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Rapid Responses: Rapid Responses published:
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Ballooning has its ups and downs
- Brian A Cattle, Darren C. Greenwood, Christopher P Gale, and Robert M West (23 May 2009)
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Is in-hospital mortality following PPCI really modifiable?
- Pitt Lim, SW17 0QT (31 May 2009)
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Brian A Cattle, Research Fellow Division of Biostatistics, University of Leeds, Leeds, LS2 9JT, Darren C. Greenwood, Christopher P Gale, and Robert M West
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Rathore et al. (1) provided evidence from the United States that treatment of ST elevation myocardial infarction (STEMI) by primary percutaneous coronary intervention (PCI) is most effective if given within the 90 minutes of admission to hospital. The 90-minute door-to-balloon time (DTB) is likely to be adopted in the UK as a hospital indictor of primary PCI performance. Management of acute coronary syndromes in the UK is monitored by the Myocardial Ischemia National Audit Project (MINAP) which covers all 228 acute hospitals (2;3). Focussing on the five largest PCI centres in the UK between 2004 and 2007 inclusive, we investigated the quality of recording of DTB, and compared this to in-hospital mortality. Patients who died in hospital were more than 50% more likely to have incomplete DTB data than those who were discharged alive: RR = 1.6 (99% CI: 1.2 to 1.9). Conversely, patients were more than twice as likely to have died in hospital if their DTB time was missing than if it was recorded in MINAP: RR = 2.1 (99% CI: 1.4 to 3.2). This could lead to an inappropriate assessment of the performance of the PCI centres concerned. This systematic bias introduced by incomplete data recording could lead to an inappropriate assessment of the performance of the PCI centres concerned. If DTB is to be used as a performance measure for STEMI, a significant effort is required to ensure that the reporting bias in the MINAP data is robustly and comprehensively tackled. References (1) Rathore SS, Curtis JP, Chen J, Wang Y, Nallamothu BK, Epstein AJ, and Krumholz HM. Association of door-to-balloon time and mortality in patients admitted to hospital with ST elevation myocardial infarction: national cohort study BMJ 2009; 338: b1807 (2) Gale CP, Manda SO, Batin PD, Weston CF, Birkhead JS, Hall AS. Predictors of in-hospital mortality for patients admitted with ST- elevation myocardial infarction: a real-world study using the Myocardial Infarction National Audit Project (MINAP) database. Heart 2008; 94(11):1407-1412. (3) Gale CP, Manda SO, Weston CF, Birkhead JS, Batin PD, Hall AS. Evaluation of risk scores for risk stratification of acute coronary syndromes in the Myocardial Infarction National Audit Project (MINAP) database. Heart 2009; 95(3):221-227. Competing interests: None declared |
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Pitt Lim, Consultant Cardiologist St George's Hospital, London, SW17 0QT
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Rathore and colleagues concluded from their large registry dataset comparing door to balloon times under 90 mins and under 30 mins, the in- hospital mortalities following PPCI were 4.3% to 3% respectively. This analysis I believe simply reflected different patient populations. Those who had prolonged door to balloon time as conceded by the authors were people who presented atypically and late, those with significant co- morbidites, and sicker patients who required stabilisation prior to going to the cardiac catheter laboratories. The complexity of the coronary anatomy and the PCI procedure were not taken into account. Whether the in- hospital mortality of these higher risk patients is modifiable by further reducing the door to balloon time is not supported by the report. Competing interests: None declared |
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