STEMI Revascularization Times All Over the Map: GWTG Registry

WASHINGTON, DC—Across the United States there continues to be substantial institutional-level variability in meeting the recommended first medical contact (FMC) to device times in patients with STEMI, according to a new analysis of the American Heart Association Get With The Guidelines Coronary Artery Disease (GWTG-CAD) registry.

The inconsistency was seen among primary presentations to PCI-capable hospitals and transfer patients, with failure to achieve the target times associated with greater risks of in-hospital mortality no matter where patients initially presented.

STEMI patients who fell outside the target treatment times were older, more likely to be women, Black, had more frequent baseline comorbidities, and were sicker on presentation, said Yasser Sammour, MD (Houston Methodist DeBakey Heart and Vascular Center, TX), reporting the study here at CRT 2025.

Approximately 60% of sites were able to achieve a FMC-to-device time of less than 90 minutes for primary presentations, but only 11% (55 sites) were able to achieve this target in at least 75% of their patients. For transfer patients, 50% achieved a FMC-to-device time of less than 120 minutes, and only 13.9% (42 sites) of those achieved the target in at least 75% of patients.

“High-performing hospitals with shorter first medical contact-to-device times consistently met the recommended quality metrics,” Sammour added.

Worse outcomes were associated with failure to meet the target FMC-to-device time and with presentation to low-performing hospitals. High-performing hospitals had a mean FMC-to-device time of 76 minutes for primary presentations compared with 83 and 93 minutes for intermediate- and low-performing centers, respectively.  Among transfers, the numbers were 100 minutes, 122 minutes, and 155 minutes, respectively.

Panelist Timothy D. Henry, MD (The Christ Hospital, Cincinnati, OH), who has long investigated efforts to provide timely access to revascularization for STEMI patients, called the variability “shocking” but not completely surprising.

“We had a similar study from the same database that showed only 17% of patients at non-PCI hospitals were being treated at target and have much higher mortality,” he said. “This confirms that again.”

Factoring in Delays and Missing Hours

The GWTG-CAD analysis included 73,826 patients (median age 62 years; 27.6% women) who underwent primary PCI at 503 hospitals.

Among those presenting to PCI-capable hospitals, 59.5% achieved the recommended FMC-to-device time ≤ 90 minutes. For transfer patients, 50.3% met the recommended FMC-to-device time ≤ 120 minutes.

High-performing centers were more likely than lower-performing centers to hit other time-based metrics: hospital arrival to electrocardiogram ≤ 10 minutes, emergency department length of stay ≤ 30 minutes, FMC to cath lab activation ≤ 20 minutes for primary presentations, and door-in-door-out time ≤ 30 for primary presentations or ≤ 45 minutes for transfers.

An analysis by rural versus urban hospital location showed no difference in meeting target FMC-to-device time for primary presentations or transfers and no differences in mortality.

Patients presenting to low-performing PCI-capable hospitals had an increased risk of mortality compared with those presenting to high-performance centers (adjusted OR 1.16; 95% CI 1.00-1.34).

Given that there are lingering questions about the relationship between outcomes and off-peak admissions that occur on evenings, weekends, and holidays, panelist David Cohen, MD (St. Francis Hospital & Heart Center, Roslyn, NY, and Cardiovascular Research Foundation, New York, NY), said there may be a need for additional sensitivity analyses.

“We know that presenting off-hours explains a lot of the longer delays,” he said. “My guess is that on-hours people hit the guidelines pretty well, but two-thirds of the hours in a week are off-hours.”

Another critical consideration, noted panelist Tim A. Fischell, MD (Ascension Borgess Heart Institute, Kalamazoo, MI), is the overlooked metric of symptom-to-door time, which data suggest is a mean of 3.5 hours.

“We’re talking about trying to get a balloon in within 90 minutes, but we’re missing the first 3 hours. . . . So I think we have to begin to think about how we can do better in getting patients to the hospital [sooner], because we haven’t done a very good job with that. Education does not work very well,” he said.

Sammour agreed, noting that those missing hours prior to first medical contact are an important and unknown variable in treatment delays especially among patients who present themselves to a hospital as walk-ins.