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Use of emergency medical service in acute myocardial infarction in an Italian Northeastern region. J Public Health (Oxf) 2022. [DOI: 10.1007/s10389-020-01422-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Satti DI, Hussain T, Ahmed S, Saqib BUH, Malik J, Umair F. Outcomes of ambulance arrival vs. self-presentation in acute heart failure: an insight from the heart failure registry in Pakistan. Expert Rev Cardiovasc Ther 2022; 20:409-413. [PMID: 35522982 DOI: 10.1080/14779072.2022.2075344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES We aimed to demonstrate the outcomes of various presentations of acute heart failure (AHF), as well as test the generalizability of previous results in routine clinical practice. METHODS This retrospective cohort study compares two patient groups of AHF: those who self-presented compared to those who used an ambulance. The primary endpoint was the measure of 30-, 180-, and 365-day cardiovascular (CV) mortality after the index hospitalization event. Secondary endpoints included HF rehospitalization within 30 days of enrollment, index hospital stay, and death from any cause during the index hospitalization. The relationship between the two modes of presentation was calculated by multivariate analysis. RESULTS A total of 14,454 patients with AHF presented to the emergency department. Patients who presented by ambulance had a higher 30-, 180-, and 365-day mortality than those who self-presented (30-day: 5.57% vs. 3.53%, OR [95% CI]: 0.65 [0.24-0.93], p-value <0.001; 180-day: 11.25% vs. 8.41%, OR [95% CI]: 0.52 [0.34-0.97], p-value = 0.021; and 365-day: 19.25% vs. 15.48%, OR [95% CI]: 0.67 [0.33-0.95], p-value <0.001). CONCLUSION AHF patients who presented via ambulance had a higher 30-, 180-, and 365-day mortality as compared to self-presentation.
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Affiliation(s)
- Danish Iltaf Satti
- Department of Medicine, Shifa Tameer e Millat University, Islamabad, Pakistan
| | - Talib Hussain
- Department of Cardiology, Armed Forces Institute of Cardiology, Rawalpindi, Pakistan
| | - Sohail Ahmed
- Department of Cardiology, DHQ Hospital Chakwal, Chakwal, Pakistan
| | | | - Jahanzeb Malik
- Department of Cardiology, Rawalpindi Institute of Cardiology, Rawalpindi, Pakistan
| | - Farhan Umair
- Department of Cardiology, Punjab Institute of Cardiology, Lahore, Pakistan
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Kim YR, Jeong MH, An MJ, Han X, Cho KH, Sim DS, Hong YJ, Kim JH, Ahn Y. Comparison of Prognosis According to the Use of Emergency Medical Services in Patients with ST-Segment Elevation Myocardial Infarction. Yonsei Med J 2022; 63:124-132. [PMID: 35083897 PMCID: PMC8819403 DOI: 10.3349/ymj.2022.63.2.124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 10/29/2021] [Accepted: 11/05/2021] [Indexed: 11/27/2022] Open
Abstract
PURPOSE This study aimed to compare long-term clinical outcomes according to the use of emergency medical services (EMS) in patients with ST-segment elevation myocardial infarction (STEMI) who arrived at the hospital within 12 hr of symptom onset. MATERIALS AND METHODS A total of 13104 patients with acute myocardial infarction were enrolled in the Korea Acute Myocardial Infarction Registry-National Institutes of Health from October 2011 to December 2015. Of them, 2416 patients with STEMI who arrived at the hospital within 12 hr were divided into two groups: 987 patients in the EMS group and 1429 in the non-EMS group. Propensity score matching (PSM) was performed to reduce bias from confounding variables. After PSM, 796 patients in the EMS group and 796 patients in the non-EMS group were analyzed. The clinical outcomes during 3 years of clinical follow-up were compared between the two groups according to the use of EMS. RESULTS The symptom-to-door time was significantly shorter in the EMS group than in the non-EMS group. The EMS group had more patients with high Killip class compared to the non-EMS group. The rates of all-cause death and major adverse cardiac events (MACE) were not significantly different between the two groups. After PSM, the rate of all-cause death and MACE were still not significantly different between the EMS and non-EMS groups. The predictors of mortality were high Killip class, renal dysfunction, old age, long door-to-balloon time, long symptom-to-door time, and heart failure. CONCLUSION EMS utilization was more frequent in high-risk patients. The use of EMS shortened the symptom-to-door time, but did not improve the prognosis in this cohort.
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Affiliation(s)
- Yu Ri Kim
- Department of Cardiovacular Medicine, Chonnnam National University Hospital and Medical School, Gwangju, Korea
- College of Nursing, Chonnam National University, Gwangju, Korea
| | - Myung Ho Jeong
- Department of Cardiovacular Medicine, Chonnnam National University Hospital and Medical School, Gwangju, Korea.
| | - Min Jeong An
- College of Nursing, Chonnam National University, Gwangju, Korea
| | - Xiongyi Han
- Department of Cardiovacular Medicine, Chonnnam National University Hospital and Medical School, Gwangju, Korea
| | - Kyung Hoon Cho
- Department of Cardiovacular Medicine, Chonnnam National University Hospital and Medical School, Gwangju, Korea
| | - Doo Sun Sim
- Department of Cardiovacular Medicine, Chonnnam National University Hospital and Medical School, Gwangju, Korea
| | - Young Joon Hong
- Department of Cardiovacular Medicine, Chonnnam National University Hospital and Medical School, Gwangju, Korea
| | - Ju Han Kim
- Department of Cardiovacular Medicine, Chonnnam National University Hospital and Medical School, Gwangju, Korea
| | - Youngkeun Ahn
- Department of Cardiovacular Medicine, Chonnnam National University Hospital and Medical School, Gwangju, Korea
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Liao BYW, Lee MAW, Dicker B, Todd VF, Stewart R, Poppe K, Kerr A. Prehospital identification of ST-segment elevation myocardial infarction and mortality (ANZACS-QI 61). Open Heart 2022; 9:openhrt-2021-001868. [PMID: 35086917 PMCID: PMC8796269 DOI: 10.1136/openhrt-2021-001868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 01/05/2022] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Early recognition of ST-segment elevation myocardial infarction (STEMI) is needed for timely cardiac monitoring and reperfusion therapy. METHODS Three anonymously linked New Zealand national datasets (July 2016-November 2018) were used to assess the utilisation of ambulance transport in STEMI cases, the concordance between ambulance initial clinical impressions and hospital STEMI diagnoses, and the association between initial paramedic clinical impressions and 30-day mortality. The St John Ambulance electronic record captures community call-outs and paramedic initial clinical impressions. The national cardiac (ANZACS-QI) registry and national administrative datasets capture all New Zealand public hospital admission diagnoses and mortality data. RESULTS Of 5465 patients with STEMI, 73% were transported to hospital by ambulance. For these patients, the initial paramedic impression was STEMI in 50.7%, another acute coronary syndrome (ACS) diagnosis in 19.9% and non-ACS diagnosis in 29.7%. Only 37% of the 5465 patients with STEMI were both transported by ambulance and clinically suspected of STEMI by paramedics. Compared with patients with paramedic-'suspected STEMI', 30-day mortality was over threefold higher for patients thought to have a non-ACS condition (10.9% and 34.9%, respectively), but after adjustment for available covariates, this was substantially ameliorated (HR 1.48, 95% CI 1.22 to 1.80). CONCLUSIONS In this national data linkage study, only 4 out of every 10 patients with STEMI were both transported by ambulance and had STEMI suspected by paramedics. Although patients with STEMI not suspected of an ACS diagnosis by paramedics had the highest mortality rate, this is largely explained by the different risk profile of these patients.
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Affiliation(s)
- Becky Yi-Wen Liao
- Department of Cardiology, Middlemore Hospital, Auckland, New Zealand .,Greenlane Cardiovascular Services, Auckland City Hospital, Auckland, New Zealand
| | | | - Bridget Dicker
- Paramedicine Research Unit, Paramedicine Department, School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand.,Clinical Audit and Research, St John New Zealand, Auckland, New Zealand
| | - Verity F Todd
- Paramedicine Research Unit, Paramedicine Department, School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand.,Clinical Audit and Research, St John New Zealand, Auckland, New Zealand
| | - Ralph Stewart
- Greenlane Cardiovascular Services, Auckland City Hospital, Auckland, New Zealand
| | - Katrina Poppe
- Section of Epidemiology and Biostatistics, School of Population Health, University of Auckland, Auckland, New Zealand
| | - Andrew Kerr
- Section of Epidemiology and Biostatistics, School of Population Health, University of Auckland, Auckland, New Zealand.,School of Medicine, University of Auckland, Auckland, New Zealand
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Li N, Ma J, Zhou S, Dong X, Maimaitiming M, Jin Y, Zheng Z. Can a Healthcare Quality Improvement Initiative Reduce Disparity in the Treatment Delay among ST-Segment Elevation Myocardial Infarction Patients with Different Arrival Modes? Evidence from 33 General Hospitals and Their Anticipated Impact on Healthcare during Disasters and Public Health Emergencies. Healthcare (Basel) 2021; 9:1462. [PMID: 34828508 PMCID: PMC8621169 DOI: 10.3390/healthcare9111462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 10/25/2021] [Accepted: 10/26/2021] [Indexed: 11/18/2022] Open
Abstract
(1) Background: Chest pain center accreditation has been associated with improved timelines of primary percutaneous coronary intervention (PCI) for ST-segment elevated myocardial infarction (STEMI). However, evidence from low- and middle-income regions was insufficient, and whether the sensitivity to improvements differs between walk-in and emergency medical service (EMS)-transported patients remained unclear. In this study, we aimed to examine the association of chest pain center accreditation status with door-to-balloon (D2B) time and the potential modification effect of arrival mode. (2) Methods: The associations were examined using generalized linear mixed models, and the effect modification of arrival mode was examined by incorporating an interaction term in the models. (3) Results: In 4186 STEMI patients, during and after accreditation were respectively associated with 65% (95% CI: 54%, 73%) and 71% (95% CI: 61%, 79%) reduced risk of D2B time being more than 90 min (using before accreditation as the reference). Decreases of 27.88 (95% CI: 19.57, 36.22) minutes and 26.55 (95% CI: 17.45, 35.70) minutes in D2B were also observed for the during and after accreditation groups, respectively. The impact of accreditation on timeline improvement was greater for EMS-transported patients than for walk-in patients. (4) Conclusions: EMS-transported patients were more sensitive to the shortened in-hospital delay associated with the initiative, which could exacerbate the existing disparity among patients with different arrival modes.
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Affiliation(s)
- Na Li
- Department of Global Health, School of Public Health, Peking University, Beijing 100871, China; (N.L.); (J.M.); (S.Z.); (X.D.); (Z.Z.)
- Institute for Global Health and Development, Peking University, Beijing 100871, China
| | - Junxiong Ma
- Department of Global Health, School of Public Health, Peking University, Beijing 100871, China; (N.L.); (J.M.); (S.Z.); (X.D.); (Z.Z.)
- Institute for Global Health and Development, Peking University, Beijing 100871, China
| | - Shuduo Zhou
- Department of Global Health, School of Public Health, Peking University, Beijing 100871, China; (N.L.); (J.M.); (S.Z.); (X.D.); (Z.Z.)
- Institute for Global Health and Development, Peking University, Beijing 100871, China
| | - Xuejie Dong
- Department of Global Health, School of Public Health, Peking University, Beijing 100871, China; (N.L.); (J.M.); (S.Z.); (X.D.); (Z.Z.)
- Institute for Global Health and Development, Peking University, Beijing 100871, China
| | | | - Yinzi Jin
- Department of Global Health, School of Public Health, Peking University, Beijing 100871, China; (N.L.); (J.M.); (S.Z.); (X.D.); (Z.Z.)
- Institute for Global Health and Development, Peking University, Beijing 100871, China
| | - Zhijie Zheng
- Department of Global Health, School of Public Health, Peking University, Beijing 100871, China; (N.L.); (J.M.); (S.Z.); (X.D.); (Z.Z.)
- Institute for Global Health and Development, Peking University, Beijing 100871, China
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Postponing calls to EMS due to religious observances - A nationwide study. Am J Emerg Med 2021; 56:362-364. [PMID: 34716061 DOI: 10.1016/j.ajem.2021.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 10/04/2021] [Accepted: 10/05/2021] [Indexed: 11/24/2022] Open
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Liu Z, Lim MJ, Pek PP, Wong ASL, Tan KBK, Yeo KK, Ong MEH. Improved door-to-balloon time for primary percutaneous coronary intervention for patients conveyed via emergency ambulance service. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2021; 50:671-678. [PMID: 34625754 DOI: 10.47102/annals-acadmedsg.2021153] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
INTRODUCTION Early reperfusion of ST-segment elevation myocardial infarction (STEMI) results in better outcomes. Interventions that have resulted in shorter door-to-balloon (DTB) time include prehospital cardiovascular laboratory activation and prehospital electrocardiogram (ECG) transmission, which are only available for patients who arrive via emergency ambulances. We assessed the impact of mode of transport on DTB time in a single tertiary institution and evaluated the factors that affected various components of DTB time. METHODS We conducted a retrospective cohort study using registry data of patients diagnosed with STEMI in the emergency department (ED) who underwent primary percutaneous coronary intervention. We compared patients who arrived by emergency ambulances with those who came via their own transport. The primary study end point was DTB, defined as the earliest time a patient arrived in the ED to balloon inflation. As deidentified data was used, ethics review was waived. RESULTS A total of 321 patients were included for analysis after excluding 7 with missing data. The mean age was 61.4±11.4 years old with 49 (15.3%) females. Ninety-nine (30.8%) patients arrived by emergency ambulance. The median DTB time was shorter for patients arriving by ambulance versus own transport (52min, interquartile range [IQR] 45-61 vs 67min, IQR 59-74; P<0.001), with shorter door-to-ECG and door-to-activation time. CONCLUSION Arrival via emergency ambulance was associated with a decreased DTB for STEMI patients compared to arriving via own transport. There is a need for public education to increase the usage of emergency ambulances for suspected heart attacks to improve outcomes.
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Affiliation(s)
- Zhenghong Liu
- Department of Emergency Medicine, Singapore General Hospital, Singapore
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In-hospital mortality of STEMI patients: A comparison of transportation modes to PCI and non-PCI centers. Am J Emerg Med 2020; 40:222-224. [PMID: 32536479 DOI: 10.1016/j.ajem.2020.04.097] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Revised: 04/16/2020] [Accepted: 04/25/2020] [Indexed: 11/21/2022] Open
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Alrawashdeh A, Nehme Z, Williams B, Stub D. Emergency medical service delays in ST-elevation myocardial infarction: a meta-analysis. Heart 2019; 106:365-373. [PMID: 31253694 DOI: 10.1136/heartjnl-2019-315034] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 05/02/2019] [Accepted: 05/26/2019] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVES To evaluate emergency medical services (EMS) delays and their impact on time to treatment and mortality in patients with ST-elevation myocardial infarction (STEMI). METHOD We collected data on EMS time intervals from published studies across five electronic databases. The primary EMS interval was the time in minutes between first medical contact and arrival at hospital door (FMC-to-door time). Secondary intervals were other components of EMS delay. Weighted means were measured using random-effects models. Meta-regression was used to identify factors associated with EMS delays and to assess the impact of EMS delay on the proportion of patients treated within90 min and mortality. RESULTS Two independent reviewers included 100 studies (125 343 patients) conducted in 20 countries. The weighted mean FMC-to-door time was 41 min (n=101 646; 95% CI 39 to 43, range 21-88). However, substantial heterogeneity was observed with each interval, which could be explained by region and urban classification, distance to hospital and method of ECG interpretation. In a meta-regression adjusted for door-to-balloon time, a 10 min increase in FMC-to-door time was associated with a 10.6% (95% CI 7.6% to 13.5%; p<0.001) reduction in the proportion of patients treated within 90 min. Shorter EMS delay was significantly associated with lower short-term mortality in patients receiving prehospital thrombolysis (p=0.018). CONCLUSION EMS delays account for half of the total system delay in STEMI. There is a fourfold global variation in EMS delays, which are not completely explained by differences in system characteristics. Reducing unexplained variation could yield improvements in the time to treatment and outcome of STEMI patients. PROSPERO REGISTRATION NUMBER CRD42017074118.
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Affiliation(s)
- Ahmad Alrawashdeh
- Department of Community Emergency Health and Paramedic Practice, Monash University, Frankston, Victoria, Australia.,Department of Allied Medical Sciences, Jordan University of Science and Technology, Irbid, Jordan
| | - Ziad Nehme
- Department of Epidemiology and PreventiveMedicine, Monash University, Prahran, Victoria, Australia.,Center for Research and Evaluation, Ambulance Victoria, Doncaster, Victoria, Australia
| | - Brett Williams
- Department of Community Emergency Health and Paramedic Practice, Monash University, Frankston, Victoria, Australia
| | - Dion Stub
- Department of Epidemiology and PreventiveMedicine, Monash University, Prahran, Victoria, Australia.,Heart Centre, Alfred Hospital, Melbourne, Victoria, Australia.,Baker IDI Heart and Diabetes Institute, Melbourne, Victoria, Australia
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Rebeiz A, Sasso R, Bachir R, Mneimneh Z, Jabbour R, El Sayed M. Emergency Medical Services Utilization and Outcomes of Patients with ST-Elevation Myocardial Infarction in Lebanon. J Emerg Med 2018; 55:827-835. [PMID: 30301584 DOI: 10.1016/j.jemermed.2018.09.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 07/30/2018] [Accepted: 09/01/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Arrival of patients with ST-elevation myocardial infarction (STEMI) by Emergency Medical Services (EMS) results in shorter reperfusion times and lower mortality in developed countries. OBJECTIVES This study examines EMS use by STEMI patients in Lebanon and associated clinical outcomes. METHODS A retrospective observational study with chart review was carried out for STEMI patients arriving to the Emergency Department of a tertiary care center in Lebanon between January 1, 2013 and August 31, 2016. A descriptive analysis was done and followed by a bivariate analysis comparing two groups of patients (EMS vs. Non-EMS). RESULTS A total of 280 patients were included in the study. They were mostly male (71.8%). Mean age was 65.1 years (95% confidence interval [CI] 63.4-66.9). Only 12.5% (95% CI 8.6-16.4) presented by EMS. Chest pain (81.1%) was the most common presenting symptom. Anterior myocardial infarction was the most common electrocardiogram (ECG) diagnosis (51.4%). Most patients were admitted (98.2%), and 72.0% of these patients were treated with primary percutaneous coronary intervention. Cardiogenic shock was the most frequent in-hospital complication (6.2%). The mortality rate was 7.1%. Mean door-to-ECG and door-to-balloon times were 10.8 (95% CI 7.1-14.4) min and 106.2 (95% CI 95.9-116.6) min, respectively. Patients' characteristics, presenting symptoms, outcomes, and performance metrics were similar between the two groups. CONCLUSION EMS is underutilized by STEMI patients in Lebanon and is not associated with improvement in clinical outcomes. Medical oversight and quality initiatives focusing on outcomes of patients with timely sensitive emergencies are needed to advance the prehospital care system in Lebanon.
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Affiliation(s)
- Abdallah Rebeiz
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Roula Sasso
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Rana Bachir
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Zeina Mneimneh
- Quality, Accreditation & Risk Management Department, American University of Beirut Medical Center, Beirut, Lebanon
| | - Rima Jabbour
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Mazen El Sayed
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon; EMS and Prehospital Care Program, Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
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Prehospital Acute ST-Elevation Myocardial Infarction Identification in San Diego: A Retrospective Analysis of the Effect of a New Software Algorithm. J Emerg Med 2018; 55:71-77. [DOI: 10.1016/j.jemermed.2018.04.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 02/21/2018] [Accepted: 04/10/2018] [Indexed: 11/16/2022]
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Sepehrvand N, Alemayehu W, Kaul P, Pelletier R, Bello AK, Welsh RC, Armstrong PW, Ezekowitz JA. Ambulance use, distance and outcomes in patients with suspected cardiovascular disease: a registry-based geographic information system study. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2018; 9:45-58. [PMID: 29652166 DOI: 10.1177/2048872618769872] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Despite guideline recommendations, the majority of patients with symptoms suggestive of acute coronary syndrome do not use emergency medical services to reach the emergency department (ED). The aim of this study was to investigate the factors associated with EMS utilisation and subsequent patient outcomes. METHODS Using administrative data, all patients who presented to an ED in the metropolitan areas of Edmonton and Calgary in the years of 2007-2013 with main ED diagnosis of acute coronary syndrome, stable angina or chest pain were included. The travel distance was estimated using the geographic information system method to approximate the distance between the ED and patient home. The clinical endpoints were the 7-day and 30-day all-cause events (death, re-hospitalisation and repeat ED visit). RESULTS Of 50,881 patients, 30.5% presented by emergency medical services. Patients with older age, female sex, ED diagnosis of acute coronary syndrome, more comorbidities and lower household income were more likely to use emergency medical services to reach the hospital. Longer travel distance was associated with higher emergency medical services use (odds ratio 1.09, 95% confidence interval 1.09-1.10), but it was not a predictor of clinical events. After adjustment for covariates and inverse propensity score weighting, emergency medical services use was associated with a higher risk of 7-day and 30-day clinical events. CONCLUSION Several demographic and clinical features were associated with higher emergency medical services use including geographical variation. Although longer travel distance was shown to be linked to higher emergency medical services use, it was not an independent predictor of patient outcome. This has implications for the design of emergency medical services systems, triage and early diagnosis and treatment options.
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Affiliation(s)
- Nariman Sepehrvand
- Canadian VIGOUR Centre, University of Alberta, Canada.,Department of Medicine, University of Alberta, Canada
| | | | - Padma Kaul
- Canadian VIGOUR Centre, University of Alberta, Canada.,Department of Medicine, University of Alberta, Canada
| | - Rick Pelletier
- Department of Renewable Resources, University of Alberta, Canada
| | - Aminu K Bello
- Department of Medicine, University of Alberta, Canada
| | - Robert C Welsh
- Canadian VIGOUR Centre, University of Alberta, Canada.,Department of Medicine, University of Alberta, Canada.,Mazankowski Alberta Heart Institute, Canada
| | | | - Justin A Ezekowitz
- Canadian VIGOUR Centre, University of Alberta, Canada.,Department of Medicine, University of Alberta, Canada.,Mazankowski Alberta Heart Institute, Canada
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Kodama N, Nakamura T, Yanishi K, Nakanishi N, Zen K, Yamano T, Shiraishi H, Shirayama T, Shiraishi J, Sawada T, Kohno Y, Kitamura M, Furukawa K, Matoba S. Impact of Door-to-Balloon Time in Patients With ST-Elevation Myocardial Infarction Who Arrived by Self-Transport - Acute Myocardial Infarction-Kyoto Multi-Center Risk Study Group. Circ J 2017; 81:1693-1698. [PMID: 28637970 DOI: 10.1253/circj.cj-17-0083] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2024]
Abstract
BACKGROUND Patients with ST-elevation myocardial infarction (STEMI) who arrive at a hospital via self-transport reportedly have a delayed door-to-balloon time (DBT). However, the clinical impacts of delayed DBT on in-hospital mortality among such patients are not well known. METHODS AND RESULTS In total, 1,172 STEMI patients who underwent primary percutaneous coronary intervention between January 2009 and December 2013 from the Acute Myocardial Infarction (AMI) Kyoto Registry were analyzed. Compared with the emergency medical service (EMS) group (n=804), the self-transport group (n=368) was younger and had a significantly longer DBT (115 min vs. 90 min, P<0.01), with fewer patients having a Killip classification of 2 or higher. The in-hospital mortality rate was lower in the self-transport group than in the EMS group (3.3% vs. 7.1%, P<0.01). A DBT >90 min was an independent predictor of in-hospital mortality in EMS patients (odds ratio (OR)=2.43, P=0.01) but not in self-transport patients (OR=0.89, P=0.87). CONCLUSIONS The present study demonstrated that there was no relationship between in-hospital prognosis and DBT ≤90 min in STEMI patients using self-transport. The prognosis of these patients cannot be improved by focusing only on DBT. Treatment strategies based on means of transport should also be considered.
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Affiliation(s)
- Naotoshi Kodama
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| | - Takeshi Nakamura
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| | - Kenji Yanishi
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| | - Naohiko Nakanishi
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| | - Kan Zen
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| | - Tetsuhiro Yamano
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| | - Hirokazu Shiraishi
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| | - Takeshi Shirayama
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| | - Jun Shiraishi
- Department of Cardiology, Kyoto First Red Cross Hospital
| | | | - Yoshio Kohno
- Department of Cardiology, Kyoto First Red Cross Hospital
| | | | | | - Satoaki Matoba
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
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Koifman E, Beigel R, Iakobishvili Z, Shlomo N, Biton Y, Sabbag A, Asher E, Atar S, Gottlieb S, Alcalai R, Zahger D, Segev A, Goldenberg I, Strugo R, Matetzky S. Impact of mobile intensive care unit use on total ischemic time and clinical outcomes in ST-elevation myocardial infarction patients - real-world data from the Acute Coronary Syndrome Israeli Survey. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2017; 7:497-503. [PMID: 28107026 DOI: 10.1177/2048872616687097] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Ischemic time has prognostic importance in ST-elevation myocardial infarction patients. Mobile intensive care unit use can reduce components of total ischemic time by appropriate triage of ST-elevation myocardial infarction patients. METHODS Data from the Acute Coronary Survey in Israel registry 2000-2010 were analyzed to evaluate factors associated with mobile intensive care unit use and its impact on total ischemic time and patient outcomes. RESULTS The study comprised 5474 ST-elevation myocardial infarction patients enrolled in the Acute Coronary Survey in Israel registry, of whom 46% ( n=2538) arrived via mobile intensive care units. There was a significant increase in rates of mobile intensive care unit utilization from 36% in 2000 to over 50% in 2010 ( p<0.001). Independent predictors of mobile intensive care unit use were Killip>1 (odds ratio=1.32, p<0.001), the presence of cardiac arrest (odds ratio=1.44, p=0.02), and a systolic blood pressure <100 mm Hg (odds ratio=2.01, p<0.001) at presentation. Patients arriving via mobile intensive care units benefitted from increased rates of primary reperfusion therapy (odds ratio=1.58, p<0.001). Among ST-elevation myocardial infarction patients undergoing primary reperfusion, those arriving by mobile intensive care unit benefitted from shorter median total ischemic time compared with non-mobile intensive care unit patients (175 (interquartile range 120-262) vs 195 (interquartile range 130-333) min, respectively ( p<0.001)). Upon a multivariate analysis, mobile intensive care unit use was the most important predictor in achieving door-to-balloon time <90 min (odds ratio=2.56, p<0.001) and door-to-needle time <30 min (odds ratio=2.96, p<0.001). One-year mortality rates were 10.7% in both groups (log-rank p-value=0.98), however inverse propensity weight model, adjusted for significant differences between both groups, revealed a significant reduction in one-year mortality in favor of the mobile intensive care unit group (odds ratio=0.79, 95% confidence interval (0.66-0.94), p=0.01). CONCLUSIONS Among patients with ST-elevation myocardial infarction, the utilization of mobile intensive care units is associated with increased rates of primary reperfusion, a reduction in the time interval to reperfusion, and a reduction in one-year adjusted mortality.
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Affiliation(s)
- Edward Koifman
- 1 Heart Institute, Chaim Sheba Medical Center, Israel.,2 Sackler School of Medicine, Tel Aviv University, Israel
| | - Roy Beigel
- 1 Heart Institute, Chaim Sheba Medical Center, Israel.,2 Sackler School of Medicine, Tel Aviv University, Israel
| | - Zaza Iakobishvili
- 2 Sackler School of Medicine, Tel Aviv University, Israel.,3 Cardiology Department, Rabin Medical Center, Israel
| | - Nir Shlomo
- 4 Israeli Association for Cardiovascular Trials, Israel
| | - Yitschak Biton
- 1 Heart Institute, Chaim Sheba Medical Center, Israel.,2 Sackler School of Medicine, Tel Aviv University, Israel
| | - Avi Sabbag
- 1 Heart Institute, Chaim Sheba Medical Center, Israel.,2 Sackler School of Medicine, Tel Aviv University, Israel
| | - Elad Asher
- 1 Heart Institute, Chaim Sheba Medical Center, Israel.,2 Sackler School of Medicine, Tel Aviv University, Israel
| | - Shaul Atar
- 5 Department of Cardiovascular Medicine, Galilee Medical Center, Nahariya, Israel.,6 Faculty of Medicine of the Galilee, Bar-Ilan University, Sefad, Israel
| | - Shmuel Gottlieb
- 7 Department of Cardiology, Shaare Zedek Medical Center, Israel
| | - Ronny Alcalai
- 8 Heart institute Hadassah, Hebrew University Medical Center and School, Israel
| | - Doron Zahger
- 9 Department of Cardiology, Soroka University Medical Center, Israel.,10 Faculty of Health Sciences, Ben-Gurion University of the Negev, Israel
| | - Amit Segev
- 1 Heart Institute, Chaim Sheba Medical Center, Israel.,2 Sackler School of Medicine, Tel Aviv University, Israel
| | - Ilan Goldenberg
- 1 Heart Institute, Chaim Sheba Medical Center, Israel.,2 Sackler School of Medicine, Tel Aviv University, Israel.,4 Israeli Association for Cardiovascular Trials, Israel
| | | | - Shlomi Matetzky
- 1 Heart Institute, Chaim Sheba Medical Center, Israel.,2 Sackler School of Medicine, Tel Aviv University, Israel.,4 Israeli Association for Cardiovascular Trials, Israel
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15
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Zègre-Hemsey JK, Pickham D, Pelter MM. Electrocardiographic indicators of acute coronary syndrome are more common in patients with ambulance transport compared to those who self-transport to the emergency department journal of electrocardiology. J Electrocardiol 2016; 49:944-950. [PMID: 27614946 PMCID: PMC5159244 DOI: 10.1016/j.jelectrocard.2016.08.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Indexed: 12/27/2022]
Abstract
INTRODUCTION The American Heart Association recommends individuals with symptoms suggestive of acute coronary syndrome (ACS) activate the Emergency Medical Services' (EMS) 911 system for ambulance transport to the emergency department (ED), which enables treatment to begin prior to hospital arrival. Despite this recommendation, the majority of patients with symptoms suspicious of ACS continue to self-transport to the ED. The IMMEDIATE AIM study was a prospective study that enrolled individuals who presented to the ED with ischemic symptoms. OBJECTIVES The purpose of this secondary analysis was to determine differences in patients presenting the ED for possible ACS who arrive by ambulance versus self-transport on: 1) time-to-initial hospital electrocardiogram (ECG), 2) presence of ischemic ECG changes, and 3) patient characteristics. METHODS Initial 12-lead ECGs acquired upon patient arrival to the ED were evaluated for ST-elevation, ST-depression, and T-wave inversion. ECG signs of ischemia were analyzed both individually and collapsed into an independent dichotomous variable (ED ECG ischemia yes/no) for statistical analysis. Patient characteristics tested included: gender, age, race, ethnicity, English speaking, living alone, mode of transport, and presenting symptoms (chest pain, jaw pain, shortness of breath, nausea/vomiting, syncope, and clinical history). RESULTS In 1299 patients (mean age 63.9, 46.7% male), 384 (29.6%) patients arrived by ambulance to the ED. The mean time-to-initial ECG was 47minutes for ambulance patients versus 53minutes for self-transport patients (p<0.001). Mode of transport was found to be an independent predictor for time-to-initial ECG controlling for age, gender, and race (p=0.004). There were significantly higher rates of ECG changes of ischemia for patients who arrived by ambulance versus self-transport (p=0.02), and patient characteristics differed by mode of transport to the ED. DISCUSSION Our findings indicate that less than 30% of individuals with symptoms of ACS activate the EMS '911' system for ambulance transport to the ED. Individuals more likely to activate 911 have timelier ECG but higher rates of ischemic changes, specifically ST-depression and T-wave inversion. Individuals least likely to activate 911 are women, younger individuals, Latino ethnicity, live with a significant other, and those experiencing chest or jaw pain.
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Affiliation(s)
| | - David Pickham
- Stanford University School of Medicine, 301 Ravenswood Ave. Office I238, Menlo Park, CA
| | - Michele M Pelter
- Department of Physiological Nursing, University of California, San Francisco (UCSF), 2 Koret Way, San Francisco, CA
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16
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Kobayashi A, Misumida N, Aoi S, Steinberg E, Kearney K, Fox JT, Kanei Y. STEMI notification by EMS predicts shorter door-to-balloon time and smaller infarct size. Am J Emerg Med 2016; 34:1610-3. [DOI: 10.1016/j.ajem.2016.06.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 06/01/2016] [Indexed: 10/21/2022] Open
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17
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Kaul P, Welsh RC, Liu W, Savu A, Weiss DR, Armstrong PW. Temporal and Provincial Variation in Ambulance Use Among Patients Who Present to Acute Care Hospitals With ST-Elevation Myocardial Infarction. Can J Cardiol 2016; 32:949-55. [DOI: 10.1016/j.cjca.2015.09.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Revised: 09/03/2015] [Accepted: 09/03/2015] [Indexed: 11/24/2022] Open
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18
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Pfister R, Lee S, Kuhr K, Baer F, Fehske W, Hoepp HW, Baldus S, Michels G. Impact of the Type of First Medical Contact within a Guideline-Conform ST-Elevation Myocardial Infarction Network: A Prospective Observational Registry Study. PLoS One 2016; 11:e0156769. [PMID: 27258655 PMCID: PMC4892676 DOI: 10.1371/journal.pone.0156769] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 05/19/2016] [Indexed: 12/31/2022] Open
Abstract
Aims The impact of type of first medical contact (FMC) in the setting of a guideline conform metropolitan ST-elevation myocardial infarction (STEMI) network providing obligatory primary percutaneous coronary intervention (PCI) is unclear. Methods and Results 3,312 patients were prospectively included between 2006 and 2012 into a registry accompanying the “Cologne Infarction Model” STEMI network, with 68.4% primarily presenting to emergency medical service (EMS), 17.6% to non-PCI-capable hospitals, and 14.0% to PCI-capable hospitals. Median contact-to-balloon time differed significantly by FMC with 89 minutes (IQR 72–115) for EMS, 107 minutes (IQR 85–148) for non-PCI- and 65 minutes (IQR 48–91) for PCI-capable hospitals (p < 0.001). TIMI-flow grade III and in-hospital mortality were 75.7% and 10.4% in EMS, 70.3% and 8.6% in non-PCI capable hospital and 84.4% and 5.6% in PCI-capable hospital presenters, respectively (p both < 0.01). The association of FMC with in-hospital mortality was not significant after adjustment for baseline characteristics, but risk of TIMI-flow grade < III remained significantly increased in patients presenting to non-PCI capable hospitals. Conclusion Despite differences in treatment delay by type of FMC in-hospital mortality did not differ significantly. The increased risk of TIMI-flow grade < III in patients presenting to non PCI-capable hospitals needs further study.
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Affiliation(s)
- Roman Pfister
- Department III of Internal Medicine, University of Cologne, Cologne, Germany
- * E-mail:
| | - Samuel Lee
- Department III of Internal Medicine, University of Cologne, Cologne, Germany
| | - Kathrin Kuhr
- Institute of Medical Statistics, Informatics and Epidemiology, University of Cologne, Cologne, Germany
| | | | | | - Hans-Wilhelm Hoepp
- Department III of Internal Medicine, University of Cologne, Cologne, Germany
| | - Stephan Baldus
- Department III of Internal Medicine, University of Cologne, Cologne, Germany
| | - Guido Michels
- Department III of Internal Medicine, University of Cologne, Cologne, Germany
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19
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Mode of admission and its effect on adherence to reperfusion therapy guidelines in Belgian STEMI patients. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2016; 5:461-7. [DOI: 10.1177/2048872616647708] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Accepted: 03/29/2016] [Indexed: 01/27/2023]
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20
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Bansal E, Dhawan R, Wagman B, Low G, Zheng L, Chan L, Newton K, Swadron SP, Testa N, Shavelle DM. Importance of hospital entry: walk-in STEMI and primary percutaneous coronary intervention. West J Emerg Med 2015; 15:81-7. [PMID: 24578769 PMCID: PMC3935790 DOI: 10.5811/westjem.2013.9.17855] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2013] [Revised: 07/09/2013] [Accepted: 09/04/2013] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Patients with ST elevation myocardial infarction (STEMI) require rapid identification and triage to initiate reperfusion therapy. Walk-in STEMI patients have longer treatment times compared to emergency medical service (EMS) transported patients. While effective triage of large numbers of critically ill patients in the emergency department is often cited as the reason for treatment delays, additional factors have not been explored. The purpose of this study was to evaluate baseline demographic and clinical differences between walk-in and EMS-transported STEMI patients and identify factors associated with prolonged door to balloon (D2B) time in walk-in STEMI patients. METHODS We performed a retrospective review of 136 STEMI patients presenting to an urban academic teaching center from January 2009 through December 2010. Baseline demographics, mode of hospital entry (walk-in versus EMS transport), treatment times, angiographic findings, procedures performed and in-hospital clinical events were collected. We compared walk-in and EMS-transported STEMI patients and identified independent factors of prolonged D2B time for walk-in patients using stepwise logistic regression analysis. RESULTS Walk-in patients (n=51) were more likely to be Latino and presented with a higher heart rate, higher systolic blood pressure, prior history of diabetes mellitus and were more likely to have an elevated initial troponin value, compared to EMS-transported patients. EMS-transported patients (n=64) were more likely to be white and had a higher prevalence of left main coronary artery disease, compared to walk-in patients. Door to electrocardiogram (ECG), ECG to catheterization laboratory (CL) activation and D2B times were significantly longer for walk-in patients. Walk-in patients were more likely to have D2B time >90 minutes, compared to EMS- transported patients; odds ratio 3.53 (95% CI 1.03, 12.07), p=0.04. Stepwise logistic regression identified hospital entry mode as the only independent predictor for prolonged D2B time. CONCLUSION Baseline differences exist between walk-in and EMS-transported STEMI patients undergoing primary percutaneous coronary intervention (PCI). Hospital entry mode was the most important predictor for prolonged treatment times for primary PCI, independent of age, Latino ethnicity, heart rate, systolic blood pressure and initial troponin value. Prolonged door to ECG and ECG to CL activation times are modifiable factors associated with prolonged treatment times in walk-in STEMI patients. In addition to promoting the use of EMS transport, efforts are needed to rapidly identify and expedite the triage of walk-in STEMI patients.
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Affiliation(s)
- Eric Bansal
- Division of Cardiovascular Medicine, University of Southern California, Los Angeles, California
| | - Rahul Dhawan
- Division of Cardiovascular Medicine, University of Southern California, Los Angeles, California
| | - Brittany Wagman
- Office of Biostatistics and Outcomes Assessment, Los Angeles County + University of Southern California Medical Center, Los Angeles, California
| | - Garren Low
- Office of Biostatistics and Outcomes Assessment, Los Angeles County + University of Southern California Medical Center, Los Angeles, California
| | - Ling Zheng
- Department of Neurology, University of Southern California, Los Angeles, California
| | - Linda Chan
- Office of Biostatistics and Outcomes Assessment, Los Angeles County + University of Southern California Medical Center, Los Angeles, California
| | - Kim Newton
- Department of Emergency Medicine, University of Southern California, Los Angeles, California
| | - Stuart P Swadron
- Department of Emergency Medicine, University of Southern California, Los Angeles, California
| | - Nicholas Testa
- Department of Emergency Medicine, University of Southern California, Los Angeles, California
| | - David M Shavelle
- Division of Cardiovascular Medicine, University of Southern California, Los Angeles, California
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21
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Mercuri M, Welsford M, Schwalm JD, Mehta SR, Rao-Melacini P, Sheth T, Rokoss M, Jolly SS, Velianou JL, Natarajan MK. Providing optimal regional care for ST-segment elevation myocardial infarction: a prospective cohort study of patients in the Hamilton Niagara Haldimand Brant Local Health Integration Network. CMAJ Open 2015; 3:E1-7. [PMID: 25844361 PMCID: PMC4382034 DOI: 10.9778/cmajo.20140035] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Although considered the evidence-based best therapy for ST-segment elevation myocardial infarction (STEMI), many patients do not receive primary percutaneous coronary intervention (PCI) because of health care resource distribution and constraints. This study describes the clinical management and outcomes of all patients identified with STEMI within a region, including those who did not receive primary PCI. METHODS This study used a prospective cohort design. Patients presenting with STEMI to PCI- and non-PCI-capable hospitals in one integrated health region in Ontario were included in the study. The primary objective was to examine use of reperfusion strategies and timeliness of care. Secondary objectives included determining (through regression models) which variables were associated with mortality within 90 days, and describing patient uptake of risk-reducing therapies and activities post-STEMI. RESULTS Between Apr. 1, 2010, and Mar. 31, 2013, data were collected on 2247 consecutive patients presenting with STEMI. Patients presenting to the PCI-capable hospital were more likely to receive primary PCI (82.5% v. 65.2%, p < 0.001) and be treated within optimal treatment times. However, there was no appreciable difference in mortality at 90 days post-STEMI between patients presenting to PCI- and non-PCI-capable hospitals (7.8% v. 7.5%, p = 0.82), even after adjustment for acuity on presentation. Despite recognized risk factors, many patients were not taking evidence-based medications for risk factor modification before STEMI. INTERPRETATION A systematic approach to regional STEMI care focusing on timely access to the best available therapies, rather than the type of reperfusion provided alone, can yield favourable outcomes.
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Affiliation(s)
- Mathew Mercuri
- Department of Medicine, Division of Cardiology, Columbia University, New York ; Department of Medicine, Division of Cardiology, McMaster University, Hamilton, Ont
| | - Michelle Welsford
- Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, Ont. ; Hamilton Health Sciences, Hamilton Ontario, Hamilton, Ont
| | - Jon-David Schwalm
- Department of Medicine, Division of Cardiology, McMaster University, Hamilton, Ont. ; Hamilton Health Sciences, Hamilton Ontario, Hamilton, Ont. ; Population Health Research Institute, Hamilton, Ont
| | - Shamir R Mehta
- Department of Medicine, Division of Cardiology, McMaster University, Hamilton, Ont. ; Hamilton Health Sciences, Hamilton Ontario, Hamilton, Ont. ; Population Health Research Institute, Hamilton, Ont
| | | | - Tej Sheth
- Department of Medicine, Division of Cardiology, McMaster University, Hamilton, Ont. ; Hamilton Health Sciences, Hamilton Ontario, Hamilton, Ont. ; Population Health Research Institute, Hamilton, Ont
| | - Michael Rokoss
- Department of Medicine, Division of Cardiology, McMaster University, Hamilton, Ont. ; Hamilton Health Sciences, Hamilton Ontario, Hamilton, Ont
| | - Sanjit S Jolly
- Department of Medicine, Division of Cardiology, McMaster University, Hamilton, Ont. ; Hamilton Health Sciences, Hamilton Ontario, Hamilton, Ont. ; Population Health Research Institute, Hamilton, Ont
| | - James L Velianou
- Department of Medicine, Division of Cardiology, McMaster University, Hamilton, Ont. ; Hamilton Health Sciences, Hamilton Ontario, Hamilton, Ont
| | - Madhu K Natarajan
- Department of Medicine, Division of Cardiology, McMaster University, Hamilton, Ont. ; Hamilton Health Sciences, Hamilton Ontario, Hamilton, Ont. ; Population Health Research Institute, Hamilton, Ont
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22
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Comparison of outcomes of ambulance users and nonusers in ST elevation myocardial infarction. Am J Cardiol 2014; 114:1289-94. [PMID: 25201215 DOI: 10.1016/j.amjcard.2014.07.060] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Revised: 07/18/2014] [Accepted: 07/18/2014] [Indexed: 11/21/2022]
Abstract
In a systematic province-wide evaluation of care and outcomes of ST elevation myocardial infarction (STEMI), we sought to examine whether a previously documented association between ambulance use and outcome remains after control for clinical risk factors. All 82 acute care hospitals in Quebec (Canada) that treated at least 30 acute myocardial infarctions annually participated in a 6-month evaluation in 2008 to 2009. Medical record librarians abstracted hospital chart data for consecutive patients with a discharge diagnosis of myocardial infarction who presented with characteristic symptoms and met a priori study criteria for STEMI. Linkage to administrative databases provided outcome data (to 1 year) and co-morbidities. Of 1,956 patients, 1,222 (62.5%) arrived by ambulance. Compared with nonusers of an ambulance, users were older, more often women, and more likely to have co-morbidities, low systolic pressure, abnormal heart rate, and a higher Thrombolysis In Myocardial Infarction risk index at presentation. Ambulance users were less likely to receive fibrinolysis or to be sent for primary angioplasty (78.5% vs 83.2% for nonusers, p = 0.01), although if they did, treatment delays were shorter (p <0.001). The 1-year mortality rate was 18.7% versus 7.1% for nonusers (p <0.001). Greater mortality persisted after adjusting for presenting risk factors, co-morbidities, reperfusion treatment, and symptom duration (hazard ratio 1.56, 95% confidence interval 1.30 to 1.87). In conclusion, ambulance users with STEMI were older and sicker than nonusers. Mortality of users was substantially greater after adjustment for clinical risk factors, although they received faster reperfusion treatment overall.
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23
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Fujii T, Masuda N, Suzuki T, Trii S, Murakami T, Nakano M, Nakazawa G, Shinozaki N, Matsukage T, Ogata N, Yoshimachi F, Ikari Y. Impact of transport pathways on the time from symptom onset of ST-segment elevation myocardial infarction to door of coronary intervention facility. J Cardiol 2014; 64:11-8. [DOI: 10.1016/j.jjcc.2013.11.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Revised: 10/06/2013] [Accepted: 11/06/2013] [Indexed: 01/25/2023]
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24
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Estévez-Loureiro R, López-Sainz &A, Pérez de Prado A, Cuellas C, Calviño Santos R, Alonso-Orcajo N, Salgado Fernández J, Vázquez-Rodríguez JM, López-Benito M, Fernández-Vázquez F. Timely reperfusion for ST-segment elevation myocardial infarction: Effect of direct transfer to primary angioplasty on time delays and clinical outcomes. World J Cardiol 2014; 6:424-433. [PMID: 24976914 PMCID: PMC4072832 DOI: 10.4330/wjc.v6.i6.424] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Accepted: 04/09/2014] [Indexed: 02/07/2023] Open
Abstract
Primary percutaneous coronary intervention (PPCI) is the preferred reperfusion therapy for patients presenting with ST-segment elevation myocardial infarction (STEMI) when it can be performed expeditiously and by experienced operators. In spite of excellent clinical results this technique is associated with longer delays than thrombolysis and this fact may nullify the benefit of selecting this therapeutic option. Several strategies have been proposed to decrease the temporal delays to deliver PPCI. Among them, prehospital diagnosis and direct transfer to the cath lab, by-passing the emergency department of hospitals, has emerged as an attractive way of diminishing delays. The purpose of this review is to address the effect of direct transfer on time delays and clinical events of patients with STEMI treated by PPCI.
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25
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Abstract
Ischemic heart disease (IHD) is the greatest single cause of mortality and loss of disability-adjusted life years worldwide, and a substantial portion of this burden falls on low- and middle-income countries (LMICs). Deaths from IHD and acute coronary syndrome (ACS) occur, on average, at younger ages in LMICs than in high-income countries, often at economically productive ages, and likewise frequently affect the poor within LMICs. Although data about ACS in LMICs are limited, there is a growing literature in this area and the research gaps are being steadily filled. In high-income countries, decades of investigation into the risk factors for ACS and development of behavioral programs, medications, interventional procedures, and guidelines have provided us with the tools to prevent and treat events. Although similar tools can be, and in fact have been, implemented in many LMICs, challenges remain in the development and implementation of cardiovascular health promotion activities across the entire life course, as well as in access to treatment for ACS and IHD. Intersectoral policy initiatives and global coordination are critical elements of ACS and IHD control strategies. Addressing the hurdles and scaling successful health promotion, clinical and policy efforts in LMICs are necessary to adequately address the global burden of ACS and IHD.
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Affiliation(s)
- Rajesh Vedanthan
- From the Department of Medicine, Division of Cardiology, Zena and Michael A. Wiener Cardiovascular Institute and Marie-Josée and Henry R. Kravis Center for Cardiovascular Health, Icahn School of Medicine at Mount Sinai, New York, NY (R.V., V.F.); Department of Biology and School of Medicine, Stanford University, Palo Alto, CA (B.S.); and Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain (V.F.)
| | - Benjamin Seligman
- From the Department of Medicine, Division of Cardiology, Zena and Michael A. Wiener Cardiovascular Institute and Marie-Josée and Henry R. Kravis Center for Cardiovascular Health, Icahn School of Medicine at Mount Sinai, New York, NY (R.V., V.F.); Department of Biology and School of Medicine, Stanford University, Palo Alto, CA (B.S.); and Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain (V.F.)
| | - Valentin Fuster
- From the Department of Medicine, Division of Cardiology, Zena and Michael A. Wiener Cardiovascular Institute and Marie-Josée and Henry R. Kravis Center for Cardiovascular Health, Icahn School of Medicine at Mount Sinai, New York, NY (R.V., V.F.); Department of Biology and School of Medicine, Stanford University, Palo Alto, CA (B.S.); and Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain (V.F.).
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26
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Peng YG, Feng JJ, Guo LF, Li N, Liu WH, Li GJ, Hao G, Zu XL. Factors associated with prehospital delay in patients with ST-segment elevation acute myocardial infarction in China. Am J Emerg Med 2014; 32:349-55. [PMID: 24512889 DOI: 10.1016/j.ajem.2013.12.053] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Revised: 12/13/2013] [Accepted: 12/28/2013] [Indexed: 01/14/2023] Open
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27
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Shavelle DM, Chen AY, Matthews RV, Roe MT, de Lemos JA, Jollis J, Thomas JL, French WJ. Predictors of reperfusion delay in patients with ST elevation myocardial infarction self-transported to the hospital (from the American Heart Association's Mission: Lifeline Program). Am J Cardiol 2014; 113:798-802. [PMID: 24393257 DOI: 10.1016/j.amjcard.2013.11.036] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2013] [Revised: 11/18/2013] [Accepted: 11/18/2013] [Indexed: 11/19/2022]
Abstract
Primary percutaneous coronary intervention for ST elevation myocardial infarction (STEMI) is beneficial if performed in a timely manner. Self-transport patients with STEMI have prolonged treatment times compared with Emergency Medical Services-transported patients. This study evaluated self-transport patients with STEMI undergoing primary percutaneous coronary intervention to identify factors associated with prolonged door-to-balloon (D2B) times. From January 2007 to March 2011, data for 13,379 self-transport patients with STEMI treated at 432 hospitals in the Acute Coronary Treatment Intervention Outcomes Network Registry-Get With The Guidelines Registry were evaluated. Patients with a D2B time >90 minutes were compared with those with D2B time ≤90 minutes. Factors associated with prolonged D2B (>90 minutes) were explored using logistic generalized estimating equations. The median (twenty-fifth, seventy-fifth percentiles) D2B time for the entire cohort was 72 minutes (58, 86), and 19% had a D2B time of >90 minutes. Over the study period, there was a significant increase in the percentage of patients achieving D2B time ≤90 minutes. There were significant baseline differences between patients with D2B time ≤ versus >90 minutes. The main factors associated with prolonged treatment time were off-hour presentation (weekends and 7 p.m. to 7 a.m. weekdays), not obtaining an electrocardiogram within 10 minutes of hospital arrival, previous coronary artery bypass surgery, black race, older age, and female gender. In conclusion, although prolonged delay from arrival to electrocardiographic acquisition is a modifiable factor contributing to prolonged D2B times among self-transport patients with STEMI, additional factors (age, race, and gender) indicate that historic disparities for cardiovascular care still persist in terms of contemporary metrics for STEMI reperfusion.
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Affiliation(s)
- David M Shavelle
- Division of Cardiovascular Medicine, University of Southern California, Los Angeles, California.
| | - Anita Y Chen
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Ray V Matthews
- Division of Cardiovascular Medicine, University of Southern California, Los Angeles, California
| | - Matthew T Roe
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - James A de Lemos
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - James Jollis
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Joseph L Thomas
- Division of Cardiology, Harbor UCLA Medical Center, Torrance, California
| | - William J French
- Division of Cardiology, Harbor UCLA Medical Center, Torrance, California
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Squire BT, Tamayo-Sarver JH, Rashi P, Koenig W, Niemann JT. Effect of Prehospital Cardiac Catheterization Lab Activation on Door-to-Balloon Time, Mortality, and False-Positive Activation. PREHOSP EMERG CARE 2013; 18:1-8. [DOI: 10.3109/10903127.2013.836263] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Nowak B, Giannitsis E, Riemer T, Münzel T, Haude M, Maier LS, Schmitt C, Schumacher B, Mudra H, Hamm C, Senges J, Voigtländer T. Self-referral to chest pain units: results of the German CPU-registry. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2013; 1:312-9. [PMID: 24062922 DOI: 10.1177/2048872612463542] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2012] [Accepted: 09/13/2012] [Indexed: 12/24/2022]
Abstract
BACKGROUND Chest pain units (CPUs) are increasingly established in emergency cardiology services. With improved visibility of CPUs in the population, patients may refer themselves directly to these units, obviating emergency medical services (EMS). Little is known about characteristics and outcomes of self-referred patients, as compared with those referred by EMS. Therefore, we described self-referral patients enrolled in the CPU-registry of the German Cardiac Society and compared them with those referred by EMS. METHODS AND RESULTS From 2008 until 2010, the prospective CPU-registry enrolled 11,581 consecutive patients. Of those 3789 (32.7%) were self-referrals (SRs), while 7792 (67.3%) were referred by EMS. SR-patients were significantly younger (63.6 vs. 70.1 years), had less prior myocardial infarction or coronary artery bypass surgery, but more previous percutaneous coronary interventions (PCIs). Acute coronary syndromes were diagnosed less frequently in the SR-patients (30.3 vs. 46.9%; p<0.0001). SR-patients showed ST-segment changes in their initial ECG in 19.6% of cases. EMS-patients underwent more coronary angiographies (60.0 vs. 47.5%; p<0.0001), while SR-patients underwent more stress tests (11.3 vs. 7.8%; p<0.001). PCI was performed in 32.6% of the EMS- and in 24.0% of the SR-group (p<0.0001). CONCLUSION These data demonstrate that patients who contact a CPU as a self-referral are younger, less severely ill and have more non-coronary problems than those calling an emergency medical service. Nevertheless, 30% of self-referral patients had an acute coronary syndrome.
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Affiliation(s)
- Bernd Nowak
- CCB, Cardioangiologisches Centrum Bethanien, Frankfurt am Main, Germany
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Estévez-Loureiro R, Calviño-Santos R, López-Sainz A, Vázquez-Rodríguez JM, Soler-Martín MR, Prada-Delgado O, Barge-Caballero E, Salgado-Fernández J, Aldama-López G, Piñón-Esteban P, Flores-Ríos X, Barreiro-Díaz M, Varela-Portas J, Freire-Tellado M, García-Guimaraes M, Vázquez-González N, Castro-Beiras A. Long-term prognostic benefit of field triage and direct transfer of patients with ST-segment elevation myocardial infarction treated by primary percutaneous coronary intervention. Am J Cardiol 2013; 111:1721-6. [PMID: 23499276 DOI: 10.1016/j.amjcard.2013.02.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2013] [Revised: 02/07/2013] [Accepted: 02/07/2013] [Indexed: 12/21/2022]
Abstract
Direct transfer (DT) to the catheterization laboratory has been demonstrated to reduce delays in primary percutaneous coronary intervention (PPCI). However, data with regard to its effect on long-term mortality are sparse. The aim of this study was to investigate the effect of DT on long-term mortality in patients with ST-segment elevation myocardial infarctions treated with PPCI. A cohort study was conducted of 1,859 patients (mean age 63.1 ± 13 years, 80.2% men) who underwent PPCI from May 2005 to December 2010. From the whole series, 425 patients (23%) were admitted by DT and 1,434 (77%) by emergency departments. DT patients were younger (mean age 61 ± 12 vs 64 ± 12 years, p = 0.017), were more frequently men (86% vs 76%, p = 0.001), and had a higher proportion of abciximab use (77% vs 64%, p <0.0001). The DT group had a shorter median contact-to-balloon time (105 vs 122 minutes, p <0.0001) and a shorter time to treatment (185 vs 255 minutes, p <0.0001) compared with the emergency department group. Thirty-day and long-term mortality (median follow-up 2.4 years, interquartile range 1.6 to 3.2) were lower in the DT group (3% vs 6%, p = 0.049, and 9.4% vs 14.4%, p = 0.008, respectively). An adjusted Cox regression analysis proved that the DT group had an improved prognosis during follow-up (hazard ratio 0.71, 95% confidence interval 0.50 to 0.99). In conclusion, DT of patients with ST-segment elevation myocardial infarctions for PPCI was associated with fewer delays and improved survival. This benefit was maintained after long follow-up. This strategy should be emphasized in all networks of ST-segment elevation myocardial infarction care.
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Affiliation(s)
- Rodrigo Estévez-Loureiro
- Interventional Cardiology Unit, Cardiology Department, Complejo Hospitalario, Universitario A Coruña, La Coruña, Spain.
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Celik DH, Mencl FR, DeAngelis A, Wilde J, Steer SH, Wilber ST, Frey JA, Bhalla MC. Characteristics of Prehospital ST-segment Elevation Myocardial Infarctions. PREHOSP EMERG CARE 2013; 17:299-303. [DOI: 10.3109/10903127.2013.785619] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Daniel H. Celik
- From the Department of Emergency Medicine, Summa Akron City Hospital (DHC, FRN, JW, SHS, STW, JAF, MCB),
Akron, Ohio; Northeast Ohio Medical University (NEOMED) (FRM, SHS, STW, MCB); and the Cardiac Catheterization Laboratory, Summa Akron City Hospital (AD),
Akron, Ohio
| | - Francis R. Mencl
- From the Department of Emergency Medicine, Summa Akron City Hospital (DHC, FRN, JW, SHS, STW, JAF, MCB),
Akron, Ohio; Northeast Ohio Medical University (NEOMED) (FRM, SHS, STW, MCB); and the Cardiac Catheterization Laboratory, Summa Akron City Hospital (AD),
Akron, Ohio
| | - Anthony DeAngelis
- From the Department of Emergency Medicine, Summa Akron City Hospital (DHC, FRN, JW, SHS, STW, JAF, MCB),
Akron, Ohio; Northeast Ohio Medical University (NEOMED) (FRM, SHS, STW, MCB); and the Cardiac Catheterization Laboratory, Summa Akron City Hospital (AD),
Akron, Ohio
| | - Joshua Wilde
- From the Department of Emergency Medicine, Summa Akron City Hospital (DHC, FRN, JW, SHS, STW, JAF, MCB),
Akron, Ohio; Northeast Ohio Medical University (NEOMED) (FRM, SHS, STW, MCB); and the Cardiac Catheterization Laboratory, Summa Akron City Hospital (AD),
Akron, Ohio
| | - Sheila H. Steer
- From the Department of Emergency Medicine, Summa Akron City Hospital (DHC, FRN, JW, SHS, STW, JAF, MCB),
Akron, Ohio; Northeast Ohio Medical University (NEOMED) (FRM, SHS, STW, MCB); and the Cardiac Catheterization Laboratory, Summa Akron City Hospital (AD),
Akron, Ohio
| | - Scott T. Wilber
- From the Department of Emergency Medicine, Summa Akron City Hospital (DHC, FRN, JW, SHS, STW, JAF, MCB),
Akron, Ohio; Northeast Ohio Medical University (NEOMED) (FRM, SHS, STW, MCB); and the Cardiac Catheterization Laboratory, Summa Akron City Hospital (AD),
Akron, Ohio
| | - Jennifer A. Frey
- From the Department of Emergency Medicine, Summa Akron City Hospital (DHC, FRN, JW, SHS, STW, JAF, MCB),
Akron, Ohio; Northeast Ohio Medical University (NEOMED) (FRM, SHS, STW, MCB); and the Cardiac Catheterization Laboratory, Summa Akron City Hospital (AD),
Akron, Ohio
| | - Mary Colleen Bhalla
- From the Department of Emergency Medicine, Summa Akron City Hospital (DHC, FRN, JW, SHS, STW, JAF, MCB),
Akron, Ohio; Northeast Ohio Medical University (NEOMED) (FRM, SHS, STW, MCB); and the Cardiac Catheterization Laboratory, Summa Akron City Hospital (AD),
Akron, Ohio
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Mehta S, Kostela JC, Oliveros E, Pena C, Rowen R, Treto K, Flores AI, Cohen S, Zhang T. Global Acute Myocardial Infarction Perspectives: Beyond Door-to-Balloon Interventions. Interv Cardiol Clin 2012; 1:479-484. [PMID: 28581965 DOI: 10.1016/j.iccl.2012.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The goal in ST-elevation myocardial infarction (STEMI) intervention is achieving a door-to-balloon time of less than 90 minutes. Challenges in North America and Europe include patient education and implementing legislative mandates for STEMI guidelines. Globally, hurdles for primary percutaneous coronary intervention include limitations of access and financial constraints to providing STEMI care to vast populations. Adherence to North American and European guidelines globally remains an unrealistic goal given the unique cultural, demographic, and fiscal dynamics in poorer countries. The authors propose a four-phased population-based strategy for global acute myocardial infarction development and a pharmacoinvasive approach to STEMI care based on socioeconomic characteristics.
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Affiliation(s)
- Sameer Mehta
- Miller School of Medicine, University of Miami, 1400 Northwest 12th Avenue, Miami, FL 33136, USA; Mercy Medical Center, 3663 South Miami Avenue, Miami, FL 33133, USA; Lumen Foundation, 55 Pinta Road, Miami, FL 33133, USA.
| | - Jennifer C Kostela
- Internal Medicine, New York Hospital Queens, 56-45 Main Street, Flushing, NY 11355, USA; Ross University School of Medicine, 630 US Highway 1, North Brunswick, NJ 08902, USA
| | | | - Camilo Pena
- Lumen Foundation, 55 Pinta Road, Miami, FL 33133, USA
| | - Rebecca Rowen
- Ross University School of Medicine, 630 US Highway 1, North Brunswick, NJ 08902, USA
| | - Kevin Treto
- Ross University School of Medicine, 786 Seneca Meadows Road, Winter Springs, FL 32708, USA
| | | | - Salomon Cohen
- Departamento de Neurocirugia, Instituto Mexicano del Seguro Social, Avenida Club de Golf#3 Torre A Dep. 1501, Lomas Country, Huixquilucan Edo de Mexico, 52779, Mexico
| | - Tracy Zhang
- Lumen Foundation, 55 Pinta Road, Miami, FL 33133, USA
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A systematic review of factors predicting door to balloon time in ST-segment elevation myocardial infarction treated with percutaneous intervention. Int J Cardiol 2012; 157:8-23. [DOI: 10.1016/j.ijcard.2011.06.042] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2011] [Revised: 03/17/2011] [Accepted: 06/06/2011] [Indexed: 11/22/2022]
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Tymchak W, Armstrong PW, Westerhout CM, Sookram S, Brass N, Fu Y, Welsh RC. Mode of hospital presentation in patients with non-ST-elevation myocardial infarction: implications for strategic management. Am Heart J 2011; 162:436-43. [PMID: 21884858 DOI: 10.1016/j.ahj.2011.06.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2011] [Accepted: 06/20/2011] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Contemporary non-ST-elevation myocardial infarction-acute coronary syndrome guidelines emphasize early-risk stratification and optimizing therapy including an invasive strategy in high-risk patients. To assess the feasibility of initiating this strategy in the prehospital environment, we examined how such patients are transported to hospital, their risk profile, and the proportion potentially eligible for such a strategy. METHODS Consecutive patients with ST-segment elevation myocardial infarction admitted in Edmonton were studied between September and November 2008 and divided according to their mode of transport to hospital: emergency medical services (EMS) versus self-presenting. Baseline characteristics, GRACE Risk Score, blinded core laboratory electrocardiogram analysis, cardiac biomarkers, in-hospital procedures, and outcomes were analyzed. RESULTS Thirty-five percent (93/263) of patients presented via EMS and often to percutaneous coronary intervention hospitals, that is, 64.5% versus 44.1% (P = .0016). They were older (75 vs 62 years, P < .001), more often female (43% vs 28.1%, P < .001), diabetic (34.4% vs 22.9%, P = .045), and hypertensive (72.0% vs 57.1%, P = .017) and had higher GRACE Risk Scores (median 166 vs 130, P < .001). Electrocardiogram analysis revealed more baseline Q waves (38.8% vs 25.5%, P = .031) and ST depression ≥2 mm (P = .027) in EMS-transported patients. Fewer EMS patients underwent cardiac catheterization (60.2% vs 88.2%, P < .001), and a paradoxical relationship existed between catheterization rates and GRACE Risk Score in the total cohort (low-risk: 93.4% vs high-risk: 59.3%, P < .001). The composite of death/re-myocardial infarction/congestive heart failure/shock was greater in EMS patients (unadjusted odds ratio 3.96, 95% CI 1.80-8.69, P = .001); these differences were attenuated after GRACE Risk Score adjustment. CONCLUSION Regional strategies using risk-based triage, early medical therapy, and timely triage to percutaneous coronary intervention centers represents an unrealized opportunity to enhance ST-segment elevation myocardial infarction care.
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Allaqaband S, Jan MF, Banday WY, Schlemm A, Ahmed SH, Mori N, Oldridge N, Gupta A, Bajwa T. Impact of 24-hr in-hospital interventional cardiology team on timeliness of reperfusion for ST-segment elevation myocardial infarction. Catheter Cardiovasc Interv 2010; 75:1015-23. [PMID: 20517963 DOI: 10.1002/ccd.22419] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE We studied the effect of 24 hr a day, 7 days a week interventional cardiology staff on door-to-balloon (D2B) time and mortality in patients undergoing primary percutaneous coronary intervention (PPCI) for ST-segment elevation myocardial infarction (STEMI). BACKGROUND Any delay in PPCI in acute STEMI is associated with higher mortality and, therefore, time to treatment should be as short as possible. Despite the use of several strategies, goal D2B time of <90 min remains elusive. METHODS The study examined 790 consecutive STEMI patients treated with PPCI as the reperfusion therapy of choice. Patients were grouped into a pre-24 x 7 and post-24 x 7 cohort to study the impact of the new protocol on D2B time and major adverse cardiovascular events (MACE) and mortality. RESULTS Median D2B time decreased from 99 min in the pre-24 x 7 group to 55 min in the post-24 x 7 group (P = 0.001) and was not influenced by time of day or day of week. Adjusted for patient and clinical characteristics, the pre-24 x 7 group had increased in-hospital cardiovascular mortality (odds ratio 1.94, 95% confidence interval 0.95-3.94; P = 0.048) and MACE (odds ratio 1.66, 95% confidence interval 1.10-2.49; P = 0.009) compared with the post-24 x 7 group. Prolonged D2B time was also associated with higher 1-year overall mortality in the pre-24 x 7 group compared with the post-24 x 7 group (12.8% vs. 8.1%; hazard ratio 1.17, 95% confidence interval 1.04-2.66; P = 0.044). CONCLUSIONS Round-the-clock, in-hospital interventional cardiology team consistently and significantly reduces D2B time, in-hospital cardiovascular mortality, MACE, and 1-year mortality in patients with STEMI.
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Takii T, Yasuda S, Takahashi J, Ito K, Shiba N, Shirato K, Shimokawa H. Trends in acute myocardial infarction incidence and mortality over 30 years in Japan: report from the MIYAGI-AMI Registry Study. Circ J 2009; 74:93-100. [PMID: 19942783 DOI: 10.1253/circj.cj-09-0619] [Citation(s) in RCA: 151] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Worldwide, the rate of aging is highest in Japan, especially the female population. To explore the trends for acute myocardial infarction (AMI) in Japan, the MIYAGI-AMI Registry Study has been conducted for 30 years since 1979, whereby all AMI patients in the Miyagi prefecture are prospectively registered. METHODS AND RESULTS In 1979-2008, 22,551 AMI patients (male/female 16,238/6,313) were registered from 43 hospitals. The age-adjusted incidence of AMI (/100,000persons/year) increased from 7.4 in 1979 to 27.0 in 2008 (P<0.001). Although control of coronary risk factors remained insufficient, the rates of ambulance use and primary percutaneous coronary intervention (PCI) have increased, and the overall in-hospital mortality (age-adjusted) has decreased from 20.0% in 1979 to 7.8% in 2008 (P<0.0001). However, the in-hospital mortality remains relatively higher in female than in male patients (12.2% vs 6.3% in 2008). Female patients were characterized by higher age and lower PCI rate. CONCLUSIONS The MIYAGI-AMI Registry Study demonstrates the steady trend of an increasing incidence, but decreasing mortality, for AMI in Japan over the past 30 years, although the female population still remains at higher risk for in-hospital death, despite improvements in the use of ambulances and primary PCI. (Circ J 2010; 74: 93 - 100).
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Affiliation(s)
- Toru Takii
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Japan
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Le May M. Code STEMI: implementation of a city-wide program for rapid assessment and management of myocardial infarction. CMAJ 2009; 181:E136-7. [PMID: 19786480 DOI: 10.1503/cmaj.091087] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Affiliation(s)
- Michel Le May
- Coronary Care Unit Research Group, University of Ottawa Heart Institute, Ottawa, Ontario, Canada.
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Song L, Yan H, Hu D. Patients with acute myocardial infarction using ambulance or private transport to reach definitive care: which mode is quicker? Intern Med J 2009; 40:112-6. [DOI: 10.1111/j.1445-5994.2009.01944.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Wang HE, Marroquin OC, Smith KJ. Direct Paramedic Transport of Acute Myocardial Infarction Patients to Percutaneous Coronary Intervention Centers: A Decision Analysis. Ann Emerg Med 2009; 53:233-240. [DOI: 10.1016/j.annemergmed.2008.07.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2008] [Revised: 06/13/2008] [Accepted: 07/17/2008] [Indexed: 10/21/2022]
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URBONAVICIENE GRAZINA, URBONAVICIUS SIGITAS, VORUM HENRIK, BLUZAITE INA, JARUSEVICIUS GEDIMINAS, HONORÉ BENT, TAMOSIUNAITE MINIJA. Evaluation of Prognostic Clinical and ECG Parameters in Patients after Myocardial Infarction By Applying Logistic Regression Method. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2008; 31:1391-8. [DOI: 10.1111/j.1540-8159.2008.01201.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Goldberg RJ, Kramer DG, Yarzebski J, Lessard D, Gore JM. Prehospital transport of patients with acute myocardial infarction: a community-wide perspective. Heart Lung 2008; 37:266-74. [PMID: 18620102 PMCID: PMC4024827 DOI: 10.1016/j.hrtlng.2007.05.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2006] [Revised: 03/19/2007] [Accepted: 05/29/2007] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The objectives of this population-based study were to examine the use of emergency medical services (EMS) in greater Worcester, Massachusetts, residents (2000 census = 478,000) hospitalized with acute myocardial infarction (AMI) at all metropolitan Worcester medical centers in four biennial periods between 1997 and 2003. A secondary study aim was to describe the demographic and clinical characteristics of patients with AMI transported to metropolitan Worcester hospitals by EMS, compared with those transported by other means, and their hospital outcomes. METHODS We reviewed the medical records of 3805 patients hospitalized for confirmed AMI at 11 greater Worcester medical centers during 1997, 1999, 2001, and 2003. Information about the use of EMS, patient characteristics, and hospital outcomes was obtained through the review of hospital charts. RESULTS A total of 2693 greater Worcester residents with AMI (70.8%) were transported to area hospitals by ambulance. Patients transported by ambulance were older, were more likely to be women, had a greater prevalence of comorbidities, and had a different symptom profile than patients transported by other means. Patients arriving at greater Worcester hospitals by ambulance were more likely to develop serious clinical complications, including heart failure and cardiogenic shock, and die during hospitalization compared with patients not transported by EMS. CONCLUSIONS Our results suggest that the majority of greater Worcester residents seeking care for AMI are transported by EMS. Patients transported by ambulance differ from patients transported by other means and are more likely to experience adverse hospital outcomes. The reasons why patients use EMS in the setting of AMI need to be further explored and patients' care-seeking behavior enhanced.
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Affiliation(s)
- Robert J. Goldberg
- Department of Medicine Division of Cardiovascular Medicine University of Massachusetts Medical School Worcester, MA 01655
- Department of Community Health Brown University Providence, RI 02912
| | - Daniel G. Kramer
- Department of Medicine Division of Cardiovascular Medicine University of Massachusetts Medical School Worcester, MA 01655
| | - Jorge Yarzebski
- Department of Medicine Division of Cardiovascular Medicine University of Massachusetts Medical School Worcester, MA 01655
| | - Darleen Lessard
- Department of Medicine Division of Cardiovascular Medicine University of Massachusetts Medical School Worcester, MA 01655
| | - Joel M. Gore
- Department of Medicine Division of Cardiovascular Medicine University of Massachusetts Medical School Worcester, MA 01655
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Influence of ambulance use on early reperfusion therapies for acute myocardial infarction. Chin Med J (Engl) 2008. [DOI: 10.1097/00029330-200805010-00001] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Treatment delay in patients undergoing primary percutaneous coronary intervention for ST-elevation myocardial infarction: a key process analysis of patient and program factors. Am Heart J 2008; 155:290-7. [PMID: 18215599 DOI: 10.1016/j.ahj.2007.10.021] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2007] [Accepted: 10/12/2007] [Indexed: 11/21/2022]
Abstract
BACKGROUND Most hospitals that perform primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) in the United States exceed the recommended door-to-balloon time. There is heightened interest in identifying and eliminating factors that introduce delay. METHODS We performed a key process analysis of our primary PCI program, assessed the relative contribution of individual time intervals on total ischemic time, and identified predictors of delay. RESULTS Median times and predictors of delay within each time interval were determined for the entire STEMI cohort ("real world") and after exclusion of patients with atypical symptoms and/or presentations of STEMI that resulted in inherent delay in diagnosis and treatment ("ideal world"). Delays in therapy were symptom onset to presentation (120 minutes [interquartile range, IQR, 60-310 minutes, ideal world] and 150 minutes [IQR 60-360 minutes, real world]; predictors of delay were peripheral vascular disease, self-transportation, daytime and weekend presentation); door-to-balloon time (118.5 minutes [IQR 96-141 minutes, ideal world] and 125 minutes [IQR 100-170 minutes, real world]; predictors of delay were female sex, previous stroke, nighttime and weekend presentation, and cardiogenic shock); and symptom onset to first balloon inflation (272 minutes [IQR 187-465 minutes, ideal world] and 297 minutes [IQR 198-560 minutes, real world]; predictors of delay were peripheral vascular disease, weekend presentation, and self-transportation). CONCLUSIONS Key process analysis of a primary PCI program identifies treatment delays unique to the hospital and the patient population it serves.
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Le May MR, So DY, Dionne R, Glover CA, Froeschl MPV, Wells GA, Davies RF, Sherrard HL, Maloney J, Marquis JF, O'Brien ER, Trickett J, Poirier P, Ryan SC, Ha A, Joseph PG, Labinaz M. A citywide protocol for primary PCI in ST-segment elevation myocardial infarction. N Engl J Med 2008; 358:231-40. [PMID: 18199862 DOI: 10.1056/nejmoa073102] [Citation(s) in RCA: 306] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND If primary percutaneous coronary intervention (PCI) is performed promptly, the procedure is superior to fibrinolysis in restoring flow to the infarct-related artery in patients with ST-segment elevation myocardial infarction. The benchmark for a timely PCI intervention has become a door-to-balloon time of less than 90 minutes. Whether regional strategies can be developed to achieve this goal is uncertain. METHODS We developed an integrated-metropolitan-area approach in which all patients with ST-segment elevation myocardial infarction were referred to a specialized center for primary PCI. We sought to determine whether there was a difference in door-to-balloon times between patients who were referred directly from the field by paramedics trained in the interpretation of electrocardiograms and patients who were referred by emergency department physicians. RESULTS Between May 1, 2005, and April 30, 2006, a total of 344 consecutive patients with ST-segment elevation myocardial infarction were referred for primary PCI: 135 directly from the field and 209 from emergency departments. Primary PCI was performed in 93.6% of patients. The median door-to-balloon time was shorter in patients referred from the field (69 minutes; interquartile range, 43 to 87) than in patients needing interhospital transfer (123 minutes; interquartile range, 101 to 153; P<0.001). Door-to-balloon times of less than 90 minutes were achieved in 79.7% of patients who were transferred from the field and in 11.9% of those transferred from emergency departments (P<0.001). CONCLUSIONS Guideline door-to-balloon-times were more often achieved when trained paramedics independently triaged and transported patients directly to a designated primary PCI center than when patients were referred from emergency departments.
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Effect of prehospital 12-lead electrocardiogram on activation of the cardiac catheterization laboratory and door-to-balloon time in ST-segment elevation acute myocardial infarction. Am J Cardiol 2008; 101:158-61. [PMID: 18178399 DOI: 10.1016/j.amjcard.2007.07.082] [Citation(s) in RCA: 127] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2007] [Revised: 07/24/2007] [Accepted: 07/24/2007] [Indexed: 11/23/2022]
Abstract
Reducing door-to-balloon (D + B) time during primary percutaneous coronary intervention for patients with ST-segment elevation myocardial infarction (STEMI) reduces mortality. Prehospital 12-lead electrocadiography (ECG) with cardiac catheterization laboratory (CCL) activation may reduce D + B time. Paramedic-performed ECG was initiated in the city of San Diego in January 2005 with STEMI diagnosis based on an automated computer algorithm. We undertook this study to determine the effect of prehospital CCL activation on D + B time for patients with acute STEMI brought to our institution. All data were prospectively collected for patients with STEMI including times to treatment and clinical outcomes. We evaluated 78 consecutive patients with STEMI from January 2005 to June 2006, and the study group consisted of all patients with prehospital activation of the CCL (field STEMI; n = 20). The control groups included concurrently-treated patients with STEMI during the same period who presented to the emergency department (nonfield STEMI; n = 28), and all patients with STEMI treated in the preceding year (2004) (historical STEMI; n = 30). Prehospital CCL activation significantly reduced D + B time (73 +/- 19 minutes field STEMI, 130 +/- 66 minutes nonfield STEMI, 141 +/- 49 minutes historical STEMI; p <0.001) with significant reductions in door-to-CCL and CCL-to-balloon times as well. The majority of patients with field STEMI achieved D + B times of <90 minutes (80% field STEMI, 25% nonfield STEMI, 10% historical STEMI; p <0.001). In conclusion, this study demonstrates that prehospital electrocardiographic diagnosis of STEMI with activation of the CCL markedly reduces D + B time.
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Rosell-Ortiz F, Mellado-Vergel FJ, Ruiz-Bailén M, Perea-Milla E. Tratamiento extrahospitalario y supervivencia al año de los pacientes con infarto agudo de miocardio con elevación de ST. Resultados del Proyecto para la Evaluación de la Fibrinólisis Extrahospitalaria (PEFEX). Rev Esp Cardiol 2008. [DOI: 10.1157/13114952] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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