Acute STEMIOn vs Off PPCINCT07860086
On vs Off-hour PPCI in STEMI Patients
An observational study of Acute STEMI and PPCI, run by Assiut University at 1 site in Egypt.
Trial summary
ST-elevation myocardial infarction (STEMI) remains a leading cause of morbidity and mortality globally, and timely reperfusion with primary percutaneous coronary intervention (PPCI) is the gold-standard treatment1. Read more about this study
- Who is it for?
- Ages 18 years and older
- Conditions the study is for
- Acute STEMI, PPCI, Observational Study
- How many people
- 450 participants
- Where
- 1 siteEgypt
- Study dates
- 15 Oct 2026to 31 Dec 2027
- Phase
- Observational
Key requirements
Who can take part, as listed by the sponsor. Only the study team can confirm whether you are eligible, so take this list to your doctor.
- Ages 18 years and older
- All sexes
- No healthy volunteers
- Adult, Older adult
Study population: All Acute STEMI Patients undergoing PPCI in AUHH
Who may be able to join
- Age ≥18 years
- Acute STEMI eligible for Primary Percutaneous Coronary Intervention
- Symptom onset ≤24 hours prior to hospital presentation
Who cannot join
- Previous myocardial infarction with known LV dysfunction (baseline LVEF <30%).
- Cardiogenic shock secondary to mechanical complication (acute mitral regurgitation, ventricular septal defect, free wall rupture) rather than myocardial infarction.
- Indication for emergent coronary artery bypass grafting at presentation (e.g., left main occlusion unsuitable for PCI).
- Intra-aortic balloon pump or mechanical circulatory support initiated prior to diagnostic angiography (devices initiated post-PPCI are not exclusions)
- Expected survival <30 days from non-cardiac causes.
Trial locations and contacts
1 site in 1 country. Contact the study team or a site near you to ask about taking part.
Egypt1 site
Assiut University Heart Hospital
Asyut, Asyut Governorate, 71515
Muhammad Hatem Maghraby, Bachelor's, 01014321553, muhammad.maghraby@gmail.com
About this study
Official title: On- Versus Off-Hour Primary Percutaneous Coronary Intervention in ST-Elevation Myocardial Infarction Patients
ST-elevation myocardial infarction (STEMI) remains a leading cause of morbidity and mortality globally, and timely reperfusion with primary percutaneous coronary intervention (PPCI) is the gold-standard treatment1. Current guidelines recommend a door-to-balloon (DTB) time of 90 minutes or less, as the benefits of PPCI increase in direct correlation with the brevity of reperfusion time.
However, there is consistent epidemiological evidence that STEMI patients presenting during off-hours (nights, weekends, and holidays) experience delays in reperfusion and worse in-hospital outcomes compared to those presenting during regular business hours. Two competing hypotheses dominate the literature. The systems hypothesis suggests that delays in care delivery during nights and weekends-including longer catheterization laboratory activation time, reduced availability of experienced operators, and logistical constraints-are the primary drivers of worse outcomes. In support of this, some studies have found that the mortality difference between off-hours and on-hours presentations is attenuated after adjusting for DTB time (Chung et al., 2020), suggesting that system-level process measures may be actionable targets for quality improvement.
Read more
Alternatively, the intrinsic severity hypothesis suggests that nocturnal STEMI presentations represent inherently more severe infarcts-characterized by higher thrombus burden, larger myocardial infarction size, and more frequent complications such as cardiogenic shock-independent of how rapidly reperfusion is achieved. Recent studies examining circadian variation in infarct size and myocardial injury biomarkers have found evidence of larger infarcts and worse systolic function in nocturnal-onset STEMI, with long-term mortality implications.
Critically, the vast majority of evidence in this field derives from retrospective registry data, particularly from North American and Western European cohorts. Data from the Middle East and North Africa (MENA) region, where demographic and healthcare system profiles differ substantially from developed nations, are essentially absent from the literature. Furthermore, contemporary data on the prospective relationships between time-of-PPCI, operator experience, procedural quality parameters (such as myocardial blush grade and ST-segment resolution), and outcomes remain limited.
A prospective study with granular intra-procedural data collection offers the opportunity to: (1) quantify the magnitude of the off-hours effect in a Middle Eastern context; (2) decompose the DTB time into its components to identify specific system bottlenecks; (3) assess whether operator seniority and team composition confound or mediate the off-hours effect6; and (4) evaluate whether procedural quality metrics (reperfusion grade, thrombus burden, microvascular perfusion) differ between daytime and nighttime PPCI and contribute to outcome disparities independent of system factors.
Read the detailed description
ST-elevation myocardial infarction (STEMI) remains a leading cause of morbidity and mortality globally, and timely reperfusion with primary percutaneous coronary intervention (PPCI) is the gold-standard treatment1. Current guidelines recommend a door-to-balloon (DTB) time of 90 minutes or less, as the benefits of PPCI increase in direct correlation with the brevity of reperfusion time.
However, there is consistent epidemiological evidence that STEMI patients presenting during off-hours (nights, weekends, and holidays) experience delays in reperfusion and worse in-hospital outcomes compared to those presenting during regular business hours. Two competing hypotheses dominate the literature. The systems hypothesis suggests that delays in care delivery during nights and weekends-including longer catheterization laboratory activation time, reduced availability of experienced operators, and logistical constraints-are the primary drivers of worse outcomes. In support of this, some studies have found that the mortality difference between off-hours and on-hours presentations is attenuated after adjusting for DTB time (Chung et al., 2020), suggesting that system-level process measures may be actionable targets for quality improvement.
Alternatively, the intrinsic severity hypothesis suggests that nocturnal STEMI presentations represent inherently more severe infarcts-characterized by higher thrombus burden, larger myocardial infarction size, and more frequent complications such as cardiogenic shock-independent of how rapidly reperfusion is achieved. Recent studies examining circadian variation in infarct size and myocardial injury biomarkers have found evidence of larger infarcts and worse systolic function in nocturnal-onset STEMI, with long-term mortality implications.
Critically, the vast majority of evidence in this field derives from retrospective registry data, particularly from North American and Western European cohorts. Data from the Middle East and North Africa (MENA) region, where demographic and healthcare system profiles differ substantially from developed nations, are essentially absent from the literature. Furthermore, contemporary data on the prospective relationships between time-of-PPCI, operator experience, procedural quality parameters (such as myocardial blush grade and ST-segment resolution), and outcomes remain limited.
A prospective study with granular intra-procedural data collection offers the opportunity to: (1) quantify the magnitude of the off-hours effect in a Middle Eastern context; (2) decompose the DTB time into its components to identify specific system bottlenecks; (3) assess whether operator seniority and team composition confound or mediate the off-hours effect6; and (4) evaluate whether procedural quality metrics (reperfusion grade, thrombus burden, microvascular perfusion) differ between daytime and nighttime PPCI and contribute to outcome disparities independent of system factors.
- Conditions
- Acute STEMI, PPCI, Observational Study, Coronary Artery Disease (CAD)
- Medical subject headings
- ST Elevation Myocardial Infarction, Coronary Artery Disease
What participants receive
What participants receive. In a randomised study each person is assigned to one group by chance.
| Study group | Role | What they receive |
|---|---|---|
| On-hour Group | Patients presenting from 8:00 AM to 8:00PM | |
| Off-Hour Group | Patients presenting from 8:00 PM to 8:00 AM, additional analysis with further stratification of holidays and weenends added to the off-hour group. |
What is being measured
The primary outcome is the main question the study is designed to answer.
In-hospital 4-point MACE
In-hospital 4-point MACE: Composite binary outcome (yes/no) incorporating any of: all-cause mortality, reinfarction, ischemic stroke, Emergent Target Vessel Revascularization (TVR). For analysis, the composite will be analyzed as a binary variable
Measured: Periprocedural
Secondary outcomes (4)
Individual MACE Components
Binary Outcome
Measured: Periprocedural
Door-to-Balloon Time Components
Measured in Minutes
Measured: Periprocedural
TIMI Flow
Measured in grades (0-3)
Measured: Periprocedural
LVEF at discharge
In Percentage
Measured: Periprocedural
Timeline
From the start of the study to its completion; the mark is today. Estimated dates are the sponsor’s plan.
- First posted6 Oct 2026
- Study start15 Oct 2026 (estimated)
- Primary completion30 Jun 2027 (estimated)
- Study completion31 Dec 2027 (estimated)
Resources
- Official record on ClinicalTrials.govThe registry entry this page is built from, with its full change history.
- Publications (20)Papers the sponsor has linked to this study.
- Other trials for Acute STEMIStudies of the same condition, open and under way.
- More trials run by Assiut UniversityThe sponsor's other registered studies.
- What the trial phases meanHow a treatment moves from first tests in people to approval.
More details
For doctors and researchers: how the study is designed, who runs it, and its registry IDs.
Study design
- Study type
- Observational
- Observational model
- Cohort
- Time perspective
- Prospective
- Enrolment
- 450 participants (estimated)
Sponsor and investigators
- Lead sponsor
- Assiut University
- Sponsor type
- University, hospital or other
- Responsible party
- Principal investigator, Muhammad Hatem Hassan Mohammed Maghraby, Assiut University
- Investigators
- Hamdy Shams Eddin Mohammad Taher, MD, Study chair, Assiut UniversityMagdy Ibrahim Aldesowky Mohamed Algowhary, MD, Study chair, Assiut University
IDs, dates and publications
- ClinicalTrials.gov ID
- NCT07860086
- Sponsor's protocol ID
- On Vs Off PPCI
- Acronym
- On vs Off PPCI
- Status last verified
- Oct 2026
- First submitted
- 11 Sep 2026
- Last updated
- 6 Oct 2026
- Results posted
- No
- FDA-regulated drug
- No
- FDA-regulated device
- No
Publications
Glaser R, Naidu SS, Selzer F, Jacobs AK, Laskey WK, Srinivas VS, Slater JN, Wilensky RL. Factors associated with poorer prognosis for patients undergoing primary percutaneous coronary intervention during off-hours: biology or systems failure? JACC Cardiovasc Interv. 2008 Dec;1(6):681-8. doi: 10.1016/j.jcin.2008.08.020.
PubMed 19463384Vrints C, Andreotti F, Koskinas KC, Rossello X, Adamo M, Ainslie J, Banning AP, Budaj A, Buechel RR, Chiariello GA, Chieffo A, Christodorescu RM, Deaton C, Doenst T, Jones HW, Kunadian V, Mehilli J, Milojevic M, Piek JJ, Pugliese F, Rubboli A, Semb AG, Senior R, Ten Berg JM, Van Belle E, Van Craenenbroeck EM, Vidal-Perez R, Winther S; ESC Scientific Document Group. 2024 ESC Guidelines for the management of chronic coronary syndromes. Eur Heart J. 2024 Sep 29;45(36):3415-3537. doi: 10.1093/eurheartj/ehae177. No abstract available.
PubMed 39210710Ma WJ, Gao SD, Huang SZ, Lin XZ, Yang YJ, Yu MY; Quality Control & Improvement Center of Cardiovascular Intervention of Beijing. Off-hours admission does not impact outcomes in patients undergoing primary percutaneous coronary intervention and with a first medical contact-to-device time within 90 min. Chin Med J (Engl). 2021 Jun 24;134(15):1795-1802. doi: 10.1097/CM9.0000000000001621.
PubMed 34172617Li X, Ge Z, Kan J, Anjum M, Xie P, Chen X, Khan HS, Guo X, Saghir T, Chen J, Gill BUA, Guo N, Sheiban I, Raza A, Wei Y, Chen F, Mintz GS, Zhang JJ, Stone GW, Chen SL; IVUS-ACS Investigators. Intravascular ultrasound-guided versus angiography-guided percutaneous coronary intervention in acute coronary syndromes (IVUS-ACS): a two-stage, multicentre, randomised trial. Lancet. 2024 May 11;403(10439):1855-1865. doi: 10.1016/S0140-6736(24)00282-4. Epub 2024 Apr 8.
PubMed 3860421216. Ishihara, M., Inoue, I., Kawagoe, T., Shimatani, Y., Kurisu, S., Nishioka, K., Umemura, S., & Nakamura, S. (2008). Circadian variation of acute myocardial infarction in patients with diabetes mellitus. Journal of the American College of Cardiology, 52(5), 343-346. https://doi.org/10.1016/j.jacc.2008.04.035
15. Yonetsu, T., Kakuta, T., & Tanaka, A. (2022). Circadian variations of ischemic burden among patients with myocardial infarction undergoing primary percutaneous coronary intervention. Circulation: Cardiovascular Interventions, 15(7), e011369. https://doi.org/10.1161/CIRCINTERVENTIONS.112.969022
14. Mert, M., Yilmaz, A., Gül, A. E., Güngör, B., & Özcan, K. S. (2019). On- versus off-hours presentation and mortality of ST-segment elevation myocardial infarction patients treated with primary percutaneous coronary intervention. Cardiovascular Revascularization Medicine, 20(10), 850-855. https://doi.org/10.1016/j.carrev.2019.01.001
13. Giri, J., Munir, A. B., Geisler, T. P., Greenberg, J. W., Rajamanoharan, R., Ramu, B., Safford, R. E., Toma, C., Whitman, G. J., & Sartori, S. (2024). Primary percutaneous coronary intervention in STEMI: SCAI 2024 guideline summary. Medscape Cardiology, 1-15.
Moller JE, Engstrom T, Jensen LO, Eiskjaer H, Mangner N, Polzin A, Schulze PC, Skurk C, Nordbeck P, Clemmensen P, Panoulas V, Zimmer S, Schafer A, Werner N, Frydland M, Holmvang L, Kjaergaard J, Sorensen R, Lonborg J, Lindholm MG, Udesen NLJ, Junker A, Schmidt H, Terkelsen CJ, Christensen S, Christiansen EH, Linke A, Woitek FJ, Westenfeld R, Mobius-Winkler S, Wachtell K, Ravn HB, Lassen JF, Boesgaard S, Gerke O, Hassager C; DanGer Shock Investigators. Microaxial Flow Pump or Standard Care in Infarct-Related Cardiogenic Shock. N Engl J Med. 2024 Apr 18;390(15):1382-1393. doi: 10.1056/NEJMoa2312572. Epub 2024 Apr 7.
PubMed 38587239Bulluck H, Nicholas J, Crimi G, White SK, Ludman AJ, Pica S, Raineri C, Cabrera-Fuentes HA, Yellon D, Rodriguez-Palomares J, Garcia-Dorado D, Hausenloy DJ. Circadian variation in acute myocardial infarct size assessed by cardiovascular magnetic resonance in reperfused STEMI patients. Int J Cardiol. 2017 Mar 1;230:149-154. doi: 10.1016/j.ijcard.2016.12.030. Epub 2016 Dec 19.
PubMed 28038815Seneviratna A, Lim GH, Devi A, Carvalho LP, Chua T, Koh TH, Tan HC, Foo D, Tong KL, Ong HY, Richards AM, Yew CK, Chan MY. Circadian Dependence of Infarct Size and Acute Heart Failure in ST Elevation Myocardial Infarction. PLoS One. 2015 Jun 3;10(6):e0128526. doi: 10.1371/journal.pone.0128526. eCollection 2015.
PubMed 260390599. Choi, J., Lee, T., Yang, C., Cairns, J., Roston, T. M., Moghaddam, N., Singer, J., Wong, G., & Fordyce, C. B. (2025). Association of daytime vs. non-daytime presentation with reperfusion times and clinical outcomes among STEMI patients complicated by cardiogenic shock. European Heart Journal, 46 (Supplement_1), ehaf784.1866. https://doi.org/10.1093/eurheartj/ehaf784.1866
Thygesen K, Alpert JS, Jaffe AS, Chaitman BR, Bax JJ, Morrow DA, White HD; Executive Group on behalf of the Joint European Society of Cardiology (ESC)/American College of Cardiology (ACC)/American Heart Association (AHA)/World Heart Federation (WHF) Task Force for the Universal Definition of Myocardial Infarction. Fourth Universal Definition of Myocardial Infarction (2018). Circulation. 2018 Nov 13;138(20):e618-e651. doi: 10.1161/CIR.0000000000000617. No abstract available.
PubMed 30571511Takamizawa K, Gohbara M, Hanajima Y, Tsutsumi K, Kirigaya H, Kirigaya J, Nakahashi H, Minamimoto Y, Kimura Y, Kawaura N, Matsushita K, Okada K, Konishi M, Iwahashi N, Kosuge M, Sugano T, Ebina T, Hibi K. Long-term outcomes and operators' experience in primary percutaneous coronary intervention for ST-segment elevation myocardial infarction. Cardiovasc Interv Ther. 2025 Jan;40(1):57-67. doi: 10.1007/s12928-024-01059-5. Epub 2024 Oct 27.
PubMed 39463209Naumann D, Fischer J, Gmeiner J, Lusebrink E, Beer BN, Grieger M, Giousouf A, Schrage B, Stremmel C, Massberg S, Orban M, Scherer C. The association of off-hour vs. on-hour intensive care unit admission time with mortality in patients with cardiogenic shock: a retrospective multi-centre analysis. Eur Heart J Acute Cardiovasc Care. 2024 May 7;13(4):347-353. doi: 10.1093/ehjacc/zuae012.
PubMed 38306600