51
|
Roswell RO, Kunkes J, Chen AY, Chiswell K, Iqbal S, Roe MT, Bangalore S. Impact of Sex and Contact-to-Device Time on Clinical Outcomes in Acute ST-Segment Elevation Myocardial Infarction-Findings From the National Cardiovascular Data Registry. J Am Heart Assoc 2017; 6:JAHA.116.004521. [PMID: 28077385 PMCID: PMC5523636 DOI: 10.1161/jaha.116.004521] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Emergent myocardial reperfusion via primary percutaneous coronary intervention is optimal care for patients presenting with ST‐segment elevation myocardial infarction (STEMI). Delays in such interventions are associated with increases in mortality. With the shift in focus to contact‐to‐device (C2D) time as a new perfusion metric, this study was designed to examine how sex affects C2D time and mortality in STEMI patients. Methods and Results Clinical data on male and female STEMI patients were extracted and analyzed from the National Cardiovascular Data Registry from July 1, 2008 to December 31, 2014. A total of 102 515 patients were included in the final analytic cohort. The median C2D time in female patients with STEMI was delayed when compared to male patients (80 [65–97] versus 75 [61–90] minutes; P<0.001). The unadjusted mortality was higher in female patients when compared to male patients with STEMI (4.1% versus 2.0%; P<0.001). For every 5‐minute increase in C2D time, the adjusted odds ratio for mortality was 1.04 (95% CI, 1.03–1.06) for female patients with STEMI and 1.07 (95% CI, 1.06–1.09) for male patients (P for sex by C2D interaction=0.003). Conclusions To date, this is the largest analysis of STEMI patients that measures the impact of the new recommended C2D reperfusion metric on in‐hospital mortality. Female STEMI patients have longer C2D times and increased mortality. The disparity can be improved and survival can increase in this high‐risk patient cohort by decreasing systems issues that cause increased reperfusion times in female STEMI patients.
Collapse
Affiliation(s)
- Robert O Roswell
- Department of Medicine, Leon H. Charney Division of Cardiology, New York University School of Medicine, New York, NY
| | - Jordan Kunkes
- Department of Medicine, Leon H. Charney Division of Cardiology, New York University School of Medicine, New York, NY
| | | | | | - Sohah Iqbal
- Department of Medicine, Leon H. Charney Division of Cardiology, New York University School of Medicine, New York, NY
| | | | - Sripal Bangalore
- Department of Medicine, Leon H. Charney Division of Cardiology, New York University School of Medicine, New York, NY
| |
Collapse
|
52
|
Achieving timely percutaneous reperfusion for rural ST-elevation myocardial infarction patients by direct transport to an urban PCI-hospital. JOURNAL OF GERIATRIC CARDIOLOGY : JGC 2016; 13:840-845. [PMID: 27928226 PMCID: PMC5131199 DOI: 10.11909/j.issn.1671-5411.2016.10.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Backgrounds ST-elevation myocardial infarction (STEMI) guidelines recommend reperfusion by primary percutaneous coronary intervention (PCI) ≤ 90 min from time of first medical contact (FMC). This strategy is challenging in rural areas lacking a nearby PCI-capable hospital. Recommended reperfusion times can be achieved for STEMI patients presenting in rural areas without a nearby PCI-capable hospital by ground transportation to a central PCI-capable hospital by use of protocol-driven emergency medical service (EMS) STEMI field triage protocol. Methods Sixty STEMI patients directly transported by EMS from three rural counties (Nassau, Camden and Charlton Counties) within a 50-mile radius of University of Florida Health-Jacksonville (UFHJ) from 01/01/2009 to 12/31/2013 were identified from its PCI registry. The STEMI field triage protocol incorporated three elements: (1) a cooperative agreement between each of the rural emergency medical service (EMS) agency and UFHJ; (2) performance of a pre-hospital ECG to facilitate STEMI identification and laboratory activation; and (3) direct transfer by ground transportation to the UFHJ cardiac catheterization laboratory. FMC-to-device (FMC2D), door-to-device (D2D), and transit times, the day of week, time of day, and EMS shift times were recorded, and odds ratio (OR) of achieving FMC2D times was calculated. Results FMC2D times were shorter for in-state STEMIs (81 ± 17 vs. 87 ± 19 min), but D2D times were similar (37 ± 18 vs. 39 ± 21 min). FMC2D ≤ 90 min were achieved in 82.7% in-state STEMIs compared to 52.2% for out-of-state STEMIs (OR = 4.4, 95% CI: 1.24–15.57; P = 0.018). FMC2D times were homogenous after adjusting for weekday vs. weekend, EMS shift times. Nine patients did not meet FMC2D ≤ 90 min. Six were within 10 min of target; all patient achieved FMC2D ≤ 120 min. Conclusions Guideline-compliant FMC2D ≤ 90 min is achievable for rural STEMI patients within a 50 mile radius of a PCI-capable hospital by use of protocol-driven EMS ground transportation. As all patients achieved a FMC2D time ≤ 120 min, bypass of non-PCI capable hospitals may be reasonable in this situation.
Collapse
|
53
|
Yadlapati A, Gajjar M, Schimmel DR, Ricciardi MJ, Flaherty JD. Contemporary management of ST-segment elevation myocardial infarction. Intern Emerg Med 2016; 11:1107-1113. [PMID: 27714584 DOI: 10.1007/s11739-016-1550-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 09/22/2016] [Indexed: 01/22/2023]
Abstract
ST-elevation myocardial infarction (STEMI), which constitutes nearly 25-40 % of current acute myocardial infarction (AMI) cases, is a medical emergency that requires prompt recognition and treatment. Since the 2013 STEMI practice guidelines, a wealth of additional data that may further advance optimal STEMI practices has emerged. These data highlight the importance of improving patient treatment and transport algorithms for STEMI from non-primary percutaneous coronary intervention (PCI) centers. In addition, a focus on the reduction of total pain-to-balloon (P2B) times rather than simply door-to-balloon (D2B) times may further improve outcomes after primary PCI for STEMI. The early administration of newer oral P2Y12 inhibitors, including crushed forms of these agents for faster absorption, represents another treatment advancement. Recent data also suggest avoiding concurrent morphine use due to interactions with P2Y12 inhibitors. Furthermore, new technological advancements and investigational therapies, including Bioresorbable Vascular Scaffolds and the use of pre-intervention intravenous microbubbles with transthoracic ultrasound, hold promise to play a useful role in future STEMI care. Despite these advancements, the prompt recognition of STEMI, at both the patient and health care system level, remains the cornerstone of optimal treatment.
Collapse
Affiliation(s)
- Ajay Yadlapati
- Division of Cardiology, Bluhm Cardiovascular Institute, Feinberg School of Medicine, Northwestern University, 676 N. St. Clair Street, Suite 600, Chicago, IL, 60611-2996, USA
| | - Mark Gajjar
- Division of Cardiology, Bluhm Cardiovascular Institute, Feinberg School of Medicine, Northwestern University, 676 N. St. Clair Street, Suite 600, Chicago, IL, 60611-2996, USA
| | - Daniel R Schimmel
- Division of Cardiology, Bluhm Cardiovascular Institute, Feinberg School of Medicine, Northwestern University, 676 N. St. Clair Street, Suite 600, Chicago, IL, 60611-2996, USA
| | - Mark J Ricciardi
- Division of Cardiology, Bluhm Cardiovascular Institute, Feinberg School of Medicine, Northwestern University, 676 N. St. Clair Street, Suite 600, Chicago, IL, 60611-2996, USA
| | - James D Flaherty
- Division of Cardiology, Bluhm Cardiovascular Institute, Feinberg School of Medicine, Northwestern University, 676 N. St. Clair Street, Suite 600, Chicago, IL, 60611-2996, USA.
| |
Collapse
|
54
|
Potter BJ, Matteau A, Mansour S, Naim C, Riahi M, Essiambre R, Montigny M, Sareault I, Gobeil F. Sustained Performance of a "Physicianless" System of Automated Prehospital STEMI Diagnosis and Catheterization Laboratory Activation. Can J Cardiol 2016; 33:148-154. [PMID: 28024553 DOI: 10.1016/j.cjca.2016.10.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 10/01/2016] [Accepted: 10/09/2016] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Treatment times for primary percutaneous coronary intervention frequently exceed the recommended maximum delay. Automated "physicianless" systems of prehospital cardiac catheterization laboratory (CCL) activation show promise, but have been met with resistance over concerns regarding the potential for false positive and inappropriate activations (IAs). METHODS From 2010 to 2015, first responders performed electrocardiograms (ECGs) in the field for all patients with a complaint of chest pain or dyspnea. An automated machine diagnosis of "acute myocardial infarction" resulted in immediate CCL activation and direct transfer without transmission or human reinterpretation of the ECG prior to patient arrival. Any activation resulting from a nondiagnostic ECG (no ST-elevation) was deemed an IA, whereas activations resulting from ECG's compatible with ST-elevation myocardial infarction but without angiographic evidence of a coronary event were deemed false positive. In 2012, the referral algorithm was modified to exclude supraventricular tachycardia and left bundle branch block. RESULTS There were 155 activations in the early cohort (2010-2012; prior to algorithm modification) and 313 in the late cohort (2012-2015). Algorithm modification resulted in a 42% relative decrease in the rate of IAs (12% vs 7%; P < 0.01) without a significant effect on treatment delay. CONCLUSIONS A combination of prehospital automated ST-elevation myocardial infarction diagnosis and "physicianless" CCL activation is safe and effective in improving treatment delay and these results are sustainable over time. The performance of the referral algorithm in terms of IA and false positive is at least on par with systems that ensure real-time human oversight.
Collapse
Affiliation(s)
- Brian J Potter
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montréal, Québec, Canada; Centre Cardiovasculaire du Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada.
| | - Alexis Matteau
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montréal, Québec, Canada; Centre Cardiovasculaire du Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Samer Mansour
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montréal, Québec, Canada; Centre Cardiovasculaire du Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada; Hôpital de la Cité de la Santé, Laval, Québec, Canada
| | - Charbel Naim
- Centre Cardiovasculaire du Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Mounir Riahi
- Centre Cardiovasculaire du Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | | | | | | | - François Gobeil
- Centre Cardiovasculaire du Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada; Hôpital de la Cité de la Santé, Laval, Québec, Canada
| |
Collapse
|
55
|
Meloni L, Floris R, Montisci R, De Candia G, Cadeddu M, Lai G, Sori P, Ruscazio M, Pinna G, Iasiello G, Pirisi R. Care quality monitoring of a ST-segment elevation myocardial infarction programme over a 5-year period. J Cardiovasc Med (Hagerstown) 2016; 17:494-500. [DOI: 10.2459/jcm.0000000000000285] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
56
|
Anderson LL, French WJ, Peng SA, Vora AN, Henry TD, Roe MT, Kontos MC, Granger CB, Bates ER, Hellkamp A, Wang TY. Direct Transfer From the Referring Hospitals to the Catheterization Laboratory to Minimize Reperfusion Delays for Primary Percutaneous Coronary Intervention: Insights From the National Cardiovascular Data Registry. Circ Cardiovasc Interv 2016; 8:e002477. [PMID: 26338881 DOI: 10.1161/circinterventions.114.002477] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND For patients with ST-segment-elevation myocardial infarction (STEMI) requiring interhospital transfer for primary percutaneous coronary intervention, direct transfer from the STEMI referral hospital to the catheterization laboratory (cath lab) at the STEMI receiving hospital may expedite reperfusion, but can be logistically challenging. METHODS AND RESULTS We studied 33,901 STEMI patients transferred for primary percutaneous coronary intervention in the Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines from July 2008 to December 2012. The majority of patients were transferred directly to the cath lab (26,510 [78.2%]), and 7391 patients (21.8%) were transferred first to the hospital emergency department/ward. We observed significant interhospital variation in transfer patterns; only 21% of STEMI receiving hospitals routinely transferred >90% of STEMI patients to the cath lab directly. Compared with patients transferred first to the emergency department/ward, STEMI patients transferred to the cath lab had significantly lower first door-to-balloon times (median 191 versus 116 minutes, P<0.0001). After multivariable logistic regression, patients transferred directly to the cath lab also had lower adjusted mortality risk (odds ratio 0.58, 95% confidence interval 0.51-0.66, P<0.0001). Cardiogenic shock, heart failure signs/symptoms, and nonsystem reasons for reperfusion delay were present in 11%, 15%, and 28% of patients transferred first to the emergency department/ward, respectively. The association of direct cath lab transfer with lower mortality persisted after excluding patients with these reasons for delay to primary percutaneous coronary intervention (adjusted odds ratio 0.62, 95% confidence interval 0.46-0.84, P=0.002). CONCLUSIONS Direct transfer of STEMI patients to the cath lab for primary percutaneous coronary intervention was associated with significantly faster reperfusion and lower mortality risk compared with transfer first to the emergency department/ward.
Collapse
Affiliation(s)
- Lindsay L Anderson
- From the Department of Medicine (L.L.A., A.N.V., M.T.R., C.B.G., T.Y.W.) and Department of Biostatistics (S.A.P., A.H.), Duke Clinical Research Institute, Duke University Medical Center, Durham, NC; Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA (W.J.F.); Department of Medicine, Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN (T.D.H.); Department of Medicine, Virginia Commonwealth University, Richmond, VA (M.C.K.); and Department of Medicine, University of Michigan, Ann Arbor, MI (E.R.B.)
| | - William J French
- From the Department of Medicine (L.L.A., A.N.V., M.T.R., C.B.G., T.Y.W.) and Department of Biostatistics (S.A.P., A.H.), Duke Clinical Research Institute, Duke University Medical Center, Durham, NC; Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA (W.J.F.); Department of Medicine, Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN (T.D.H.); Department of Medicine, Virginia Commonwealth University, Richmond, VA (M.C.K.); and Department of Medicine, University of Michigan, Ann Arbor, MI (E.R.B.)
| | - S Andrew Peng
- From the Department of Medicine (L.L.A., A.N.V., M.T.R., C.B.G., T.Y.W.) and Department of Biostatistics (S.A.P., A.H.), Duke Clinical Research Institute, Duke University Medical Center, Durham, NC; Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA (W.J.F.); Department of Medicine, Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN (T.D.H.); Department of Medicine, Virginia Commonwealth University, Richmond, VA (M.C.K.); and Department of Medicine, University of Michigan, Ann Arbor, MI (E.R.B.)
| | - Amit N Vora
- From the Department of Medicine (L.L.A., A.N.V., M.T.R., C.B.G., T.Y.W.) and Department of Biostatistics (S.A.P., A.H.), Duke Clinical Research Institute, Duke University Medical Center, Durham, NC; Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA (W.J.F.); Department of Medicine, Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN (T.D.H.); Department of Medicine, Virginia Commonwealth University, Richmond, VA (M.C.K.); and Department of Medicine, University of Michigan, Ann Arbor, MI (E.R.B.)
| | - Timothy D Henry
- From the Department of Medicine (L.L.A., A.N.V., M.T.R., C.B.G., T.Y.W.) and Department of Biostatistics (S.A.P., A.H.), Duke Clinical Research Institute, Duke University Medical Center, Durham, NC; Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA (W.J.F.); Department of Medicine, Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN (T.D.H.); Department of Medicine, Virginia Commonwealth University, Richmond, VA (M.C.K.); and Department of Medicine, University of Michigan, Ann Arbor, MI (E.R.B.)
| | - Matthew T Roe
- From the Department of Medicine (L.L.A., A.N.V., M.T.R., C.B.G., T.Y.W.) and Department of Biostatistics (S.A.P., A.H.), Duke Clinical Research Institute, Duke University Medical Center, Durham, NC; Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA (W.J.F.); Department of Medicine, Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN (T.D.H.); Department of Medicine, Virginia Commonwealth University, Richmond, VA (M.C.K.); and Department of Medicine, University of Michigan, Ann Arbor, MI (E.R.B.)
| | - Michael C Kontos
- From the Department of Medicine (L.L.A., A.N.V., M.T.R., C.B.G., T.Y.W.) and Department of Biostatistics (S.A.P., A.H.), Duke Clinical Research Institute, Duke University Medical Center, Durham, NC; Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA (W.J.F.); Department of Medicine, Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN (T.D.H.); Department of Medicine, Virginia Commonwealth University, Richmond, VA (M.C.K.); and Department of Medicine, University of Michigan, Ann Arbor, MI (E.R.B.)
| | - Christopher B Granger
- From the Department of Medicine (L.L.A., A.N.V., M.T.R., C.B.G., T.Y.W.) and Department of Biostatistics (S.A.P., A.H.), Duke Clinical Research Institute, Duke University Medical Center, Durham, NC; Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA (W.J.F.); Department of Medicine, Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN (T.D.H.); Department of Medicine, Virginia Commonwealth University, Richmond, VA (M.C.K.); and Department of Medicine, University of Michigan, Ann Arbor, MI (E.R.B.)
| | - Eric R Bates
- From the Department of Medicine (L.L.A., A.N.V., M.T.R., C.B.G., T.Y.W.) and Department of Biostatistics (S.A.P., A.H.), Duke Clinical Research Institute, Duke University Medical Center, Durham, NC; Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA (W.J.F.); Department of Medicine, Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN (T.D.H.); Department of Medicine, Virginia Commonwealth University, Richmond, VA (M.C.K.); and Department of Medicine, University of Michigan, Ann Arbor, MI (E.R.B.)
| | - Anne Hellkamp
- From the Department of Medicine (L.L.A., A.N.V., M.T.R., C.B.G., T.Y.W.) and Department of Biostatistics (S.A.P., A.H.), Duke Clinical Research Institute, Duke University Medical Center, Durham, NC; Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA (W.J.F.); Department of Medicine, Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN (T.D.H.); Department of Medicine, Virginia Commonwealth University, Richmond, VA (M.C.K.); and Department of Medicine, University of Michigan, Ann Arbor, MI (E.R.B.)
| | - Tracy Y Wang
- From the Department of Medicine (L.L.A., A.N.V., M.T.R., C.B.G., T.Y.W.) and Department of Biostatistics (S.A.P., A.H.), Duke Clinical Research Institute, Duke University Medical Center, Durham, NC; Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA (W.J.F.); Department of Medicine, Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN (T.D.H.); Department of Medicine, Virginia Commonwealth University, Richmond, VA (M.C.K.); and Department of Medicine, University of Michigan, Ann Arbor, MI (E.R.B.).
| |
Collapse
|
57
|
Kahlon TS, Barn K, Akram MMA, Blankenship JC, Bower-Stout C, Carey DJ, Sun H, Tompkins Weber K, Skelding KA, Scott TD, Green SM, Berger PB. Impact of pre-hospital electrocardiograms on time to treatment and one year outcome in a rural regional ST-segment elevation myocardial infarction network. Catheter Cardiovasc Interv 2016; 89:245-251. [DOI: 10.1002/ccd.26567] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 04/10/2016] [Indexed: 12/21/2022]
Affiliation(s)
| | | | | | | | | | | | - Haiyan Sun
- Geisinger Medical Center; Danville Pennsylvania
| | | | | | | | | | | |
Collapse
|
58
|
Musey PI, Studnek JR, Garvey L. Characteristics of ST Elevation Myocardial Infarction Patients Who Do Not Undergo Percutaneous Coronary Intervention After Prehospital Cardiac Catheterization Laboratory Activation. Crit Pathw Cardiol 2016; 15:16-21. [PMID: 26881815 DOI: 10.1097/hpc.0000000000000069] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
OBJECTIVES To assess the clinical and electrocardiographic characteristics of patients diagnosed with ST elevation myocardial infarction (STEMI) that are associated with an increased likelihood of not undergoing percutaneous coronary intervention (PCI) after prehospital Cardiac Catheterization Laboratory activation in a regional STEMI system. METHODS We performed a retrospective analysis of prehospital Cardiac Catheterization Laboratory activations in Mecklenburg County, North Carolina, between May 2008 and March 2011. Data were extracted from the prehospital patient record, the prehospital electrocardiogram, and the regional STEMI database. The independent variables of interest included objective patient characteristics as well as documented cardiac history and risk factors. Analysis was performed using descriptive statistics and logistic regression. RESULTS Two hundred thirty-one prehospital activations were included in the analysis. Five independent variables were found to be associated with an increased likelihood of not undergoing PCI: increasing age, bundle branch block, elevated heart rate, left ventricular hypertrophy, and non-white race. The variables with the most significance were any type of bundle branch block [adjusted odds ratios (AOR), 5.66; 95% confidence interval (CI), 1.91-16.76], left ventricular hypertrophy (AOR, 4.63; 95% CI, 2.03-10.53), and non-white race (AOR, 3.53; 95% CI, 1.76-7.08). Conversely, the only variable associated with a higher likelihood of undergoing PCI was the presence of arm pain (AOR, 2.94; 95% CI, 1.36-6.25). CONCLUSIONS Several of the above variables are expected electrocardiogram mimics; however, the decreased rate of PCI in non-white patients highlights an area for investigation and process improvement. This may guide the development of prehospital STEMI protocols, although avoiding false positive and inappropriate activations.
Collapse
Affiliation(s)
- Paul I Musey
- From the *Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN; †Mecklenburg Emergency Medical Services Agency, Charlotte, NC; and ‡Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC
| | | | | |
Collapse
|
59
|
Choi SW, Shin SD, Ro YS, Song KJ, Lee YJ, Lee EJ. Effect of Emergency Medical Service Use and Inter-hospital Transfer on Time to Percutaneous Coronary Intervention in Patients with ST Elevation Myocardial Infarction: A Multicenter Observational Study. PREHOSP EMERG CARE 2016; 20:66-75. [DOI: 10.3109/10903127.2015.1056892] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
60
|
Kawakami S, Tahara Y, Noguchi T, Yagi N, Kataoka Y, Asaumi Y, Nakanishi M, Goto Y, Yokoyama H, Nonogi H, Ogawa H, Yasuda S. Time to Reperfusion in ST-Segment Elevation Myocardial Infarction Patients With vs. Without Pre-Hospital Mobile Telemedicine 12-Lead Electrocardiogram Transmission. Circ J 2016; 80:1624-33. [DOI: 10.1253/circj.cj-15-1322] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Shoji Kawakami
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
- Department of Advanced Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
| | - Yoshio Tahara
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Teruo Noguchi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | | | - Yu Kataoka
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Yasuhide Asaumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Michio Nakanishi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Yoichi Goto
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Hiroyuki Yokoyama
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | | | - Hisao Ogawa
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
- Department of Advanced Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
- Department of Advanced Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
| |
Collapse
|
61
|
Thomas JL, French WJ. Current State of ST-Segment Myocardial Infarction: Evidence-based Therapies and Optimal Patient Outcomes in Advanced Systems of Care. Heart Fail Clin 2015; 12:49-63. [PMID: 26567974 DOI: 10.1016/j.hfc.2015.08.005] [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: 11/26/2022]
Abstract
Advances in reperfusion therapy for ST-segment elevation myocardial infarction (STEMI) provide optimal patient outcomes. Reperfusion therapies, including contemporary primary percutaneous coronary intervention, represent decades of clinical evidence development in large clinical trials and national databases. However, rapid identification of STEMI and guideline-directed management of patients across broad populations have been best achieved in advanced systems of care. Current outcomes in STEMI reflect the evolution of both clinical data and idealized health care delivery networks.
Collapse
Affiliation(s)
- Joseph L Thomas
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; Division of Cardiology, Harbor UCLA Medical Center, 1000 West Carson Street, Torrance, CA 90509, USA
| | - William J French
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; Division of Cardiology, Harbor UCLA Medical Center, 1000 West Carson Street, Torrance, CA 90509, USA.
| |
Collapse
|
62
|
Affiliation(s)
- Comilla Sasson
- From University of Colorado, Aurora, Colorado, and Denver Health Medical Center, Denver, Colorado
| | - Jason S. Haukoos
- From University of Colorado, Aurora, Colorado, and Denver Health Medical Center, Denver, Colorado
| |
Collapse
|
63
|
Nguyen B, Fennessy M, Leya F, Nowak W, Ryan M, Freeberg S, Gill J, Dieter RS, Steen L, Lewis B, Cichon M, Probst B, Jarotkiewicz M, Wilber D, Lopez JJ. Comparison of primary percutaneous coronary intervention in patients with ST-elevation myocardial infarction during and prior to availability of an in-house STEMI system: early experience and intermediate outcomes of the HARRT program for achieving routine D2B times <60 minutes. Catheter Cardiovasc Interv 2015; 86:186-96. [PMID: 25504976 DOI: 10.1002/ccd.25769] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Accepted: 12/06/2014] [Indexed: 11/09/2022]
Abstract
BACKGROUND Over the last decade, significant advances in ST-elevation myocardial infarction (STEMI) workflow have resulted in most hospitals reporting door-to-balloon (D2B) times within the 90 min standard. Few programs have been enacted to systematically attempt to achieve routine D2B within 60 min. We sought to determine whether 24-hr in-house catheterization laboratory coverage via an In-House Interventional Team Program (IHIT) could achieve D2B times below 60 min for STEMI and to compare the results to the standard primary percutaneous coronary intervention (PCI) approach. METHODS An IHIT program was established consisting of an attending interventional cardiologist, and a catheterization laboratory team present in-hospital 24 hr/day. For all consecutive STEMI patients, we compared the standard primary PCI approach during the two years prior to the program (group A) to the initial 20 months of the IHIT program (group B), and repeated this analysis for only CMS-reportable patients. The D2B process was analyzed by calculating workflow intervals. The primary endpoint was D2B process times, and secondary endpoints included in-hospital and 6-month cardiovascular outcomes and resource utilization. RESULTS An IHIT program for STEMI resulted in significant reductions across all treatment intervals with an overall 57% reduction in D2B time, and an absolute reduction in mean D2B time of 71 min. There were no differences pre- and post-program implementation in regard to individual or composite components of in-hospital cardiovascular outcomes; however at 6 months, there was a reduction in cardiovascular rehospitalization after program implementation (30 vs. 5%, P < 0.01). The IHIT program resulted in a significant reduction in length-of-stay (LOS) (90 ± 102 vs. 197 ± 303 hr, P = 0.02), and critical care time (54 ± 97 vs. 149 ± 299 hr, P = 0.02). CONCLUSIONS Availability of an in-house 24-hr STEMI team significantly decreased reperfusion time and led to improved clinical outcomes and a shorter LOS for PCI-treated STEMI patients.
Collapse
Affiliation(s)
- Bryant Nguyen
- Division of Cardiology, Department of Medicine, Loyola University Medical Center, Stritch School of Medicine, Maywood, Illinois
| | - Michelle Fennessy
- Division of Cardiology, Department of Medicine, Loyola University Medical Center, Stritch School of Medicine, Maywood, Illinois
| | - Ferdinand Leya
- Division of Cardiology, Department of Medicine, Loyola University Medical Center, Stritch School of Medicine, Maywood, Illinois
| | - Wojciech Nowak
- Division of Cardiology, Department of Medicine, Loyola University Medical Center, Stritch School of Medicine, Maywood, Illinois
| | - Michael Ryan
- Division of Cardiology, Department of Medicine, Loyola University Medical Center, Stritch School of Medicine, Maywood, Illinois
| | - Sheldon Freeberg
- Division of Cardiology, Department of Medicine, Loyola University Medical Center, Stritch School of Medicine, Maywood, Illinois
| | - Jasrai Gill
- Division of Cardiology, Department of Medicine, Loyola University Medical Center, Stritch School of Medicine, Maywood, Illinois
| | - Robert S Dieter
- Division of Cardiology, Department of Medicine, Loyola University Medical Center, Stritch School of Medicine, Maywood, Illinois
| | - Lowell Steen
- Division of Cardiology, Department of Medicine, Loyola University Medical Center, Stritch School of Medicine, Maywood, Illinois
| | - Bruce Lewis
- Division of Cardiology, Department of Medicine, Loyola University Medical Center, Stritch School of Medicine, Maywood, Illinois
| | - Mark Cichon
- Division of Cardiology, Department of Medicine, Loyola University Medical Center, Stritch School of Medicine, Maywood, Illinois
| | - Beatrice Probst
- Division of Cardiology, Department of Medicine, Loyola University Medical Center, Stritch School of Medicine, Maywood, Illinois
| | - Michael Jarotkiewicz
- Division of Cardiology, Department of Medicine, Loyola University Medical Center, Stritch School of Medicine, Maywood, Illinois
| | - David Wilber
- Division of Cardiology, Department of Medicine, Loyola University Medical Center, Stritch School of Medicine, Maywood, Illinois
| | - John J Lopez
- Division of Cardiology, Department of Medicine, Loyola University Medical Center, Stritch School of Medicine, Maywood, Illinois
| |
Collapse
|
64
|
Chua S, Lee FY, Tsai TH, Sheu JJ, Leu S, Sun CK, Chen YL, Chang HW, Chai HT, Liu CF, Lu HI, Yip HK. Inhibition of dipeptidyl peptidase-IV enzyme activity protects against myocardial ischemia-reperfusion injury in rats. J Transl Med 2014; 12:357. [PMID: 25496837 PMCID: PMC4301397 DOI: 10.1186/s12967-014-0357-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2014] [Accepted: 12/04/2014] [Indexed: 11/10/2022] Open
Abstract
Background We investigated whether attenuating dipeptidyl peptidase-IV (DPP4) enzyme activity protected rat heart from ischemia-reperfusion (IR) injury (40-min left anterior descending coronary artery ligation followed by 72 h reperfusion). Methods and results Adult male Fischer 344 rats (n = 24) were equally divided into sham-control (WT-SC), WT-IR, and WT-IR-Sita (oral sitagliptin 400 mg/kg/day for 3 days) groups, whereas adult male DPP4-deficiency (DPP4D) rats (n = 16) were equally divided into DPP4D-SC and DPP4D-IR groups. Animals were sacrificed at 72 h after reperfusion with collection of heart specimens. Infarct area (H&E), collagen deposition (Sirius-red stain), fibrotic area (Masson's trichrome), and fluorescent-ROS intensity (H2DCFDA-labeling myocardium) of left ventricle were significantly higher in WT-IR than those in other groups, significantly higher in WT-IR-Sita and DPP4D-IR groups than in WT-SC and DPP4D-SC groups (all p < 0.001), but there was no difference between the latter two groups. Protein expressions of oxidative stress (oxidized protein), reactive oxygen species (NOX-1, NOX-2), inflammation (TNF-α, NF-κB, MMP-9, VCAM-1), apoptosis (mitochondrial Bax, cleaved caspase-3 and PARP), myocardial damage markers (cytosolic cytochrome-C, γ-H2AX), and number of inflammatory cells (CD14+, CD68+, CD40+ cells) showed a pattern identical to that of histological changes among all groups (all p < 0.005), whereas markers of anti-apoptosis (Bcl-2) and mitochondrial integrity (mitochondrial cytochrome-C) as well as left ventricular ejection fraction showed an opposite pattern (all p < 0.001). Protein expressions of anti-oxidants (HO-1, NQO-1), angiogenesis factors (SDF-1α, CXCR4), and glycogen-like-peptide-1-receptor were significantly higher inWT-IR-Sita and DPP4D-IR than those in other groups (all p < 0.001). Conclusion Abrogation of DPP4 activity protects against myocardial IR injury and preserved heart function.
Collapse
|
65
|
Nicholson BD, Dhindsa HS, Roe MT, Chen AY, Jollis JG, Kontos MC. Relationship of the distance between non-PCI hospitals and primary PCI centers, mode of transport, and reperfusion time among ground and air interhospital transfers using NCDR's ACTION Registry-GWTG: a report from the American Heart Association Mission: Lifeline Program. Circ Cardiovasc Interv 2014; 7:797-805. [PMID: 25406204 DOI: 10.1161/circinterventions.113.001307] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND ST-segment myocardial infarction patients frequently present to non-percutaneous coronary intervention (PCI) hospitals and require interhospital transfer for primary PCI. The effect of distance and mode of transport to the PCI center and the frequency that recommended primary PCI times are met are not clear. METHODS AND RESULTS Data from the ACTION Registry(®)-GWTG™ were used to determine the distance between the Non-PCI and PCI center and first door time to balloon time based on transfer mode (ground and air) for patients having interhospital transfer for primary PCI. From July 1, 2008, to December 31, 2012, 17 052 ST-segment myocardial infarction patients were transferred to 413 PCI hospitals. The median distance from the non-PCI hospital to the primary PCI center was 31.9 miles (Q1, Q3: 19.1, 47.9; ground 25.2 miles; air 43.9 miles; P<0.001). At distances <40 miles, ground transport was the primary transport method, whereas at distances >40 miles air transport predominanted. Median first door time to balloon time time for patients transferred for primary PCI was 118 minutes (Q1, Q3: 95 152), with time for patients transported by air significantly longer (median 124 versus 113 minutes; respectively, P<0.001) than for patients transported by ground. Fifty-three percent of patients had a first door time to balloon time ≤120 minutes, with only 20% ≤90 minutes. A first door time to balloon time ≤120 minutes was more likely in ground than in air transport patients (57.0% versus 45.6%; P<0.001). CONCLUSIONS Interhospital transfer for primary PCI is associated with prolonged reperfusion times. These delays should prompt increased consideration of fibrinolytic therapy, emergency medical services hospital bypass protocols, and improved systems of care for ST-segment myocardial infarction patients requiring transfer.
Collapse
Affiliation(s)
- Benjamin D Nicholson
- From the Virginia Commonwealth University (B.D.N.), Department of Emergency Medicine (H.S.D.), and Department of Internal Medicine (M.C.K.), Richmond, VA; and Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.T.R., A.Y.C., J.G.J.); and on behalf of the NCDR
| | - Harinder S Dhindsa
- From the Virginia Commonwealth University (B.D.N.), Department of Emergency Medicine (H.S.D.), and Department of Internal Medicine (M.C.K.), Richmond, VA; and Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.T.R., A.Y.C., J.G.J.); and on behalf of the NCDR
| | - Matthew T Roe
- From the Virginia Commonwealth University (B.D.N.), Department of Emergency Medicine (H.S.D.), and Department of Internal Medicine (M.C.K.), Richmond, VA; and Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.T.R., A.Y.C., J.G.J.); and on behalf of the NCDR
| | - Anita Y Chen
- From the Virginia Commonwealth University (B.D.N.), Department of Emergency Medicine (H.S.D.), and Department of Internal Medicine (M.C.K.), Richmond, VA; and Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.T.R., A.Y.C., J.G.J.); and on behalf of the NCDR
| | - James G Jollis
- From the Virginia Commonwealth University (B.D.N.), Department of Emergency Medicine (H.S.D.), and Department of Internal Medicine (M.C.K.), Richmond, VA; and Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.T.R., A.Y.C., J.G.J.); and on behalf of the NCDR
| | - Michael C Kontos
- From the Virginia Commonwealth University (B.D.N.), Department of Emergency Medicine (H.S.D.), and Department of Internal Medicine (M.C.K.), Richmond, VA; and Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.T.R., A.Y.C., J.G.J.); and on behalf of the NCDR.
| |
Collapse
|
66
|
Sardi GL, Loh JP, Torguson R, Satler LF, Waksman R. Real-time, two-way interaction during ST-segment elevation myocardial infarction management improves door-to-balloon times. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2014; 15:263-8. [PMID: 25178666 DOI: 10.1016/j.carrev.2014.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Accepted: 05/14/2014] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The study aimed to determine if utilization of the CodeHeart application (CHap) reduces door-to-balloon (DTB) times of ST-segment elevation myocardial infarction (STEMI) patients. BACKGROUND A pre-hospital electrocardiogram improves the management of patients with STEMI. Current telecommunication systems do not permit real-time interaction with the initial care providers. Our institution developed a novel telecommunications system based on a software application that permits real-time, two-way video and voice interaction over a secured network. METHODS All STEMI system activations after implementation of the CHap were prospectively entered into a database. Consecutive CHap activations were compared to routine activations as controls, during the same time period. RESULTS A total of 470 STEMI system activations occurred; CHap was used in 83 cases (17.7%). DTB time was reduced by the use of CHap when compared to controls (CHap 103 minutes, 95% CI [87.0-118.3] vs. standard 149 minutes, 95% CI [134.0-164.8], p<0.0001), as was first call-to-balloon time (CHap 70 minutes, 95% CI [60.8-79.5] vs. standard 92 minutes, 95% CI [85.8-98.9], p=0.0002). The percentage of 'true positive' catheterization laboratory activations was nominally higher with the use of CHap, although this did not reach statistical significance [CHap 47/83 (56.6%) vs. routine 178/387 (45.9%), p=0.103]. CONCLUSION The implementation of a two-way telecommunications system allowing real-time interactions between interventional cardiologists and referring practitioners improves overall DTB time. In addition, it has the potential to decrease the frequency of false activations, thereby improving the cost efficiency of a network's STEMI system.
Collapse
Affiliation(s)
- Gabriel L Sardi
- Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC
| | - Joshua P Loh
- Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC
| | - Rebecca Torguson
- Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC
| | - Lowell F Satler
- Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC
| | - Ron Waksman
- Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC.
| |
Collapse
|
67
|
Brunetti ND, Di Pietro G, Aquilino A, Bruno AI, Dellegrottaglie G, Di Giuseppe G, Lopriore C, De Gennaro L, Lanzone S, Caldarola P, Antonelli G, Di Biase M. Pre-hospital electrocardiogram triage with tele-cardiology support is associated with shorter time-to-balloon and higher rates of timely reperfusion even in rural areas: data from the Bari- Barletta/Andria/Trani public emergency medical service 118 registry on primary angioplasty in ST-elevation myocardial infarction. EUROPEAN HEART JOURNAL: ACUTE CARDIOVASCULAR CARE 2014; 3:204-213. [DOI: 10.1177/2048872614527009] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
|
68
|
Brunetti ND, Dellegrottaglie G, Di Giuseppe G, Di Biase M. Remote tele-medicine cardiologist support for care manager nursing of chronic cardiovascular disease: preliminary report. Int J Cardiol 2014; 176:552-6. [DOI: 10.1016/j.ijcard.2014.07.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Accepted: 07/05/2014] [Indexed: 11/26/2022]
|
69
|
Thomas JL, French WJ. Current state of ST-segment myocardial infarction: evidence-based therapies and optimal patient outcomes in advanced systems of care. Cardiol Clin 2014; 32:371-85. [PMID: 25091964 DOI: 10.1016/j.ccl.2014.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Advances in reperfusion therapy for ST-segment elevation myocardial infarction (STEMI) provide optimal patient outcomes. Reperfusion therapies, including contemporary primary percutaneous coronary intervention, represent decades of clinical evidence development in large clinical trials and national databases. However, rapid identification of STEMI and guideline-directed management of patients across broad populations have been best achieved in advanced systems of care. Current outcomes in STEMI reflect the evolution of both clinical data and idealized health care delivery networks.
Collapse
Affiliation(s)
- Joseph L Thomas
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; Division of Cardiology, Harbor UCLA Medical Center, 1000 West Carson Street, Torrance, CA 90509, USA
| | - William J French
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; Division of Cardiology, Harbor UCLA Medical Center, 1000 West Carson Street, Torrance, CA 90509, USA.
| |
Collapse
|
70
|
Nam J, Caners K, Bowen JM, Welsford M, O'Reilly D. Systematic Review and Meta-analysis of the Benefits of Out-of-Hospital 12-Lead ECG and Advance Notification in ST-Segment Elevation Myocardial Infarction Patients. Ann Emerg Med 2014; 64:176-86, 186.e1-9. [DOI: 10.1016/j.annemergmed.2013.11.016] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Revised: 11/06/2013] [Accepted: 11/11/2013] [Indexed: 12/21/2022]
|
71
|
Mumma BE, Kontos MC, Peng SA, Diercks DB. Association between prehospital electrocardiogram use and patient home distance from the percutaneous coronary intervention center on total reperfusion time in ST-segment-elevation myocardial infarction patients: a retrospective analysis from the national cardiovascular data registry. Am Heart J 2014; 167:915-20. [PMID: 24890543 DOI: 10.1016/j.ahj.2014.03.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Accepted: 03/19/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Current guidelines recommend ≤90 minutes from first medical contact to percutaneous coronary intervention (FMC2B) for ST-segment-elevation myocardial infarction (STEMI) patients. We evaluated the relationship between patient home distance from a percutaneous coronary intervention (PCI) center, prehospital electrocardiogram (ECG) use, and FMC2B time among patients with STEMI. METHODS We performed a retrospective cohort study including all STEMI patients in the ACTION-Get With The Guidelines registry from July 1, 2008, to September 30, 2012, who were transported by ambulance to a PCI center. Patient home distance was defined as the driving distance from the patient's home zip code to the PCI center address. Distance was classified into tertiles, and linear regression was used to characterize the interaction between prehospital ECG use and patient home distance with respect to FMC2B time. RESULTS Of the 29,506 STEMI patients, 19,690 (67%) received a prehospital ECG. The median patient home distance to the PCI center was 11.0 miles among patients with and 9.9 miles among those without a prehospital ECG. Prehospital ECGs were associated with a 10-minute reduction in the FMC2B time (P < .0001), which was consistent across distance tertiles (11 vs 11 vs 10 minutes). The association between prehospital ECGs and shorter FMC2B was attenuated by 0.8 minute for every 10-mile increase in distance (interaction P = .0002). CONCLUSIONS Prehospital ECGs are associated with a 10-minute reduction in the FMC2B time. However, patient home distance from a PCI center does not substantially change this association.
Collapse
|
72
|
O'Connor RE, Nichol G, Gonzales L, Manoukian SV, Moyer PH, Rokos I, Sayre MR, Solomon RC, Wingrove GL, Brady WJ, McBride S, Lorden AL, Roettig ML, Acuna A, Jacobs AK. Emergency medical services management of ST-segment elevation myocardial infarction in the United States--a report from the American Heart Association Mission: Lifeline Program. Am J Emerg Med 2014; 32:856-63. [PMID: 24865499 DOI: 10.1016/j.ajem.2014.04.029] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Revised: 04/06/2014] [Accepted: 04/11/2014] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE ST-segment elevation myocardial infarction (STEMI) is a major cause of morbidity and mortality in the United States. Emergency medical services (EMS) agencies play a critical role in its initial identification and treatment. We conducted this study to assess EMS management of STEMI care in the United States. METHODS A structured questionnaire was administered to leaders of EMS agencies to define the elements of STEMI care related to 4 core measures: (1) electrocardiogram (ECG) capability at the scene, (2) destination protocols, (3) catheterization laboratory activation before hospital arrival, and (4) 12-lead ECG quality review. Geographic areas were grouped into large metropolitan, small metropolitan, micropolitan, and noncore (or rural) by using Urban Influence Codes, with a stratified analysis. RESULTS Data were included based on responses from 5296 EMS agencies (36% of those in the United States) serving 91% of the US population, with at least 1 valid response from each of the 50 states and the District of Columbia. Approximately 63% of agencies obtained ECGs at the scene using providers trained in ECG acquisition and interpretation. A total of 46% of EMS systems used protocols to determine hospital destination, cardiac catheterization laboratory activation, and communications with the receiving hospital. More than 75% of EMS systems used their own agency funds to purchase equipment, train personnel, and provide administrative oversight. A total of 49% of agencies have quality review programs in place. In general, EMS systems covering higher population densities had easier access to resources needed to maintain STEMI systems of care. Emergency medical services systems that have adopted all 4 core elements cover 14% of the US population. CONCLUSIONS There are large differences in EMS systems of STEMI care in the United States. Most EMS agencies have implemented at least 1 of the 4 core elements of STEMI care, with many having implemented multiple elements.
Collapse
Affiliation(s)
- Robert E O'Connor
- Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, VA.
| | - Graham Nichol
- University of Washington-Harborview Center for Prehospital Emergency Care, University of Washington, Seattle, WA
| | | | - Steven V Manoukian
- Clinical and Physician Services Group, Hospital Corporation of America, Nashville, TN
| | | | - Ivan Rokos
- Department of Emergency Medicine, Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Michael R Sayre
- Division of Emergency Medicine, Department of Medicine, University of Washington, Seattle, WA
| | | | | | - William J Brady
- Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, VA
| | - Susan McBride
- School of Nursing, Texas Tech University Health Sciences Center, Lubbock, TX
| | - Andrea L Lorden
- Department of Health Policy and Management, Texas A&M Health Science Center, College Station, TX
| | | | | | - Alice K Jacobs
- Department of Medicine, Boston University School of Medicine, Boston, MA
| |
Collapse
|
73
|
Roswell RO, Greet B, Parikh P, Mignatti A, Freese J, Lobach I, Guo Y, Keller N, Radford M, Bangalore S. From door-to-balloon time to contact-to-device time: predictors of achieving target times in patients with ST-elevation myocardial infarction. Clin Cardiol 2014; 37:389-94. [PMID: 24700343 DOI: 10.1002/clc.22278] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Revised: 03/02/2014] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The 2013 American College of Cardiology Foundation/American Heart Association ST-segment elevation myocardial infarction (STEMI) guidelines have shifted focus from door-to-balloon (D2B) time to the time from first medical contact to device activation (contact-to-device time [C2D] ). HYPOTHESIS This study investigates the impact of prehospital wireless electrocardiogram transmission (PHT) on reperfusion times to assess the impact of the new guidelines. METHODS From January 2009 to December 2012, data were collected on STEMI patients who received percutaneous coronary interventions; 245 patients were included for analysis. The primary outcome was median C2D time in the PHT group and the secondary outcome was D2B time. RESULTS Prehospital wireless electrocardiogram transmission was associated with reduced C2D times vs no PHT: 80 minutes (interquartile range [IQR], 64-94) vs 96 minutes (IQR, 79-118), respectively, P < 0.0001. The median D2B time was lower in the PHT group vs the no-PHT group: 45 minutes (IQR, 34-56) vs 63 minutes (IQR, 49-81), respectively, P < 0.0001. Multivariate analysis showed PHT to be the strongest predictor of a C2D time of <90 minutes (odds ratio: 3.73, 95% confidence interval: 1.65-8.39, P = 0.002). Female sex was negatively predictive of achieving a C2D time <90 minutes (odds ratio: 0.23, 95% confidence interval: 0.07-0.73, P = 0.01). CONCLUSIONS In STEMI patients, PHT was associated with significantly reduced C2D and D2B times and was an independent predictor of achieving a target C2D time. As centers adapt to the new guidelines emphasizing C2D time, targeting a shorter D2B time (<50 minutes) is ideal to achieve a C2D time of <90 minutes.
Collapse
Affiliation(s)
- Robert O Roswell
- Department of Medicine, Leon H. Charney Division of Cardiology, New York University School of Medicine, New York, New York
| | | | | | | | | | | | | | | | | | | |
Collapse
|
74
|
Temporal trends of system of care for STEMI: insights from the Jakarta Cardiovascular Care Unit Network System. PLoS One 2014; 9:e86665. [PMID: 24520322 PMCID: PMC3919720 DOI: 10.1371/journal.pone.0086665] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2013] [Accepted: 12/12/2013] [Indexed: 11/19/2022] Open
Abstract
AIM Guideline implementation programs are of paramount importance in optimizing acute ST-elevation myocardial infarction (STEMI) care. Assessment of performance indicators from a local STEMI network will provide knowledge of how to improve the system of care. METHODS AND RESULTS Between 2008-2011, 1505 STEMI patients were enrolled. We compared the performance indicators before (n = 869) and after implementation (n = 636) of a local STEMI network. In 2011 (after introduction of STEMI networking) compared to 2008-2010, there were more inter-hospital referrals for STEMI patients (61% vs 56%, p<0.001), more primary percutaneous coronary intervention (PCI) procedures (83% vs 73%, p = 0.005), and more patients reaching door-to-needle time ≤ 30 minutes (84.5% vs 80.2%, p<0.001). However, numbers of patients who presented very late (>12 hours after symptom onset) were similar (53% vs 51%, NS). Moreover, the numbers of patients with door-to-balloon time ≤ 90 minutes were similar (49.1% vs 51.3%, NS), and in-hospital mortality rates were similar (8.3% vs 6.9%, NS) in 2011 compared to 2008-2010. CONCLUSION After a local network implementation for patients with STEMI, there were significantly more inter-hospital referral cases, primary PCI procedures, and patients with a door-to-needle time ≤ 30 minutes, compared to the period before implementation of this network. However, numbers of patients who presented very late, the targeted door-to-balloon time and in-hospital mortality rate were similar in both periods. To improve STEMI networking based on recent guidelines, existing pre-hospital and in-hospital protocols should be improved and managed more carefully, and should be accommodated whenever possible.
Collapse
|
75
|
Garberich RF, Traverse JH, Claussen MT, Rodriguez G, Poulose AK, Chavez IJ, Rutten-Ramos S, Hildebrandt DA, Henry TD. ST-elevation myocardial infarction diagnosed after hospital admission. Circulation 2014; 129:1225-32. [PMID: 24389237 DOI: 10.1161/circulationaha.113.005568] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Treatment times for ST-elevation myocardial infarction (STEMI) patients presenting to percutaneous coronary intervention hospitals have improved dramatically over the past 10 years, particularly for patients using emergency medical services. Limited data exist regarding treatment times and outcomes for patients who develop STEMI after hospital admission. METHODS AND RESULTS With the use of a comprehensive prospective regional STEMI program database, we evaluated the characteristics and outcomes for patients who develop STEMI after hospital admission. Of the 3795 consecutive STEMI patients treated by the use of the Minneapolis Heart Institute regional STEMI program from March 2003 to January 2013, 990 (26.1%) presented initially to the percutaneous coronary intervention facility, including 640 arriving via emergency medical services, 267 self/family driven, and 83 already admitted to the hospital. Patients with in-hospital presentation were older with higher body mass indexes, were more likely to have hypertension, and to present with pre-percutaneous coronary intervention cardiac arrest and cardiogenic shock. Door-to-balloon times (diagnostic ECG-to-balloon for in-hospital patients) were longer than for patients using emergency medical services (76 versus 51 minutes; P<0.001), but similar to self/family-driven patients (76 versus 66 minutes; P=0.13). In-hospital patients had longer lengths of stay (5 versus 3 versus 3 days; P<0.001) and higher 1-year mortality (16.9% versus 10.3% versus 7.1%; P=0.032). These patients frequently had high-risk and complex reasons for admission, including 30.1% with acute coronary syndrome, 22.9% postsurgery, 13.3% respiratory failure, and 8.4% ventricular fibrillation. CONCLUSIONS Patients who develop STEMI while in-hospital represent a unique, high-risk subset of patients. They have increased treatment time and lengths of stay and higher mortality rates than the patients presenting via emergency medical services or who are self/family driven.
Collapse
Affiliation(s)
- Ross F Garberich
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN
| | | | | | | | | | | | | | | | | |
Collapse
|
76
|
Langabeer JR, Dellifraine J, Fowler R, Jollis JG, Stuart L, Segrest W, Griffin R, Koenig W, Moyer P, Henry TD. Emergency medical services as a strategy for improving ST-elevation myocardial infarction system treatment times. J Emerg Med 2013; 46:355-62. [PMID: 24268897 DOI: 10.1016/j.jemermed.2013.08.112] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2012] [Revised: 04/22/2013] [Accepted: 08/15/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Reducing delays in time to treatment is a key goal of ST-elevation myocardial infarction (STEMI) emergency care. Emergency medical services (EMS) are a critical component of the STEMI chain of survival. STUDY OBJECTIVE We sought to assess the impact of the careful integration of EMS as a strategy for improving systemic treatment times for STEMI. METHODS We conducted a study of all 747 nontransfer STEMI patients who underwent primary percutaneous coronary intervention (PCI) in Dallas County, Texas from October 1, 2010 through December 31, 2011. EMS leaders from 24 agencies and 15 major PCI receiving hospitals collected and shared common, de-identified patient data. We used 15 months of data to develop a generalized linear regression to assess the impact of EMS on two treatment metrics-hospital door to balloon (D2B) time, and symptom onset to arterial reperfusion (SOAR) time, a new metric we developed to assess total treatment times. RESULTS We found statistically significant reductions in median D2B (11.1-min reduction) and SOAR (63.5-min reduction) treatment times when EMS transported patients to the receiving facility, compared to self-transport. In addition, when trained EMS paramedics field-activated the cardiac catheterization laboratory using predefined specified protocols, D2B times were reduced by 38% (43 min) after controlling for confounding variables, and field activation was associated with a 21.9% reduction (73 min) in the mean SOAR time (both with p < 0.001). CONCLUSION Active EMS engagement in STEMI treatment was associated with significantly lower D2B and total coronary reperfusion times.
Collapse
Affiliation(s)
| | | | - Raymond Fowler
- University of Texas Southwestern Medical Center, Dallas, Texas
| | | | | | | | | | - William Koenig
- Los Angeles County Emergency Medical Services, University of California Los Angeles School of Medicine, Los Angeles, California
| | - Peter Moyer
- Boston University School of Medicine, Boston, Massachusetts
| | - Timothy D Henry
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota
| |
Collapse
|
77
|
Givertz MM, Teerlink JR, Albert NM, Westlake Canary CA, Collins SP, Colvin-Adams M, Ezekowitz JA, Fang JC, Hernandez AF, Katz SD, Krishnamani R, Stough WG, Walsh MN, Butler J, Carson PE, Dimarco JP, Hershberger RE, Rogers JG, Spertus JA, Stevenson WG, Sweitzer NK, Tang WHW, Starling RC. Acute decompensated heart failure: update on new and emerging evidence and directions for future research. J Card Fail 2013; 19:371-89. [PMID: 23743486 DOI: 10.1016/j.cardfail.2013.04.002] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2013] [Accepted: 04/17/2013] [Indexed: 01/10/2023]
Abstract
Acute decompensated heart failure (ADHF) is a complex clinical event associated with excess morbidity and mortality. Managing ADHF patients is challenging because of the lack of effective treatments that both reduce symptoms and improve clinical outcomes. Existing guideline recommendations are largely based on expert opinion, but several recently published trials have yielded important data to inform both current clinical practice and future research directions. New insight has been gained regarding volume management, including dosing strategies for intravenous loop diuretics and the role of ultrafiltration in patients with heart failure and renal dysfunction. Although the largest ADHF trial to date (ASCEND-HF, using nesiritide) was neutral, promising results with other investigational agents have been reported. If these findings are confirmed in phase III trials, novel compounds, such as relaxin, omecamtiv mecarbil, and ularitide, among others, may become therapeutic options. Translation of research findings into quality clinical care can not be overemphasized. Although many gaps in knowledge exist, ongoing studies will address issues around delivery of evidence-based care to achieve the goal of improving the health status and clinical outcomes of patients with ADHF.
Collapse
Affiliation(s)
- Michael M Givertz
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
78
|
Bush M, Glickman LT, Fernandez AR, Garvey JL, Glickman SW. Variation in the use of 12-lead electrocardiography for patients with chest pain by emergency medical services in North Carolina. J Am Heart Assoc 2013; 2:e000289. [PMID: 23920232 PMCID: PMC3828790 DOI: 10.1161/jaha.113.000289] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Prehospital 12‐lead electrocardiography (ECG) is critical to timely STEMI care although its use remains inconsistent. Previous studies to identify reasons for failure to obtain a prehospital ECG have generally only focused on individual emergency medical service (EMS) systems in urban areas. Our study objective was to identify patient, geographic, and EMS agency‐related factors associated with failure to perform a prehospital ECG across a statewide geography. Methods and Results We analyzed data from the Prehospital Medical Information System (PreMIS) in North Carolina from January 2008 to November 2010 for patients >30 years of age who used EMS and had a prehospital chief complaint of chest pain. Among 3.1 million EMS encounters, 134 350 patients met study criteria. From 2008–2010, 82 311 (61%) persons with chest pain received a prehospital ECG; utilization increased from 55% in 2008 to 65% in 2010 (trend P<0.001). Utilization by health referral region ranged from 22.9% to 74.2% and was lowest in rural areas. Men were more likely than women to have an ECG performed (63.0% vs 61.3%, adjusted RR 1.02, 95% CI 1.01 to 1.04). The certification‐level of the EMS provider (paramedic vsbasic/intermediate) and system‐level ECG equipment availability were the strongest predictors of ECG utilization. Persons in an ambulance with a certified paramedic were significantly more likely to receive a prehospital ECG than nonparamedics (RR 2.15, 95% CI 1.55, 2.99). Conclusions Across a large geographic area prehospital ECG use increased significantly, although important quality improvement opportunities remain. Increasing ECG availability and improving EMS certification and training levels are needed to improve overall care and reduce rural‐urban treatment differences.
Collapse
Affiliation(s)
- Montika Bush
- Department of Emergency Medicine, University of North Carolina
| | | | | | | | | |
Collapse
|
79
|
Bagai A, Jollis JG, Dauerman HL, Peng SA, Rokos IC, Bates ER, French WJ, Granger CB, Roe MT. Emergency Department Bypass for ST-Segment–Elevation Myocardial Infarction Patients Identified With a Prehospital Electrocardiogram. Circulation 2013; 128:352-9. [DOI: 10.1161/circulationaha.113.002339] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Akshay Bagai
- From the Duke Clinical Research Institute, Durham, NC (A.B., J.G.J., S.A.P., C.B.G., M.T.R.); University of Vermont, Burlington, VT (H.L.D.); University of California at Los Angeles–Olive View Medical Center, Geffen School of Medicine, Sylmar, CA (I.C.R.); University of Michigan, Ann Arbor, MI (E.R.B.); and Harbor–University of California at Los Angeles Medical Center, Torrance, CA (W.J.F.)
| | - James G. Jollis
- From the Duke Clinical Research Institute, Durham, NC (A.B., J.G.J., S.A.P., C.B.G., M.T.R.); University of Vermont, Burlington, VT (H.L.D.); University of California at Los Angeles–Olive View Medical Center, Geffen School of Medicine, Sylmar, CA (I.C.R.); University of Michigan, Ann Arbor, MI (E.R.B.); and Harbor–University of California at Los Angeles Medical Center, Torrance, CA (W.J.F.)
| | - Harold L. Dauerman
- From the Duke Clinical Research Institute, Durham, NC (A.B., J.G.J., S.A.P., C.B.G., M.T.R.); University of Vermont, Burlington, VT (H.L.D.); University of California at Los Angeles–Olive View Medical Center, Geffen School of Medicine, Sylmar, CA (I.C.R.); University of Michigan, Ann Arbor, MI (E.R.B.); and Harbor–University of California at Los Angeles Medical Center, Torrance, CA (W.J.F.)
| | - S. Andrew Peng
- From the Duke Clinical Research Institute, Durham, NC (A.B., J.G.J., S.A.P., C.B.G., M.T.R.); University of Vermont, Burlington, VT (H.L.D.); University of California at Los Angeles–Olive View Medical Center, Geffen School of Medicine, Sylmar, CA (I.C.R.); University of Michigan, Ann Arbor, MI (E.R.B.); and Harbor–University of California at Los Angeles Medical Center, Torrance, CA (W.J.F.)
| | - Ivan C. Rokos
- From the Duke Clinical Research Institute, Durham, NC (A.B., J.G.J., S.A.P., C.B.G., M.T.R.); University of Vermont, Burlington, VT (H.L.D.); University of California at Los Angeles–Olive View Medical Center, Geffen School of Medicine, Sylmar, CA (I.C.R.); University of Michigan, Ann Arbor, MI (E.R.B.); and Harbor–University of California at Los Angeles Medical Center, Torrance, CA (W.J.F.)
| | - Eric R. Bates
- From the Duke Clinical Research Institute, Durham, NC (A.B., J.G.J., S.A.P., C.B.G., M.T.R.); University of Vermont, Burlington, VT (H.L.D.); University of California at Los Angeles–Olive View Medical Center, Geffen School of Medicine, Sylmar, CA (I.C.R.); University of Michigan, Ann Arbor, MI (E.R.B.); and Harbor–University of California at Los Angeles Medical Center, Torrance, CA (W.J.F.)
| | - William J. French
- From the Duke Clinical Research Institute, Durham, NC (A.B., J.G.J., S.A.P., C.B.G., M.T.R.); University of Vermont, Burlington, VT (H.L.D.); University of California at Los Angeles–Olive View Medical Center, Geffen School of Medicine, Sylmar, CA (I.C.R.); University of Michigan, Ann Arbor, MI (E.R.B.); and Harbor–University of California at Los Angeles Medical Center, Torrance, CA (W.J.F.)
| | - Christopher B. Granger
- From the Duke Clinical Research Institute, Durham, NC (A.B., J.G.J., S.A.P., C.B.G., M.T.R.); University of Vermont, Burlington, VT (H.L.D.); University of California at Los Angeles–Olive View Medical Center, Geffen School of Medicine, Sylmar, CA (I.C.R.); University of Michigan, Ann Arbor, MI (E.R.B.); and Harbor–University of California at Los Angeles Medical Center, Torrance, CA (W.J.F.)
| | - Matthew T. Roe
- From the Duke Clinical Research Institute, Durham, NC (A.B., J.G.J., S.A.P., C.B.G., M.T.R.); University of Vermont, Burlington, VT (H.L.D.); University of California at Los Angeles–Olive View Medical Center, Geffen School of Medicine, Sylmar, CA (I.C.R.); University of Michigan, Ann Arbor, MI (E.R.B.); and Harbor–University of California at Los Angeles Medical Center, Torrance, CA (W.J.F.)
| |
Collapse
|
80
|
Performance of a new "physician-less" automated system of prehospital ST-segment elevation myocardial infarction diagnosis and catheterization laboratory activation. Am J Cardiol 2013; 112:156-61. [PMID: 23587278 DOI: 10.1016/j.amjcard.2013.03.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Revised: 03/06/2013] [Accepted: 03/06/2013] [Indexed: 11/23/2022]
Abstract
The door-to-balloon times frequently exceed the recommended delay. We therefore evaluated the performance of a novel "physician-less" cardiac catheterization laboratory (CCL) activation system relying on the automated electrocardiographic diagnosis alone. From January 2010 to 2012, first responders performed electrocardiograms in the field for all patients with a complaint of chest pain or dyspnea. An automated machine diagnosis of "acute myocardial infarction" resulted in immediate CCL activation and direct transfer without human reinterpretation or transmission of the electrocardiogram. Any activation resulting from a nondiagnostic ECG (no ST-segment elevation) was deemed inappropriate and classified as resulting from either human or machine error. Of 155 activations, 136 (88%) were electrocardiographically appropriate. Of these, 128 patients had a final diagnosis of ST-segment elevation myocardial infarction. A door-to-balloon time of <90 minutes was achieved in 99%, the procedural success was high (94%), and the overall mortality was low (3%). Of the electrocardiographically appropriate activations, 8 (5%) were false-positive results. The remaining 19 activations (12%) were inappropriate. Compared with the electrocardiographically appropriate activations, those with inappropriate activations had significantly greater rates of hypertension (p = 0.0070) and known coronary artery disease (p = 0.0008) and higher presenting heart rates (p <0.0001). The causes for inappropriate activation were approximately evenly split between human and machine error. In conclusion, a combination of prehospital automated ST-segment elevation myocardial infarction diagnosis and "physician-less" CCL activation was safe and effective in ensuring target door-to-balloon times in virtually all patients and resulted in an acceptable rate of inappropriate CCL activation.
Collapse
|
81
|
Wilson RE, Kado HS, Percy RF, Butterfield RC, Sabato J, Strom JA, Box LC. An algorithm for identification of ST-elevation myocardial infarction patients by emergency medicine services. Am J Emerg Med 2013; 31:1098-102. [DOI: 10.1016/j.ajem.2013.04.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2013] [Revised: 04/04/2013] [Accepted: 04/04/2013] [Indexed: 10/26/2022] Open
|
82
|
DelliFraine J, Langabeer J, Segrest W, Fowler R, King R, Moyer P, Henry TD, Koenig W, Warner J, Stuart L, Griffin R, Fathiamini S, Emert J, Roettig ML, Jollis J. Developing an ST-elevation myocardial infarction system of care in Dallas County. Am Heart J 2013; 165:926-31. [PMID: 23708163 DOI: 10.1016/j.ahj.2013.02.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2012] [Accepted: 02/12/2013] [Indexed: 11/26/2022]
Abstract
BACKGROUND The American Heart Association Caruth Initiative (AHACI) is a multiyear project to increase the speed of coronary reperfusion and create an integrated system of care for patients with ST-elevation myocardial infarction (STEMI) in Dallas County, TX. The purpose of this study was to determine if the AHACI improved key performance metrics, that is, door-to-balloon (D2B) and symptom-onset-to-balloon times, for nontransfer patients with STEMI. METHODS Hospital patient data were obtained through the National Cardiovascular Data Registry Action Registry-Get With The Guidelines, and prehospital data came from emergency medical services (EMS) agencies through their electronic Patient Care Record systems. Initial D2B and symptom-onset-to-balloon times for nontransfer primary percutaneous coronary intervention (PCI) STEMI care were explored using descriptive statistics, generalized linear models, and logistic regression. RESULTS Data were collected by 15 PCI-capable Dallas hospitals and 24 EMS agencies. In the first 18 months, there were 3,853 cases of myocardial infarction, of which 926 (24%) were nontransfer patients with STEMI undergoing primary PCI. D2B time decreased significantly (P < .001), from a median time of 74 to 64 minutes. Symptom-onset-to-balloon time decreased significantly (P < .001), from a median time of 195 to 162 minutes. CONCLUSION The AHACI has improved the system of STEMI care for one of the largest counties in the United States, and it demonstrates the benefits of integrating EMS and hospital data, implementing standardized training and protocols, and providing benchmarking data to hospitals and EMS agencies.
Collapse
|
83
|
Clinical pathway: helicopter scene STEMI protocol to facilitate long-distance transfer for primary PCI. Crit Pathw Cardiol 2013; 11:193-8. [PMID: 23149361 DOI: 10.1097/hpc.0b013e318261c995] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The latest American College of Cardiology/American Heart Association guidelines recommend primary percutaneous coronary intervention (PCI) in acute ST-elevation myocardial infarction (STEMI) patients within 90 minutes from presentation to the emergency room. For interhospital transfers, the most recent PCI guidelines recommend first medical contact-to-device times ≤120 minutes. Although PCI-capable hospitals have improved door-to-balloon times, many patients present to non-PCI-capable facilities and have been excluded from national quality measures. METHODS In our acute myocardial infarction network, not only do we enable non-PCI hospitals to transfer STEMI patients but empower outside emergency medical services (EMS) to activate the catheterization laboratory team with a burst page and transfer STEMI patients directly from the scene. Data on patient characteristics, outcomes, and time elements were collected for "scene STEMI" patients who circumvented outlying rural non-PCI hospitals and are presented in this case series. RESULTS From December 2007 to November 2010, 22 STEMI patients with higher than average acuity were transported by helicopter directly to our medical center for primary PCI. Median distance from the scene to our medical center was 47 miles [25th to 75th interquartile range (IQR) = 39-71 miles]. Median EMS-to-balloon time was 120 minutes (IQR = 111-134 minutes). There were no false activations by EMS. In comparison, our median time for interhospital STEMI transfers (N = 335) was 145 minutes (IQR = 121-186 minutes) from 2007 to 2009. CONCLUSIONS In our single-center experience, 22 scene STEMI patients were diagnosed and appropriately triaged by EMS to our center for primary PCI. Our data show feasibility of an EMS-activated STEMI network over long distances with good reperfusion times.
Collapse
|
84
|
Ong MEH, Wong ASL, Seet CM, Teo SG, Lim BL, Ong PJL, Lai SM, Ong SH, Lee FCY, Chan KP, Anantharaman V, Chua TSJ, Pek PP, Li H. Nationwide Improvement of Door-to-Balloon Times in Patients With Acute ST-Segment Elevation Myocardial Infarction Requiring Primary Percutaneous Coronary Intervention With Out-of-Hospital 12-Lead ECG Recording and Transmission. Ann Emerg Med 2013; 61:339-47. [DOI: 10.1016/j.annemergmed.2012.08.020] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2012] [Revised: 07/25/2012] [Accepted: 08/06/2012] [Indexed: 10/27/2022]
|
85
|
Fosbøl EL, Granger CB, Peterson ED, Lin L, Lytle BL, Shofer FS, Lohmeier C, Mears GD, Garvey JL, Corbett CC, Jollis JG, Glickman SW. Prehospital system delay in ST-segment elevation myocardial infarction care: a novel linkage of emergency medicine services and in hospital registry data. Am Heart J 2013; 165:363-70. [PMID: 23453105 DOI: 10.1016/j.ahj.2012.11.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2012] [Accepted: 11/24/2012] [Indexed: 11/19/2022]
Abstract
BACKGROUND Emergency medical services (EMS) are critical in the treatment of ST-segment elevation myocardial infarction (STEMI). Prehospital system delays are an important target for improving timely STEMI care, yet few limited data are available. METHODS Using a deterministic approach, we merged EMS data from the North Carolina Pre-hospital Medical Information System (PreMIS) with data from the Reperfusion of Acute Myocardial Infarction in Carolina Emergency Departments-Emergency Response (RACE-ER) Project. Our sample included all patients with STEMI from June 2008 to October 2010 who arrived by EMS and who had primary percutaneous coronary intervention (PCI). Prehospital system delays were compared using both RACE-ER and PreMIS to examine agreement between the 2 data sources. RESULTS Overall, 8,680 patients with STEMI in RACE-ER arrived at a PCI hospital by EMS; 21 RACE-ER hospitals and 178 corresponding EMS agencies across the state were represented. Of these, 6,010 (69%) patients were successfully linked with PreMIS. Linked and notlinked patients were similar. Overall, 2,696 patients were treated with PCI only and were taken directly to a PCI-capable hospital by EMS; 1,750 were transferred from a non-PCI facility. For those being transported directly to a PCI center, 53% reached the 90-minute target guideline goal. For those transferred from a non-PCI facility, 24% reached the 120-minute target goal for primary PCI. CONCLUSIONS We successfully linked prehospital EMS data with in hospital clinical data. With this linked STEMI cohort, less than half of patients reach goals set by guidelines. Such a data source could be used for future research and quality improvement interventions.
Collapse
Affiliation(s)
- Emil L Fosbøl
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
86
|
Steg G, James SK, Atar D, Badano LP, Blomstrom Lundqvist C, A. Borger M, di Mario C, Dickstein K, Ducrocq G, Fernández-Avilés F, H. Gershlick A, Giannuzzi P, Halvorsen S, Huber K, Juni P, Kastrati A, Knuuti J, J. Lenzen M, W. Mahaffey K, Valgimigli M, van’t Hof A, Widimsky P, Zahger D, J. Bax J, Baumgartner H, Ceconi C, Dean V, Deaton C, Fagard R, Funck-Brentano C, Hasdai D, Hoes A, Kirchhof P, Knuuti J, Kolh P, McDonagh T, Moulin C, Popescu BA, Reiner Z, Sechtem U, Sirnes PA, Tendera M, Torbicki A, Vahanian A, Windecker S, Astin F, Astrom-Olsson K, Budaj A, Clemmensen P, Collet JP, Fox KA, Fuat A, Gustiene O, Hamm CW, Kala P, Lancellotti P, Pietro Maggioni A, Merkely B, Neumann FJ, Piepoli MF, Werf FVD, Verheugt F, Wallentin L. Guía de práctica clínica de la ESC para el manejo del infarto agudo de miocardio en pacientes con elevación del segmento ST. Rev Esp Cardiol 2013. [DOI: 10.1016/j.recesp.2012.10.014] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
|
87
|
Le May MR, Wells GA, So DY, Glover CA, Froeschl M, Maloney J, Dionne R, Marquis JF, O'Brien ER, Dick A, Sherrard HL, Trickett J, Poirier P, Blondeau M, Bernick J, Labinaz M. Reduction in mortality as a result of direct transport from the field to a receiving center for primary percutaneous coronary intervention. J Am Coll Cardiol 2012; 60:1223-30. [PMID: 23017532 DOI: 10.1016/j.jacc.2012.07.008] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2012] [Revised: 06/21/2012] [Accepted: 07/03/2012] [Indexed: 11/16/2022]
Abstract
OBJECTIVES This study sought to determine whether mortality complicating ST-segment elevation myocardial infarction (STEMI) was impacted by the design of transport systems. BACKGROUND It is recommended that regions develop systems to facilitate rapid transfer of STEMI patients to centers equipped to perform primary percutaneous coronary intervention (PCI), yet the impact on mortality from the design of such systems remains unknown. METHODS Within the framework of a citywide system where all STEMI patients are referred for primary PCI, we compared patients referred directly from the field to a PCI center to patients transported beforehand from the field to a non-PCI-capable hospital. The primary outcome was all-cause mortality at 180 days. RESULTS A total of 1,389 consecutive patients with STEMI were assessed by the emergency medical services (EMS) and referred for primary PCI: 822 (59.2%) were referred directly from the field to a PCI center, and 567 (40.8%) were transported to a non-PCI-capable hospital first. Death at 180 days occurred in 5.0% of patients transferred directly from the field, and in 11.5% of patients transported from the field to a non-PCI-capable hospital (p < 0.0001. After adjusting for baseline characteristics in a multivariable logistic regression model, mortality remained lower among patients referred directly from the field to the PCI center (odds ratio: 0.52, 95% confidence interval: 0.31 to 0.88, p = 0.01). Similar results were obtained by using propensity score methods for adjustment. CONCLUSIONS A STEMI system allowing EMS to transport patients directly to a primary PCI center was associated with a significant reduction in mortality. Our results support the concept of STEMI systems that include pre-hospital referral by EMS.
Collapse
Affiliation(s)
- Michel R Le May
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
88
|
O'Gara PT, Kushner FG, Ascheim DD, Casey DE, Chung MK, de Lemos JA, Ettinger SM, Fang JC, Fesmire FM, Franklin BA, Granger CB, Krumholz HM, Linderbaum JA, Morrow DA, Newby LK, Ornato JP, Ou N, Radford MJ, Tamis-Holland JE, Tommaso CL, Tracy CM, Woo YJ, Zhao DX. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2012; 61:485-510. [PMID: 23256913 DOI: 10.1016/j.jacc.2012.11.018] [Citation(s) in RCA: 462] [Impact Index Per Article: 38.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
89
|
O'Gara PT, Kushner FG, Ascheim DD, Casey DE, Chung MK, de Lemos JA, Ettinger SM, Fang JC, Fesmire FM, Franklin BA, Granger CB, Krumholz HM, Linderbaum JA, Morrow DA, Newby LK, Ornato JP, Ou N, Radford MJ, Tamis-Holland JE, Tommaso CL, Tracy CM, Woo YJ, Zhao DX, Anderson JL, Jacobs AK, Halperin JL, Albert NM, Brindis RG, Creager MA, DeMets D, Guyton RA, Hochman JS, Kovacs RJ, Kushner FG, Ohman EM, Stevenson WG, Yancy CW. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2012; 127:e362-425. [PMID: 23247304 DOI: 10.1161/cir.0b013e3182742cf6] [Citation(s) in RCA: 1071] [Impact Index Per Article: 89.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
|
90
|
O'Gara PT, Kushner FG, Ascheim DD, Casey DE, Chung MK, de Lemos JA, Ettinger SM, Fang JC, Fesmire FM, Franklin BA, Granger CB, Krumholz HM, Linderbaum JA, Morrow DA, Newby LK, Ornato JP, Ou N, Radford MJ, Tamis-Holland JE, Tommaso CL, Tracy CM, Woo YJ, Zhao DX, Anderson JL, Jacobs AK, Halperin JL, Albert NM, Brindis RG, Creager MA, DeMets D, Guyton RA, Hochman JS, Kovacs RJ, Kushner FG, Ohman EM, Stevenson WG, Yancy CW. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2012; 127:529-55. [PMID: 23247304 DOI: 10.1161/cir.0b013e3182742c84] [Citation(s) in RCA: 1818] [Impact Index Per Article: 151.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
|
91
|
O'Gara PT, Kushner FG, Ascheim DD, Casey DE, Chung MK, de Lemos JA, Ettinger SM, Fang JC, Fesmire FM, Franklin BA, Granger CB, Krumholz HM, Linderbaum JA, Morrow DA, Newby LK, Ornato JP, Ou N, Radford MJ, Tamis-Holland JE, Tommaso CL, Tracy CM, Woo YJ, Zhao DX. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2012; 61:e78-e140. [PMID: 23256914 DOI: 10.1016/j.jacc.2012.11.019] [Citation(s) in RCA: 2191] [Impact Index Per Article: 182.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
|
92
|
Horvath SA, Xu K, Nwanyanwu F, Chan R, Correa L, Nass N, Jaraki AR, Jurkovich D, Kennedy R, Andrzejewski L, Vignola PA, Cubeddu RJ. Impact of the prehospital activation strategy in patients with ST-elevation myocardial infarction undergoing primary percutaneous revascularization: a single center community hospital experience. Crit Pathw Cardiol 2012; 11:186-192. [PMID: 23149360 DOI: 10.1097/hpc.0b013e3182647df7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
The strategy of prehospital activation by the emergency medical system (EMS) in patients with ST-elevation myocardial infarction (STEMI) has been poorly adopted among the US hospitals that currently offer 24/7 primary percutaneous coronary intervention. In this study, we report a single center experience after the implementation of this strategy. From 2008 to 2011, we identified a total 188 STEMI patients (age 65 ± 15 years) presenting via EMS for primary percutaneous coronary intervention. Of these, 112 (59.6%) underwent prehospital activation (EMS group), whereas the remaining 76 (40.4%) underwent emergency department activation [emergency department (ED) group]. Baseline demographic characteristics were similar between both groups. The overall median door-to-balloon (DTB) time was 49 ± 14 minutes. Patients undergoing prehospital activation had on average significantly lower overall DTB times (EMS 44 ± 11 minutes vs. ED 57 ± 15 minutes; P < 0.001). Concordantly, DTB times <60 minutes were much more commonly achieved with this strategy (EMS 95.5% vs. ED 64.5%; P < 0.001). Fallouts beyond the recommended 90-minute DTB time were seen among ED patients only. No difference in in-hospital death (EMS 5.4% vs. ED 6.6%; P = 0.75) or cumulative 30-day mortality (EMS 6.3% vs. ED 7.9%; P = 0.68) was observed between both groups. However, on average, EMS patients had higher postinfarct left ventricular ejection fraction (EMS 48 ± 9.5% vs. ED 39 ± 14.6%; P = 0.004). Differences in DTB time and left ventricular ejection fraction remained significant after adjusting for differences in baseline characteristics. In conclusion, the prehospital activation strategy is largely effective and should be systematically adopted in the treatment scheme of STEMI patients to lower mechanical reperfusion times and reduce the potential for untoward clinical outcomes.
Collapse
Affiliation(s)
- Sofia A Horvath
- Department of Medicine, Division of Cardiology, Aventura Hospital and Medical Center, Miami, FL, USA
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
93
|
Improved Survival Associated With Pre-Hospital Triage Strategy in a Large Regional ST-Segment Elevation Myocardial Infarction Program. JACC Cardiovasc Interv 2012; 5:1239-46. [DOI: 10.1016/j.jcin.2012.07.013] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2012] [Revised: 07/12/2012] [Accepted: 07/19/2012] [Indexed: 12/26/2022]
|
94
|
Bagai A, Granger CB. Regionalization of ST-segment elevation myocardial infarction care: a task unfinished. Am Heart J 2012; 164:633-5. [PMID: 23137491 DOI: 10.1016/j.ahj.2012.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2012] [Accepted: 08/14/2012] [Indexed: 11/25/2022]
|
95
|
Forsyth CJ, Pathak EB, Strom JA. De Facto regionalization of care for ST-elevation myocardial infarction in Florida, 2001-2009. Am Heart J 2012; 164:681-8. [PMID: 23137498 DOI: 10.1016/j.ahj.2012.06.027] [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: 09/08/2011] [Accepted: 06/22/2012] [Indexed: 11/18/2022]
Abstract
ACC/AHA guidelines recommend STEMI patients receive percutaneous coronary intervention (PCI) at high volume hospitals performing ≥400 procedures/year. The objective of this study was to evaluate changes in the organization and implementation of care for STEMI patients in Florida. We assessed trends and predictors of STEMI patients first hospitalized at high PCI volume hospitals in Florida from 2001-2009. This is the first study to examine statewide trends in hospital admission for all STEMI patients. We classified Florida hospitals by PCI volume (high, medium, low, non-PCI) for each quarter from January, 2001 through June, 2009. Using hospital discharge data, we determined the percent of STEMI patients who went to each type of hospital and analyzed multiple predictors. From 2001-2009 the proportion of STEMI patients first hospitalized at high PCI volume hospitals rose from 62.4 to 89.7%, while admissions to non-PCI hospitals declined from 31% to 4.9%. Persistent barriers to high PCI volume hospital admission were age ≥85 years (OR 0.56, 95% CI 0.50-0.62), female gender (OR 0.85, 95% CI 0.79-0.91), and residence in a major metropolitan county. Through the efforts of local coalitions throughout Florida, by 2009 almost 90% of Florida STEMI patients were first admitted to high PCI volume hospitals. Greater hospital competition may explain lower admission rates to high PCI volume hospitals in major metropolitan counties. The age and gender disadvantage we observed requires further research to determine potential causes.
Collapse
Affiliation(s)
- Colin J Forsyth
- Department of Epidemiology and Biostatistics, College of Public Health, University of South Florida, Tampa, FL 33612, USA.
| | | | | |
Collapse
|
96
|
"Register and Roll": A Novel Initiative to Improve First Door-to-Balloon Time in ST Elevation Myocardial Infarction. Cardiol Res Pract 2012; 2012:616940. [PMID: 23094193 PMCID: PMC3472551 DOI: 10.1155/2012/616940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2012] [Accepted: 09/06/2012] [Indexed: 11/17/2022] Open
Abstract
Objective. We examined the cause of transfer delay in patients with an acute ST-segment myocardial infarction (STEMI) from non percutaneous coronary intervention (PCI) capable to PCI capable hospitals. We then implemented a novel, simple, and reliable initiative to improve the transfer process. Background. Guidelines established by the ACC/AHA call for door-to-balloon times of ≤90 minutes for patients with STEMI. When hospital transfer is necessary, this is only met in 8.6% of cases. Methods. All patients presenting with STEMI to a non-PCI capable hospital from April 2006 to February 2009 were analyzed retrospectively. After identifying causes of transfer delay the “Register and Roll” initiative was developed. An analysis of effect was conducted from March 2009 to July 2011. Results. 144 patients were included, 74 pre-initiative and 70 post- initiative. Time to EMS activation was a major delay in patient transfer. After implementation, the EMS activation time has significantly decreased and time to reperfusion approaches recommended goal (Median 114 min versus 90 min, P < 0.001), with 55% in <90 minutes. Conclusion. “Register and Roll” streamlines the triage process and improves hospital transfer times. This initiative is easily instituted and reliable in a community hospital setting where resources are limited.
Collapse
|
97
|
Bhalla MC, Mencl F, Gist MA, Wilber S, Zalewski J. Prehospital Electrocardiographic Computer Identification of ST-segment Elevation Myocardial Infarction. PREHOSP EMERG CARE 2012; 17:211-6. [DOI: 10.3109/10903127.2012.722176] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Mary Colleen Bhalla
- From the Department of Emergency Medicine, Summa Health System (MCB, MAG),
Akron, Ohio; and Summa Akron City Hospital (FM, SW, JZ), Akron, Ohio
| | - Francis Mencl
- From the Department of Emergency Medicine, Summa Health System (MCB, MAG),
Akron, Ohio; and Summa Akron City Hospital (FM, SW, JZ), Akron, Ohio
| | - Mikki Amber Gist
- From the Department of Emergency Medicine, Summa Health System (MCB, MAG),
Akron, Ohio; and Summa Akron City Hospital (FM, SW, JZ), Akron, Ohio
| | - Scott Wilber
- From the Department of Emergency Medicine, Summa Health System (MCB, MAG),
Akron, Ohio; and Summa Akron City Hospital (FM, SW, JZ), Akron, Ohio
| | - Jon Zalewski
- From the Department of Emergency Medicine, Summa Health System (MCB, MAG),
Akron, Ohio; and Summa Akron City Hospital (FM, SW, JZ), Akron, Ohio
| |
Collapse
|
98
|
Nfor T, Kostopoulos L, Hashim H, Jan MF, Gupta A, Bajwa T, Allaqaband S. Identifying False-positive ST-elevation Myocardial Infarction in Emergency Department Patients. J Emerg Med 2012; 43:561-7. [DOI: 10.1016/j.jemermed.2011.09.027] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2011] [Revised: 05/16/2011] [Accepted: 09/28/2011] [Indexed: 01/09/2023]
|
99
|
Rodríguez-Vilá O, Campos-Esteve MA. Setting Up a Population-Based Program to Optimize ST-Segment Elevation Myocardial Infarction Care. Interv Cardiol Clin 2012; 1:583-597. [PMID: 28581971 DOI: 10.1016/j.iccl.2012.06.009] [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: 11/17/2022]
Abstract
The development of ST-segment elevation myocardial infarction (STEMI) systems of care at the city, region, or nation levels has not only improved the speed of reperfusion but also enhanced the reach of primary angioplasty to areas far from percutaneous coronary intervention (PCI) centers. Setting up a STEMI system of care is a sophisticated process that requires a solid PCI hospital and emergency medical services infrastructure, disciplined collaboration, and a focus on outcomes measurement and continuous quality improvement. This article reviews the accumulated evidence supporting the development of STEMI systems of care and offers practical insights into this process.
Collapse
Affiliation(s)
- Orlando Rodríguez-Vilá
- Cardiac Catheterization Laboratories, Cardiology Section, VA Caribbean Healthcare System, 10 Casia Street, San Juan 00921, Puerto Rico; Cardiac Catheterization Laboratories, Auxilio Mutuo Hospital, 735 Ponce de Leon, Suite 503, Torre Medical Auxilio Mutuo, Hato Rey 00917, Puerto Rico.
| | - Miguel A Campos-Esteve
- Cardiac Catheterization Laboratories, Pavia Hospital, 1462 Asia Street, Santurce 00909, Puerto Rico
| |
Collapse
|
100
|
Steg PG, James SK, Atar D, Badano LP, Blömstrom-Lundqvist C, Borger MA, Di Mario C, Dickstein K, Ducrocq G, Fernandez-Aviles F, Gershlick AH, Giannuzzi P, Halvorsen S, Huber K, Juni P, Kastrati A, Knuuti J, Lenzen MJ, Mahaffey KW, Valgimigli M, van 't Hof A, Widimsky P, Zahger D. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J 2012; 33:2569-619. [PMID: 22922416 DOI: 10.1093/eurheartj/ehs215] [Citation(s) in RCA: 3661] [Impact Index Per Article: 305.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
-
- AP-HP, Hôpital Bichat / Univ Paris Diderot, Sorbonne Paris-Cité / INSERM U-698, Paris, France.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|