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Review
. 2014 Jan 21:348:f7393.
doi: 10.1136/bmj.f7393.

Off-hour presentation and outcomes in patients with acute myocardial infarction: systematic review and meta-analysis

Atsushi Sorita  1 , Adil Ahmed, Stephanie R Starr, Kristine M Thompson, Darcy A Reed, Larry Prokop, Nilay D Shah, M Hassan Murad, Henry H Ting
Affiliations
Review

Off-hour presentation and outcomes in patients with acute myocardial infarction: systematic review and meta-analysis

Atsushi Sorita et al. BMJ. .

Abstract

Objective: To assess the association between off-hour (weekends and nights) presentation, door to balloon times, and mortality in patients with acute myocardial infarction.

Data sources: Medline in-process and other non-indexed citations, Medline, Embase, Cochrane Database of Systematic Reviews, and Scopus through April 2013.

Study selection: Any study that evaluated the association between time of presentation to a healthcare facility and mortality or door to balloon times among patients with acute myocardial infarction was included.

Data extraction: Studies' characteristics and outcomes data were extracted. Quality of studies was assessed with the Newcastle-Ottawa scale. A random effect meta-analysis model was applied. Heterogeneity was assessed using the Q statistic and I(2).

Results: 48 studies with fair quality, enrolling 1,896,859 patients, were included in the meta-analysis. 36 studies reported mortality outcomes for 1,892,424 patients with acute myocardial infarction, and 30 studies reported door to balloon times for 70,534 patients with ST elevation myocardial infarction (STEMI). Off-hour presentation for patients with acute myocardial infarction was associated with higher short term mortality (odds ratio 1.06, 95% confidence interval 1.04 to 1.09). Patients with STEMI presenting during off-hours were less likely to receive percutaneous coronary intervention within 90 minutes (odds ratio 0.40, 0.35 to 0.45) and had longer door to balloon time by 14.8 (95% confidence interval 10.7 to 19.0) minutes. A diagnosis of STEMI and countries outside North America were associated with larger increase in mortality during off-hours. Differences in mortality between off-hours and regular hours have increased in recent years. Analyses were associated with statistical heterogeneity.

Conclusion: This systematic review suggests that patients with acute myocardial infarction presenting during off-hours have higher mortality, and patients with STEMI have longer door to balloon times. Clinical performance measures may need to account for differences arising from time of presentation to a healthcare facility.

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Conflict of interest statement

Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: no support from any organization for the submitted work other than those listed above; no financial relationships with any organizations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

Figures

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Fig 1 Flow chart for selection of eligible studies
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Fig 2 Odds ratio for in-hospital or 30 day mortality due to acute myocardial infarction during off-hours versus regular hours. Forest plot of 42 cohorts. PCI=percutaneous coronary intervention
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Fig 3 Odds ratio for proportion of STEMI patients with door to balloon times within 90 minutes during off-hours versus regular hours. Forest plot of 7 cohorts
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