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ACTION Registry® – GWTG™

The National Cardiovascular Data Registry is comprised of ten different registries, each covering a specific cardiovascular-related clinical area. ACTION® (Acute Coronary Treatment and Intervention Outcomes Network) – GWTG™ (Get with the Guidelines) is a hospital quality programme focusing on acute myocardial infarction and its treatment.1


As of 2014, more than 71,000 STEMI patients were enrolled from more than 900 participating hospitals.1


Of the STEMI patients treated within ACTION® – GWTG™ hospitals between 2011 and 2014:

  • The majority of patients receive timely PPCI (within 90 minutes of first presentation) if they arrive directly at a PCI-capable facility.

  • Less than a third of patients who are transferred to a PCI-capable facility for PPCI receive timely reperfusion.

  • Just under half of all patients receiving fibrinolysis did so within 30 minutes of initial presentation (see Table 1).1

Table 1: Proportion of STEMI patients receiving timely reperfusion within the ACTION® – GWTG™ hospital programme (2011-2014)1

Table 1 Proportion of STEMI patients receiving timely reperfusion within the ACTION – GWTG™ hospital programme

 

Several analyses have been conducted using ACTION® – GWTG™ registry data. Some of the most recent STEMI analyses are summarised here.

Fibrinolysis and inter-hospital transfer2

Among patients with STEMI who require inter-hospital transfer, it is unclear how reperfusion strategy selection and outcomes vary with inter-hospital drive times. Using the ACTION® – GWTG™ data, this study aims to assess the association of estimated inter-hospital drive times with reperfusion strategy selection among transferred patients with STEMI in the United States.

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22,481 patients eligible for PPCI or fibrinolysis who were transferred from 1,771 STEMI-referring centres to 366 STEMI-receiving centres within the registry between 1 July 2008 and 31 March 2012 were identified.

  • The median estimated inter-hospital drive time was 57 minutes (interquartile range [IQR], 36-88 minutes).
  • As the estimated drive time increased, the proportion of patients achieving a first DTB time within 120 minutes was lower and the proportion of patients receiving fibrinolysis was higher (Table 2).

Table 2: Proportion of patients who received primary percutaneous coronary intervention stratified by the estimated inter-hospital drive time

Table showing the proportion of patients receiving PCI intervention depending on the drive time

 

  • When the estimated drive time exceeded 30 minutes, only 42.6% of transfer patients treated with PPCI achieved the first DTB time within 120 minutes.
  • Only 52.7% of eligible patients with a drive time exceeding 60 minutes received fibrinolysis.
  • Among 15,437 patients with estimated drive times of 30 to 120 minutes who were eligible for fibrinolysis or PPCI, 5,296 (34.3%) received pre-transfer fibrinolysis, with a median DTN time of 34 minutes (IQR, 23-53 minutes).
  • After fibrinolysis, the median time to transfer to the STEMI receiving centre was 49 minutes (IQR, 34-69 minutes), and 97.1% underwent follow-up angiography.
  • Patients treated with fibrinolysis vs PPCI had no significant mortality difference (3.7% vs 3.9%; adjusted odds ratio, 1.13; 95%CI, 0.94-1.36) but had marginally significant higher risk of bleeding (10.7% vs 9.5%; adjusted odds ratio, 1.17; 95%CI, 1.02-1.33).

In the United States, neither fibrinolysis nor PPCI is being optimally used to achieve guideline-recommended reperfusion targets. For patients who are unlikely to receive timely PPCI, pre-transfer fibrinolysis followed by early transfer for angiography may be a reperfusion option when the potential benefits of timely reperfusion outweigh bleeding risk.

Pre-hospital electrocardiogram and distance patients must travel to PCI-centre on total reperfusion time3

  • More than 29,500 STEMI patients were transported by ambulance to a PCI-capable facility within the ACTION® – GWTG™ registry from July 2008 through September 2012.
  • A retrospective cohort study found that more than two thirds (67% or n=19,690) of these patients received a pre-hospital ECG while the remaining 33% did not.
  • Analysis showed use of pre-hospital ECG was associated with a 10-minute reduction in time from first medical contact to balloon time. Furthermore, association was not affected by the distance between the patient’s home and the PCI-capable facility.

 

Race and STEMI4

Using registry data to look at racial trends in STEMI with respect to patient characteristics and treatment strategy, investigators found that black STEMI patients tended to be younger, more likely to be current smokers, had a higher prevalence of diabetes mellitus and hypertension, were more likely to have had prior stroke, a higher heart rate upon admission and higher initial Cr levels, and were more educated than white STEMI patients but have a lower household income and tended to live in non-rural communities (p<0.0001 for all values for both males and females). White male STEMI patients were more likely to have dyslipidaemia than black male STEMI patients (p<0.0001).


Although there were significant differences in patient baseline characteristics, the rates of invasive or interventional procedures were similar. Black patients had less CABG, less overall revascularisation and were not as likely to be referred to discharge therapy and counselling compared to their white counterparts. Despite these differences, there were no significant differences in the rates of death or major bleeding between the two patient groups.

References: 

  1. Masoudi FA, et al. Trends in U.S. Cardiovascular Care: 2016 Report from 4 ACC National Cardiovascular Data Registries. JACC 2017. doi: 10.1016/j.jacc.2016.12.005.

  2. Vora AN, et al. Fibrinolysis use among patients requiring inter-hospital transfer for ST-segment elevation myocardial infarction care a report from the US national cardiovascular data registry. JAMA Intern Med2015;175(2):207-215.

  3. Mumma BE, Kontos MC, Peng SA, Diercks DB. Association Between Prehospital ECG Use and Patient Home Distance from the PCI Center on Total Reperfusion Time in STEMI Patients: A Retrospective Analysis from the NCDR. Am Heart J 2014;167(6):915-920.

  4. Anstey, DE, Li, S, Thomas, L, et al; Race and Sex Differences in Management and Outcomes of Patients After ST-Elevation and Non-ST-Elevation Myocardial Infarct: Results From the NCDR. Clinical Cardiology 2016;39(10):585-595.