Education Program Reduces STEMI-Symptom-to-Treatment Time

Reed Miller

November 24, 2010

November 24, 2010 (Chicago, Illinois) — A regional network in Minnesota has reduced the total time from when a patient first feels the symptoms of MI until the balloon catheter reperfuses the blocked coronary, especially in rural areas far from PCI-capable hospitals [1].

Reducing the total time to reperfusion--the time from the first chest pain or other symptoms to reperfusion in the cath lab--is a critical goal for providers and researchers trying to improve outcomes in patients suffering an ST-segment elevation MI (STEMI).

However, most of the focus so far has been on decreasing the time from when patients first present to the hospital until they are reperfused, the so-called door-to-balloon time, because that is the part of the process the hospital or emergency medical services (EMS) staff can influence. The time it takes for the patient to reach medical care is mostly determined by the patients' decisions and hard to influence. Data from the National Registry of Myocardial Infarction (NRMI) between 1995 and 2004 shows that the mean time to presentation was 114 minutes from symptom onset and that less than one-third of patients arrive at the hospital within one hour of the onset of symptoms; about half take more than two hours, and almost 10% take at least 12 hours after the onset of symptoms to seek medical help.

So a network of 32 rural and community hospitals and 10 clinics throughout Minnesota has developed a regional STEMI system and led extensive training and public-education efforts focused on improving symptoms-to-presentation times in STEMI patients. The training included healthcare professionals and physicians involved in EMS in rural and community hospitals throughout the state. A public-education campaign has tried to increase local community awareness of STEMI and the importance of getting the patient to the hospital as fast as possible after symptoms begin.

The network established a standardized protocol for PCI in STEMI patients and collected data on the response times for patients in three groups. The first group is those patients who came directly to Abbott Northwestern Hospital in Minneapolis, a PCI hospital. Zone 1 included those hospitals and clinics that were up to 60 miles from the PCI center, and Zone 2 included centers 60 to 210 miles from the PCI hospital. The protocol called for all STEMI patients to get aspirin and 600-mg clopidogrel and an intravenous bolus of heparin when they first presented with MI symptoms. Patients in Zone 2 were also given lytic therapy. All patients were transported to the cath lab for reperfusion.

Results of the key time segments and in-hospital mortality for 2625 consecutive patients from 2003 to 2009 were reported by Dr Timothy D Henry (Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, MN) at the American Heart Association Scientific Sessions.

Median Reported Response Times (Minutes)

Time segment Abbott Northwestern, 599 Patients Zone 1, 1191 Patients Zone 2, 835 Patients P for Abbott Northwestern vs Zone 1/Abbott Northwestern vs Zone 2
Chest Pain Onset to Presentation 103 88 90 0.001/<0.001
Door-to-Balloon 62 94 122 <0.001/<0.001
Total Reperfusion Time 172 191 219 0.009/<0.001
In-Hospital Mortality 4.8% 4.8% 6.1% 096/0.2

As expected, the total door-to-balloon times were longer for patients who had to be transferred to a PCI center from the center they initially presented to, but patients in the rural and suburban areas where the community-education program was implemented had shorter average symptom-to-presentation times than people presenting directly to the major urban PCI center, which offset the longer door-to-balloon times somewhat. This may help to explain why longer door-to-balloon times in the rural areas did not lead to a significantly greater mortality rate.

Still Lots of Room for Improvement

"The most likely reason that the symptom-onset-to-hospital time is faster is this local community education," Henry told heartwire . He also pointed out that groups that had have slower symptom-to-presentation times in previous studies, such as women and older patients, did not have significantly slower response times in this study. He recalled that the REACT trial in 2000 found that an 18-month community-education effort was unable to change response times. The lack of success in REACT perhaps deterred further efforts to improve response times over the past 10 years, he suggested. But "we think these are really compelling data," that at least in small rural and community hospitals, improvement is possible.

Although the community-education effort appears to have made a significant impact, Henry said there is still plenty of room to improve the symptom-to-presentation times. "It's still an hour and a half [in most areas]. That's 30 minutes faster than the national average, and a half hour saves a lot of time, but there is an ongoing opportunity to improve on that." The need for more education on responding to heart-attack symptoms was also highlighted by the recent CRUSADE trial of non-STEMI response times in Minnesota, Henry noted. As reported by heartwire ,that study of 104 622 patients in 568 hospitals showed that about half of patients took more than two hours to get to the hospital.

Henry's group is also trying to improve the response times in the urban and nearby suburban areas, but it is more difficult to draw attention to their education efforts in larger media markets than in small towns where everyone reads the same local newspaper. "If you put an article in the paper about the local hospital and its new care for heart attacks, telling people that if they have chest pain to come to the hospital quickly, you can make a much bigger impact in that small rural community than in [a big city]," Henry said. "It starts with people with known coronary disease, doing good patient education with them," but it "continues to be a major challenge."