The time to reperfusion for patients with ST-segment elevation myocardial infarction (STEMI) varies significantly in the United States largely because of differences in the organization and delivery of emergency care. The Duke Clinical Research Institute (DCRI) partnered with the American Heart Association (AHA) on the Mission: Lifeline STEMI ACCELERATOR-2 Study to implement evidence-based protocols for timely reperfusion in STEMI patients.
James G. Jollis, MD, of Duke and the University of North Carolina at Chapel Hill, presented findings from the ACCELERATOR-2 project at the AHA's Scientific Sessions held November 11 to 15, 2017, in Anaheim, CA. Results of ACCELERATOR-2 were simultaneously published in Circulation. Other investigators involved in the study included Hussein Al-Khalidi, PhD, Mayme Lou Roettig, RN, MSN, Lisa Monk, RN, MSN, Shannon Doerfler, PhD, Ajar Kochar, MD, Jay Shavadia, MD, and Christopher Granger, MD, of Duke. Jollis, Granger, Roettig, and Michele Bolles, of AHA, composed the central organizing committee for ACCELERATOR-2.
Duke and AHA hypothesized that coordinated care at a regional level could reduce times to reperfusion and improve mortality rates. Recruitment of participating centers began in the second quarter of 2015. ACCELERATOR-2 identified regional leadership centers in 12 metropolitan statistical areas in the United States, which included 132 hospitals designated as primary percutaneous coronary intervention (PCI) capable (providing 24-hour care, 7 days a week) and 971 emergency medical services (EMS) agencies.
Regional leaders had to commit to common protocols for treating STEMI, participate in the ACTION Registry-Get With the Guidelines (AR-G) program, and enter consecutive STEMI patients into AR-G during the study period. A regional coordinator, not employed by local facilities, was chosen by local AHA representatives to oversee implementation of ACCELERATOR-2. Data collection and feedback on quarterly reports were key aspects of the study, as the reports pinpointed areas where protocols were not being applied and identified systemic barriers.
Between April 2015 and March 2017, a total of 10,730 STEMI patients were transported by EMS to a primary PCI facility. Of this initial cohort, 6,695 met AHA-specified inclusion criteria. Reasons for exclusion included cardiac arrest prior to PCI, intubation prior to PCI, vascular access difficulty, inability to cross the lesion, or delayed consent.
ACCELERATOR-2 assessed the time between first medical contact (FMC) and catheterization laboratory activation. Patients treated at the 132 primary PCI facilities in the baseline quarter (n = 974) were compared with those treated at the same hospitals in the final quarter of the study (n = 972). Symptom onset to FMC was a median of 50 minutes in both the baseline and final quarters.
There was a significant improvement in the time between FMC and catheterization laboratory activation over the study period. At baseline, FMC to catheterization laboratory activation was attained in 20 minutes or less for 38% of STEMI patients. In the final quarter, this short catheterization laboratory activation time was achieved for more than one-half of patients (56%; P < .0001). A corresponding increase was seen in patients who were quickly moved out of the emergency department (ED), with 43% of STEMI patients in the final quarter spending 20 minutes or less in the ED, an improvement from 33% at baseline.
TABLE 1. Comparison of FMC to Catheterization Laboratory Activation and ED Dwell Time
|Baseline, %||Final, %|
|FMC to Catheterization Laboratory Activation|
|≤ 20 min||38||56|
|>20 min to ≤ 30 min||24||22|
|> 30 min||38||22|
|ED Dwell Time|
|≤ 20 min||33||43|
|> 20 min to ≤ 30 min||25||24|
|> 30 min||42||33|
Faster treatment was associated with better mortality rates. Patients who had FMC to catheterization laboratory activation of 20 minutes or less had an in-hospital mortality rate of 2.2%. This is in comparison to 4.5% for catheterization laboratory activation of more than 20 minutes.
The national goal is for 75% of STEMI patients to undergo reperfusion within 90 minutes of FMC. At baseline, 67% of PCI facilities in ACCELERATOR-2 achieved an FMC to reperfusion time of 90 minutes or less; this improved to 74% of centers in the final quarter. Of note, 9 of the 12 regions improved their FMC to catheterization laboratory activation time, and 8 regions met the national goal of 75%.
Results from the ACCELERATOR-2 cohort (N = 6,695) were compared with those of STEMI patients treated at nonstudy hospitals during the study period. Patients treated at ACCELERATOR-2 facilities had significantly lower in-hospital mortality compared with controls (P = .019).
Jollis and colleagues attributed the success of ACCELERATOR-2 to having full-time regional coordinators. If broadly applied, ACCELERATOR-2 could make a significant contribution to reducing STEMI mortality rates across the United States. To that end, DCRI and AHA are making the operating manual for ACCELERATOR-2 publicly available to facilitate widespread adoption.
Source: Jollis JG, Al-Khalidi HR, Roettig ML, et al. Impact of regionalization of ST elevation myocardial infarction care on treatment times and outcomes for emergency medical services transported patients presenting to hospitals with percutaneous coronary intervention. Presented at: American Heart Association Scientific Sessions 2017; November 11-15, 2017; Anaheim, CA. Abstract LBS.06.