Coronary artery disease
Outcome of Patients With ST-Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention During On- Versus Off-hours (A Harmonizing Outcomes With RevasculariZatiON and Stents in Acute Myocardial Infarction [HORIZONS-AMI] Trial Substudy)

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Patients with ST-segment elevation myocardial infarction (STEMI) admitted during nonregular working hours (off-hours) have been reported to have greater mortality than those admitted during regular working hours (on-hours), perhaps because of the lower availability of catheterization laboratory services and longer door-to-balloon times. This might not be the case, however, for hospital centers in which primary percutaneous coronary intervention (PCI) is invariably performed. We conducted a substudy using the Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction study data to determine whether the STEMI arrival time was associated with differing clinical outcomes. We identified all patients with STEMI admitted to a PCI-capable hospital who underwent primary PCI. Patients presenting during on-hours were compared to those presenting during off-hours. The primary outcome of death, major adverse cardiovascular events, and net adverse clinical events was examined. We identified 2,440 patients (1,205 [49%] on-hours and 1,235 [51%] off-hours). Similar baseline characteristics were observed. The off-hour patients had a significantly longer door-to-balloon time (92 vs 75 minutes; p <0.0001) and total ischemic time (209 vs 194 minutes; p <0.0001). Despite these differences, the risk-adjusted all-cause mortality, major adverse cardiovascular events, and net adverse clinical events rates were similar for both groups during the in-hospital, 1-year, and 3-year follow-up. In conclusion, patients with STEMI presenting to primary PCI hospitals during off-hours might have slightly longer delays to revascularization; however, they experienced similar short- and long-term survival and clinical outcomes as those arriving during on-hours.

Section snippets

Methods

The HORIZONS-AMI trial was a prospective, open-label, dual-arm, factorial, randomized, multicenter trial in which bivalirudin alone was compared to heparin plus a glycoprotein IIb/IIIa inhibitor, and paclitaxel-eluting stents were compared to bare metal stents in patients with STEMI undergoing primary PCI.14 The study enrolled 3,602 patients from March 2005 to May 2007 among 123 hospitals in 11 countries. Consecutive patients aged ≥18 years who presented within 12 hours after the onset of

Results

Of the 2,440 patients included in the present substudy, 1,205 (49%) arrived to a PCI hospital during on-hours and 1,235 (51%) during off-hours. The median age was 60.2 years (interquartile range 52.4 to 69.7), with 76.6% men and 16.8% diabetics. The baseline demographic characteristics are listed in Table 1. The on-hours patients had, on average, a greater prevalence of previous angina (p = 0.008), and those presenting during off-hours were more likely to report a history of hyperlipidemia (p =

Discussion

Our results have indicated that the clinical outcomes of rather “low-risk” patients with STEMI admitted to hospitals with primary PCI capacity during off-hours are similar to those admitted during on-hours, although longer revascularization time can be expected. These findings are unique and the first to arise from nonregistry data. The HORIZONS-AMI was a large, prospective, randomized, multicenter trial of patients with STEMI. Consequently, in the present substudy, all the data were

Disclosures

Dr. Kovacic is supported by National Institutes of Health grant 1K08HL111330-01 (Bethesda, Maryland); Dr. Dangas has received research grants (institutional) from The Medicines Company (Parsippany, New Jersey), Bristol-Myers Squibb/Sanofi (New York, New York and Paris, France), and Eli Lilly and Company/Daiichi Sankyo Co. (Indianapolis, Indiana and Tokyo, Japan), and is a consultant to Abbott Vascular (Santa Clara, California), AstraZeneca (Wilmington, Delaware), Janssen Pharmaceuticals

References (26)

Cited by (36)

  • Comparison of Outcomes of ST-Elevation Myocardial Infarction Treated by Percutaneous Coronary Intervention During Off-Hours Versus On-Hours

    2017, American Journal of Cardiology
    Citation Excerpt :

    The number of events in each trial was extracted when available. Table 1 depicts studies and patients' baseline characteristics.1,3,5–7,9–42 Methodological quality was defined as the control of bias assessed through the reported methods in each individual study using the Cochrane risk of bias tool43 and the Newcastle-Ottawa Scale44 to assess the quality of observational cohort studies.

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The HORIZONS-AMI trial was sponsored by the Cardiovascular Research Foundation with research grant support from Boston Scientific (Natick, Massachusetts) and The Medicines Company (Parsippany, New Jersey).

See page 953 for disclosure information.

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