 in Lazio Region (Italy). We calculated the minimum travel time from residential address to emergency department where the first medical contact occurred. We defined system delay as the sum of travel time and DTBT time. Logistic regression models, including clinical and demographic characteristics were used to estimate the effect of TT and DTBT on mortality. RESULTS: Among patients with 0-90 minutes of system delay, TT above the median value is positively associated with mortality (OR = 2.46; P = 0.009). Survival benefit associated with DTBT below the median results only among patients with TT below the median (OR for DTBT below the median = 0.39; P = 0.013), (OR for interaction between TT and DTBT = 2.36; p = 0.076). CONCLUSION: TT affects survival after PCI for STEMI, even in the presence of health care systems compliant with current guidelines. Results emphasize the importance of health system initiatives to reduce pre-hospital delay. Utilization of TT can contribute to a better estimate of patient mortality risk in the evaluation of quality of care.

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