title: 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.
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.affiliation: Department of Emergency Medicine, University of Pennsylvania Hospital, Philadelphia, PA 19107, USA. pollackc@pahosp.com
authors.forename: Charles V
authors.initials: CV
authors.lastname: Pollack
authors.forename: Judd E
authors.initials: JE
authors.lastname: Hollander
authors.forename: Anita Y
authors.initials: AY
authors.lastname: Chen
authors.forename: Eric D
authors.initials: ED
authors.lastname: Peterson
authors.forename: Sripal
authors.initials: S
authors.lastname: Bangalore
authors.forename: Frank W
authors.initials: FW
authors.lastname: Peacock
authors.forename: Christopher P
authors.initials: CP
authors.lastname: Cannon
authors.forename: John G
authors.initials: JG
authors.lastname: Canto
authors.forename: Brian W
authors.initials: BW
authors.lastname: Gibler
authors.forename: Magnus E
authors.initials: ME
authors.lastname: Ohman
authors.forename: Matthew T
authors.initials: MT
authors.lastname: Roe
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D000789:Angina, Unstable / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D015906:Angioplasty, Balloon, Coronary / Q000592:standards / Q000639:trends; D006328:Cardiac Catheterization / Q000592:standards / Q000639:trends; D003131:Combined Modality Therapy; D001026:Coronary Artery Bypass / Q000592:standards / Q000639:trends; D004562:Electrocardiography; D004636:Emergency Service, Hospital / Q000592:standards* / Q000639:trends; D004638:Emergency Treatment / Q000592:standards / Q000639:trends; D005260:Female; D005500:Follow-Up Studies; D019538:Health Care Surveys; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D017063:Outcome Assessment, Health Care; D011336:Probability; D018570:Risk Assessment; D012720:Severity of Illness Index; D012737:Sex Factors; D016019:Survival Analysis; D013997:Time Factors; D016896:Treatment Outcome