Effect of a community intervention on patient delay and emergency medical service use in acute coronary heart disease: The Rapid Early Action for Coronary Treatment (REACT) Trial

Utilization of emergency medical services by patients with acute coronary syndromes in the Arab Gulf States

BACKGROUND

Emergency Medical Services (EMS) play a central role in caring for patients with acute coronary syndromes (ACS). To date, no data exist on utilization of EMS systems in the Arab Gulf States.

OBJECTIVE

To examine EMS use by patients with ACS in the Gulf Registry of Acute Coronary Events (Gulf RACE).

METHODS

Gulf RACE was a prospective, multinational study conducted in 2007 of all patients hospitalized with ACS in 65 centers in six Arab countries. Data were analyzed based on mode of presentation (EMS vs. other).

RESULTS

Of 7859 patients hospitalized with ACS through the emergency department (ED), only 1336 (17%) used EMS, with wide variation among countries (2% in Yemen to 37% in Oman). Younger age (odds ratio [OR] 1.09; 95% confidence interval [CI] 1.03-1.15 per 10-year decrement), presence of chest pain (OR 1.73; 95% CI 1.48-2.03), prior myocardial infarction (OR 1.58; 95% CI 1.34-1.86), prior percutaneous coronary intervention (OR 1.27; 95% CI 1.02-1.59), family history of premature coronary disease (OR 1.25; 95% CI 1.09-1.51), and current smoking (OR 1.30; 95% CI 1.13-1.50) were independently associated with not utilizing EMS. Patients with ST-segment elevation myocardial infarction/left bundle branch block myocardial infarction who were transported by EMS were significantly less likely to exhibit major delay in presentation, and were significantly more likely to receive favorable processes of care, including shorter door-to-electrocardiogram time, more frequent coronary reperfusion therapy, and thrombolytic therapy within 30 min of arrival at the ED.

CONCLUSION

Despite current recommendations, fewer than 1 in 5 patients with ACS use EMS in the Arab Gulf States, highlighting a significant opportunity for improvement. Factors causing this underutilization deserve further investigation.

Constrained physical therapist practice: an ethical case analysis of recommending discharge placement from the acute care setting

BACKGROUND AND PURPOSE

Constrained practice is routinely encountered by physical therapists and may limit the physical therapist's primary moral responsibility-which is to help the patient to become well again. Ethical practice under such conditions requires a certain moral character of the practitioner. The purposes of this article are: (1) to provide an ethical analysis of a typical patient case of constrained clinical practice, (2) to discuss the moral implications of constrained clinical practice, and (3) to identify key moral principles and virtues fostering ethical physical therapist practice.

CASE

The case represents a common scenario of discharge planning in acute care health facilities in the northeastern United States.

METHODS

An applied ethics approach was used for case analysis.

RESULTS

The decision following analysis of the dilemma was to provide the needed care to the patient as required by compassion, professional ethical standards, and organizational mission.

DISCUSSION AND CONCLUSION

Constrained clinical practice creates a moral dilemma for physical therapists. Being responsive to the patient's needs moves the physical therapist's practice toward the professional ideal of helping vulnerable patients become well again. Meeting the patient's needs is a professional requirement of the physical therapist as moral agent. Acting otherwise requires an alternative position be ethically justified based on systematic analysis of a particular case. Skepticism of status quo practices is required to modify conventional individual, organizational, and societal practices toward meeting the patient's best interest.

Gender-specific characteristics of individuals with depressive symptoms and coronary heart disease

OBJECTIVE

In individuals with depressive symptoms and coronary heart disease (CHD), little is known about gender-specific characteristics that may inform treatments and outcomes. This study sought to identify characteristics that distinguish men from women with both conditions.

METHODS

By cross-sectional design, 1951 adults with CHD and elevated depressive symptoms completed questionnaires to measure anxiety, hostility, perceived control, and knowledge, attitudes, and beliefs about CHD. Gender differences were evaluated by multivariable logistic regression.

RESULTS

Women were more likely to be single (odds ratio [OR] 3.61, P < .001), to be unemployed (OR 2.52, P < .001), to be poorly educated (OR 2.52, P < .001), to be anxious (OR 1.14, P < .01), and to perceive lower control over health (OR 1.34, P < .01) than men.

CONCLUSION

Women with CHD and depressive symptoms have fewer resources, greater anxiety, and lower perceived control than men. In women, targeting modifiable factors, such as anxiety and perceived control, is warranted.

Health care insurance, financial concerns in accessing care, and delays to hospital presentation in acute myocardial infarction

CONTEXT

Little is known about how health insurance status affects decisions to seek care during emergency medical conditions such as acute myocardial infarction (AMI).

OBJECTIVE

To examine the association between lack of health insurance and financial concerns about accessing care among those with health insurance, and the time from symptom onset to hospital presentation (prehospital delays) during AMI.

DESIGN, SETTING, AND PATIENTS

Multicenter, prospective study using a registry of 3721 AMI patients enrolled between April 11, 2005, and December 31, 2008, at 24 US hospitals. Health insurance status was categorized as insured without financial concerns, insured but have financial concerns about accessing care, and uninsured. Insurance information was determined from medical records while financial concerns among those with health insurance were determined from structured interviews.

MAIN OUTCOME MEASURE

Prehospital delay times (< or = 2 hours, > 2-6 hours, or > 6 hours), adjusted for demographic, clinical, and social and psychological factors using hierarchical ordinal regression models.

RESULTS

Of 3721 patients, 2294 were insured without financial concerns (61.7%), 689 were insured but had financial concerns about accessing care (18.5%), and 738 were uninsured (19.8%). Uninsured and insured patients with financial concerns were more likely to delay seeking care during AMI and had prehospital delays of greater than 6 hours among 48.6% of uninsured patients and 44.6% of insured patients with financial concerns compared with only 39.3% of insured patients without financial concerns. Prehospital delays of less than 2 hours during AMI occurred among 36.6% of those insured without financial concerns compared with 33.5% of insured patients with financial concerns and 27.5% of uninsured patients (P < .001). After adjusting for potential confounders, prehospital delays were associated with insured patients with financial concerns (adjusted odds ratio, 1.21 [95% confidence interval, 1.05-1.41]; P = .01) and with uninsured patients (adjusted odds ratio, 1.38 [95% confidence interval, 1.17-1.63]; P < .001).

CONCLUSION

Lack of health insurance and financial concerns about accessing care among those with health insurance were each associated with delays in seeking emergency care for AMI.

Delay to reperfusion in patients with acute myocardial infarction presenting to acute care hospitals: an international perspective

AIMS

To examine the extent of delay from initial hospital presentation to fibrinolytic therapy or primary percutaneous coronary intervention (PCI), characteristics associated with prolonged delay, and changes in delay patterns over time in patients with ST-segment elevation myocardial infarction (STEMI).

METHODS AND RESULTS

We analysed data from 5170 patients with STEMI enrolled in the Global Registry of Acute Coronary Events from 2003 to 2007. The median elapsed time from first hospital presentation to initiation of fibrinolysis was 30 min (interquartile range 18-60) and to primary PCI was 86 min (interquartile range 53-135). Over the years under study, there were no significant changes in delay times to treatment with either strategy. Geographic region was the strongest predictor of delay to initiation of fibrinolysis >30 min. Patient's transfer status and geographic location were strongly associated with delay to primary PCI. Patients treated in Europe were least likely to experience delay to fibrinolysis or primary PCI.

CONCLUSION

These data suggest no improvements in delay times from hospital presentation to initiation of fibrinolysis or primary PCI during our study period. Geographic location and patient transfer were the strongest predictors of prolonged delay time, suggesting that improvements in modifiable healthcare system factors can shorten delay to reperfusion therapy even further.

Time to treatment for acute coronary syndromes: the cost of indecision

BACKGROUND AND RESEARCH OBJECTIVES

: Multiple sociodemographic and environmental factors have been associated with urgent treatment-seeking behaviors for patients experiencing acute coronary syndromes (ACSs). However, variables that directly affect the decision to seek care in the emergency department (ED) have been less well defined. The objective of this study was to explore the factors associated with a decision to seek care for symptoms of ACSs and to describe patient characteristics associated with time to presentation.

SUBJECTS AND METHODS

: A cross-sectional, descriptive design was used. The nonprobability sample included 256 patients admitted to the hospital with ACSs. The study was conducted on cardiac step-down units at 2 large urban medical centers. Reasons for seeking care were elicited during structured interviews in the patient's room. These factors and other patient characteristics were treated as predictor variables in an analysis of time from symptom onset to arrival in the ED.

RESULTS AND CONCLUSIONS

: Five categories of decision making were identified through descriptive content analyses and were labeled new onset of chest pain, ongoing evaluation of symptom severity, symptoms other than chest pain that worsened or were unrelieved, externally motivated, and internally motivated. Median time from symptom onset to arrival in the ED was 9.5 hours for women and 6 hours for men. Patients who experienced constant pain (hazard ratio, 1.44; P =.01) and those with ST-segment elevation myocardial infarction (hazard ratio, 1.59; P = .004) sought treatment significantly sooner than patients with intermittent pain. Older patients sought treatment later (hazard ratio, 0.99; P = .02). Patients who are older and experience intermittent pain should be encouraged to seek emergent treatment for symptoms that may represent ACSs. New evidence of patients' decision-making processes and dangerous delay in time to treatment provides knowledge needed to counsel patients about the benefits of seeking care quickly when symptoms begin.

Apyrase treatment of myocardial infarction according to a clinically applicable protocol fails to reduce myocardial injury in a porcine model

Background

Ectonucleotidase dependent adenosine generation has been implicated in preconditioning related cardioprotection against ischemia-reperfusion injury, and treatment with a soluble ectonucleotidase has been shown to reduce myocardial infarct size (IS) when applied prior to induction of ischemia. However, ectonucleotidase treatment according to a clinically applicable protocol, with administration only after induction of ischemia, has not previously been evaluated. We therefore investigated if treatment with the ectonucleotidase apyrase, according to a clinically applicable protocol, would reduce IS and microvascular obstruction (MO) in a large animal model.

Methods

A percutaneous coronary intervention balloon was inflated in the left anterior descending artery for 40 min, in 16 anesthetized pigs (40-50 kg). The pigs were randomized to 40 min of 1 ml/min intracoronary infusion of apyrase (10 U/ml, n = 8) or saline (0.9 mg/ml, n = 8), twenty minutes after balloon inflation. Area at risk (AAR) was evaluated by ex vivo SPECT. IS and MO were evaluated by ex vivo MRI.

Results

No differences were observed between the apyrase group and saline group with respect to IS/AAR (75.7 ± 4.2% vs 69.4 ± 5.0%, p = NS) or MO (10.7 ± 4.8% vs 11.4 ± 4.8%, p = NS), but apyrase prolonged the post-ischemic reactive hyperemia.

Conclusion

Apyrase treatment according to a clinically applicable protocol, with administration of apyrase after induction of ischemia, does not reduce myocardial infarct size or microvascular obstruction.

Act in time to heart attack signs: update on the National Heart Attack Alert Program's campaign to reduce patient delay

Outcomes of reperfusion treatment for acute myocardial infarction (MI) can be dramatically enhanced if patients present early after symptom onset. Yet delayed presentation by patients with acute coronary syndrome (ACS) symptoms (including MI and unstable angina) remains a tenacious challenge. The "Act in Time to Heart Attack Signs" is a public education campaign sponsored by the National Heart, Lung, and Blood Institute's (NHLBI's) National Heart Attack Alert Program (NHAAP) that addresses early recognition and response to ACS symptoms by patients, providers, and the general public. The campaign's materials and messages are based on those used in a multicenter research program, the Rapid Early Action for Coronary Treatment (REACT), funded by the National Heart, Lung, and Blood Institute from 1994-1998. Materials are available for providers, patients, and the public discussing heart attack risk, common heart attack symptoms, the importance of seeking early care, common misconceptions about how heart attacks present, and the importance of accessing care by calling 9-1-1. There is a critical need for all healthcare providers to relay this lifesaving information to the patients seen in their practice settings.

A personal perspective: at the crossroads of heart attack care: designing an effective nationwide public education program to hasten patient hospital arrival

This report presents a field-tested approach to the greatest health care problem facing our country, the fact that two-thirds of the deaths from acute myocardial infarction occur before hospital admission. Scores of fundraising appearances for the Missouri Heart Association during the 1950s and 1960s throughout the 1,000,000 population rural/urban Southwest Missouri region gave an ideal setting for teaching the public the early symptoms of heart attack. Audiences were advised that if any of these appeared they should immediately call their doctor or quickly get to the nearest hospital emergency room. These presentations led to a steady increase in hospital admissions. The Missouri Heart Association responded by launching the Early Warning Signs of Heart Attack Public and Professional Education Program in July 1971, incorporating these messages in radio, TV, and newspaper Public Service Announcements. In less than 6 months, analysis of consecutive admissions to the cardiovascular intensive care unit of the base hospital showed that the median time from the onset of symptoms to starting to the hospital was reduced from 4 to 2.2 hours; 64% of those patients called their doctor as their first step in seeking help and 58% went to the hospital by car. This message content was carried through the 1980s and 1990s under other auspices. The methods of the successful Missouri program are contrasted with others that have failed, establishing essential features in designing a nationwide program effective in hastening acute myocardial infarction patient hospital arrival.

Age and sex differences in duration of prehospital delay in patients with acute myocardial infarction: a systematic review

BACKGROUND

Coronary heart disease is the leading cause of morbidity and mortality in American men and women. Although there have been dramatic changes in the management of patients hospitalized with acute myocardial infarction (AMI) over the past several decades, a considerable proportion of patients with AMI continue to delay seeking medical care in a timely manner. This review provides an overview of the published literature that has examined age and sex differences in extent of prehospital delay in patients hospitalized with AMI.

METHODS AND RESULTS

A systematic review of the literature from 1960 to 2008, including publications that provided data on duration of prehospital delay in patients hospitalized with AMI, was conducted. A total of 44 articles (42 studies) were included in the present analysis. The majority of studies showed that in patients hospitalized with AMI, women and older persons were more likely to arrive at the hospital later than men and younger persons. Several factors associated with duration of prehospital delay, including sociodemographic, medical history, clinical, and contextual characteristics differed according to sex.

CONCLUSIONS

The elderly and women were more likely to exhibit longer delays in seeking medical care after the development of symptoms suggestive of AMI compared with other groups. Further research is needed to more fully understand the reasons for delay in these vulnerable groups.

A randomized clinical trial to reduce patient prehospital delay to treatment in acute coronary syndrome

BACKGROUND

Delay from onset of acute coronary syndrome (ACS) symptoms to hospital admission continues to be prolonged. To date, community education campaigns on the topic have had disappointing results. Therefore, we conducted a clinical randomized trial to test whether an intervention tailored specifically for patients with ACS and delivered one-on-one would reduce prehospital delay time.

METHODS AND RESULTS

Participants (n=3522) with documented coronary heart disease were randomized to experimental (n=1777) or control (n=1745) groups. Experimental patients received education and counseling about ACS symptoms and actions required. Patients had a mean age of 67+/-11 years, and 68% were male. Over the 2 years of follow-up, 565 patients (16.0%) were admitted to an emergency department with ACS symptoms a total of 842 times. Neither median prehospital delay time (experimental, 2.20 versus control, 2.25 hours) nor emergency medical system use (experimental, 63.6% versus control, 66.9%) was different between groups, although experimental patients were more likely than control to call the emergency medical system if the symptoms occurred within the first 6 months following the intervention (P=0.036). Experimental patients were significantly more likely to take aspirin after symptom onset than control patients (experimental, 22.3% versus control, 10.1%, P=0.02). The intervention did not result in an increase in emergency department use (experimental, 14.6% versus control, 17.5%).

CONCLUSIONS

The education and counseling intervention did not lead to reduced prehospital delay or increased ambulance use. Reducing the time from onset of ACS symptoms to arrival at the hospital continues to be a significant public health challenge.

CLINICAL TRIAL REGISTRATION

clinicaltrials.gov. Identifier NCT00734760.

Use of emergency medical services in patients with acute myocardial infarction in China

BACKGROUND

Although guidelines strongly recommend use of the Emergency Medical Systems (EMS) by patients with acute myocardial infarction (AMI), it remains underutilized in western countries. Information about its current use in China is unclear. The objective of this study was to examine the use of the EMS by patients with AMI in China, and investigate factors affecting its use.

METHODS

A prospective survey study, which included 803 patients with AMI who were admitted to 21 hospitals in China between November 1, 2005 and December 31, 2006.

RESULTS

Only 39.5% of patients called up the EMS at the onset of symptoms (EMS group, n=317), whereas the rest presented to the hospital by some other means (self-transport group, n=486, 60.5%). Predictors of EMS users were older age, symptom onset at evening, unbearable symptoms, having received training and acquired knowledge on heart attack, as well as having a higher income and medical history of heart failure or stroke. Prehospital delay (median 110 min vs. 143 min, p<0.001), door to needle time (median 85 min vs. 93 min, p<0.005) and door-to-balloon time (median 118 min vs. 160 min, p<0.001) were significantly shorter in the EMS group. The early reperfusion rate was also significantly higher in the EMS group (84.8% vs. 78.2%, p=0.019), mainly because of a greater incidence of primary percutaneous coronary intervention (68.1% vs. 61.7%, p=0.046).

CONCLUSIONS

The emergency medical services are underutilized by patients with AMI in China. Use of the EMS may be advantageous in view of greater administration of reperfusion therapy. New public health strategies should be developed to facilitate greater use of the EMS for AMI.

Understanding Why Patients Delay Seeking Care for Acute Coronary Syndromes

Background— Better insight into the psychosocial factors associated with prehospital delays in seeking care for acute coronary syndromes is needed to inform the design of future interventions. Delay in presenting for care after the onset of symptoms is common, limits the potential benefit of acute reperfusion, and has not been reduced by interventions tested thus far.

Methods and Results— Seven hundred ninety-six patients with suspected ischemic heart disease scheduled for clinically indicated imaging stress tests completed questionnaires concerning psychological distress and attachment styles (worthiness to receive care, trustworthiness of others to provide care). The primary dependent variable for this study was response to a question from the rapid early action for coronary treatment trial concerning intention to “wait until very sure” before seeking care for a possible “heart attack.” Responses to this question were strongly associated with actual emergency department-reported and self-reported care delay in the rapid early action for coronary treatment trial. In multivariable ordinal regression models, a more negative view of the trustworthiness of others, greater physical limitations from angina, and no previous revascularization were independently associated with increased intention to wait to seek care for a myocardial infarction. Intention to wait was not associated with inducible ischemia or self-perceived risk of myocardial infarction.

Conclusions— Intention to delay seeking care for acute coronary syndromes is associated with a patient’s view of the trustworthiness of others, previous experience with revascularization, and functional limitations, even after adjustment for objective and perceived acute coronary syndromes risk. These findings provide insight into novel factors contributing to longer delay times and may inform future interventions to reduce delay time.

Prehospital Delay in Patients With Acute Coronary Syndromes (from the Global Registry of Acute Coronary Events [GRACE])

Duration of delay in seeking medical care in persons with symptoms of evolving acute myocardial infarction (AMI) is of current interest given the time-dependent benefits associated with early use of coronary reperfusion approaches. The objectives of this multinational study were to describe geographic variation in the extent of and factors associated with prehospital delay in patients enrolled in the GRACE study. Data were collected from 44,695 patients hospitalized with an acute coronary syndrome in 14 countries from 2000 to 2006. The regions under study included Argentina and Brazil (n = 8,203), United States/Canada (n = 12,810), Europe (n = 19,354), and Australia/New Zealand (n = 4,328). Patients with ST-segment elevation AMI, non-ST-segment elevation AMI, and unstable angina comprised the study population. There were marked geographic differences in extent of prehospital delay in patients with ST-segment elevation AMI and those with non-ST-segment elevation AMI/unstable angina. In patients with ST-segment elevation AMI, the shortest duration of prehospital delay was observed in patients from Australia/New Zealand (median 2.2 hours), whereas patients from Argentina and Brazil delayed the longest (median 4.0 hours). Median duration of prehospital delay was shortest (2.5 hours) in patients with ST-segment elevation AMI, whereas patients with non-ST-segment elevation AMI/unstable angina showed considerably longer prehospital delay (3.1 hours). Several demographic and clinical characteristics were associated with prolonged delay overall and in the different geographic locations under study. In conclusion, results of this large multinational registry provided insights into contemporary patterns of care-seeking behavior in patients with acute coronary disease.

The effect of a short one-on-one nursing intervention on knowledge, attitudes and beliefs related to response to acute coronary syndrome in people with coronary heart disease: a randomized controlled trial

BACKGROUND

Coronary heart disease (CHD) and acute coronary syndrome (ACS) remain significant public health problems. The effect of ACS on mortality and morbidity is largely dependent on the time from symptom onset to the time of reperfusion, but patient delay in presenting for treatment is the main reason timely reperfusion is not received.

OBJECTIVES

We tested the effect of an education and counseling intervention on knowledge, attitudes and beliefs about ACS symptoms and the appropriate response to symptoms, and identified patient characteristics associated with changes in knowledge, attitudes and beliefs over time.

METHODS

We conducted a two-group randomized controlled trial in 3522 people with CHD. The intervention group received a 40 min, one-on-one education and counseling session. The control group received usual care. Knowledge, attitudes and beliefs were measured at baseline, 3 and 12 months using the ACS Response Index and analyzed with repeated measures analysis of variance.

RESULTS

Knowledge, attitudes and beliefs scores increased significantly from baseline in the intervention group compared to the control group at 3 months, and these differences were sustained at 12 months (p=.0005 for all). Higher perceived control over cardiac illness was associated with more positive attitudes (p<.0005) and higher state anxiety was associated with lower levels of knowledge (p<.05), attitudes (p<.05) and beliefs (p<.0005).

CONCLUSION

A relatively short education and counseling intervention increased knowledge, attitudes and beliefs about ACS and response to ACS symptoms in individuals with CHD. Higher perceived control over cardiac illness was associated with more positive attitudes and higher state anxiety was associated with lower levels of knowledge, attitudes and beliefs about responding to the health threat of possible ACS.

Declining severity of myocardial infarction from 1987 to 2002: the Atherosclerosis Risk in Communities (ARIC) Study

BACKGROUND

Death rates for coronary heart disease have been declining in the United States, but the reasons for this decline are not clear. One factor that could contribute to this decline is a reduction in the severity of acute myocardial infarction (MI). We hypothesized that for those patients hospitalized in the Atherosclerosis Risk in Communities (ARIC) Study with acute incident MI, there was a decline in MI severity from 1987 to 2002.

METHODS AND RESULTS

The community surveillance component of the ARIC Study consisted of tracking residents 35 to 74 years of age with hospitalized MI or fatal coronary heart disease in 4 diverse communities. For incident, hospitalized MI, a probability sample of hospital discharges was validated and an MI classification was assigned according to an algorithm consisting of chest pain, ECG evidence, and cardiac biomarkers. Severity indicators were chosen from abstracted hospital charts validated as a definite or probable MI. With few exceptions, the MI severity indicators suggested a significant decline in the severity of MI during the period of 1987 to 2002. The percent of MI cases with major ECG abnormalities decreased as evidenced by a 1.9%/y (P=0.002) decline in the proportion of those with initial ST-segment elevation, a 3.9%/y (P<0.001) decline in those with subsequent Q-waves, and a 4.5%/y (P<0.001) decline in those with any major Q wave. Maximum creatine kinase and creatine kinase-MB values declined (5.2% and 7.6%; P<0.001, P<0.001 per year, respectively), although in the later years, maximum troponin I values remained stable (1.1%/y decline; P=0.66). The percent with shock declined (5.7%/y; P<0.001), although those with congestive heart failure remained stable. A combined severity score, the Predicting Risk of Death in Cardiac Disease Tool (PREDICT) score, also declined (0.2%/y; P<0.001). Results for blacks paralleled those of the entire group, as did results for women.

CONCLUSIONS

Evidence from ARIC community surveillance suggests that the severity of acute MI has declined among community residents hospitalized for incident MI. This reduction in severity may have contributed, along with other factors, to the decline in death rates for coronary heart disease.

The comparative effectiveness of heart disease prevention and treatment strategies

BACKGROUND

Policymakers must be able to calculate the comparative effectiveness of interventions to control heart disease if they are to optimize the population impact of programmatic initiatives.

METHODS

A model was created to calculate the number of deaths that would be prevented or postponed if perfect care for heart disease prevention and treatment were achieved--that is, the elimination of risk factors and the prescription of all effective medications before and between acute events, and the delivery of all effective therapies to individuals suffering an acute heart disease event. The impact of perfect care was calculated for a hypothetic population aged 30-84 years with risk-factor levels, event rates, current patterns of behavior, levels of treatment, and mortality rates resembling those of the U.S. The analysis was performed in 2007 and 2008.

RESULTS

In this population, 44% of all deaths were due to heart disease. Perfect care before the first heart disease event would prevent or postpone 33% of all deaths. Perfect care between acute events would prevent or postpone 23% of all deaths. Perfect care during acute events would prevent or postpone 8% of all deaths.

CONCLUSIONS

This direct comparison of heart disease prevention and treatment strategies indicates that nearly 90% of the impact from perfect care for heart disease would accrue from interventions before and between acute events. The impact of risk-factor interventions before or between events is amplified by the fact that these interventions also reduce the risk of death from other chronic diseases.

Trends in reperfusion strategies, door-to-needle and door-to-balloon times, and in-hospital mortality among patients with ST-segment elevation myocardial infarction enrolled in the National Registry of Myocardial Infarction from 1990 to 2006

BACKGROUND

Among patients with ST-segment elevation myocardial infarction (STEMI), rapid reperfusion is associated with improved mortality. As such, door-to-needle (D2N) and door-to-balloon (D2B) times have become metrics of quality of care and targets for intense quality improvement.

METHODS

The National Registry of Myocardial Infarction (NRMI) collected data regarding reperfusion therapy, its timing and in-hospital mortality among STEMI patients from 1990 through 2006.

RESULTS

Since 1990, NRMI has enrolled 1,374,232 STEMI patients at 2,157 hospitals. Among those, 774,279 (56.3%) were eligible for reperfusion upon arrival. The proportion receiving fibrinolytic therapy fell from 52.5% in 1990 to 27.6% in 2006 (P < .001), while the proportion undergoing primary percutaneous coronary intervention (pPCI) increased from 2.6% to 43.2%. Among reperfusion-eligible patients who received fibrinolytic therapy, there was a nearly linear decline in median D2N time from 59 minutes in 1990 to 29 minutes in 2006 (P < .001 for trend) as well as a decrease in mortality from 7.0% in 1994 to 6.0% in 2006 (P < .001). Among those undergoing pPCI, D2B time among nontransfer patients declined linearly from 111 minutes in 1994 to 79 minutes in 2006 (P < .001) with a decline in mortality from 8.6% to 3.1% (P < .001). The relative improvement in mortality attributable to improvements in D2N time was 16.3% and to D2B time was 7.5%.

CONCLUSIONS

Since 1990, there has been a progressive decline in D2N and D2B time among reperfusion-eligible STEMI patients. These improvements have contributed, at least in part, to a progressive decline in mortality.

Disparities in knowledge of heart attack and stroke symptoms among adult men: an analysis of behavioral risk factor surveillance survey data

CONTEXT

The staggering burden of myocardial infarction and stroke in men and for men of African-American descent in particular provided the impetus for this study. Morbidity and mortality from these vascular disorders can be reduced by early treatment, which requires correct prehospital identification of symptoms.

OBJECTIVE

The purpose of this study was to assess current knowledge of myocardial infarction and stroke symptoms and to examine if there were disparities in knowledge of these among U.S. males.

DESIGN

This is a cross-sectional study analyzing public use 2003-2005 Behavioral Risk Factor Surveillance Survey data. Univariate, bivariate and multivariate techniques were used.

SETTING

Random-digit-dial telephone survey focused on health risk factors and behaviors. Data collection was done under the direction of the Centers for Disease Control and Prevention.

PATIENTS OR OTHER PARTICIPANTS

Data collections targeted noninstitutionalized U.S. adults 18-90 years of age. This study focused on the adult male population.

MAIN OUTCOME MEASURES

From the 13 heart attack and stroke symptom knowledge questions asked on the survey, a heart attack and stroke knowledge score was computed for each respondent.

RESULTS

Multivariate analysis revealed that both Caucasian and African-American men earning low scores on the knowledge questions were more likely to: have less than a high-school education, have deferred medical care in the past 12 months because of cost and not have health insurance in the past 12 months. African-American men were also more likely to live in households with annual incomes < $35,000 and were more likely to not have a primary care provider; this was not true for Caucasian men.

CONCLUSIONS

There is a disparity in myocardial infarction and stroke symptom knowledge along racial and socioeconomic lines. African-American males, poorer individuals and those with lower levels of education had significantly lower scores. Since these subgroups are also among those at higher risk for stroke and myocardial infarction, targeting measures to enhance knowledge in these groups might yield more benefit than programs aimed at the general male populace.

Regional variation in out-of-hospital cardiac arrest incidence and outcome

CONTEXT

The health and policy implications of regional variation in incidence and outcome of out-of-hospital cardiac arrest remain to be determined.

OBJECTIVE

To evaluate whether cardiac arrest incidence and outcome differ across geographic regions.

DESIGN, SETTING, AND PATIENTS

Prospective observational study (the Resuscitation Outcomes Consortium) of all out-of-hospital cardiac arrests in 10 North American sites (8 US and 2 Canadian) from May 1, 2006, to April 30, 2007, followed up to hospital discharge, and including data available as of June 28, 2008. Cases (aged 0-108 years) were assessed by organized emergency medical services (EMS) personnel, did not have traumatic injury, and received attempts at external defibrillation or chest compressions or resuscitation was not attempted. Census data were used to determine rates adjusted for age and sex.

MAIN OUTCOME MEASURES

Incidence rate, mortality rate, case-fatality rate, and survival to discharge for patients assessed or treated by EMS personnel or with an initial rhythm of ventricular fibrillation.

RESULTS

Among the 10 sites, the total catchment population was 21.4 million, and there were 20,520 cardiac arrests. A total of 11,898 (58.0%) had resuscitation attempted; 2729 (22.9% of treated) had initial rhythm of ventricular fibrillation or ventricular tachycardia or rhythms that were shockable by an automated external defibrillator; and 954 (4.6% of total) were discharged alive. The median incidence of EMS-treated cardiac arrest across sites was 52.1 (interquartile range [IQR], 48.0-70.1) per 100,000 population; survival ranged from 3.0% to 16.3%, with a median of 8.4% (IQR, 5.4%-10.4%). Median ventricular fibrillation incidence was 12.6 (IQR, 10.6-5.2) per 100,000 population; survival ranged from 7.7% to 39.9%, with a median of 22.0% (IQR, 15.0%-24.4%), with significant differences across sites for incidence and survival (P<.001).

CONCLUSION

In this study involving 10 geographic regions in North America, there were significant and important regional differences in out-of-hospital cardiac arrest incidence and outcome.

Angina pectoris during daily activities and exercise stress testing: The role of inducible myocardial ischemia and psychological distress

Physicians often consider angina pectoris to be synonymous with myocardial ischemia. However, the relationship between angina and myocardial ischemia is highly variable and we have little insight into the sources of this variability. We investigated the relationship of inducible myocardial ischemia on SPECT stress perfusion imaging to angina reported with routine daily activities during the previous four weeks (N=788) and to angina reported during an exercise stress test (N=371) in individuals with confirmed or suspected coronary disease referred for clinical testing. We found that angina experienced during daily life is more strongly and consistently associated with psychological distress and the personal threat associated with angina than with inducible myocardial ischemia. In multivariable models, the presence of any angina during routine activities over the prior month was significantly associated with age, perceived risk of myocardial infarction, and anxiety when compared to those with no reported angina in the past month. Angina during daily life was not significantly associated with inducible myocardial ischemia on stress perfusion imaging in bivariate or multivariable models. In contrast, angina experienced during exercise stress testing was significantly related to image and ECG ischemia, though it was also significantly associated with anxiety. These results suggest that angina frequency over the previous four weeks is more strongly associated with personal threat and psychosocial distress than with inducible myocardial ischemia. These results lend support to angina treatment strategies that aim to reduce threat and distress as well as to reduce myocardial ischemia.

Impact of delayed presentation on management and outcome of non-ST-elevation acute coronary syndromes

BACKGROUND

The impact of delayed presentation on the management and outcomes of patients with non-ST-elevation acute coronary syndromes (NSTE-ACS) has not been well studied. Furthermore, the prognostic value of initial biomarker level in relation to the time of presentation has not been determined.

METHODS

The Canadian ACS II registry was a national, multicenter, prospective observational study of 1,956 patients with NSTE-ACS (October 2002-December 2003). We compared the baseline characteristics, treatment, and outcomes in early (within 6 hours of symptom onset) versus late presenters (>6 hours). A logistic regression model was developed to examine the independent association of late presentation with 1-year mortality. We also evaluated the prognostic value of initial biomarker level in relation to early versus late presentation.

RESULTS

A total of 1,219 (62.3%) patients presented early, whereas 727 (37.7%) presented late; their rates of in-hospital revascularization were similar (40.5% vs 42.5%, respectively, P = .39). There was also no significant difference in hospital mortality (1.6% vs 2.2%, P = .30) or 1-year mortality (7.6% vs 5.7%, P = .13) between early and late presenters. After adjusting for other prognosticators, late presentation was not an independent predictor of 1-year mortality (adjusted odds ratio 0.78, 95% confidence interval 0.48-1.26, P = .3). Elevated initial biomarker was independently associated with higher 1-year mortality (adjusted odds ratio 2.17, 95% CI 1.31-3.58, P = .002) regardless of whether hospital presentation was early or late (P for interaction = .74).

CONCLUSIONS

There is still considerable delay between symptom onset of NSTE-ACS and hospital presentation in the contemporary era. In contrast to studies of ST-elevation myocardial infarction, we found no significant differences in the management and outcome of early presenters as compared with late presenters with NSTE-ACS. Nevertheless, measures to reduce patient delay time should continue to be implemented. Initial biomarker status is a useful prognosticator irrespective of the delay time.

Factors that influence the use of ambulance in acute coronary syndrome

BACKGROUND

National guidelines recommend activation of the emergency medical service by patients who have symptoms of acute coronary syndrome (ACS). In spite of this, only 50% to 60% of persons with myocardial infarction initiate care by using the emergency medical service. The aim of this study was to define factors influencing the use of ambulance in ACS.

METHODS

The method used in this study was a national survey comprising intensive cardiac care units at 11 hospitals in Sweden; 1,939 patients with diagnosed ACS and symptom onset outside the hospital completed a questionnaire a few days after admission.

RESULTS

Half of the patients went to the hospital by ambulance. Factors associated with ambulance use were knowledge of the importance of quickly seeking medical care and calling for an ambulance when having chest pain (odds ratio [OR] 3.61, 95% CI 2.43-5.45), abrupt onset of pain reaching maximum intensity within minutes (OR 2.08, 1.62-2.69), nausea or cold sweat (OR 2.02, 1.54-2.65), vertigo or near syncope (OR 1.63, 1.21-2.20), ST-elevation ACS (OR 1.58, 1.21-2.06), increasing age (per year) (OR 1.03, 1.02-1.04), previous history of heart failure (OR 2.48, 1.47-4.26), and distance to the hospital of >5 km (OR 2.0, 1.55-2.59). Those who did not call for an ambulance thought self-transport would be faster or did not believe they were sick enough.

CONCLUSIONS

Symptoms, patient characteristics, ACS characteristics, and perceptions and knowledge were all associated with ambulance use in ACS. The fact that knowledge increases ambulance use and the need for behavioral change pose a challenge for health-care professionals.

Prehospital transport of patients with acute myocardial infarction: a community-wide perspective

OBJECTIVE

The objectives of this population-based study were to examine the use of emergency medical services (EMS) in greater Worcester, Massachusetts, residents (2000 census = 478,000) hospitalized with acute myocardial infarction (AMI) at all metropolitan Worcester medical centers in four biennial periods between 1997 and 2003. A secondary study aim was to describe the demographic and clinical characteristics of patients with AMI transported to metropolitan Worcester hospitals by EMS, compared with those transported by other means, and their hospital outcomes.

METHODS

We reviewed the medical records of 3805 patients hospitalized for confirmed AMI at 11 greater Worcester medical centers during 1997, 1999, 2001, and 2003. Information about the use of EMS, patient characteristics, and hospital outcomes was obtained through the review of hospital charts.

RESULTS

A total of 2693 greater Worcester residents with AMI (70.8%) were transported to area hospitals by ambulance. Patients transported by ambulance were older, were more likely to be women, had a greater prevalence of comorbidities, and had a different symptom profile than patients transported by other means. Patients arriving at greater Worcester hospitals by ambulance were more likely to develop serious clinical complications, including heart failure and cardiogenic shock, and die during hospitalization compared with patients not transported by EMS.

CONCLUSIONS

Our results suggest that the majority of greater Worcester residents seeking care for AMI are transported by EMS. Patients transported by ambulance differ from patients transported by other means and are more likely to experience adverse hospital outcomes. The reasons why patients use EMS in the setting of AMI need to be further explored and patients' care-seeking behavior enhanced.

Acute coronary syndrome: what do patients know?

BACKGROUND

The effectiveness of therapy for an acute coronary syndrome (ACS) is dependent on patients' quick decision to seek treatment. We surveyed patients' level of knowledge about heart disease and self-perceived risk for a future acute myocardial infarction (AMI) in patients with documented ischemic heart disease.

METHODS

Patients (N = 3522) had a mean age of 67 years, 68% were male, and all had a history of AMI or invasive cardiac procedure for ischemic heart disease. Data were gathered using a 26-item instrument focusing on ACS symptoms and appropriate steps to seeking treatment. Patients were asked to identify their level of perceived risk for a future AMI.

RESULTS

Forty-six percent of patients had low knowledge levels (ie, <70% of answers were correct). The mean score was 71%. Higher knowledge scores were significantly related to female sex (P = .001), younger age (P = .001), higher education (P = .001), participation in cardiac rehabilitation (P = .001), and receiving care by a cardiologist rather than an internist or general practitioner (P = .005). Clinical history (eg, AMI [P = .24] and cardiac surgery [P = .38]) were not significant predictors of knowledge. Most (57%) identified themselves as being at higher risk for a future AMI compared with an age-matched individual without heart disease with 1 exception. Namely, patients who had undergone coronary artery bypass surgery felt significantly less vulnerable for a future AMI than other individuals of the same age.

CONCLUSIONS

Even following diagnosis of ACS and numerous interactions with physicians and other health care professionals, knowledge about ACS symptoms and treatment on the part of patients with cardiac disease remains poor. Patients require continued reinforcement about the nature of cardiac symptoms, the benefits of early treatment, and their risk status.

Assessment of Initiation Time of Thrombolytic Therapy in Patients with ST-Segment Elevation Myocardial Infarction in Hamad General Hospital

The elevation of reperfusion therapy for acute STsegment elevation myocardial infarction are time-related and there are decreasing benefits with increasing delays to therapy. To determine whether the time interval between a patient's arrival at the emergency department of Hamad General Hospital, Qatar and initiation of thrombolytic therapy in the coronary care unit (door-to-needle time) is within the 30 minutes recommended by American College of Cardiology!American Heart Association guidelines, the medical records were reviewed of 213 patients with STsegment elevation myocardial infarction who were admitted through the Emergency Department to receive thrombolysis in the Coronary Care Unit in the twelve months May 2006-April 2007. Medians were calculated for door-to-needle and painto-needle times and intermediate points. The median painto-needle and pain-to-door times were 211 and 143 minutes respectively, both increasing significantly with the age of the patient and were shorter in men than in women. The median door-to-needle time was 60 minutes with 11.7% of the sample having a door-to-needle time within the recommended 30 minutes. It is concluded that the need for transferring such patients from the emergency department to the coronary care unit of the hospital before the administration of thrombolysis incurs inevitable delays that can be minimized by administering thrombolysis in the emergency department.

Symptom-to-door time in ST segment elevation myocardial infarction: overemphasized or overlooked? Results from the AMI-McGill study

BACKGROUND

Ischemic time is a major determinant of infarct size in ST segment elevation myocardial infarction (STEMI). Emphasis is placed on reducing the door-to-reperfusion therapy time component, whereas the symptom-to-door time is often overlooked.

OBJECTIVES

To correlate the symptom-to-door time with left ventricular ejection fraction (LVEF) in patients with STEMI.

METHODS

Acute Myocardial Infarction (AMI)-McGill was a cohort study of consecutive patients with STEMI who presented to three adult university hospitals. Multivariate linear regression was performed to correlate the symptom-to-door time with postinfarction LVEF adjusted for reperfusion method, prior myocardial infarction and components of the Thrombolysis In Myocardial Infarction (TIMI) risk score.

RESULTS

There were 188 patients, with a mean age of 66 years. On arrival to hospital, 23% of patients were in Killip class II to IV and 87% received reperfusion therapy (20% fibrinolytic therapy and 67% primary percutaneous coronary intervention). The median symptom-to-door time was 120 min (first quartile: 60 min, third quartile: 290 min) and the median door-to-reperfusion therapy time was 93 min (first quartile: 54 min, third quartile: 155 min). Three variables were independently correlated with LVEF in the study's regression model: symptom-to-door time (beta: -0.66, 95% CI -1.18 to -0.14; P=0.01), Killip class II to IV on arrival (beta: -6.43, 95% CI -11.87 to -0.99; P=0.02) and anterior territory of the infarction (beta: -5.86, 95% CI -10.55 to -1.18; P=0.02).

CONCLUSIONS

Symptom-to-door time was negatively correlated with postinfarction LVEF in patients with STEMI. Strategies to shorten this delay, such as educating high-risk patients about the symptoms of AMI, should be considered.

Facilitated PCI in patients with ST-elevation myocardial infarction

BACKGROUND

We hypothesized that percutaneous coronary intervention (PCI) preceded by early treatment with abciximab plus half-dose reteplase (combination-facilitated PCI) or with abciximab alone (abciximab-facilitated PCI) would improve outcomes in patients with acute ST-segment elevation myocardial infarction, as compared with abciximab administered immediately before the procedure (primary PCI).

METHODS

In this international, double-blind, placebo-controlled study, we randomly assigned patients with ST-segment elevation myocardial infarction who presented 6 hours or less after the onset of symptoms to receive combination-facilitated PCI, abciximab-facilitated PCI, or primary PCI. All patients received unfractionated heparin or enoxaparin before PCI and a 12-hour infusion of abciximab after PCI. The primary end point was the composite of death from all causes, ventricular fibrillation occurring more than 48 hours after randomization, cardiogenic shock, and congestive heart failure during the first 90 days after randomization.

RESULTS

A total of 2452 patients were randomly assigned to a treatment group. Significantly more patients had early ST-segment resolution with combination-facilitated PCI (43.9%) than with abciximab-facilitated PCI (33.1%) or primary PCI (31.0%; P=0.01 and P=0.003, respectively). The primary end point occurred in 9.8%, 10.5%, and 10.7% of the patients in the combination-facilitated PCI group, abciximab-facilitated PCI group, and primary-PCI group, respectively (P=0.55); 90-day mortality rates were 5.2%, 5.5%, and 4.5%, respectively (P=0.49).

CONCLUSIONS

Neither facilitation of PCI with reteplase plus abciximab nor facilitation with abciximab alone significantly improved the clinical outcomes, as compared with abciximab given at the time of PCI, in patients with ST-segment elevation myocardial infarction. (ClinicalTrials.gov number, NCT00046228 [ClinicalTrials.gov].)

Factors associated with longer time from symptom onset to hospital presentation for patients with ST-elevation myocardial infarction

BACKGROUND

Previous studies have demonstrated the effects of single factors, such as age, sex, and race, with longer delays from symptom onset to hospital presentation in patients with ST-elevation myocardial infarction.

METHODS

We studied risk factors individually and in combination to determine the cumulative effect on delay times in 482,327 patients with ST-elevation myocardial infarction enrolled in the National Registry of Myocardial Infarction between January 1, 1995, and December 31, 2004. We analyzed patient subgroups with the following risk factors in combination: younger than 70 years vs 70 years and older, race/ethnicity, men vs women, and nondiabetic vs diabetic.

RESULTS

The geometric mean for delay time was 114 minutes, with a decreasing trend from 123 minutes in 1995 to 113 minutes in 2004 (P < .001). Nearly half of the patients (45.5%) presented more than 2 hours and 8.7% presented more than 12 hours after the onset of symptoms. Compared with the reference group (those < 70 years, men, white, and did not have diabetes mellitus [DM]), subgroups with longer delay times (P < .01 for all) included those younger than 70 years, men, black, and had DM (+43 minutes); those younger than 70 years, women, black, and had DM (+55 minutes); those 70 years and older, men, black, and had DM (+60 minutes); and those 70 years and older, women, black, and had DM (+63 minutes).

CONCLUSIONS

Patient subgroups with a combination of factors (older age, women, Hispanic or black race, and DM) have particularly long delay times that may be 60 minutes longer than subgroups without those characteristics. Improving patient responsiveness in these subgroups represents an important opportunity to improve quality of care and minimize disparities in care.

The causes of prehospital delay in myocardial infarction

INTRODUCTION

The elapsed time between the onset of symptoms and reperfusion is a critical determinant of the clinical course of patients with myocardial infarction. The patients' own decision time is the most important component of prehospital delay.

METHODS

Selective literature review based on the references in a meta-analysis, complemented by a PubMed search on the expression "prehospital delay" in combination with "myocardial infarction," "acute coronary syndrome," "psychological factors," "gender," and "public campaign." A total of 73 papers addressing factors that influence prehospital delay were selected.

RESULTS

The reasons for delays of more than 120 minutes in a patient with symptoms of myocardial infarction reaching the hospital are still not sufficiently elucidated. Patients' uncertainty about their symptoms, advanced age, and female sex are three factors that appear to be associated with longer delays.

DISCUSSION

Factors influencing prehospital delay operate at the following levels: the perception of acute symptoms, the recognition of the importance of these symptoms, and the decision to call for help. Intervention trials should consider these levels in meeting the needs of clinically relevant subpopulations.

Delay in presentation and reperfusion therapy in ST-elevation myocardial infarction

BACKGROUND

We studied the relationship between longer delays from symptom onset to hospital presentation and the use of any reperfusion therapy, door-to-balloon time, and door-to-drug time.

METHODS

Cohort study of patients with ST-elevation myocardial infarction enrolled in the National Registry of Myocardial Infarction from January 1, 1995 to December 31, 2004. Delay in hospital presentation was categorized into 1-hour intervals as < or =1 hour, >1-2 hours, >2-3 hours, etc, up to >11-12 hours. The study analyzed 3 groups: 440,398 patients for the association between delay and use of any reperfusion therapy; 67,207 patients for the association between delay and door-to-balloon time; 183,441 patients for the association between delay and door-to-drug time.

RESULTS

In adjusted analyses, patients with longer delays between symptom onset and hospital presentation were less likely to receive any reperfusion therapy, had longer door-to-balloon times, and had longer door-to-needle times (all P <.0001 for linear trend). For patients presenting < or =1 hour, >1-2 hours, >2-3 hours, >9-10 hours, >10-11 hours, and >11-12 hours after symptom onset, the use of any reperfusion therapy were 77%, 77%, 73%, 53%, 50%, and 46%, respectively. Door-to-balloon times were 99, 101, 106, 123, 125, and 123 minutes, respectively, and door-to-drug times were 33, 34, 36, 46, 44, and 47 minutes, respectively.

CONCLUSIONS

Longer delays from symptom onset to hospital presentation were associated with reduced likelihood of receiving primary reperfusion therapy, and even among those treated, late presenters had significantly longer door-to-balloon and door-to-drug times.

Delays in seeking medical care in hospitalized patients with decompensated heart failure

PURPOSE

The magnitude of, and factors associated with, prolonged delay in seeking medical care in patients with acute myocardial infarction has been well described. It is unknown, however, what the extent of, and factors associated with, prehospital delay are in patients hospitalized with acute heart failure. The purpose of this study was to examine patterns of prehospital delay, and factors associated with delay in seeking medical care, in patients hospitalized with acute heart failure at all 11 medical centers in the Worcester, Massachusetts metropolitan area.

METHODS

The medical records of 2587 greater Worcester residents with decompensated heart failure who were hospitalized in 2000 were reviewed for the collection of information about prehospital delay and demographic and clinical factors associated with extent of delay.

RESULTS

Information about acute symptom onset and duration of delay in seeking medical care was available in only 44% of the hospital charts of patients with heart failure. The average delay time was 13.3 hours, while the median was 2.0 hours. Male sex, multiple presenting symptoms, absence of a history of heart failure, and seeking medical care between midnight and 6:00 am were associated with prolonged prehospital delay.

CONCLUSIONS

The results of this study in residents of a large New England metropolitan area suggest that patients hospitalized with acute heart failure exhibit considerable delays in seeking medical care. Several demographic and clinical characteristics were associated with prolonged delay. More research is needed to better understand the reasons why patients with this serious and increasingly prevalent clinical syndrome delay seeking medical care in a timely fashion.

Impact of point-of-care testing in the emergency department evaluation and treatment of patients with suspected acute coronary syndromes

OBJECTIVES

To assess the impact of point-of-care testing (POCT) for troponin I (cTnI) measurement on the time to anti-ischemic therapy (TAIT) for patients with suspected non-ST-segment elevation acute coronary syndrome (NSTE-ACS) presenting to the emergency department (ED).

METHODS

This was an open-label, randomized, single-center trial conducted in a university-affiliated hospital. cTnI measurement of patients with suspicion of NSTE-ACS coming to the ED was randomly allocated to POCT or central hospital laboratory testing (CHLT). The authors compared patients' baseline characteristics, time to anti-ischemic therapy, and medical outcomes between the randomized groups, in all study participants and in high-risk NSTE-ACS (cTnI level >or= 0.10 microg/mL), and in those with low suspicion ACS (no chest pain and no ST deviation).

RESULTS

Of the 860 patients enrolled, 113 were high-risk NSTE-ACS patients, including 53 (46.9%) allocated to POCT and 60 (53.1%) to CHLT. POCT was associated with decreased time to anti-ischemic therapy of about three-quarters of an hour, which was due to a shorter time to physician notification of cTnI level, in both all and subgroup participants. In contrast, neither ED length of stay nor medical outcomes differed between study groups.

CONCLUSIONS

Point-of-care testing for cTnI measurement might be clinically relevant for ED patients with a suspicion of NSTE-ACS, particularly for high-risk patients with a low suspicion of ACS.