Causes of Delay and Associated Mortality in Patients Transferred With ST-Segment-Elevation...

242 Abstracts

that without information on specific NSAID types and dosages,the findings represent a class effect, and that placebo-controlledtrials of specific agents are needed to determine the exact safetyprofile of individual agents. They concluded that despite lowermean blood pressures, the net effect from the multivariate mod-eling and propensity matching was an overall increase inadverse cardiovascular events, and they support the AmericanGeriatric Society Panel’s recommendation of acetaminophenas the first-line agent in chronic pain in the elderly until random-ized trial data for specific agents are available.

[Lina Tran, MD

Denver Health Medical Center, Denver, CO]

Comments: Although this study was limited by a lack ofinformation regarding specific NSAIDs or doses, it does offerstatistically significant data on the possible adverse cardiovas-cular outcomes of chronic NSAID use on hypertensive patientswith coronary artery disease, from a large randomized trial fromwhich long-term blood pressure measures and cardiovascularoutcomes were documented and available. This is of particularimportance as NSAIDs have become the mainstay treatment forchronic pain syndromes and is one of the most common recom-mendations made by emergency physicians to patients present-ing to the emergency department for pain complaints.

, CAUSESOFDELAYANDASSOCIATEDMORTALITYIN PATIENTS TRANSFERRED WITH ST-SEGMENT-ELEVATION MYOCARDIAL INFARCTION. MiedemaMD, Newell, MC, Duval S. Circulation 2011;124:1636–44.

Primary percutaneous coronary intervention (PCI) has beenshown to decrease mortality in a linear fashion, yet only 25% ofUnited States hospitals have PCI capabilities. The EuropeanSociety of Cardiology guidelines have recently adopted a goalfor total door-to-balloon time of 120 min for transferredST-segment-elevation myocardial infarction (STEMI) patients,whereas the American College of Cardiology/American HeartAssociation gives no recommendation for transferred patients,but states a door-to-balloon time of 90 min for primary PCI.This was a single-center prospective, observational study ofpatients with the diagnosis of STEMI, who were transferredfor PCI. There were 2034 patients over 5 years from 31 hospi-tals, including 11 hospitals within 60 miles of the PCI center(designated zone 1) and 20 hospitals (zone 2) between 60 and210 miles away entered into a database and categorized.Overall, 30.4% of patients (n = 613) were treated in# 90 minand 65.7% (n = 1324) were treated in# 120 min. Referralhospitals had the most frequent delays (64.0%, n = 1298), fol-lowed by PCI centers (15.7%, n = 317) and transport-relateddelays (12.6%, n = 255). The delays at the referral center weremost commonly from awaiting transport (26.4%, n = 535) oremergency department (ED) delays (14.3%, n = 289). Of theED delays, diagnostic dilemmas (median, 95.5 min) andnon-diagnostic initial electrocardiograms (81 min) led to delaysof the greatest magnitude. However, these delays were associ-ated with a lower in-hospital and 1-year mortality (7.3% and12.4%; 0% and 3.3%, respectively) compared to delays causedby cardiac arrest or cardiogenic shock that had the highestin-hospital and 1-year mortality (30.6% and 38.7%,

respectively). Delays at the PCI center and from transport hadsignificant variance and clinical impact.

[Douglas Melzer, MD

Denver Health Medical Center, Denver, CO]

Comments: Delays to PCI continue to be related to varioussystem issues that were highlighted in this study. What remainsto be determined is how often these delays contribute to poorclinical outcomes. Although there are external motivations tosystem development to meet the established 90 min-to-PCIguidelines, knowing how delays beyond this window impactoutcomes is equally important as knowing where the delaysoccur. This retrospective study, limited as it is by its design,provides only a small amount of information in those regards.

, INFLAMMATORYBIOMARKERSANDPREDICTIONFOR INTENSIVE CARE UNIT ADMISSION IN SEVERECOMMUNITY-ACQUIRED PNEUMONIA. Ramirez P,Ferrer M, Marti V, et al. Crit Care Med 2011;39:2211–7.

This prospective clinical cohort study measured inflamma-tory biomarkers and attempted correlation with clinical out-comes, specifically the need for intensive care unit (ICU) vs.ward care in patients with community-acquired pneumonia(CAP). Various biomarkers (procalcitonin, interleukin [IL]-1,IL-6, IL-8, IL-10, tumor necrosis factor alpha [TNF-a], andC-reactive protein [CRP]), as well as demographic data andPneumonia Severity Index scores, were measured within 24 hof admission in patients not requiring mechanical ventilationor vasopressors at two university hospitals in Spain fromJanuary 2003 to October 2005. Of the 685 patients included inthis study, 58 required ICU admission: 36 at the time of admis-sion as determined by the admitting physician, and 22 after sub-sequent clinical deterioration on the ward. Of the 22 delayedICU admissions, 14 (68%) met the Infectious Disease Societyof America/American Thoracic Society (IDSA/ATS) guidelinesfor severe CAP criteria and may have warranted ICU admissionat time of initial evaluation. Overall, levels of procalcitonin,CRP, IL-6, and TNF-a were higher in ICU patients who alsomet IDSA/ATS clinical criteria for severe pneumonia. In con-trast, none of the patients (n = 78) who met IDSA/ATS criteriafor severe CAP by minor criteria but had normal procalcitoninlevels (below 0.35 ng/mL) required ICU care. The authorsdetermined that procalcitonin levels below a set cut-off of0.35 ng/mL had a negative predictive value for ICU admittedpatients of 0.23, whereas the other studied biomarkers andIDSA/ATS criteria had a negative predictive value rangingfrom 0.42 to 0.56. In a separate arm, ICU patients were matchedto ward patients and adjusted for age, comorbidities, and Pneu-monia Severity Index. This study arm showed that procalcitoninand CRP levels were higher in patients requiring early vs.delayed ICU admission, but with little difference in positivelikelihood ratios (3.32-2.17) for ICU admission to suggestsignificance. Patients meeting IDSA/ITS criteria for severepneumonia had a higher positive predictive value of 5.61 forICU admission when compared to the various inflammatorybiomarkers (1.52–2.81). The authors concluded that IDSA/ATS clinical guidelines were better at predicting ICU admissionthan any measured biomarkers, although procalcitonin levels