Elsevier

American Heart Journal

Volume 156, Issue 6, December 2008, Pages 1035-1044
American Heart Journal

Special Articles: NRMI 1990-2006
Trends in reperfusion strategies, door-to-needle and door-to-balloon times, and in-hospital mortality among patients with ST-segment elevation myocardial infarction enrolled in the National Registry of Myocardial Infarction from 1990 to 2006

https://doi.org/10.1016/j.ahj.2008.07.029Get rights and content

Background

Among patients with ST-segment elevation myocardial infarction (STEMI), rapid reperfusion is associated with improved mortality. As such, door-to-needle (D2N) and door-to-balloon (D2B) times have become metrics of quality of care and targets for intense quality improvement.

Methods

The National Registry of Myocardial Infarction (NRMI) collected data regarding reperfusion therapy, its timing and in-hospital mortality among STEMI patients from 1990 through 2006.

Results

Since 1990, NRMI has enrolled 1,374,232 STEMI patients at 2,157 hospitals. Among those, 774,279 (56.3%) were eligible for reperfusion upon arrival. The proportion receiving fibrinolytic therapy fell from 52.5% in 1990 to 27.6% in 2006 (P < .001), while the proportion undergoing primary percutaneous coronary intervention (pPCI) increased from 2.6% to 43.2%. Among reperfusion-eligible patients who received fibrinolytic therapy, there was a nearly linear decline in median D2N time from 59 minutes in 1990 to 29 minutes in 2006 (P < .001 for trend) as well as a decrease in mortality from 7.0% in 1994 to 6.0% in 2006 (P < .001). Among those undergoing pPCI, D2B time among nontransfer patients declined linearly from 111 minutes in 1994 to 79 minutes in 2006 (P < .001) with a decline in mortality from 8.6% to 3.1% (P < .001). The relative improvement in mortality attributable to improvements in D2N time was 16.3% and to D2B time was 7.5%.

Conclusions

Since 1990, there has been a progressive decline in D2N and D2B time among reperfusion-eligible STEMI patients. These improvements have contributed, at least in part, to a progressive decline in mortality.

Section snippets

Methods

NRMI is an industry-sponsored observational study whose methods have previously been described.13, 16

To be included in the registry, patients must have had an acute MI documented according to local hospital criteria, usually including a history suggestive of acute MI and corroborated by cardiac enzymes, 12-lead electrocardiogram (ECG), coronary angiography, or International Classification of Diseases, Ninth Revision, diagnostic code of MI. STEMI was defined as ST-segment elevation or left

Results

Since 1990, NRMI has enrolled 2,515,106 patients presenting with acute MI from 2,157 hospitals. Among the 1,374,232 (54.6%) patients with STEMI, 905,590 (65.9%) were eligible for reperfusion upon arrival to the hospital and 774,279 (56.3%) were eligible for time-to-reperfusion performance metrics. Among the reperfusion-eligible patients, fibrinolytic therapy was the most prevalent reperfusion modality in 1990, but its prevalence fell from 52.5% in 1990 to 27.6% in 2006 (Figure 1,A). The use of

Discussion

Early and complete revascularization after STEMI has been consistently associated with lower mortality in observational studies.1, 2, 3, 4 Current guidelines suggest that a realistic goal is to facilitate rapid recognition and treatment of patients with STEMI such that fibrinolytic therapy can be administered within 30 minutes of presentation and pPCI can be performed within 90 minutes.5, 6 Since its inception in 1990, NRMI has documented the association of improvement in time-to-reperfusion

Conclusion

Among more than 1.3 million STEMI patients enrolled in NRMI, D2N and D2B times have decreased significantly over the past several years. This has been associated with a significant decline in in-hospital mortality, and the contribution of improved D2N and D2B times to improvement in mortality was significant.

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    This study was supported in part by Genentech (San Francisco, CA).

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