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. 2020 Mar;9(1_suppl):34-44.
doi: 10.1177/2048872618813907. Epub 2018 Nov 27.

Prognostic significance of emergency department bypass in stable and unstable patients with ST-segment elevation myocardial infarction

Karl Heinrich Scholz  1 , Tim Friede  2   3 , Thomas Meyer  3   4 , Claudius Jacobshagen  3   5 , Björn Lengenfelder  6   7 , Jens Jung  8 , Claus Fleischmann  9 , Hiller Moehlis  10 , Hans G Olbrich  11 , Rainer Ott  12 , Albrecht Elsässer  13 , Stephen Schröder  14 , Christian Thilo  15 , Werner Raut  16 , Andreas Franke  17 , Lars S Maier  18 , Sebastian Kg Maier  7   19
Affiliations

Prognostic significance of emergency department bypass in stable and unstable patients with ST-segment elevation myocardial infarction

Karl Heinrich Scholz et al. Eur Heart J Acute Cardiovasc Care. 2020 Mar.

Abstract

Background: In ST-segment elevation myocardial infarction (STEMI) patients treated with percutaneous coronary intervention, direct transport from the scene to the catheterisation laboratory bypassing the emergency department has been shown to shorten times to reperfusion. The aim of this study was to investigate the effects of emergency department bypass on mortality in both haemodynamically stable and unstable STEMI patients.

Methods: The analysis is based on a large cohort of STEMI patients prospectively included in the German multicentre Feedback Intervention and Treatment Times in ST-Elevation Myocardial Infarction (FITT-STEMI) trial.

Results: Out of 13,219 STEMI patients who were brought directly from the scene by emergency medical service transportation and were treated with percutaneous coronary intervention, the majority were transported directly to the catheterisation laboratory bypassing the emergency department (n=6740, 51% with emergency department bypass). These patients had a significantly lower in-hospital mortality than their counterparts with no emergency department bypass (6.2% vs. 10.0%, P<0.0001). The reduced mortality related to emergency department bypass was observed in both stable (n=11,594, 2.8% vs. 3.8%, P=0.0024) and unstable patients presenting with cardiogenic shock (n=1625, 36.3% vs. 46.2%, P<0.0001). Regression models adjusted for the Thrombolysis In Myocardial Infarction (TIMI) risk score consistently confirmed a significant and independent predictive effect of emergency department bypass on survival in the total study population (odds ratio 0.64, 95% confidence interval 0.56-0.74, P<0.0001) and in the subgroup of shock patients (OR 0.69, 95% CI 0.54-0.88, P=0.0028).

Conclusion: In STEMI patients, emergency department bypass is associated with a significant reduction in mortality, which is most pronounced in patients presenting with cardiogenic shock. Our data encourage treatment protocols for emergency department bypass to improve the survival of both haemodynamically stable patients and, in particular, unstable patients. Clinical Trial Registration: NCT00794001 ClinicalTrials.gov: NCT00794001.

Keywords: ST-segment elevation myocardial infarction (STEMI); bypassing emergency department; cardiogenic shock; mortality; outcome; percutaneous coronary intervention (PCI); treatment times.

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Conflict of interest statement

Conflict of interest: Tim Friede reports personal fees for consultancies (including data monitoring committees) from Novartis, Bayer, Biogen, AstraZeneca, Janssen, Grünenthal, Pharmalog, SGS and Roche, all outside the submitted work. Furthermore, he has received research funding by the European Commission for statistical analyses on the EUTrigTreat (NCT01209494) and EU-CERT-ICD (NCT02064192) clinical studies. All relationships declared are modest. All other authors declare no conflict of interest.

Figures

Figure 1.
Figure 1.
Flow diagram of the FITT–STEMI study cohort.
Figure 2.
Figure 2.
Frequencies of door-to-balloon time intervals as demonstrated by histograms separately for percutaneous coronary intervention (PCI)-treated ST-segment elevation myocardial infarction (STEMI) patients with direct transfer to the catheterisation laboratory bypassing the emergency department (ED) (a) and with indirect transfer to the catheterisation laboratory due to a transient stop in the ED (b).
Figure 3.
Figure 3.
Mortality rates in percutaneous coronary intervention (PCI)-treated ST-segment elevation myocardial infarction (STEMI) patients with (blue columns) and without (red columns) emergency department bypass by cardiogenic shock (a) and predefined Thrombolysis In Myocardial Infarction (TIMI) risk score intervals (b). Significant group differences are marked with asterisks.
See this image and copyright information in PMC

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