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Background: For patients presenting with ST-segment-elevation myocardial infarction, national quality initiatives monitor hospitals' proportion of cases with door-to-balloon (D2B) time under 90 minutes. Hospitals are allowed to exclude patients from reporting and may modify behavior to improve performance. We sought to identify whether there is a discontinuity in the number of cases included in the D2B time metric at 90 minutes and whether operators were increasingly likely to pursue femoral access in patients with less time to meet the 90-minute quality metric., Methods: Adult patients with ST-segment-elevation myocardial infarction undergoing primary percutaneous coronary intervention from 2011 to 2018 were identified from the Cardiac Care Outcomes Assessment Program, a quality improvement registry in Washington state. We used the regression discontinuity framework to test for discontinuity at 90 minutes among the included cases. We defined a novel variable, remaining D2B as 90 minutes minus the time between hospital arrival and catheterization laboratory arrival. We estimated multivariable logistic regression models to assess the relationship between remaining D2B time and access site., Results: A total of 19 348 patients underwent primary percutaneous coronary intervention and were included in the analysis. Overall, 7436 (38.4%) were excluded from the metric. There appeared to be a visual discontinuity in included cases around 90 minutes; however, local quadratic regression around the 90-minute cutoff did not reveal evidence of a significant discontinuity ( P =0.66). Multivariable analysis showed no significant relationship between remaining D2B time and the odds of undergoing femoral access ( P =0.73)., Conclusions: Among patients undergoing percutaneous coronary intervention for ST-segment-elevation myocardial infarction, we did not find evidence of a statistically significant discontinuity in the frequency of included cases around 90 minutes or an increased preference for femoral access correlated with decreasing time to meet the 90-minute D2B time quality metric. Together, these findings indicate no evidence of widespread inappropriate methods to improve performance on D2B time metrics.

Objectives: The aims of this study were to describe variability in intensive care unit (ICU) utilization for patients with uncomplicated ST-segment elevation myocardial infarction (STEMI), evaluate the proportion of these patients who developed in-hospital complications requiring ICU care, and assess whether ICU use patterns and complication rates vary across categories of first medical contact to device times., Background: In the era of rapid primary percutaneous coronary intervention, ICUs may be overutilized as patients presenting with STEMI are less likely to develop complications requiring ICU care., Methods: Using data from the Chest Pain-MI Registry linked to Medicare claims, the authors examined patterns of ICU utilization among hemodynamically stable patients with STEMI ≥65 years of age treated with uncomplicated primary percutaneous coronary intervention, stratified by timing of reperfusion: early (first medical contact-to-device time ≤60 min), intermediate (61 to 90 min), or late (>90 min)., Results: Of 19,507 patients with STEMI treated at 707 hospitals, 82.3% were treated in ICUs, with a median ICU stay of 1 day (interquartile range [IQR]: 1 to 2 days). The median FMC-to-device time was 79 min (IQR: 63 to 99 min); 22.0% of patients had early, 44.8% intermediate, and 33.2% late reperfusion. ICU utilization rates did not differ between patients with early, intermediate, and late reperfusion times (82%, 83%, and 82%; p for trend = 0.44). Overall, 3,159 patients (16.2%) developed complications requiring ICU care while hospitalized: 3.7% died, 3.7% had cardiac arrest, 8.7% shock, 0.9% stroke, 4.1% high-grade atrioventricular block requiring treatment, and 5.7% respiratory failure. Patients with longer FMC-to-device times were more likely to develop at least 1 of these complications (early 13.4%, intermediate 15.7%, and late 18.7%; p for trend <0.001; adjusted odds ratio [early as reference] for intermediate: 1.13 [95% confidence interval: 1.01 to 1.25]; adjusted odds ratio for late: 1.22 [95% confidence interval: 1.08 to 1.37])., Conclusions: Although >80% of stable patients with STEMI are treated in the ICU after primary percutaneous coronary intervention, the risk for developing a complication requiring ICU care is 16%. Implementing a risk-based triage strategy, inclusive of factors such as degree of reperfusion delay, could optimize ICU utilization for patients with STEMI., (Copyright © 2019 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: The aim of this study was to describe the prevalence of pre-hospital cardiac catheterization laboratory activation and its association with reperfusion timeliness and in-hospital mortality., Background: For patients with ST-segment elevation myocardial infarction diagnosed in the field, catheterization laboratory pre-activation may lead to more timely reperfusion and improved outcomes., Methods: A total of 27,840 patients with ST-segment elevation myocardial infarction transported via emergency medical services to 744 percutaneous coronary intervention-capable hospitals in the ACTION Registry from January 2015 to March 2017 were evaluated, excluding patients with cardiac arrest or requiring pre-percutaneous coronary intervention intubation. Catheterization laboratory pre-activation was defined as activation >10 min prior to hospital arrival., Results: Catheterization laboratory pre-activation occurred in 41% of patients (n = 11,379), with minor presenting differences between those with and without catheterization laboratory pre-activation. Compared with no catheterization laboratory pre-activation, pre-activation patients were more likely to be directly transported to the catheterization laboratory on hospital arrival (23.3% vs. 5.3%), to have shorter hospital arrival-to-catheterization laboratory arrival time (median 17 min [interquartile range (IQR): 7 to 25 min] vs. 28 min [IQR: 18 to 39 min]), to have shorter door-to-device time (40 min [IQR: 30 to 51 min] vs. 52 min [IQR: 41 to 65 min]), and to have a greater likelihood of achieving first medical contact-to-device time ≤90 min (76.6% vs. 68.6%) (p < 0.001 for all). Pre-activation was associated with lower in-hospital mortality (2.8% vs. 3.4%; p = 0.01). Patients treated at hospitals in the lowest tertile of pre-activation rates had higher mortality than those treated at hospitals in the highest tertile before and after adjustment (3.6% vs. 2.7%; adjusted odds ratio: 1.33; 95% confidence interval: 1.08 to 1.63)., Conclusions: In the United States, catheterization laboratory pre-activation occurred in fewer than one-half of emergency medical services-transported patients with ST-segment elevation myocardial infarction. Its association with faster reperfusion and lower mortality supports greater use of this strategy., (Copyright © 2018 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Guidelines recommend P2Y 12 inhibitor therapy for 1 year after myocardial infarction (MI), yet little guidance is provided on antiplatelet management for patients with recurrent ischemic events during that year. We describe changes in P2Y 12 inhibitor type among patients with recurrent ischemic events in the first year after MI., Methods and Results: The TRANSLATE-ACS (Treatment With ADP Receptor Inhibitors: Longitudinal Assessment of Treatment Patterns and Events After Acute Coronary Syndrome) study enrolled 12 365 patients with MI treated with percutaneous coronary intervention. We examined whether P2Y 12 inhibitor choice changed among patients with recurrent MI, stent thrombosis, and/or unplanned revascularization during the first year after MI, and modeled factors associated with P2Y 12 inhibitor intensification (changing clopidogrel to prasugrel or ticagrelor). In the first year after MI, 1414 patients (11%) had a total of 1740 recurrent ischemic events (771 recurrent MIs, 969 unplanned revascularizations, and 165 stent thromboses). Median time to the first recurrent ischemic event was 154 days (25th-75th percentiles, 55-287 days). Of those with recurrent ischemic events, 101 of 1092 (9.3%) occurring in clopidogrel-treated patients led to P2Y 12 inhibitor intensification. Recurrent events involving stent thrombosis or MI were the strongest factors associated with P2Y 12 inhibitor intensification, yet only 40% of patients with stent thrombosis and 14% of patients with recurrent MI had P2Y 12 inhibitor intensification. Increasing age and longer time from the index MI were associated with lower likelihood for intensification., Conclusions: Few patients after MI with a recurrent ischemic event who were taking clopidogrel switched to a more potent P2Y 12 inhibitor, even after stent thrombosis events. Specific guidance is needed for patients who have recurrent ischemic events, particularly when closely spaced., Clinical Trial Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01088503., (© 2018 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.)

Background: Angina has important implications for patients' quality of life and healthcare utilization. Angina management after acute myocardial infarction (MI) treated with percutaneous coronary intervention (PCI) is unknown., Methods and Results: TRANSLATE-ACS (Treatment With Adenosine Diphosphate Receptor Inhibitors: Longitudinal Assessment of Treatment Patterns and Events After Acute Coronary Syndrome) was a longitudinal study of MI patients treated with percutaneous coronary intervention at 233 US hospitals from 2010 to 2012. Among patients with self-reported angina at 6 weeks post-MI, we described patterns of angina and antianginal medication use through 1 year postdischarge. Of 10 870 percutaneous coronary intervention-treated MI patients, 3190 (29.3%) reported angina symptoms at 6 weeks post-MI; of these, 658 (20.6%) had daily/weekly angina while 2532 (79.4%) had monthly angina. Among patients with 6-week angina, 2936 (92.0%) received β-blockers during the 1 year post-MI, yet only 743 (23.3%) were treated with other antianginal medications. At 1 year, 1056 patients (33.1%) with 6-week angina reported persistent angina symptoms. Of these, only 31.2% had been prescribed non-β-blocker antianginal medications at any time in the past year. Among patients undergoing revascularization during follow-up, only 25.9% were on ≥1 non-β-blocker anti-anginal medication at the time of the procedure., Conclusions: Angina is present in one third of percutaneous coronary intervention-treated MI patients as early as 6 weeks after discharge, and many of these patients have persistent angina at 1 year. Non-β-blocker antianginal medications are infrequently used in these patients, even among those with persistent angina and those undergoing revascularization., (© 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.)

The RCTs of AF-PCI/ACS patients lack such information (Table 1).[[5], [7]] A subgroup analysis of the REDUAL PCI trial showed that only 9.9% of included patients had high-risk procedural factors and only 10% had both high-risk procedural and clinical complexity factors.[13] Although high-risk procedural features were not explicit exclusion criteria, the dearth of procedural details and the absence of statistically powered outcome stratification by PCI complexity prevent generalization of the four RCT results to PCI patients with high ischaemic risk PCI, which may represent up to 60% of cases according to a recent study.[12] Sub-analyses and specific high-risk subgroups. These patients made up only a fraction of the patients enrolled in WOEST (27%), PIONEER AF-PCI (29%), RE-DUAL (50%), AUGUSTUS (51%), and ENTRUST-AF PCI (52%), and individual trials were not powered to detect a treatment by subgroup interaction. The low thrombogenicity of new stent platforms, together with the increasing awareness of the prognostic impact of bleeding events have prompted the design of many RCTs testing a de-escalation or shortening of antithrombotic therapy, aiming at reducing bleeding without any trade-off in ischaemic events (Table 1).[38] Among them, the RCTs including patients with AF-PCI/ACS were the only ones in which: (i) the primary endpoints did not include ischaemic outcomes; (ii) procedural details were not reported; (iii) ACS patients were not well represented, as none focused entirely on the acute setting; (iv) "de-escalation" was started very early after PCI (Table 1). [Extracted from the article]