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Non-ST-elevation myocardial infarction patients who present during off hours have higher risk profiles and are treated less aggressively, but their outcomes are not worse: a report from Can Rapid Risk Stratification of Unstable Angina Patients Suppress ADverse Outcomes with Early Implementation of the ACC/AHA Guidelines CRUSADE initiative.
Crit Pathw Cardiol. 2009 Mar; 8(1):29-33.CP

Abstract

Evidence-based guidelines call for advanced and definitive therapy for patients with non-ST-elevation myocardial infarction (NSTEMI). It is not known whether these guidelines are follow more diligently when patients arrive in the ED during regular hours, during which hospital resources including cardiology consultation may be more readily available. To determine whether patients with NSTEMI who present to the ED outside of usual hours have prolonged times to advanced and definitive therapy and poorer short-term outcomes.We examined NSTEMI patients from the Can Rapid Risk Stratification of Unstable Angina Patients Suppress ADverse Outcomes with Early Implementation of the ACC/AHA Guidelines (CRUSADE) national quality improvement initiative (January 2001-April 2003) and compared demographics, risk profiles, intensity of medical management, and timing and intensity of intervention by whether presentation occurred during usual or off hours. We analyzed 34,297 NSTEMI presentations; 15,090 (44%) occurred during usual hours; 19,207 (56%) occurred during off hours. Off-hours-presenting patients had generally higher cardiac risk and received initial ECGs more quickly than patients who presented during usual hours (median 15 minutes vs. 18 minutes, P < 0.0001), and received similar (although suboptimal) medical management. In contrast, those who presented during off hours were less likely to receive timely diagnostic angiography, PCI, and bypass surgery (cath: median 32.9 hours vs. 24.3 hours, P < 0.0001; PCI: 28.6 hours vs. 23.6 hours, P < 0.0001). Despite these differences, in-hospital outcomes were similar. Time of patient presentation has a modest impact on the timeliness of intervention in NSTEMI but was not associated with lower mortality. Although intensity of medical management was similar between groups, it was generally lower than current guidelines recommend, indicating potential for improvement in NSTEMI outcomes, regardless of time of presentation.

Authors+Show Affiliations

Department of Emergency Medicine, University of Pennsylvania Hospital, Philadelphia, PA 19107, USA. pollackc@pahosp.comNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Comparative Study
Journal Article
Practice Guideline

Language

eng

PubMed ID

19258835

Citation

Pollack, Charles V., et al. "Non-ST-elevation Myocardial Infarction Patients Who Present During Off Hours Have Higher Risk Profiles and Are Treated Less Aggressively, but Their Outcomes Are Not Worse: a Report From Can Rapid Risk Stratification of Unstable Angina Patients Suppress ADverse Outcomes With Early Implementation of the ACC/AHA Guidelines CRUSADE Initiative." Critical Pathways in Cardiology, vol. 8, no. 1, 2009, pp. 29-33.
Pollack CV, Hollander JE, Chen AY, et al. Non-ST-elevation myocardial infarction patients who present during off hours have higher risk profiles and are treated less aggressively, but their outcomes are not worse: a report from Can Rapid Risk Stratification of Unstable Angina Patients Suppress ADverse Outcomes with Early Implementation of the ACC/AHA Guidelines CRUSADE initiative. Crit Pathw Cardiol. 2009;8(1):29-33.
Pollack, C. V., Hollander, J. E., Chen, A. Y., Peterson, E. D., Bangalore, S., Peacock, F. W., Cannon, C. P., Canto, J. G., Gibler, B. W., Ohman, M. E., & Roe, M. T. (2009). Non-ST-elevation myocardial infarction patients who present during off hours have higher risk profiles and are treated less aggressively, but their outcomes are not worse: a report from Can Rapid Risk Stratification of Unstable Angina Patients Suppress ADverse Outcomes with Early Implementation of the ACC/AHA Guidelines CRUSADE initiative. Critical Pathways in Cardiology, 8(1), 29-33. https://doi.org/10.1097/HPC.0b013e3181980f9f
Pollack CV, et al. Non-ST-elevation Myocardial Infarction Patients Who Present During Off Hours Have Higher Risk Profiles and Are Treated Less Aggressively, but Their Outcomes Are Not Worse: a Report From Can Rapid Risk Stratification of Unstable Angina Patients Suppress ADverse Outcomes With Early Implementation of the ACC/AHA Guidelines CRUSADE Initiative. Crit Pathw Cardiol. 2009;8(1):29-33. PubMed PMID: 19258835.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Non-ST-elevation myocardial infarction patients who present during off hours have higher risk profiles and are treated less aggressively, but their outcomes are not worse: a report from Can Rapid Risk Stratification of Unstable Angina Patients Suppress ADverse Outcomes with Early Implementation of the ACC/AHA Guidelines CRUSADE initiative. AU - Pollack,Charles V,Jr AU - Hollander,Judd E, AU - Chen,Anita Y, AU - Peterson,Eric D, AU - Bangalore,Sripal, AU - Peacock,Frank W, AU - Cannon,Christopher P, AU - Canto,John G, AU - Gibler,Brian W, AU - Ohman,Magnus E, AU - Roe,Matthew T, PY - 2009/3/5/entrez PY - 2009/3/5/pubmed PY - 2009/6/16/medline SP - 29 EP - 33 JF - Critical pathways in cardiology JO - Crit Pathw Cardiol VL - 8 IS - 1 N2 - Evidence-based guidelines call for advanced and definitive therapy for patients with non-ST-elevation myocardial infarction (NSTEMI). It is not known whether these guidelines are follow more diligently when patients arrive in the ED during regular hours, during which hospital resources including cardiology consultation may be more readily available. To determine whether patients with NSTEMI who present to the ED outside of usual hours have prolonged times to advanced and definitive therapy and poorer short-term outcomes.We examined NSTEMI patients from the Can Rapid Risk Stratification of Unstable Angina Patients Suppress ADverse Outcomes with Early Implementation of the ACC/AHA Guidelines (CRUSADE) national quality improvement initiative (January 2001-April 2003) and compared demographics, risk profiles, intensity of medical management, and timing and intensity of intervention by whether presentation occurred during usual or off hours. We analyzed 34,297 NSTEMI presentations; 15,090 (44%) occurred during usual hours; 19,207 (56%) occurred during off hours. Off-hours-presenting patients had generally higher cardiac risk and received initial ECGs more quickly than patients who presented during usual hours (median 15 minutes vs. 18 minutes, P < 0.0001), and received similar (although suboptimal) medical management. In contrast, those who presented during off hours were less likely to receive timely diagnostic angiography, PCI, and bypass surgery (cath: median 32.9 hours vs. 24.3 hours, P < 0.0001; PCI: 28.6 hours vs. 23.6 hours, P < 0.0001). Despite these differences, in-hospital outcomes were similar. Time of patient presentation has a modest impact on the timeliness of intervention in NSTEMI but was not associated with lower mortality. Although intensity of medical management was similar between groups, it was generally lower than current guidelines recommend, indicating potential for improvement in NSTEMI outcomes, regardless of time of presentation. SN - 1535-2811 UR - https://www.unboundmedicine.com/medline/citation/19258835/Non_ST_elevation_myocardial_infarction_patients_who_present_during_off_hours_have_higher_risk_profiles_and_are_treated_less_aggressively_but_their_outcomes_are_not_worse:_a_report_from_Can_Rapid_Risk_Stratification_of_Unstable_Angina_Patients_Suppress_ADverse_Outcomes_with_Early_Implementation_of_the_ACC/AHA_Guidelines_CRUSADE_initiative_ L2 - https://doi.org/10.1097/HPC.0b013e3181980f9f DB - PRIME DP - Unbound Medicine ER -