Root Cause Analysis of Deaths in ST-Segment Elevation Myocardial Infarctions Treated With Primary PCI: What Can We Do Better?

OBJECTIVE: Recent data demonstrate that mortality of patients with ST-elevation myocardial infarction (STEMI) has not changed despite dramatic reduction in door-to-balloon times. Identifying potential areas in care that can be further optimized to decrease mortality remains a priority.

METHODS: We performed a root cause analysis of all patients who died following primary percutaneous coronary intervention (PCI) during index hospitalization from 2008 to 2013 at the University of Michigan. Using a standardized data collection form, two interventional cardiologists and one non-invasive cardiologist reviewed patient care prior to arrival to the catheterization lab, while in the catheterization lab, and after primary PCI to determine cause of death and to rate potential preventability of death on a Likert scale (0 unpreventable - 4 mostly preventable).

RESULTS: Of the 25 deaths over the 5-year period, 8 were deemed at least mildly preventable by one or more reviewer. No death was deemed totally preventable. Interreviewer agreement was moderate for both cause of death (nominal Krippendorff's alpha = .58) and preventability of death (nominal alpha = .233). In spite of this overall lack of agreement, in all 8 preventable cases at least one reviewer cited ischemia to balloon time as a potentially addressable factor associated with the death.

CONCLUSION: Mortality following primary PCI was deemed mostly unpreventable. However, improvement in total ischemic time, and in particular symptom-onset to medical care, was identified as one potential target that might be of value in further reducing the mortality associated with STEMI.