Time to Reperfusion for In-Hospital STEMI: Dramatic Gains Achievable with Comprehensive Protocol

Implementing a comprehensive protocol for treatment of in-hospital ST elevation myocardial infarction (STEMI) yielded a 45 percent decrease in ECG-to-balloon time at Cleveland Clinic and doubled the percentage of patients treated within the guideline-recommended 90-minute time window. So finds a Cleveland Clinic analysis presented at the American College of Cardiology’s 67th Scientific Session (ACC.18).

“Patients with STEMI during hospitalization are a high-risk, vulnerable population who tend to experience delays in reperfusion relative to patients who present to the emergency department with STEMI,” says the study’s senior author, Umesh Khot, MD, Vice Chair of Cardiovascular Medicine at Cleveland Clinic.

“Recognizing this, we implemented a comprehensive STEMI protocol for hospitalized patients at our institution in July 2014,” notes co-author Samir Kapadia, MD, Director of Cleveland Clinic’s Sones Cardiac Catheterization Laboratory. Main features of the protocol included:

• A nursing chest pain protocol
• Improved access to ECGs in the electronic medical record
• A checklist for initial triage and management
• Commitment to ensuring cath lab readiness on a 24/7 basis
• Use of a “radial artery first” approach for access during primary percutaneous coronary intervention (PPCI)

“To determine the protocol’s effectiveness, we reviewed consecutive cases of STEMI among hospitalized patients treated with PPCI at our institution from the beginning of 2011 through the end of 2016,” says co-author Chetan Huded, MD, MSc, who presented the study at ACC.18. “We compared time to reperfusion — measured as the time from ECG to balloon inflation — before and after implementation of the protocol.”

Among the 79 patients with in-hospital STEMI during the six-year study period, 48 (61 percent) were managed before the protocol and 31 (39 percent) after protocol implementation. Mean age was 65 ± 14 years, and 60 percent of patients were men.

Key outcomes were as follows:

• Use of radial access for PPCI increased from 17 percent during the pre-protocol period to 71 percent in the post-protocol period (P < .001).
• Median ECG-to-balloon time declined from 107 minutes (interquartile range [IQR] = 118 minutes) before the protocol to 60 minutes (IQR = 35 minutes) after the protocol (P < .001).
• The proportion of patients with an ECG-to-balloon time within the guideline-recommended window of 90 minutes or less rose from 39.1 percent before the protocol to 87.1 percent after the protocol (P < .001).

The study’s findings are timely, as they come in the wake of a special communication from the In-Hospital STEMI Quality Improvement Project published by JAMA Cardiology in February 2018. That report notes that while in-hospital STEMI carries mortality rates tenfold higher than those for out-of-hospital STEMI, “few [hospitals] have established systems for the recognition, triage and treatment of in-hospital STEMI.”

“The In-Hospital STEMI Quality Improvement Project concluded its communication with a call for quality improvement projects and protocols to expedite care and improve outcomes from STEMI in this highly vulnerable patient population,” says Dr. Khot. “Cleveland Clinic is proud to share our relevant experience from this new study. We look forward to opportunities to exchange insights with other organizations to help define best practices for better addressing this population’s unmet needs.”