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Original Research |

Health Care System Delay and Heart Failure in Patients With ST-Segment Elevation Myocardial Infarction Treated With Primary Percutaneous Coronary Intervention: Follow-up of Population-Based Medical Registry Data

Christian Juhl Terkelsen, MD, PhD; Lisette Okkels Jensen, MD, DmSc, PhD; Hans-Henrik Tilsted, MD; Sven Trautner, MD; Søren Paaske Johnsen, MD, PhD; Werner Vach, PhD; Hans Erik Bøtker, MD, DmSc; Leif Thuesen, MD, DmSc; and Jens Flensted Lassen, MD, PhD
[+] Article and Author Information

From Aarhus University Hospital, Aarhus, Denmark; Odense University Hospital, Odense, Denmark; Aalborg University Hospital, Aalborg, Denmark; Falck Emergency Medical Service, Copenhagen, Denmark; and University Medical Centre, Freiburg, Germany.


Grant Support: By grants from the Karl G. Andersen Foundation, the Helga and Peter Korning Foundation, the Health Research Fund of Central Denmark Region, the Research Foundation at Skejby University Hospital, the Riisfort Foundation, and the Arvid Nilsson Foundation.

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M11-0337.

Reproducible Research Statement:Study protocol and statistical code: Available from Dr. Terkelsen (e-mail, Christian_Juhl_Terkelsen@hotmail.com). Data set: Available from Dr. Terkelsen; however, signed agreement regarding the purpose and an approval from the Danish Data Protection Agency are required.

Requests for Single Reprints: Christian Juhl Terkelsen, MD, PhD, Department of Cardiology B, Aarhus University Hospital, DK-8200 Aarhus, Denmark; e-mail, Christian_Juhl_Terkelsen@hotmail.com.

Current Author Addresses: Dr. Terkelsen: Department of Cardiology B, Aarhus University Hospital, Skejby, Brendstrupgaardsvej 100, DK-8200 Aarhus, Denmark.

Dr. Jensen: Department of Cardiology, Odense University Hospital, Sdr. Boulevard 29, DK-5000 Odense, Denmark.

Dr. Tilsted: Department of Cardiology, Aalborg University Hospital, Hobrovej 18-22, DK-9100 Aalborg, Denmark.

Dr. Trautner: Falck Emergency Medical Service, The Falck House, Polititorvet, DK-1780 Copenhagen, Denmark.

Dr. Johnsen: Department of Clinical Epidemiology, Aarhus University Hospital, Oluf Palmes Alle 43-45, DK-8200 Aarhus, Denmark.

Dr. Vach: Department of Clinical Epidemiology, University Medical Centre, Stefan-Meier-Strasse 26, 79106 Freiburg, Germany.

Drs. Bøtker, Thuesen, and Lassen: Department of Cardiology, Aarhus University Hospital, Skejby, Brendstrupgaardsvej 100, DK-8200 Aarhus, Denmark.

Author Contributions: Conception and design: C.J. Terkelsen.

Analysis and interpretation of the data: C.J. Terkelsen, S.P. Johnsen, W. Vach.

Drafting of the article: C.J. Terkelsen, H.E. Bøtker.

Critical revision of the article for important intellectual content: C.J. Terkelsen, L.O. Jensen, H. Tilsted, S. Trautner, S.P. Johnsen, W. Vach, H.E. Bøtker, L. Thuesen, J.F. Lassen.

Final approval of the article: C.J. Terkelsen, L.O. Jensen, H. Tilsted, S. Trautner, S.P. Johnsen, W. Vach, H.E. Bøtker, L. Thuesen, J.F. Lassen.

Statistical expertise: C.J. Terkelsen, S.P. Johnsen.

Administrative, technical, or logistic support: C.J. Terkelsen, S. Trautner, H.E. Bøtker.

Collection and assembly of data: C.J. Terkelsen, L.O. Jensen, H. Tilsted, S. Trautner, S.P. Johnsen.


Ann Intern Med. 2011;155(6):361-367. doi:10.7326/0003-4819-155-6-201109200-00004
Text Size: A A A

Background: In patients with ST-segment elevation myocardial infarction (STEMI), delay between contact with the health care system and initiation of reperfusion therapy (system delay) is associated with mortality, but data on the associated risk for congestive heart failure (CHF) among survivors are limited.

Objective: To evaluate the association between system delay and the risk for readmissions or outpatient contacts due to CHF after primary percutaneous coronary intervention (PPCI) in patients with STEMI.

Design: Historical follow-up study using population-based medical registries.

Setting: Western Denmark.

Patients: Patients with STEMI who were transported by emergency medical service from 1 January 1999 to 7 February 2010 and treated with PPCI within 12 hours of symptom onset and who had a system delay of 6 hours or less (n = 7952). The median duration of follow-up was 3.1 years.

Measurements: Cumulative incidence of readmissions or outpatient contacts due to CHF was determined by using competing-risk regression analysis, with death as the competing risk. Crude and adjusted cause-specific hazard ratios for readmissions or outpatient contacts due to CHF were determined for system delay and other covariates.

Results: System delays of 60 minutes or less (n = 451), 61 to 120 minutes (n = 3457), 121 to 180 minutes (n = 2655), and 181 to 360 minutes (n = 1389) corresponded with long-term risks for readmissions or outpatient contacts due to CHF of 10.1%, 10.6%, 12.3%, and 14.1%, respectively (P < 0.001). In multivariable analysis, system delay was an independent predictor of readmissions or outpatient contacts due to CHF (adjusted hazard ratio per hour increase in delay, 1.10 [95% CI, 1.02 to 1.17]).

Limitation: In any nonrandomized study, there are risks for selection bias and residual confounding.

Conclusion: In patients with STEMI, shorter delay to PPCI is associated with lower risk for readmissions or outpatient contacts due to CHF during follow-up.

Primary Funding Source: The Karl G. Andersen Foundation, the Helga and Peter Korning Foundation, the Health Research Fund of Central Denmark Region, the Research Foundation at Skejby University Hospital, the Riisfort Foundation, and the Arvid Nilsson Foundation.

Figures

Grahic Jump Location
Figure.
Cumulative incidence of readmissions or outpatient contacts due to congestive heart failure in patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention.

Competing-risk regression analysis was used, with death as the competing risk. Data were stratified according to intervals of system delay (time from emergency medical service call to primary percutaneous coronary intervention) (n = 7952).

Grahic Jump Location

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