Magnitude and impact of treatment delays on weeknights and weekends in patients undergoing primary angioplasty for acute myocardial infarction (the cadillac trial)

doi:10.1016/j.amjcard.2004.05.030

The American Journal of Cardiology

Volume 94, Issue 5, 1 September 2004, Pages 637-640

https://doi.org/10.1016/j.amjcard.2004.05.030 Get rights and content

From a prospective, multicenter study of 2,082 patients with acute myocardial infarctions who underwent primary angioplasty, the outcomes of patients presenting during peak hours were compared with those presenting during off-peak hours (weeknights from 8 p.m. to 8 a.m. and weekends). Despite an additional 21-minute mean delay from hospital arrival to reperfusion, patients who underwent primary angioplasty during off-peak hours achieved similar rates of Thrombolysis In Myocardial Infarction grade 3 flow, 30-day and 1-year mortality, and improvement in ejection fraction and regional wall motion as those presenting on weekdays.

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Cited by (48)

The Impact of Out-of-Hours Presentation on Clinical Outcomes in ST-Elevation Myocardial Infarction
2020, Heart Lung and Circulation
Systems of care have been established to ensure patients with ST-elevation myocardial infarction (STEMI) get timely access to primary percutaneous coronary intervention (PPCI). In this study, we evaluated whether patients undergoing PPCI both in-hours and out-of-hours experience similar care and clinical outcomes.
Of 9,865 patients who underwent PCI for STEMI from 2005 to 2016 and were enrolled in the multi-centre Melbourne Interventional Group registry, patients who had initially presented to a non-PCI capable hospital, received thrombolysis or presented >12 hours post-symptom onset were excluded. Our final study cohort of 4,590 patients were dichotomised by whether PPCI was performed in-hours or out-of-hours, and compared. The primary outcome was 30-day mortality.
The in-hours group included 1,865 patients (40.6%) while 2,725 patients (59.4%) had out-of-hours PPCI. Patients presenting out-of-hours had longer median door-to-balloon time (DTBT; 83 [IQR 61–109] vs. 60 [IQR 41–88] mins, p < 0.01) and were more likely to receive a drug-eluting stent (p = 0.001). Procedural characteristics were otherwise similar although rates of radial access were low overall (18.4%). No differences in in-hospital, 30-day or 12-month mortality were observed between the groups (p = NS). On Cox proportional hazards modelling, out-of-hours presentation was not an independent predictor of 30-day mortality (HR 0.94, 95% CI 0.71–1.22). A landmark analysis of data from 2012 did not change the primary outcome.
Despite a slightly longer DTBT, patients undergoing PPCI out-of-hours experienced similar care and clinical outcomes to the in-hours group. Given the majority of patients with STEMI present out-of-hours, these data have implications for STEMI systems of care.
On- Versus Off-Hours Presentation and Mortality of ST-Segment Elevation Myocardial Infarction Patients Treated With Primary Percutaneous Coronary Intervention
2019, JACC: Cardiovascular Interventions
The authors sought to assess the association between admission time with patient’s care, procedure characteristics, and clinical outcomes within a contemporary ST-segment elevation myocardial infarction (STEMI) network of patients referred for primary percutaneous coronary intervention (PCI).
The effect of admission time on STEMI patient's outcomes remains controversial when primary PCI is the preferred reperfusion strategy.
Characteristics and clinical outcomes of 2,167 consecutive STEMI patients admitted in a tertiary PCI-capable center were collected. On-hours were defined as admission from Monday through Friday between 8 am and 6 pm and off-hours as admission during night shift, weekend, and nonworking holidays. In-hospital and 1-year all-cause mortality were assessed as well as key time delays.
A total of 1,048 patients (48.3%) were admitted during on-hours, and 1,119 patients (51.7%) during off-hours. Characteristics were well-balanced between the 2 groups, including rates of cardiac arrest (7.9% vs. 8.8%; p = 0.55) and cardiogenic shock (12.3% vs. 14.7%; p = 0.16). Median symptom-to-first medical contact time and median first medical contact-to-sheath insertion time did not differ according to on- versus off-hours admission (120 min vs. 126 min; p = 0.25 and 90 min vs. 93 min; p = 0.58, respectively), as well as the rate of radial access for catheterization (85.6% vs. 87.5%; p = 0.27). There was no association between on- versus off-hours groups and in-hospital (8.1% vs. 7.0%; p = 0.49) or 1-year mortality (11.0% vs. 11.1%; p = 0.89), respectively.
In a contemporary organized STEMI network, patients admitted in a high-volume tertiary primary PCI center during on-hours or off-hours had similar management and 1-year outcomes.
Off-hours presentation does not affect in-hospital mortality of Japanese patients with acute myocardial infarction: J-MINUET substudy
2017, Journal of Cardiology
Citation Excerpt :
Several studies have found an association between patients with AMI who present during off-hours and clinical outcomes. Some of these reports have indicated higher mortality rates among patients with AMI who presented during off-hours [7–9], whereas, others did not identify significant differences in mortality rates between regular hours and off-hours [10,11]. The results of other studies have been inconsistent [12,13].
The association between patients with acute myocardial infarction (AMI) who present during off-hours and clinical outcomes has not been fully elucidated.
We investigated 3283 consecutive patients with AMI who were selected from a prospective, nationwide, multicenter registry (J-MINUET) database comprising 28 institutions in Japan between July 2012 and March 2014 to determine the current impact of off-hours presentation on in-hospital mortality among Japanese patients with AMI.
Among the patients, 52% presented in off-hours. Baseline characteristics were comparable, although those who presented during off-hours were younger and had a higher incidence of ST-elevation myocardial infarction and advanced Killip Class. The time from symptom onset to presentation time was shorter in off-hour patients (120 min, interquartile range 60 to 256 vs. 215 min, interquartile range 90 to 610, p < 0.0001). In contrast, 85% of patients underwent primary percutaneous coronary intervention (PCI) and door to balloon time was comparable between the groups (74 min, interquartile range 52 to 113 vs. 75 min, interquartile range 52 to 126, p = 0.34). The rates of in-hospital mortality were comparable (6.2% vs 6.8%, p = 0.39). Multivariate logistic regression analysis revealed that off-hours presentation was not significantly associated with in-hospital mortality [odds ratio (OR) 0.94; 95% CI, 0.68–1.30, p = 0.70].
The clinical impact of presenting during off-hours or regular hours on AMI patients in Japan is comparable in contemporary practice.
UMIN Unique trial Number: UMIN000010037.
Comparison of Outcomes of ST-Elevation Myocardial Infarction Treated by Percutaneous Coronary Intervention During Off-Hours Versus On-Hours
2017, American Journal of Cardiology
Previous studies have reported worse outcomes and longer door-to-balloon times (DBTs) in patients presenting with ST-elevation myocardial infarction (STEMI) after normal working hours, during weekends, and on holidays (off-hours) compared with normal business hours (on-hours). Recent studies, however, have reported similar outcomes regardless of presentation time. MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were queried from January 1990 through December 2016. Only studies comparing STEMI outcomes during off-hours versus on-hours with percutaneous coronary intervention were included. A random-effects meta-analysis model was used to pool outcomes across the studies. Clinical end points included short- (<30 days of presentation), intermediate- (at 1 to 2 years), and long-term (at 3 to 4 years) stent thrombosis, mortality, recurrent myocardial infarction (MI), and major adverse cardiovascular events (MACEs). A total of 86,776 patients (62 years and 74.5% male) were identified from 39 studies. There was no significant difference between both groups with regard to mean DBT (odds ratio [OR] 0.74, 95% confidence interval [CI] −2.73 to 4.22, p = 0.67) or median DBT (p = 0.19). There was no significant difference between the 2 groups for short-term end points including mortality (OR 1.11, 95% CI 0.99 to 1.25, p = 0.08), MI (OR 1.25, 95% CI 0.90 to 1.74, p = 0.18), MACE (OR 1.06, 95% CI 0.93 to 1.20, p = 0.40), or stent thrombosis (OR 1.23, 95% CI 0.83 to 1.82, p = 0.31). Similarly, intermediate-term end points were not statistically different for mortality (OR 0.97, 95% CI 0.89 to 1.05, p = 0.46), MI (OR 0.86, 95% CI 0.73 to 1.02, p = 0.08), or MACE (OR 1.00, 95% CI 0.92 to 1.08, p = 0.98). Long-term end points did not differ statistically between groups for mortality (OR 0.95, 95% CI 0.83 to 1.09, p = 0.46), MI (OR 1.19, 95% CI 0.77 to 1.84, p = 0.44), or MACE (OR 0.98, 95% CI 0.89 to 1.08, p = 0.67). In conclusion, patients presenting with STEMI during off-hours and treated with percutaneous coronary intervention had similar short-, intermediate-, and long-term outcomes compared with patients presenting during on-hours. DBT was not affected by the time of presentation.
Impact of time of admission on short- and long-term mortality in the Vienna STEMI registry
2017, International Journal of Cardiology
Several studies have shown contradictive findings regarding mortality and hospital admission time in patients presenting with ST-elevation myocardial infarction (STEMI). The aim of this study was to assess the impact of “on-” or “off-hour” admission on short- and long-term all-cause mortality of patients in the advanced Vienna STEMI network between 2003 and 2009.
In total, 2829 patients were included into this analysis. Patients were stratified according to admission time into “on-hour” admission (07:30 until 15:00 h on weekdays) and “off-hour” admission (15:00–7:30 h on weekdays and 24 h on weekends). As endpoint of interest, all-cause mortality was investigated after 30 days and 3 years of follow-up, the latter for all patients and as Landmark analysis for survivors of the index event.
Mean age was 60.5 ± 13.3 years, 2048 (72.4%) patients were male and 1260 (44.5%) patients presented with anterior wall infarction. 683 (24.1%) patients were admitted “on-hours”, 2146 (75.9%) patients were admitted “off-hours”. All-cause death occurred in 176 (6.2%) patients after a follow-up of 30 days and in 337 (11.9%) patients after 3 years.
For short- and long-term all-cause mortality no significant differences could be detected between “on-” and “off-hour” admission in univariate and multivariate Cox proportional hazard analyses as well as for propensity score adjusted outcome analysis.
In the Vienna STEMI network, “on-” or “off-hour” admission had no impact on short- and long-term mortality for all-comers presenting with acute STEMI. Our findings confirm the imperative need for well-structured STEMI networks of care, as previous data repeatedly demonstrated increased adverse cardiovascular outcome for “off-hour” admission.
Off-hour admission and outcomes for patients with acute myocardial infarction undergoing percutaneous coronary interventions
2015, American Heart Journal
Prior studies have suggested that patients with acute myocardial infarction (AMI) who are admitted during off-hours (weekends, nights and holidays) have higher mortality when compared with patients admitted during regular hours.
We analyzed consecutive patients with AMI (ST-elevation myocardial infarction [STEMI] and non-STEMI) who were treated with percutaneous coronary interventions from January 1998 to June 2010 at an academic medical center. Multivariable logistic regression models were used to estimate the association between off-hour admission and clinical outcomes adjusted for demographic and clinical variables.
There were 3,422 and 2,664 patients with AMI admitted during off-hours and regular hours, respectively. Patients admitted during off-hours were more likely to have STEMI (56% vs 48%, P < .001), have cardiogenic shock at presentation (6% vs 4%, P = .002), and develop shock after presentation (6% vs 5%, P = .004). After multivariable analyses, off-hour admission was not significantly associated with in-hospital mortality (odds ratio [OR] 1.12, 95% CI 0.84-1.49), 30-day mortality (OR 1.12, 0.87-1.45), or 30-day readmissions (OR 1.01, 0.84-1.20) but was significantly associated with composite major complications and any of emergent coronary artery bypass graft surgery, ventricular arrhythmia, stroke/transient ischemic attack, and gastrointestinal/retroperitoneal/intracranial bleeding (OR 1.27, 1.05-1.55, P = .015). There was no significant time trend in the adjusted mortality difference between off-hours and regular hours. The results were not different between STEMI and non-STEMI.
Patients who were admitted during off-hours did not have higher mortality or readmission rates as compared with ones admitted during regular hours at an academic medical center.

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: The CADILLAC trial was supported by Guidant Corp., Santa Clara, California, and Lilly Research Laboratories, Indianapolis, Indiana.

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Magnitude and impact of treatment delays on weeknights and weekends in patients undergoing primary angioplasty for acute myocardial infarction (the cadillac trial)

J Am Coll Cardiol

Am J Cardiol

Am J Cardiol

J Am Coll Cardiol

Am J Cardiol

Am J Cardiol

J Am Coll Cardiol

Lancet

Comparison of angioplasty with stenting, with or without abciximab, in acute myocardial infarction

N Engl J Med

Mortality among patients admitted to hospitals on weekends as compared with weekdays

N Engl J Med