Relation between door-to-balloon times and mortality after primary percutaneous coronary intervention over time: a retrospective study.
Relation between door-to-balloon times and mortality after primary percutaneous coronary intervention over time: a retrospective study.
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DOI：
10.1016/s0140-6736(14)61932-2
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发表时间：
2015-03-21
期刊：
影响因子：
168.9
通讯作者：
Krumholz, Harlan M.
中科院分区：
文献类型：
--
作者：
Nallamothu, Brahmajee K.;Normand, Sharon-Lise T.;Wang, Yongfei;Hofer, Timothy P.;Brush, John E., Jr.;Messenger, John C.;Bradley, Elizabeth H.;Rumsfeld, John S.;Krumholz, Harlan M.
最近在人口一级的平均门到气球(D2B)时间的下降与死亡率的下降无关。这项研究通过同时评估个体和群体层面的关联成分来调查这一看似自相矛盾的观察。我们的假设是，接受直接经皮冠状动脉介入治疗(PPCI)的患者人数的变化导致了死亡风险增加的长期趋势，尽管D2B时间较短的个体患者的死亡率一直较低。这是一项对2005年1月至2011年12月在美国国家心血管数据注册中心(NCDR)进行pPCI治疗的ST段抬高型心肌梗死(STEMI)患者的回顾性研究。建立多水平模型来评估D2B时间与住院和6个月死亡率之间的关系，在调整了患者和程序因素后，包括这种关联的个人和人群水平的组成部分。423家医院报告了150,116例手术的数据，在这段时间的第一年和最后几年，在这些设施接受经皮冠状动脉介入治疗的患者数量增加了55.4%，患者和程序因素也发生了许多变化。年D2B次数从2005年的中位数86分钟显著下降到2011年的63分钟(p<；0.001)，同时风险调整住院死亡率(4.7%至5.3%；p=0.06)和风险调整6个月死亡率(12.9%至14.4%；p=0.001)同时上升。在多水平模型中，较短的患者特定D2B时间在个体水平上与较低的住院死亡率(调整后的OR为每10分钟减少0.92；95%CI，0.91至0.93；p<；0.001)和6个月死亡率(调整后的OR每10分钟减少0.94；95%CI，0.93至0.95；p<；0.001)相关。相比之下，在人群水平上，风险调整后的住院和6个月死亡率，与患者特定的D2B时间无关，在研究期间不断增长和变化的接受经皮冠状动脉介入治疗的患者中上升。患者特有的D2B时间越短，几年内死亡率越低，而长期趋势表明，随着时间的推移，pPCI人群的死亡风险增加。在STEMI患者中，缺乏每年D2B时间和人群水平死亡率的变化不应被解释为其个体水平关系的指示，但更可能反映了高危患者在以后接受经皮冠状动脉介入治疗。
Recent declines in average door-to-balloon (D2B) times at the population-level have not been associated with decreases in mortality. This study investigated this seemingly paradoxical observation by evaluating individual and population-level components of the association simultaneously. Our hypothesis was that the changing population of patients undergoing primary percutaneous coronary intervention (pPCI) contributed to secular trends toward an increasing mortality risk, despite consistently lower mortality among individual patients with shorter D2B times. This was a retrospective study of ST-elevation myocardial infarction (STEMI) patients who underwent pPCI between January 2005 and December 2011 in the National Cardiovascular Data Registry (NCDR) CathPCI Registry. Multilevel models were constructed to evaluate the relationship between D2B time and in-hospital and 6-month mortality, including both individual and population-level components of this association after adjusting for patient and procedural factors. 423 hospitals reported data on 150,116 procedures with a 55.4% increase in the number of patients undergoing pPCI between the first and last years of this period at these facilities, as well as numerous changes in patient and procedural factors. Annual D2B times decreased significantly from a median of 86 minutes in 2005 to 63 minutes in 2011 (p<0.001) with a concurrent rise in risk-adjusted in-hospital mortality (4.7% to 5.3%; p=0.06) and risk-adjusted 6-month mortality (12.9% to 14.4%; p=0.001). In multilevel models, shorter patient-specific D2B times were consistently associated at the individual-level with lower in-hospital mortality (adjusted OR for each 10-min decrease, 0.92; 95% CI, 0.91 to 0.93; p<0.001) and 6-month mortality (adjusted OR for each 10-min decrease, 0.94; 95% CI, 0.93 to 0.95; p<0.001). In contrast, risk-adjusted in-hospital and 6-month mortality at the population-level, independent of patient-specific D2B times, rose in the growing and changing population of patients undergoing pPCI during the study period. Shorter patient-specific D2B times were consistently correlated with lower mortality within years, while secular trends suggest increased mortality risk over time in the pPCI population. The lack of association of annual D2B time and changes in mortality at the population-level should not be interpreted as an indication of its individual-level relationship in STEMI patients, but more likely reflects higher-risk patients undergoing pPCI in later years.