Value of registries in ST-segment-elevation myocardial infarction care in both the pre-coronavirus disease 2019 and the coronavirus disease 2019 eras

Abstract

Expeditious coronary artery recanalization of the occluded infarct artery, either by fibrinolytic therapy or primary percutaneous coronary intervention (PCI), has been firmly established in the treatment of ST-segment-elevation myocardial infarction (STEMI) for >3 decades. The direct relationship between the paradigm of “time is muscle” with in-hospital and longitudinal mortality has been demonstrated in multiple randomized clinical trials and in observational registries, such as the NRMI (National Registry of Myocardial Infarction), the ACC-NCDR (American College of Cardiology National Cardiovascular Data Registry), the CathPCI Registry, and the CP-MI (Chest Pain-Myocardial Infarction) registry, as well as in many international registries. Clinical practice guidelines for STEMI have focused on the promotion of STEMI systems of care. Both the American Heart Association and the ACC have aggressively advanced professional and patient education to minimize the “door-to-balloon (D2B)" time, the “door-to-needle” time, and the “symptom (pain) onset-to-balloon (P2B)" time to decrease myocardial necrosis occurring because of STEMI.1-3 “One cannot manage what one does not measure” describes the central role that MI registries have had in decreasing STEMI mortality throughout the world. Successful quality improvement initiatives, such as the Door-to-Balloon Campaign,4 have led to marked improvement in D2B times nationally, as demonstrated in the NCDR CathPCI registry 2019 to 2020 report, which included data from >1750 hospitals representing >90% of PCIs performed in the United States.5 Greater than 94% of patients achieved D2B times of <90 minutes, with a median D2B time of 61 minutes in 121 740 patients with STEMI, representing 15.6% of the 709 494 PCIs performed in the United States. Of interest, 9% of all patients with STEMI had a documented “patient-centered” reason for delay in primary PCI, the most common being a 39% incidence of cardiac arrest or need for intubation before primary PCI. The NCDR Chest Pain- MI Registry report from the 2019 to 2020 time frame is populated with data from >780 US hospitals and offers important additional information related to STEMI care.6 The median time from symptom onset to hospital arrival was 96 minutes, with the median time from symptom onset to device activation of 162 minutes. Symptom onset to device activation ≤120 minutes occurred only 29% of the time.