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Champagne-Langabeer T, Kim J, Bower JK, Gardner A, Fowler R, Langabeer JR. Obesity, Treatment Times, and Cardiovascular Outcomes After ST-Elevation Myocardial Infarction: Findings From Mission: Lifeline North Texas. J Am Heart Assoc 2017; 6:JAHA.117.005827. [PMID: 28939712 PMCID: PMC5634256 DOI: 10.1161/jaha.117.005827] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [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 With increasing rates of obesity and its link with cardiovascular disease, there is a need for better understanding of the obesity-outcome relationship. This study explores the association between categories of obesity with treatment times and mortality for patients experiencing ST-segment elevation myocardial infarction. METHODS AND RESULTS We examined 8725 patients with ST-segment elevation myocardial infarction who underwent primary percutaneous coronary intervention and used regression models to analyze the relationship between 6 categories of body mass index with key door-to-balloon time, total ischemic time, and in-hospital mortality. We relied on data from the Mission: Lifeline North Texas program, consisting of 33 percutaneous coronary intervention-capable hospitals in 6 counties surrounding Dallas, Texas. Data were extracted from the National Cardiovascular Data Registry for each participating hospital. Of the samples, 76% were overweight or obese. Comparing the univariate differences between the normal-weight group and the pooled sample, we observed a U-shaped association between body mass index and both mortality and door-to-balloon times. The most underweight and severely obese had the highest mortality and median door-to-balloon time, respectively. These differences persisted after multivariate adjustments for door-to-balloon time, but not for mortality. CONCLUSIONS Extremely obese patients have longer treatment time delays than other body mass index categories. However, this did not extend to significant differences in mortality in the multivariate models. We conclude that clinicians should incorporate body mass assessments into their diagnosis and treatment plans to mitigate observed disparities.
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Affiliation(s)
| | - Junghyun Kim
- The University of Texas Health Sciences Center, Houston, TX
| | | | - Angela Gardner
- The University of Texas Southwestern Medical Center, Dallas, TX
| | - Raymond Fowler
- The University of Texas Southwestern Medical Center, Dallas, TX
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202
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Fordyce CB. Reduced critical care utilization: Another victory for effective bystander interventions in cardiac arrest. Resuscitation 2017; 119:A4-A5. [PMID: 28818522 DOI: 10.1016/j.resuscitation.2017.08.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 08/07/2017] [Indexed: 01/06/2023]
Affiliation(s)
- Christopher B Fordyce
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada.
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203
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Shiomi H, Kosuge M, Morimoto T, Watanabe H, Taniguchi T, Nakatsuma K, Toyota T, Yamamoto E, Shizuta S, Tada T, Furukawa Y, Nakagawa Y, Ando K, Kadota K, Kimura K, Kimura T. QRS Score at Presentation Electrocardiogram Is Correlated With Infarct Size and Mortality in ST-Segment Elevation Myocardial Infarction Patients Undergoing Primary Percutaneous Coronary Intervention. Circ J 2017; 81:1129-1136. [PMID: 28381693 DOI: 10.1253/circj.cj-16-1255] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND In ST-segment elevation myocardial infarction (STEMI), QRS score at presentation ECG may reflect the progression of infarction and facilitate prediction of the degree of myocardial salvage achieved by reperfusion therapy.Methods and Results:Admission electrocardiogram (ECG) was studied in 2,607 patients with STEMI undergoing primary percutaneous coronary intervention (PCI) within 24 h of symptom onset. Patients were classified into 3 groups according to QRS score: low (0-3, n=1,227), intermediate (4-7, n=810), and high (≥8, n=570). An increase of infarct size estimated by median peak creatine phosphokinase was observed as QRS score increased (low score, 1,836 IU/L; inter-quartile range (IQR), 979-3,190 IU/L; intermediate score, 2,488 IU/L; IQR, 1,126-4,640 IU/L; high score, 3,454 IU/L; IQR, 1,759-5,639 IU/L; P<0.001). Higher QRS score was associated with higher long-term mortality (low, intermediate, and high score, 15.6%, 19.7%, and 23.7% at 5 years, respectively; log-rank P<0.001). The positive relationship of QRS score with mortality was consistently seen when stratified by infarct location. The association of high QRS score with increased mortality was most remarkably seen in patients with early (≤2 h) presentation (low, intermediate, and high score: 16.7%, 16.6%, and 28.1% at 5 years, respectively; log-rank P<0.001). CONCLUSIONS Higher QRS score at presentation ECG was associated with larger infarct size, and higher long-term mortality in patients with STEMI undergoing primary PCI. QRS score appears to be important in the early risk stratification for STEMI.
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Affiliation(s)
- Hiroki Shiomi
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Masami Kosuge
- Division of Cardiology, Yokohama City University Medical Center
| | | | - Hiroki Watanabe
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Tomohiko Taniguchi
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Kenji Nakatsuma
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Toshiaki Toyota
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Erika Yamamoto
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Satoshi Shizuta
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | | | - Yutaka Furukawa
- Division of Cardiology, Kobe City Medical Center General Hospital
| | | | - Kenji Ando
- Division of Cardiology, Kokura Memorial Hospital
| | | | - Kazuo Kimura
- Division of Cardiology, Yokohama City University Medical Center
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
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204
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Dharmarajan K, Wang Y, Lin Z, Normand SLT, Ross JS, Horwitz LI, Desai NR, Suter LG, Drye EE, Bernheim SM, Krumholz HM. Association of Changing Hospital Readmission Rates With Mortality Rates After Hospital Discharge. JAMA 2017; 318:270-278. [PMID: 28719692 PMCID: PMC5817448 DOI: 10.1001/jama.2017.8444] [Citation(s) in RCA: 154] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
IMPORTANCE The Affordable Care Act has led to US national reductions in hospital 30-day readmission rates for heart failure (HF), acute myocardial infarction (AMI), and pneumonia. Whether readmission reductions have had the unintended consequence of increasing mortality after hospitalization is unknown. OBJECTIVE To examine the correlation of paired trends in hospital 30-day readmission rates and hospital 30-day mortality rates after discharge. DESIGN, SETTING, AND PARTICIPANTS Retrospective study of Medicare fee-for-service beneficiaries aged 65 years or older hospitalized with HF, AMI, or pneumonia from January 1, 2008, through December 31, 2014. EXPOSURE Thirty-day risk-adjusted readmission rate (RARR). MAIN OUTCOMES AND MEASURES Thirty-day RARRs and 30-day risk-adjusted mortality rates (RAMRs) after discharge were calculated for each condition in each month at each hospital in 2008 through 2014. Monthly trends in each hospital's 30-day RARRs and 30-day RAMRs after discharge were examined for each condition. The weighted Pearson correlation coefficient was calculated for hospitals' paired monthly trends in 30-day RARRs and 30-day RAMRs after discharge for each condition. RESULTS In 2008 through 2014, 2 962 554 hospitalizations for HF, 1 229 939 for AMI, and 2 544 530 for pneumonia were identified at 5016, 4772, and 5057 hospitals, respectively. In January 2008, mean hospital 30-day RARRs and 30-day RAMRs after discharge were 24.6% and 8.4% for HF, 19.3% and 7.6% for AMI, and 18.3% and 8.5% for pneumonia. Hospital 30-day RARRs declined in the aggregate across hospitals from 2008 through 2014; monthly changes in RARRs were -0.053% (95% CI, -0.055% to -0.051%) for HF, -0.044% (95% CI, -0.047% to -0.041%) for AMI, and -0.033% (95% CI, -0.035% to -0.031%) for pneumonia. In contrast, monthly aggregate changes across hospitals in hospital 30-day RAMRs after discharge varied by condition: HF, 0.008% (95% CI, 0.007% to 0.010%); AMI, -0.003% (95% CI, -0.005% to -0.001%); and pneumonia, 0.001% (95% CI, -0.001% to 0.003%). However, correlation coefficients in hospitals' paired monthly changes in 30-day RARRs and 30-day RAMRs after discharge were weakly positive: HF, 0.066 (95% CI, 0.036 to 0.096); AMI, 0.067 (95% CI, 0.027 to 0.106); and pneumonia, 0.108 (95% CI, 0.079 to 0.137). Findings were similar in secondary analyses, including with alternate definitions of hospital mortality. CONCLUSIONS AND RELEVANCE Among Medicare fee-for-service beneficiaries hospitalized for heart failure, acute myocardial infarction, or pneumonia, reductions in hospital 30-day readmission rates were weakly but significantly correlated with reductions in hospital 30-day mortality rates after discharge. These findings do not support increasing postdischarge mortality related to reducing hospital readmissions.
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Affiliation(s)
- Kumar Dharmarajan
- Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Now with Clover Health, Jersey City, New Jersey
| | - Yongfei Wang
- Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Zhenqiu Lin
- Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, Connecticut
| | - Sharon-Lise T. Normand
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts
| | - Joseph S. Ross
- Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, Connecticut
- Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- The Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
| | - Leora I. Horwitz
- Center for Healthcare Innovation and Delivery Science, NYU Langone Medical Center, New York, New York
- Division of Healthcare Delivery Science, Department of Population Health, New York University School of Medicine, New York
- Division of General Internal Medicine and Clinical Innovation, Department of Medicine, New York University School of Medicine, New York
| | - Nihar R. Desai
- Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Lisa G. Suter
- Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, Connecticut
- Section of Rheumatology, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Elizabeth E. Drye
- Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, Connecticut
- Section of General Pediatrics, Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut
| | - Susannah M. Bernheim
- Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, Connecticut
- Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- The Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Harlan M. Krumholz
- Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- The Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
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205
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Lange DC, Rokos IC, Garvey JL, Larson DM, Henry TD. False Activations for ST-Segment Elevation Myocardial Infarction. Interv Cardiol Clin 2017; 5:451-469. [PMID: 28581995 DOI: 10.1016/j.iccl.2016.06.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
First-medical-contact-to-device (FMC2D) times have improved over the past decade, as have clinical outcomes for patients presenting with ST-elevation myocardial infarction (STEMI). However, with improvements in FMC2D times, false activation of the cardiac catheterization laboratory (CCL) has become a challenging problem. The authors define false activation as any patient who does not warrant emergent coronary angiography for STEMI. In addition to clinical outcome measures for these patients, STEMI systems should collect data regarding the total number of CCL activations, the total number of emergency coronary angiograms, and the number revascularization procedures performed.
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Affiliation(s)
- David C Lange
- Division of Cardiology, Cedars-Sinai Heart Institute, Los Angeles, CA, USA
| | - Ivan C Rokos
- Department of Emergency Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - J Lee Garvey
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC, USA
| | - David M Larson
- Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Timothy D Henry
- Division of Cardiology, Cedars-Sinai Heart Institute, Los Angeles, CA, USA.
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206
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Abstract
This article discusses the lessons learned by an interdisciplinary team in a large metropolitan specialty hospital during the implementation of the Code Aorta protocol for aortic emergencies and the subsequent application of technological enhancements to improve data transfer. Aortic dissections require rapid diagnosis and surgical treatment; thus, in order to optimize patient outcomes, clinicians must be accessible, data must be readily available, and proper prompts and notifications must be made to alert and ready teams. An interdisciplinary team reviewed our hospital's processes and architecture of systems to define how we provide care during aortic emergencies. Based on this insight into patient flow, we ultimately developed a Code Aorta protocol to streamline provision of care during aortic emergencies. This process focused on protocol development, human-technology interfaces, and outcome-oriented metrics. The team also aimed to heighten awareness of the emergent process and to understand relevant outcomes data. After introduction of the Code Aorta protocol, a 78% reduction was achieved in time-to-treatment from the previous year's average time. In addition, the average length of stay was reduced by 2.4 days (18%). The team's efforts focused on clinical communication, aiming to link technology to maximize clinical efficiency. The initial results of our Code Aorta protocol show promise that continual refinement of patient care processes during aortic emergencies will improve outcomes for patients suffering aortic dissection.
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207
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Russo J, Le May MR. Time to Treatment: Focus on Transfer in ST-Elevation Myocardial Infarction. Interv Cardiol Clin 2017; 5:427-437. [PMID: 28581993 DOI: 10.1016/j.iccl.2016.06.003] [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: 11/27/2022]
Abstract
In the modern ST-elevation myocardial infarction (STEMI) system, the use of electrocardiogram by emergency medical services (EMS) personnel and the option to bypass emergency departments on route to a PCI-capable hospital is of particular importance. Through training and a standardized referral process, EMS personnel can now accurately diagnose and refer STEMI patients directly to the catheterization laboratory of a percutaneous coronary intervention-capable hospital. Regional STEMI models have been implemented successfully across North America, resulting in palpable reductions in door-to-balloon time, morbidity, and mortality.
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Affiliation(s)
- Juan Russo
- Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa K1Y 4W7, Canada
| | - Michel R Le May
- Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa K1Y 4W7, Canada.
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208
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Akashi N, Sakakura K, Yamamoto K, Taniguchi Y, Wada H, Momomura SI, Fujita H. Minimization of door-to-balloon time for ST-elevation acute myocardial infarction: a case report. Clin Case Rep 2017; 5:787-791. [PMID: 28588811 PMCID: PMC5457994 DOI: 10.1002/ccr3.939] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Revised: 03/07/2017] [Accepted: 03/09/2017] [Indexed: 11/24/2022] Open
Abstract
It is of utmost importance to minimize the door‐to‐balloon time for the initial treatment of ST‐elevation acute myocardial infarction. In this case report, we made all kinds of efforts to minimize procedures in the emergency department (ED minimization) as well as in the catheter laboratory without sacrificing safety.
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Affiliation(s)
- Naoyuki Akashi
- Division of Cardiovascular Medicine Saitama Medical Center Jichi Medical University Omiya-ku Saitama Japan
| | - Kenichi Sakakura
- Division of Cardiovascular Medicine Saitama Medical Center Jichi Medical University Omiya-ku Saitama Japan
| | - Kei Yamamoto
- Division of Cardiovascular Medicine Saitama Medical Center Jichi Medical University Omiya-ku Saitama Japan
| | - Yousuke Taniguchi
- Division of Cardiovascular Medicine Saitama Medical Center Jichi Medical University Omiya-ku Saitama Japan
| | - Hiroshi Wada
- Division of Cardiovascular Medicine Saitama Medical Center Jichi Medical University Omiya-ku Saitama Japan
| | - Shin-Ichi Momomura
- Division of Cardiovascular Medicine Saitama Medical Center Jichi Medical University Omiya-ku Saitama Japan
| | - Hideo Fujita
- Division of Cardiovascular Medicine Saitama Medical Center Jichi Medical University Omiya-ku Saitama Japan
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209
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Cacciani L, Agabiti N, Bargagli AM, Davoli M. Access to percutaneous transluminal coronary angioplasty and 30-day mortality in patients with incident STEMI: Differentials by educational level and gender over 11 years. PLoS One 2017; 12:e0175038. [PMID: 28384181 PMCID: PMC5383153 DOI: 10.1371/journal.pone.0175038] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 03/20/2017] [Indexed: 11/19/2022] Open
Abstract
Background Socioeconomic status and gender are associated with access to cardiac procedures and mortality after AMI, also in countries with universal health care systems. Our objective was to evaluate the association and trends of educational level or gender and the following outcomes: 1) access to PTCA; 2) 30-day mortality. Methods We conducted an observational study based on 14,013 subjects aged 35–74 years, residing in Rome in 2001, and hospitalised for incident STEMI within 2012 in the Lazio region. We estimated adjusted ORs of educational level or gender and: 1) PTCA within 2 days after hospitalisation, 2) 30-day mortality. We evaluated time trends of outcomes, and time trends of educational or gender differentials estimating ORs stratified by time period (two time periods between 2001 and 2012). We performed a hierarchical analysis to account for clustering of hospitals. Results Access to PTCA among patients with incident STEMI increased during the study period, while 30-day mortality was stable. We observed educational differentials in PTCA procedure only in the first time period, and gender differentials in both periods. Patterns for 30-day mortality were less marked, with educational differentials emerging only in the second period, and gender differentials only in the first one, with patients with low educational level and females being disadvantaged. Conclusions Educational differentials in the access to PTCA disappeared in Lazio region over time, coherently with scientific literature, while gender differentials seem to persist. It may be important to assess the role of female gender in patients with STEMI, both from a social and a clinical point of view.
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Affiliation(s)
- Laura Cacciani
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | - Nera Agabiti
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | - Anna Maria Bargagli
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
- * E-mail:
| | - Marina Davoli
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
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210
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Maddox TM, Albert NM, Borden WB, Curtis LH, Ferguson TB, Kao DP, Marcus GM, Peterson ED, Redberg R, Rumsfeld JS, Shah ND, Tcheng JE. The Learning Healthcare System and Cardiovascular Care: A Scientific Statement From the American Heart Association. Circulation 2017; 135:e826-e857. [DOI: 10.1161/cir.0000000000000480] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The learning healthcare system uses health information technology and the health data infrastructure to apply scientific evidence at the point of clinical care while simultaneously collecting insights from that care to promote innovation in optimal healthcare delivery and to fuel new scientific discovery. To achieve these goals, the learning healthcare system requires systematic redesign of the current healthcare system, focusing on 4 major domains: science and informatics, patient-clinician partnerships, incentives, and development of a continuous learning culture. This scientific statement provides an overview of how these learning healthcare system domains can be realized in cardiovascular disease care. Current cardiovascular disease care innovations in informatics, data uses, patient engagement, continuous learning culture, and incentives are profiled. In addition, recommendations for next steps for the development of a learning healthcare system in cardiovascular care are presented.
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211
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Analysis of reperfusion time trends in patients with ST-elevation myocardial infarction across New York State from 2004 to 2012. Int J Cardiol 2017; 232:140-146. [DOI: 10.1016/j.ijcard.2017.01.039] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 12/21/2016] [Accepted: 01/04/2017] [Indexed: 11/17/2022]
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212
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Benjamin EJ, Blaha MJ, Chiuve SE, Cushman M, Das SR, Deo R, de Ferranti SD, Floyd J, Fornage M, Gillespie C, Isasi CR, Jiménez MC, Jordan LC, Judd SE, Lackland D, Lichtman JH, Lisabeth L, Liu S, Longenecker CT, Mackey RH, Matsushita K, Mozaffarian D, Mussolino ME, Nasir K, Neumar RW, Palaniappan L, Pandey DK, Thiagarajan RR, Reeves MJ, Ritchey M, Rodriguez CJ, Roth GA, Rosamond WD, Sasson C, Towfighi A, Tsao CW, Turner MB, Virani SS, Voeks JH, Willey JZ, Wilkins JT, Wu JH, Alger HM, Wong SS, Muntner P. Heart Disease and Stroke Statistics-2017 Update: A Report From the American Heart Association. Circulation 2017; 135:e146-e603. [PMID: 28122885 PMCID: PMC5408160 DOI: 10.1161/cir.0000000000000485] [Citation(s) in RCA: 6083] [Impact Index Per Article: 869.0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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213
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Mathew A, Abdullakutty J, Sebastian P, Viswanathan S, Mathew C, Nair V, Mohanan PP, George Koshy A. Population access to reperfusion services for ST-segment elevation myocardial infarction in Kerala, India. Indian Heart J 2017; 69 Suppl 1:S51-S56. [PMID: 28400039 PMCID: PMC5388050 DOI: 10.1016/j.ihj.2017.02.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 02/13/2017] [Accepted: 02/20/2017] [Indexed: 01/17/2023] Open
Abstract
Background Population access to timely reperfusion is a decisive factor in determining the success and acceptability of any regional system of ST-segment elevation myocardial infarction (STEMI) care. We sought to determine the proportion of population of the southern Indian state of Kerala having timely access to STEMI reperfusion. Methods We identified the STEMI reperfusion facilities available at all acute-care hospitals, in Kerala, by conducting a cross-sectional survey. We mapped the geographical catchment areas of these hospitals using historical travel speeds and appropriate Geospatial Information Systems (GIS) analyses. Subsequently, using block level population data, we estimated the proportion of the population residing within these geographies. Results We estimated that 23.33 million people, forming 69.84% of the state population, resided in the green zone (within half-hour travel distance of a percutaneous coronary intervention [PCI]-capable hospital), which covered 47.94% of the geographical area of the state. Outside this green zone, 21.87% of the state population resided within 1 hr travel distance of a thrombolysis-capable hospital. Finally, 8.28% of the state population resided in the red zone, where access to any reperfusion-capable hospital took >1 hr, which covered 22.15% of the geographical area of the state. Conclusions A majority of the population of Kerala had timely access to PCI-capable hospitals. GIS-based mapping of Indian states, in terms of access to STEMI reperfusion, may help devise protocols to achieve seamless transfer of patients to reperfusion-capable hospitals. Such regionalization of STEMI care would enhance organizational synergies to achieve better access to reperfusion, especially in remote areas.
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Affiliation(s)
- Anoop Mathew
- MOSC Medical College Hospital, Kolenchery, Kerala, India.
| | | | | | | | - Cibu Mathew
- Government Medical College Hospital, Thrissur, Kerala, India
| | | | | | - A George Koshy
- Government Medical College Hospital, Thiruvanathapuram, Kerala, India
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214
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Ruptured aneurysm systems of care: A national imperative to improve clinical outcomes. J Vasc Surg 2017; 65:589-590. [DOI: 10.1016/j.jvs.2016.10.091] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 10/14/2016] [Indexed: 12/16/2022]
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215
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Ikemura N, Sawano M, Shiraishi Y, Ueda I, Miyata H, Numasawa Y, Noma S, Suzuki M, Momiyama Y, Inohara T, Hayashida K, Yuasa S, Maekawa Y, Fukuda K, Kohsaka S. Barriers Associated With Door-to-Balloon Delay in Contemporary Japanese Practice. Circ J 2017; 81:815-822. [PMID: 28228609 DOI: 10.1253/circj.cj-16-0905] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Door-to-balloon (DTB) time ≤90 min is an important quality indicator in the management of ST-elevation myocardial infarction (STEMI), but a considerable number of patients still do not meet this goal, particularly in countries outside the USA and Europe.Methods and Results:We analyzed 2,428 STEMI patients who underwent primary PCI ≤12 h of symptom onset who were registered in an ongoing prospective multicenter database (JCD-KiCS registry), between 2008 and 2013. We analyzed both the time trend in DTB time within this cohort in the registry, and independent predictors of delayed DTB time >90 min. Median DTB time was 90 min (IQR, 68-115 min) during the study period and there were no significant changes with year. Predictors for delay in DTB time included peripheral artery disease, prior revascularization, off-hour arrival, age >75 years, heart failure at arrival, and use of IABP or VA-ECMO. Notably, high-volume PCI-capable institutions (PCI ≥200/year) were more adept at achieving shorter DTB time compared with low-volume institutions (PCI <200/year). CONCLUSIONS Half of the present STEMI patients did not achieve DTB time ≤90 min. Targeting the elderly and patients with multiple comorbidities, and PCI performed in off-hours may aid in its improvement.
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Affiliation(s)
| | - Mitsuaki Sawano
- Department of Cardiology, Keio University School of Medicine
| | | | - Ikuko Ueda
- Department of Cardiology, Keio University School of Medicine
| | - Hiroaki Miyata
- Department of Health Policy and Management, Keio University School of Medicine
| | - Yohei Numasawa
- Department of Cardiology, Japanese Red Cross Ashikaga Hospital
| | | | - Masahiro Suzuki
- Department of Cardiology, National Hospital Organization, Saitama National Hospital
| | - Yukihiko Momiyama
- Department of Cardiology, National Hospital Organization, Tokyo Medical Center
| | - Taku Inohara
- Department of Cardiology, Keio University School of Medicine
| | | | - Shinsuke Yuasa
- Department of Cardiology, Keio University School of Medicine
| | | | - Keiichi Fukuda
- Department of Cardiology, Keio University School of Medicine
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine
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Kawecki D, Gierlotka M, Morawiec B, Hawranek M, Tajstra M, Skrzypek M, Wojakowski W, Poloński L, Nowalany-Kozielska E, Gąsior M. Direct Admission Versus Interhospital Transfer for Primary Percutaneous Coronary Intervention in ST-Segment Elevation Myocardial Infarction. JACC Cardiovasc Interv 2017; 10:438-447. [PMID: 28216215 DOI: 10.1016/j.jcin.2016.11.028] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Accepted: 11/17/2016] [Indexed: 11/26/2022]
Abstract
OBJECTIVES This study sought to assess the influence of direct admission versus transfer via regional hospital to a percutaneous coronary intervention (PCI) center on time delays and 12-month mortality in ST-segment elevation myocardial infarction (STEMI) patients from a real-life perspective. BACKGROUND Reduction of delays to reperfusion is crucial in a STEMI system of care. However, it is still debated whether direct admission to a PCI center is superior to interhospital transfer in terms of long-term prognosis. The authors hypothesized that compared with interhospital transfer, direct admission shortens the total ischemic time, limits the loss of left ventricular systolic function, and finally, reduces 12-month mortality. METHODS Prospective nationwide registry data of STEMI patients admitted to PCI centers within 12 h of symptom onset and treated with PCI between 2006 and 2013 were analyzed. Patients admitted directly were compared with patients transferred to a PCI center via a regional non-PCI-capable facility in terms of time delays, left ventricular ejection fraction (LVEF), and 12-month mortality. Data were adjusted using propensity-matched and multivariate Cox analyses. RESULTS Of the 70,093 patients eligible for analysis, 39,144 (56%) were admitted directly to a PCI center. Direct admission was associated with a shorter median symptoms-to-admission time (by 44 min; p < 0.001) and total ischemic time (228 vs. 270 min; p < 0.001), higher LVEF (47.5% vs. 46.3%; p < 0.001), and lower propensity-matched 12-month mortality (9.6% vs. 10.4%; p < 0.001). In propensity-matched multivariate Cox analysis, direct admission (hazard ratio [HR]: 1.06, 95% confidence interval [CI]: 1.01 to 1.11) and shorter symptoms-to-admission time (HR: 1.03; 95% CI: 1.01 to 1.06) were significant predictors of lower 12-month mortality. CONCLUSIONS In a large, community-based cohort of patients with STEMI treated by PCI, direct admission to a primary PCI center was associated with lower 12-month mortality and should be preferred to transfer via a regional non-PCI-capable facility.
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Affiliation(s)
- Damian Kawecki
- 2nd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, Katowice, Poland.
| | - Marek Gierlotka
- 3rd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, Katowice, Poland; Department of Science, Training and New Medical Technologies, Silesian Center for Heart Diseases, Zabrze, Poland
| | - Beata Morawiec
- 2nd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Michał Hawranek
- 3rd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, Katowice, Poland; Department of Science, Training and New Medical Technologies, Silesian Center for Heart Diseases, Zabrze, Poland
| | - Mateusz Tajstra
- 3rd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, Katowice, Poland; Department of Science, Training and New Medical Technologies, Silesian Center for Heart Diseases, Zabrze, Poland
| | - Michał Skrzypek
- Department of Science, Training and New Medical Technologies, Silesian Center for Heart Diseases, Zabrze, Poland; Department of Biostatistics, School of Public Health in Bytom, Medical University of Silesia, Katowice, Poland
| | - Wojciech Wojakowski
- 3rd Department of Cardiology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Lech Poloński
- 3rd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, Katowice, Poland; Department of Science, Training and New Medical Technologies, Silesian Center for Heart Diseases, Zabrze, Poland
| | - Ewa Nowalany-Kozielska
- 2nd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Mariusz Gąsior
- 3rd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, Katowice, Poland; Department of Science, Training and New Medical Technologies, Silesian Center for Heart Diseases, Zabrze, Poland
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217
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Liu HL, Jin ZG, Yang SL, Han W, Jing QM, Zhang L, Luo JP, Ma DX, Liu Y, Yang LX, Jiang TM, Qu P, Li WM, Li SM, Xu B, Gao RL, Han YL. Five-year outcomes of ST-elevation myocardial infarction versus non-ST-elevation acute coronary syndrome treated with biodegradable polymer-coated sirolimus-eluting stents: Insights from the CREATE trial. J Cardiol 2017; 69:149-155. [DOI: 10.1016/j.jjcc.2016.02.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 02/02/2016] [Accepted: 02/07/2016] [Indexed: 11/26/2022]
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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.
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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.
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Addo T, Swanson N, Gershlick A. Primary and Rescue PCI in Acute Myocardial Infarction and Elements of Myocardial Conditioning. Interv Cardiol 2016. [DOI: 10.1002/9781118983652.ch13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- Tayo Addo
- University of Texas Southwestern Medical Center; Dallas TX USA
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220
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Buccheri S, Capranzano P, Condorelli A, Scalia M, Tamburino C, Capodanno D. Risk stratification after ST-segment elevation myocardial infarction. Expert Rev Cardiovasc Ther 2016; 14:1349-1360. [PMID: 27817218 DOI: 10.1080/14779072.2017.1256201] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Risk stratification according to the timing of assessment, treatment modality and outcome of interest is highly advisable in patients with ST-elevation myocardial infarction (STEMI) to identify optimal treatment strategies, proper length of hospital stay and correct timing of follow-up. Areas covered: This review is an overview summarizing the characteristics and performance of available risk-scoring systems for STEMI. In particular, we sought to highlight the characteristics of STEMI cohorts used for derivation and validation of the available algorithms and appraise their discrimination ability, calibration and global accuracy. Expert commentary: Applying the appropriate score, customized on patients' profile and clinical characteristics at presentation or during the hospitalization, might prove useful to improve the overall quality of care provided to STEMI patients.
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Affiliation(s)
- Sergio Buccheri
- a Cardiovascular Department, Ferrarotto Hospital , University of Catania , Catania , Italy
| | - Piera Capranzano
- a Cardiovascular Department, Ferrarotto Hospital , University of Catania , Catania , Italy
| | - Antonio Condorelli
- a Cardiovascular Department, Ferrarotto Hospital , University of Catania , Catania , Italy
| | - Matteo Scalia
- a Cardiovascular Department, Ferrarotto Hospital , University of Catania , Catania , Italy
| | - Corrado Tamburino
- a Cardiovascular Department, Ferrarotto Hospital , University of Catania , Catania , Italy
| | - Davide Capodanno
- a Cardiovascular Department, Ferrarotto Hospital , University of Catania , Catania , Italy
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Dharmarajan K. Comprehensive Strategies to Reduce Readmissions in Older Patients With Cardiovascular Disease. Can J Cardiol 2016; 32:1306-1314. [DOI: 10.1016/j.cjca.2016.01.030] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Revised: 01/29/2016] [Accepted: 01/29/2016] [Indexed: 02/01/2023] Open
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Kim HK, Jeong MH, Ahn Y, Chae SC, Kim YJ, Hur SH, Seong IW, Hong TJ, Choi DH, Cho MC, Kim CJ, Seung KB, Jang YS, Rha SW, Bae JH, Kim SS, Park SJ. Relationship between time to treatment and mortality among patients undergoing primary percutaneous coronary intervention according to Korea Acute Myocardial Infarction Registry. J Cardiol 2016; 69:377-382. [PMID: 27720323 DOI: 10.1016/j.jjcc.2016.09.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 09/04/2016] [Accepted: 09/13/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND Despite large reductions in door-to-balloon times over the period, several studies from regional and national data showed that annual mortality rates were not decreased among patients who underwent primary percutaneous coronary intervention (PCI). However, these studies mostly focused on door-to-balloon time, and there was no consideration of total ischemic time in a trend of mortality. The aim of this study was to assess the annual trend between time to treatment and 1-month mortality among patients undergoing primary PCI. METHODS AND RESULTS The study population consisted of 8040 patients who underwent primary PCI at hospitals participating in the nationwide prospective Korea Acute Myocardial Infarction Registry (KAMIR) between January 2008 and December 2011. The primary end point of this study was 1-month all-cause mortality, and time to treatment (door-to-balloon time, symptom-to-balloon time). One-month death occurred in 452 patients (5.6%) from 2008 to 2011. Additional reductions in door-to-balloon time were not translated into parallel reductions in mortality rate and total ischemic time. After adjustment using clinical risk, shorter total ischemic time was an independent predictor of 1-month mortality [adjusted odds ratio (OR) 0.78, 95% confidential interval (CI) 0.62-0.99, p=0.04]. Total ischemic time could be reduced by using emergency medical services. CONCLUSION Despite improvements in door-to-balloon time, no parallel reductions in mortality rate and total ischemic time were observed. Total ischemic time was associated with mortality. The present study suggests that additional efforts are needed to shorten total ischemic time including patient and pre-hospital systemic delay for better prognosis after primary PCI.
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Affiliation(s)
- Hyun Kuk Kim
- Chosun University Hospital, Gwangju, Republic of Korea
| | - Myung Ho Jeong
- Chonnam National University Hospital, Gwangju, Republic of Korea.
| | - Youngkeun Ahn
- Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Shung Chull Chae
- Kyungpook National University Hosptial, Daegu, Republic of Korea
| | - Young Jo Kim
- Yeungnam University Hospital, Daegu, Republic of Korea
| | - Seung Ho Hur
- Keimyung University Hospital, Daegu, Republic of Korea
| | - In Whan Seong
- Chungnam National University Hospital, Daejon, Republic of Korea
| | - Taek Jong Hong
- Busan National University Hospital, Busan, Republic of Korea
| | - Dong Hoon Choi
- Yonsei University Severans Hospital, Seoul, Republic of Korea
| | - Myeong Chan Cho
- Chungbuk National University Hospital, Cheonju, Republic of Korea
| | - Chong Jin Kim
- Kyunghee University Hospital, Seoul, Republic of Korea
| | - Ki Bae Seung
- Catholic University Hospital, Seoul, Republic of Korea
| | - Yang Soo Jang
- Yonsei University Severans Hospital, Seoul, Republic of Korea
| | | | - Jang Ho Bae
- Konyang University Hospital, Seoul, Republic of Korea
| | - Sung Soo Kim
- Kwangju Christian Hospital, Gwangju, Republic of Korea
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Fordyce CB, Cairns JA, Singer J, Lee T, Park JE, Vandegriend RA, Perry M, Largy W, Gao M, Ramanathan K, Wong GC. Evolution and Impact of a Regional Reperfusion System for ST-Elevation Myocardial Infarction. Can J Cardiol 2016; 32:1222-1230. [DOI: 10.1016/j.cjca.2015.11.026] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Revised: 11/22/2015] [Accepted: 11/24/2015] [Indexed: 10/24/2022] Open
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Abstract
The mortality from acute myocardial infarction (AMI) remains significant, and the prevalence of post-myocardial infarction heart failure is increasing. Therefore, cardioprotection beyond timely reperfusion is needed. Conditioning procedures are the most powerful cardioprotective interventions in animal experiments. However, ischemic preconditioning cannot be used to reduce infarct size in patients with AMI because its occurrence is not predictable; several studies in patients undergoing surgical coronary revascularization report reduced release of creatine kinase and troponin. Ischemic postconditioning reduces infarct size in most, but not all, studies in patients undergoing interventional reperfusion of AMI, but may require direct stenting and exclusion of patients with >6 hours of symptom onset to protect. Remote ischemic conditioning reduces infarct size in patients undergoing interventional reperfusion of AMI, elective percutaneous or surgical coronary revascularization, and other cardiovascular surgery in many, but not in all, studies. Adequate dose-finding phase II studies do not exist. There are only 2 phase III trials, both on remote ischemic conditioning in patients undergoing cardiovascular surgery, both with neutral results in terms of infarct size and clinical outcome, but also both with major problems in trial design. We discuss the difficulties in translation of cardioprotection from animal experiments and proof-of-concept trials to clinical practice. Given that most studies on ischemic postconditioning and all studies on remote ischemic preconditioning in patients with AMI reported reduced infarct size, it would be premature to give up on cardioprotection.
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Affiliation(s)
- Gerd Heusch
- From the Institute for Pathophysiology (G.H.) and Clinic for Cardiology (T.R.), West German Heart and Vascular Center, University School of Medicine Essen, Essen, Germany
| | - Tienush Rassaf
- From the Institute for Pathophysiology (G.H.) and Clinic for Cardiology (T.R.), West German Heart and Vascular Center, University School of Medicine Essen, Essen, Germany
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225
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The effect of door-to-balloon delay in primary percutaneous coronary intervention on clinical outcomes of STEMI: a systematic review and meta-analysis protocol. Syst Rev 2016; 5:130. [PMID: 27484905 PMCID: PMC4971724 DOI: 10.1186/s13643-016-0304-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Accepted: 07/20/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Acute myocardial infarction (AMI) is a medical emergency in which sudden occlusion of coronary artery(ies) results in ischemia and necrosis of the cardiac tissues. Reperfusion therapies that aim at reopening the occluded artery remain the mainstay of treatment for AMI. Primary percutaneous coronary intervention (PCI), which enables the restoration of blood flow by reopening the occluded artery(ies) via a catheter with an inflatable balloon, is currently the preferred treatment for AMI with ST segment elevation (STEMI). The door-to-balloon (D2B) delay refers to the time interval counting from the arrival of a patient with STEMI at a hospital to the time of the balloon inflation (or stent deployment) that reopens the occluded artery(ies). Reducing this delay in primary PCI is thought to be an important strategy toward achieving better patient outcomes. Unfortunately, significant reduction of D2B delay in the USA over the last decade has not been shown to be associated with improved STEMI mortality. It has been suggested that the lack of impact could be due to the expanding use of primary PCI in STEMI as well as the survival cohort effect, leading to a shift toward a higher risk population receiving the procedure. Others have suggested that reduction in D2B delay may not be as impactful as expected, given that it only represents a small fraction of the total ischemic time. Although most existing evidence have pointed to the presence of a beneficial effect of shorter D2B delay, some inconsistencies however exist. This study aims to synthesize available evidence in order to answer the following questions: (1) what is the overall effect of D2B delay on clinical outcomes in patients with STEMI treated with primary PCI? (2) What factors explain the differences of the effect estimates among the studies? (3) What are the important strength and limitation of the existing body of evidence? METHOD We will search PubMed/MEDLINE, EMBASE, ClinicalTrials.gov, WHO International Clinical Trials Registry, CINAHL Database, and the Cochrane Library using a predefined search strategy. Other sources of literature will include proceedings from the European Society of Cardiology, the American College of Cardiology, the American Heart Association, the EUROPCR, and the ProQuest Dissertations and Theses Database. We will include data from observational studies (case-control and cohort study design) and randomized control trials (that have investigated the relationship of D2B time and clinical outcome(s) in an adult (older than 18) STEMI population). Mortality (cardiac related and all-cause) and incidence heart failure (HF) have been prioritized as the primary outcomes. All eligible studies will be assessed for risk of bias using the Risk Of Bias in Non-randomized Studies - of Interventions tool. The Grading of Recommendations, Assessment, and Evaluation (GRADE) framework will be used to report the quality of evidence and strength of recommendations. We will proceed to analyze the data quantitatively if the pre-specified conditions are satisfied. DISCUSSION Recent discussion on the negative findings of improved D2B delay over time being unrelated to better STEMI outcomes at the population level has reminded us of an important knowledge gap we have on this domain. This systematic review will serve to address some of these key questions not previously examined. Answers to these questions could clarify the controversies and offer empirical support for or against the suggested hypotheses. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42015026069.
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226
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Jollis JG, Al-Khalidi HR, Roettig ML, Berger PB, Corbett CC, Dauerman HL, Fordyce CB, Fox K, Garvey JL, Gregory T, Henry TD, Rokos IC, Sherwood MW, Suter RE, Wilson BH, Granger CB. Regional Systems of Care Demonstration Project: American Heart Association Mission: Lifeline STEMI Systems Accelerator. Circulation 2016; 134:365-74. [PMID: 27482000 PMCID: PMC4975540 DOI: 10.1161/circulationaha.115.019474] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 06/01/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Up to 50% of patients fail to meet ST-segment-elevation myocardial infarction (STEMI) guideline goals recommending a first medical contact-to-device time of <90 minutes for patients directly presenting to percutaneous coronary intervention-capable hospitals and <120 minutes for transferred patients. We sought to increase the proportion of patients treated within guideline goals by organizing coordinated regional reperfusion plans. METHODS We established leadership teams, coordinated protocols, and provided regular feedback for 484 hospitals and 1253 emergency medical services (EMS) agencies in 16 regions across the United States. RESULTS Between July 2012 and December 2013, 23 809 patients presented with acute STEMI (direct to percutaneous coronary intervention hospital: 11 765 EMS transported and 6502 self-transported; 5542 transferred). EMS-transported patients differed from self-transported patients in symptom onset to first medical contact time (median, 47 versus 114 minutes), incidence of cardiac arrest (10% versus 3%), shock on admission (11% versus 3%), and in-hospital mortality (8% versus 3%; P<0.001 for all comparisons). There was a significant increase in the proportion of patients meeting guideline goals of first medical contact-to-device time, including those directly presenting via EMS (50% to 55%; P<0.001) and transferred patients (44%-48%; P=0.002). Despite regional variability, the greatest gains occurred among patients in the 5 most improved regions, increasing from 45% to 57% (direct EMS; P<0.001) and 38% to 50% (transfers; P<0.001). CONCLUSIONS This Mission: Lifeline STEMI Systems Accelerator demonstration project represents the largest national effort to organize regional STEMI care. By focusing on first medical contact-to-device time, coordinated treatment protocols, and regional data collection and reporting, we were able to increase significantly the proportion of patients treated within guideline goals.
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Affiliation(s)
- James G Jollis
- From University of North Carolina, Chapel Hill (J.G.J.); Duke Clinical Research Institute, Duke University, Durham, NC (H.R.A.-K., M.L.R., C.B.F., K.F., M.W.S., C.B.G.); Northwell Health, New Hyde Park, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); American Heart Association, Dallas, TX (T.G., R.E.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.)
| | - Hussein R Al-Khalidi
- From University of North Carolina, Chapel Hill (J.G.J.); Duke Clinical Research Institute, Duke University, Durham, NC (H.R.A.-K., M.L.R., C.B.F., K.F., M.W.S., C.B.G.); Northwell Health, New Hyde Park, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); American Heart Association, Dallas, TX (T.G., R.E.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.)
| | - Mayme L Roettig
- From University of North Carolina, Chapel Hill (J.G.J.); Duke Clinical Research Institute, Duke University, Durham, NC (H.R.A.-K., M.L.R., C.B.F., K.F., M.W.S., C.B.G.); Northwell Health, New Hyde Park, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); American Heart Association, Dallas, TX (T.G., R.E.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.)
| | - Peter B Berger
- From University of North Carolina, Chapel Hill (J.G.J.); Duke Clinical Research Institute, Duke University, Durham, NC (H.R.A.-K., M.L.R., C.B.F., K.F., M.W.S., C.B.G.); Northwell Health, New Hyde Park, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); American Heart Association, Dallas, TX (T.G., R.E.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.)
| | - Claire C Corbett
- From University of North Carolina, Chapel Hill (J.G.J.); Duke Clinical Research Institute, Duke University, Durham, NC (H.R.A.-K., M.L.R., C.B.F., K.F., M.W.S., C.B.G.); Northwell Health, New Hyde Park, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); American Heart Association, Dallas, TX (T.G., R.E.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.)
| | - Harold L Dauerman
- From University of North Carolina, Chapel Hill (J.G.J.); Duke Clinical Research Institute, Duke University, Durham, NC (H.R.A.-K., M.L.R., C.B.F., K.F., M.W.S., C.B.G.); Northwell Health, New Hyde Park, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); American Heart Association, Dallas, TX (T.G., R.E.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.)
| | - Christopher B Fordyce
- From University of North Carolina, Chapel Hill (J.G.J.); Duke Clinical Research Institute, Duke University, Durham, NC (H.R.A.-K., M.L.R., C.B.F., K.F., M.W.S., C.B.G.); Northwell Health, New Hyde Park, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); American Heart Association, Dallas, TX (T.G., R.E.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.)
| | - Kathleen Fox
- From University of North Carolina, Chapel Hill (J.G.J.); Duke Clinical Research Institute, Duke University, Durham, NC (H.R.A.-K., M.L.R., C.B.F., K.F., M.W.S., C.B.G.); Northwell Health, New Hyde Park, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); American Heart Association, Dallas, TX (T.G., R.E.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.)
| | - J Lee Garvey
- From University of North Carolina, Chapel Hill (J.G.J.); Duke Clinical Research Institute, Duke University, Durham, NC (H.R.A.-K., M.L.R., C.B.F., K.F., M.W.S., C.B.G.); Northwell Health, New Hyde Park, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); American Heart Association, Dallas, TX (T.G., R.E.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.)
| | - Tammy Gregory
- From University of North Carolina, Chapel Hill (J.G.J.); Duke Clinical Research Institute, Duke University, Durham, NC (H.R.A.-K., M.L.R., C.B.F., K.F., M.W.S., C.B.G.); Northwell Health, New Hyde Park, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); American Heart Association, Dallas, TX (T.G., R.E.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.)
| | - Timothy D Henry
- From University of North Carolina, Chapel Hill (J.G.J.); Duke Clinical Research Institute, Duke University, Durham, NC (H.R.A.-K., M.L.R., C.B.F., K.F., M.W.S., C.B.G.); Northwell Health, New Hyde Park, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); American Heart Association, Dallas, TX (T.G., R.E.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.)
| | - Ivan C Rokos
- From University of North Carolina, Chapel Hill (J.G.J.); Duke Clinical Research Institute, Duke University, Durham, NC (H.R.A.-K., M.L.R., C.B.F., K.F., M.W.S., C.B.G.); Northwell Health, New Hyde Park, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); American Heart Association, Dallas, TX (T.G., R.E.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.)
| | - Matthew W Sherwood
- From University of North Carolina, Chapel Hill (J.G.J.); Duke Clinical Research Institute, Duke University, Durham, NC (H.R.A.-K., M.L.R., C.B.F., K.F., M.W.S., C.B.G.); Northwell Health, New Hyde Park, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); American Heart Association, Dallas, TX (T.G., R.E.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.)
| | - Robert E Suter
- From University of North Carolina, Chapel Hill (J.G.J.); Duke Clinical Research Institute, Duke University, Durham, NC (H.R.A.-K., M.L.R., C.B.F., K.F., M.W.S., C.B.G.); Northwell Health, New Hyde Park, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); American Heart Association, Dallas, TX (T.G., R.E.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.)
| | - B Hadley Wilson
- From University of North Carolina, Chapel Hill (J.G.J.); Duke Clinical Research Institute, Duke University, Durham, NC (H.R.A.-K., M.L.R., C.B.F., K.F., M.W.S., C.B.G.); Northwell Health, New Hyde Park, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); American Heart Association, Dallas, TX (T.G., R.E.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.)
| | - Christopher B Granger
- From University of North Carolina, Chapel Hill (J.G.J.); Duke Clinical Research Institute, Duke University, Durham, NC (H.R.A.-K., M.L.R., C.B.F., K.F., M.W.S., C.B.G.); Northwell Health, New Hyde Park, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); American Heart Association, Dallas, TX (T.G., R.E.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.).
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227
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Cambios en el tratamiento y el pronóstico del síndrome coronario agudo con la implantación del código infarto en un hospital con unidad de hemodinámica. Rev Esp Cardiol 2016. [DOI: 10.1016/j.recesp.2015.12.021] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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228
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Song JX, Zhu L, Lee CY, Ren H, Cao CF, Chen H. Total ischemic time and outcomes for patients with ST-elevation myocardial infarction: does time of admission make a difference? J Geriatr Cardiol 2016; 13:658-664. [PMID: 27781055 PMCID: PMC5067426 DOI: 10.11909/j.issn.1671-5411.2016.08.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023] Open
Abstract
OBJECTIVE To investigate whether admission time was associated with the delay of reperfusion therapy and in-hospital death in patients with ST-elevation myocardial infarction (STEMI). METHODS All patients with STEMI who were admitted to the emergency department and underwent primary percutaneous coronary intervention at Peking University People's Hospital between April 2012 and March 2015 were included. We examined differences in clinical characteristics, total ischemic time, and in-hospital death between patients admitted during off-hours and those admitted during regular hours. Multivariate logistic regression was used to estimate the relationship between off-hours admission and clinical outcome. RESULTS The sample comprised 184 and 105 patients with STEMI admitted to hospital during off-hours and regular hours, respectively. Total ischemic and onset-to-door times were significantly shorter in patients admitted during off-hours than among those admitted during regular hours (all P < 0.05). Door-to-balloon (DTB) time, the rate of DTB time ≤ 90 min, and in-hospital death were comparable between groups. Multivariate logistic regression showed that age and creatinine level, but not off-hours admission, were associated independently with increased in-hospital death. CONCLUSIONS Off-hours admission did not result in delayed reperfusion therapy or increased in-hospital mortality in patients with STEMI. Further efforts should focus on identifying pivotal factors associated with the pre-hospital and in-hospital delay of reperfusion therapy, and implementing quality improvement initiatives for reperfusion programs.
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Affiliation(s)
- Jun-Xian Song
- Department of Cardiology, Peking University People's Hospital, Beijing, China; Beijing Key Laboratory of Early Prediction and Intervention of Acute Myocardial Infarction, Peking University People's Hospital, Beijing, China; Center for Cardiovascular Translational Research, Peking University People's Hospital, Beijing, China
| | - Li Zhu
- Department of Nephrology, Peking University People's Hospital, Beijing, China
| | - Chong-You Lee
- Department of Cardiology, Peking University People's Hospital, Beijing, China; Beijing Key Laboratory of Early Prediction and Intervention of Acute Myocardial Infarction, Peking University People's Hospital, Beijing, China; Center for Cardiovascular Translational Research, Peking University People's Hospital, Beijing, China
| | - Hui Ren
- Department of Cardiology, Peking University People's Hospital, Beijing, China; Beijing Key Laboratory of Early Prediction and Intervention of Acute Myocardial Infarction, Peking University People's Hospital, Beijing, China; Center for Cardiovascular Translational Research, Peking University People's Hospital, Beijing, China
| | - Cheng-Fu Cao
- Department of Cardiology, Peking University People's Hospital, Beijing, China; Beijing Key Laboratory of Early Prediction and Intervention of Acute Myocardial Infarction, Peking University People's Hospital, Beijing, China; Center for Cardiovascular Translational Research, Peking University People's Hospital, Beijing, China
| | - Hong Chen
- Department of Cardiology, Peking University People's Hospital, Beijing, China; Beijing Key Laboratory of Early Prediction and Intervention of Acute Myocardial Infarction, Peking University People's Hospital, Beijing, China; Center for Cardiovascular Translational Research, Peking University People's Hospital, Beijing, China
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229
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Ward MJ, Kripalani S, Zhu Y, Storrow AB, Wang TJ, Speroff T, Munoz D, Dittus RS, Harrell FE, Self WH. Role of Health Insurance Status in Interfacility Transfers of Patients With ST-Elevation Myocardial Infarction. Am J Cardiol 2016; 118:332-7. [PMID: 27282834 PMCID: PMC4949088 DOI: 10.1016/j.amjcard.2016.05.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 05/05/2016] [Accepted: 05/05/2016] [Indexed: 11/20/2022]
Abstract
Lack of health insurance is associated with interfacility transfer from emergency departments for several nonemergent conditions, but its association with transfers for ST-elevation myocardial infarction (STEMI), which requires timely definitive care for optimal outcomes, is unknown. Our objective was to determine whether insurance status is a predictor of interfacility transfer for emergency department visits with STEMI. We analyzed data from the 2006 to 2011 Nationwide Emergency Department Sample examining all emergency department visits for patients age 18 years and older with a diagnosis of STEMI and a disposition of interfacility transfer or hospitalization at the same institution. For emergency department visits with STEMI, our multivariate logistic regression model included emergency department disposition status (interfacility transfer vs hospitalization at the same institution) as the primary outcome, and insurance status (none vs any [including Medicare, Medicaid, and private insurance]) as the primary exposure. We found that among 1,377,827 emergency department STEMI visits, including 249,294 (18.1%) transfers, patients without health insurance (adjusted odds ratio 1.6, 95% CI 1.5 to 1.7) were more likely to be transferred than those with insurance. Lack of health insurance status was also an independent risk factor for transfer compared with each subcategory of health insurance, including Medicare, Medicaid, and private insurance. In conclusion, among patients presenting to United States emergency departments with STEMI, lack of insurance was an independent predictor of interfacility transfer. In conclusion, because interfacility transfer is associated with longer delays to definitive STEMI therapy than treatment at the same facility, lack of health insurance may lead to important health disparities among patients with STEMI.
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Affiliation(s)
- Michael J Ward
- Department of Emergency Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee.
| | - Sunil Kripalani
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Center for Clinical Quality and Implementation Research, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Yuwei Zhu
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Alan B Storrow
- Department of Emergency Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Thomas J Wang
- Division of Cardiology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Theodore Speroff
- Geriatric Research, Education, and Clinical Center, Department of Medicine, VA Tennessee Valley Healthcare System, Nashville, Tennessee
| | - Daniel Munoz
- Division of Cardiology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Robert S Dittus
- Geriatric Research, Education, and Clinical Center, Department of Medicine, VA Tennessee Valley Healthcare System, Nashville, Tennessee; Department of Medicine, Institute for Medicine and Public Health, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Frank E Harrell
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Wesley H Self
- Department of Emergency Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
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230
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Varcoe RW, Clayton TC, Gray HH, de Belder MA, Ludman PF, Henderson RA. Impact of call-to-balloon time on 30-day mortality in contemporary practice. Heart 2016; 103:117-124. [PMID: 27411838 DOI: 10.1136/heartjnl-2016-309658] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 05/27/2016] [Accepted: 06/16/2016] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE Studies reporting an association between treatment delay and outcome for patients with ST segment elevation myocardial infarction (STEMI) have generally not included patients treated by a primary percutaneous coronary intervention (PPCI) service that systematically delivers reperfusion therapy to all eligible patients. We set out to determine the association of call-to-balloon (CTB) time with 30-day mortality after PPCI in a contemporary series of patients treated within a national reperfusion service. METHODS We analysed data on 16 907 consecutive patients with STEMI treated by PPCI in England and Wales in 2011 with CTB time of ≤6 hours. RESULTS The median CTB and door-to-balloon times were 111 and 41 min, respectively, with 80.9% of patients treated within 150 min of the call for help. An out-of-hours call time (58.2% of patients) was associated with a 10 min increase in CTB time, whereas inter-hospital transfer for PPCI (18.5% of patients) was associated with a 49 min increase in CTB time. CTB time was independently associated with 30-day mortality (p<0.0001) with a HR of 1.95 (95% CI 1.54 to 2.47) for a CTB time of >180-240 min compared with ≤90 min. The relationship between CTB time and 30-day mortality was influenced by patient risk profile with a greater absolute impact of increasing CTB time on mortality in high-risk patients. CONCLUSION CTB time is a useful metric to assess the overall performance of a PPCI service. Delays to reperfusion remain important even in the era of organised national PPCI services with rapid treatment times and efforts should continue to minimise treatment delays.
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Affiliation(s)
- Richard W Varcoe
- Trent Cardiac Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Tim C Clayton
- London School of Hygiene and Tropical Medicine, London, UK
| | - Huon H Gray
- Wessex Cardiac Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | - Peter F Ludman
- Queen Elizabeth Hospital, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Robert A Henderson
- Trent Cardiac Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
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231
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Fujita H. Redefinition of Prehospital Area as Critical Target for ST-Elevation Myocardial Infarction Care - "Time Is Myocardium". Circ J 2016; 80:1700-1. [PMID: 27430251 DOI: 10.1253/circj.cj-16-0651] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Hideo Fujita
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University
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232
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Pines JM, Lotrecchiano GR, Zocchi MS, Lazar D, Leedekerken JB, Margolis GS, Carr BG. A Conceptual Model for Episodes of Acute, Unscheduled Care. Ann Emerg Med 2016; 68:484-491.e3. [PMID: 27397857 DOI: 10.1016/j.annemergmed.2016.05.029] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 05/17/2016] [Accepted: 05/24/2016] [Indexed: 10/21/2022]
Abstract
We engaged in a 1-year process to develop a conceptual model representing an episode of acute, unscheduled care. Acute, unscheduled care includes acute illnesses (eg, nausea and vomiting), injuries, or exacerbations of chronic conditions (eg, worsening dyspnea in congestive heart failure) and is delivered in emergency departments, urgent care centers, and physicians' offices, as well as through telemedicine. We began with a literature search to define an acute episode of care and to identify existing conceptual models used in health care. In accordance with this information, we then drafted a preliminary conceptual model and collected stakeholder feedback, using online focus groups and concept mapping. Two technical expert panels reviewed the draft model, examined the stakeholder feedback, and discussed ways the model could be improved. After integrating the experts' comments, we solicited public comment on the model and made final revisions. The final conceptual model includes social and individual determinants of health that influence the incidence of acute illness and injury, factors that affect care-seeking decisions, specific delivery settings where acute care is provided, and outcomes and costs associated with the acute care system. We end with recommendations for how researchers, policymakers, payers, patients, and providers can use the model to identify and prioritize ways to improve acute care delivery.
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Affiliation(s)
- Jesse M Pines
- Departments of Emergency Medicine and Health Policy and Management, The George Washington University, Washington, DC; Office for Clinical Practice Innovation, George Washington School of Medicine and Health Science, Washington, DC
| | - Gaetano R Lotrecchiano
- Departments of Clinical Research and Leadership and Pediatrics, The George Washington University, Washington, DC; Office for Clinical Practice Innovation, George Washington School of Medicine and Health Science, Washington, DC
| | - Mark S Zocchi
- Office for Clinical Practice Innovation, George Washington School of Medicine and Health Science, Washington, DC.
| | - Danielle Lazar
- Office for Clinical Practice Innovation, George Washington School of Medicine and Health Science, Washington, DC
| | - Jacob B Leedekerken
- Office for Clinical Practice Innovation, George Washington School of Medicine and Health Science, Washington, DC
| | - Gregg S Margolis
- Emergency Care Coordination Center, Office of the Assistant Secretary for Preparedness and Response, US Department of Health and Human Services, Washington, DC
| | - Brendan G Carr
- Emergency Care Coordination Center, Office of the Assistant Secretary for Preparedness and Response, US Department of Health and Human Services, Washington, DC; Sidney Kimmel Medical College, Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA
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233
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Loh JPY, Poh KK. Changes in the practice of cardiology: therapies at the forefront of science. Singapore Med J 2016; 57:344-6. [PMID: 27440236 PMCID: PMC4958708 DOI: 10.11622/smedj.2016115] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Joshua Ping-Yun Loh
- Department of Cardiology, National University Heart Centre, National University Health System, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Kian-Keong Poh
- Department of Cardiology, National University Heart Centre, National University Health System, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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234
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Thomas MP, Bates ER. Update on primary PCI for patients with STEMI. Trends Cardiovasc Med 2016; 27:95-102. [PMID: 27450063 DOI: 10.1016/j.tcm.2016.06.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 06/22/2016] [Accepted: 06/22/2016] [Indexed: 10/21/2022]
Abstract
Primary PCI is the dominant reperfusion strategy for patients with ST-elevation myocardial infarction and continues to evolve. The purpose of this review is to summarize recent reports that focused on the relationship of door-to-balloon time with mortality, radial versus femoral artery access, aspiration thrombectomy, culprit versus multivessel primary PCI, drug-eluting stents, and anticoagulation and antiplatelet therapies.
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Affiliation(s)
- Michael P Thomas
- Division of Cardiovascular Diseases, Department of Internal Medicine, University of Michigan Medical Center, 1500 E. Medical Center Drive, Ann Arbor, MI 48109-5869
| | - Eric R Bates
- Division of Cardiovascular Diseases, Department of Internal Medicine, University of Michigan Medical Center, 1500 E. Medical Center Drive, Ann Arbor, MI 48109-5869.
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235
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Pharmacoinvasive and Primary Percutaneous Coronary Intervention Strategies in ST-Elevation Myocardial Infarction (from the Mayo Clinic STEMI Network). Am J Cardiol 2016; 117:1904-10. [PMID: 27131614 DOI: 10.1016/j.amjcard.2016.03.036] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 03/21/2016] [Accepted: 03/21/2016] [Indexed: 12/24/2022]
Abstract
The effectiveness of a pharmacoinvasive strategy consisting of fibrinolysis and transfer for percutaneous coronary intervention (PCI) compared to primary PCI (PPCI) in patients presenting to non-PCI-capable hospitals with ST-elevation myocardial infarction (STEMI) is not well defined. We analyzed data from the Mayo Clinic STEMI database of patients treated with a pharmacoinvasive strategy (favored in those presenting early after symptom onset) or PPCI in a regional STEMI network from 2004 to 2012. A total of 364 and 1,337 patients were included in the pharmacoinvasive and PPCI groups, respectively. Patients in the PPCI group were older and more frequently had cardiogenic shock at the time of presentation (12.1% vs 7.7%, p = 0.018). Death from any cause occurred in 58 (16%) and 314 (23%) patients in the pharmacoinvasive and PPCI groups, respectively (median follow-up 3.9 and 4.4 years, respectively). In multivariate analyses adjusting for age, gender, and other variables for which the 2 groups differed at baseline, there was no significant difference between the 2 strategies for 30-day (hazard ratio 0.66, 95% confidence interval 0.36 to 1.21) or overall mortality (hazard ratio 0.84, 95% confidence interval 0.63 to 1.12). Shorter door-to-balloon time was associated with increased effectiveness of PPCI (p for trend = 0.015), but there was no difference between the 2 strategies even when considering only the patients with door-to-balloon time in the lowest quartile. In conclusion, fibrinolysis followed by transfer for PCI represents a reasonable alternative when PPCI is not readily available especially in patients presenting early after symptom onset.
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236
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Couture EL, Bérubé S, Dalery K, Gervais A, Harvey R, Nguyen M, Parenteau É, Daneault B. Culprit Vessel Revascularization Prior to Diagnostic Angiography as a Strategy to Reduce Delays in Primary Percutaneous Coronary Intervention: A Propensity-Matched Analysis. Circ Cardiovasc Interv 2016; 9:e003510. [PMID: 27162215 DOI: 10.1161/circinterventions.115.003510] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Accepted: 04/14/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Delays are important markers of quality of care in primary percutaneous coronary intervention. There is scarce data on the impact of obtaining a complete diagnostic angiography before primary percutaneous coronary intervention. METHODS AND RESULTS Consecutive patients treated with primary percutaneous coronary intervention at our institution between January 2012 and December 2014 were studied. After excluding patients with prior coronary artery bypass surgery, 925 patients were included in the analysis. Patients were classified into 3 groups according to the as-treated revascularization strategy: culprit-vessel revascularization first, contralateral angiography first, or complete angiography first. Propensity score matching was used to minimize difference in clinical characteristics between groups. Predictors of culprit-vessel first revascularization were anterior/lateral infarct location and absence of diabetes mellitus. After propensity score matching, the median vascular access-to-balloon time was 4 to 6 minutes shorter with a culprit-vessel revascularization first strategy. This reduction in time to reperfusion increased the proportion of patients treated within recommended delays. However, there was no significant difference in 30-day clinical outcomes associated with these delays reduction. CONCLUSIONS Performing culprit-vessel primary percutaneous coronary intervention before contralateral or complete diagnostic angiography is associated with a statistically significant reduction in vascular access-to-balloon time, although the 4- to 6-minute difference is unlikely to be clinically relevant. This small but significant reduction could translate in an augmentation in the proportion of patients treated within recommended delays.
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Affiliation(s)
- Etienne L Couture
- From the Department of Medicine, Centre Hospitalier Universitaire de Sherbrooke/Université de Sherbrooke, Sherbrooke, Canada (E.L.C., S.B., K.D., A.G., R.H., M.N., B.D.); and Department of Medicine, Université de Sherbrooke, Faculty of Medicine, Sherbrooke, Canada (É.P.)
| | - Simon Bérubé
- From the Department of Medicine, Centre Hospitalier Universitaire de Sherbrooke/Université de Sherbrooke, Sherbrooke, Canada (E.L.C., S.B., K.D., A.G., R.H., M.N., B.D.); and Department of Medicine, Université de Sherbrooke, Faculty of Medicine, Sherbrooke, Canada (É.P.)
| | - Karl Dalery
- From the Department of Medicine, Centre Hospitalier Universitaire de Sherbrooke/Université de Sherbrooke, Sherbrooke, Canada (E.L.C., S.B., K.D., A.G., R.H., M.N., B.D.); and Department of Medicine, Université de Sherbrooke, Faculty of Medicine, Sherbrooke, Canada (É.P.)
| | - André Gervais
- From the Department of Medicine, Centre Hospitalier Universitaire de Sherbrooke/Université de Sherbrooke, Sherbrooke, Canada (E.L.C., S.B., K.D., A.G., R.H., M.N., B.D.); and Department of Medicine, Université de Sherbrooke, Faculty of Medicine, Sherbrooke, Canada (É.P.)
| | - Richard Harvey
- From the Department of Medicine, Centre Hospitalier Universitaire de Sherbrooke/Université de Sherbrooke, Sherbrooke, Canada (E.L.C., S.B., K.D., A.G., R.H., M.N., B.D.); and Department of Medicine, Université de Sherbrooke, Faculty of Medicine, Sherbrooke, Canada (É.P.)
| | - Michel Nguyen
- From the Department of Medicine, Centre Hospitalier Universitaire de Sherbrooke/Université de Sherbrooke, Sherbrooke, Canada (E.L.C., S.B., K.D., A.G., R.H., M.N., B.D.); and Department of Medicine, Université de Sherbrooke, Faculty of Medicine, Sherbrooke, Canada (É.P.)
| | - Émilie Parenteau
- From the Department of Medicine, Centre Hospitalier Universitaire de Sherbrooke/Université de Sherbrooke, Sherbrooke, Canada (E.L.C., S.B., K.D., A.G., R.H., M.N., B.D.); and Department of Medicine, Université de Sherbrooke, Faculty of Medicine, Sherbrooke, Canada (É.P.)
| | - Benoit Daneault
- From the Department of Medicine, Centre Hospitalier Universitaire de Sherbrooke/Université de Sherbrooke, Sherbrooke, Canada (E.L.C., S.B., K.D., A.G., R.H., M.N., B.D.); and Department of Medicine, Université de Sherbrooke, Faculty of Medicine, Sherbrooke, Canada (É.P.).
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Bogaty P, Brophy JM. STEMI Treatment 2016: Is Outcome Improvement Stalling and If So, Why? Can J Cardiol 2016; 32:1193-1196. [PMID: 27094124 DOI: 10.1016/j.cjca.2016.01.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Revised: 01/21/2016] [Accepted: 01/21/2016] [Indexed: 10/22/2022] Open
Affiliation(s)
- Peter Bogaty
- Laval University, Institut universitaire de cardiologie et de pneumologie de Québec, Québec City, Québec, Canada.
| | - James M Brophy
- McGill University (Royal Victoria Hospital), Montreal, Québec, Canada
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238
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Aghaebrahim A, Streib C, Rangaraju S, Kenmuir CL, Giurgiutiu DV, Horev A, Saeed Y, Callaway CW, Guyette FX, Martin-Gill C, Pacella C, Ducruet AF, Jankowitz BT, Jovin TG, Jadhav AP. Streamlining door to recanalization processes in endovascular stroke therapy. J Neurointerv Surg 2016; 9:340-345. [DOI: 10.1136/neurintsurg-2016-012324] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Revised: 03/08/2016] [Accepted: 03/12/2016] [Indexed: 11/04/2022]
Abstract
BackgroundIn acute stroke due to large vessel occlusion, faster reperfusion leads to better outcomes. We analyzed the effect of optimization steps aimed to reduce treatment delays at our center.MethodsConsecutive patients with ischemic stroke treated with endovascular therapy were prospectively analyzed. We divided the patients into pre-optimization (20 April 2012 to 8 October 2013) and post-optimization (9 October 2013 to 29 July 2014) periods. The main interventions included: (1) continuous feedback; (2) standardized immediate emergency department attending to stroke attending communication with interventional team activation for all potential interventions; (3) pre-notification by the emergency medical service; (4) minimizing additional diagnostic testing; (5) direct transport to the CT scanner; (6) transport directly from the CT scanner to the angiography suite. The main metric used to measure improvement was door to groin puncture time (D2P).ResultsWe included a total of 286 patients (178 pre-optimization, 108 post-optimization). There were no significant differences between major baseline characteristics between the groups with the exception of higher median CT Alberta Stroke Program Early CT Score in the pre-optimization group (p=0.01). Median D2P improved from 105 min pre-optimization to 67 min post-optimization (p=0.0002). Rates of good clinical outcomes (modified Rankin Scale 0–2 at 3 months) were similar in both groups, with a trend toward a better outcome in the post-optimization group in a subgroup analysis of patients with anterior circulation occlusion who received intravenous tissue plasminogen activator.ConclusionsThis pilot study demonstrates that D2P times can be significantly reduced with a standardized multidisciplinary approach. There was no significant difference in the rate of 3-month good outcome, which is most likely due to the small sample size and confounding baseline patient characteristics.
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239
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Cordero A, López-Palop R, Carrillo P, Frutos A, Miralles S, Gunturiz C, García-Carrilero M, Bertomeu-Martínez V. Changes in Acute Coronary Syndrome Treatment and Prognosis After Implementation of the Infarction Code in a Hospital With a Cardiac Catheterization Unit. ACTA ACUST UNITED AC 2016; 69:754-9. [PMID: 26979766 DOI: 10.1016/j.rec.2015.12.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 12/04/2015] [Indexed: 10/22/2022]
Abstract
INTRODUCTION AND OBJECTIVES Emergency care systems have been created to improve treatment and revascularization in myocardial infarction but they may also improve the management of all patients with acute coronary syndrome. METHODS A comparative study of all patients admitted with acute coronary syndrome before and after implementation of an infarction protocol. RESULTS The study included 1210 patients. While the mean age was the same in both periods, the patient group admitted after implementation of the protocol had a lower prevalence of diabetes mellitus and hypertension but more active smokers and higher GRACE scores. The percentage of ST-segment elevation acute coronary syndrome (29.8%-39.5%) and coronary revascularizations (82.1%-90.1%) significantly increased among patients admitted with acute coronary syndrome, and primary angioplasty became routine (51.9%-94.9%); there was also a reduction in time to catheterization and an increase in early revascularization. The mean hospital stay was significantly shorter after implementation of the infarction protocol. In-hospital mortality was unchanged, except in high-risk patients (38.8%-22.4%). After discharge, no differences were observed between the 2 periods in cardiovascular mortality, all-cause mortality, reinfarction, or major cardiovascular complications. CONCLUSIONS After implementation of the infarction protocol, the percentage of patients admitted with ST-segment elevation acute coronary syndrome and the mean GRACE score increased among patients admitted with acute coronary syndrome. Hospital stay was reduced, and primary angioplasty use increased. In-hospital mortality was reduced in high-risk patients, and prognosis after discharge was the same in both periods.
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Affiliation(s)
- Alberto Cordero
- Departamento de Cardiología, Hospital Universitario de San Juan, San Juan de Alicante, Alicante, Spain.
| | - Ramón López-Palop
- Departamento de Cardiología, Hospital Universitario de San Juan, San Juan de Alicante, Alicante, Spain
| | - Pilar Carrillo
- Departamento de Cardiología, Hospital Universitario de San Juan, San Juan de Alicante, Alicante, Spain
| | - Araceli Frutos
- Departamento de Cardiología, Hospital Universitario de San Juan, San Juan de Alicante, Alicante, Spain
| | - Sandra Miralles
- Departamento de Cardiología, Hospital Universitario de San Juan, San Juan de Alicante, Alicante, Spain
| | - Clara Gunturiz
- Departamento de Cardiología, Hospital Universitario de San Juan, San Juan de Alicante, Alicante, Spain
| | - María García-Carrilero
- Departamento de Cardiología, Hospital Universitario de San Juan, San Juan de Alicante, Alicante, Spain
| | - Vicente Bertomeu-Martínez
- Departamento de Cardiología, Hospital Universitario de San Juan, San Juan de Alicante, Alicante, Spain
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240
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Grines CL, Harjai KJ, Schreiber TL. Percutaneous Coronary Intervention: 2015 in Review. J Interv Cardiol 2016; 29:11-26. [PMID: 26864949 DOI: 10.1111/joic.12272] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
| | - Kishore J. Harjai
- Geisinger Clinic; Pearsall Heart Hospital; Wilkes-Barre Pennsylvania
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241
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Yin WH, Lu TH, Chen KC, Cheng CF, Lee JC, Liang FW, Huang YT, Yang LT. The temporal trends of incidence, treatment, and in-hospital mortality of acute myocardial infarction over 15years in a Taiwanese population. Int J Cardiol 2016; 209:103-13. [PMID: 26889592 DOI: 10.1016/j.ijcard.2016.02.022] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Revised: 01/08/2016] [Accepted: 02/01/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND The study was conducted to examine the nationwide temporal trends of incidence, treatment, and short-term outcomes for acute myocardial infarction (AMI) over a 15-year period in Taiwan. METHODS We identified patients who were hospitalized for incident AMI between 1997 and 2011 from the inpatient medical claim dataset of the National Health Insurance Research Database. Age- and sex-adjusted incidence and in-hospital mortality rates were calculated for AMI, and separately for ST-segment elevation and non-ST-segment elevation myocardial infarction (STEMI and NSTEMI). RESULTS A total of 144,634 patients were identified. The incidence rates (per 100,000 population) of AMI increased from 30 in 1997 to 42 in 2011, which was mainly driven by the increase of NSTEMI. The in-hospital mortality rate after AMI decreased from 9.1% in 1997 to 6.5% in 2011, which was also driven by the case mortality rate for NSTEMI. Although the in-hospital mortality rates significantly decreased from 7.3% to 5.1% between 1997 and 2003 for STEMI, it did not change significantly from 2004 to 2011. Moreover, AMI patients undergoing revascularization treatment, particularly PCI, was the most important independent predictor for improved in-hospital survival. CONCLUSION The results of this study demonstrated a recent dramatic increase in the incidence rates and a decrease in short-term mortality in patients with NSTEMI; while the incidence and in-hospital morality of STEMI only modestly changed over time in Taiwan. Further quality improvement approaches for AMI prevention and treatment to favorably affect the incidence and outcomes from both major types of AMI are highly recommended.
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Affiliation(s)
- Wei-Hsian Yin
- Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan; Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.
| | - Tsung-Hsueh Lu
- Department of Public Health, National Cheng Kung University, Tainan, Taiwan
| | - Kuan-Chun Chen
- Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan; Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | | | - Jo-Chi Lee
- Department of Public Health, National Cheng Kung University, Tainan, Taiwan
| | - Fu-Wen Liang
- Department of Public Health, National Cheng Kung University, Tainan, Taiwan
| | - Yu-Tung Huang
- Program in Ageing and Long-term Care, Kaohsiuang Medical University, Kaohsiung, Taiwan
| | - Li-Tan Yang
- Department of Internal Medicine, National Cheng Kung University College of Medicine and Hospital, Tainan, Taiwan
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242
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AlHabib KF, Sulaiman K, Al Suwaidi J, Almahmeed W, Alsheikh-Ali AA, Amin H, Al Jarallah M, Alfaleh HF, Panduranga P, Hersi A, Kashour T, Al Aseri Z, Ullah A, Altaradi HB, Nur Asfina K, Welsh RC, Yusuf S. Patient and System-Related Delays of Emergency Medical Services Use in Acute ST-Elevation Myocardial Infarction: Results from the Third Gulf Registry of Acute Coronary Events (Gulf RACE-3Ps). PLoS One 2016; 11:e0147385. [PMID: 26807577 PMCID: PMC4726591 DOI: 10.1371/journal.pone.0147385] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Accepted: 01/04/2016] [Indexed: 11/20/2022] Open
Abstract
Background Little is known about Emergency Medical Services (EMS) use and pre-hospital triage of patients with acute ST-elevation myocardial infarction (STEMI) in Arabian Gulf countries. Methods Clinical arrival and acute care within 24 h of STEMI symptom onset were compared between patients transferred by EMS (Red Crescent and Inter-Hospital) and those transferred by non-EMS means. Data were retrieved from a prospective registry of 36 hospitals in 6 Arabian Gulf countries, from January 2014 to January 2015. Results We enrolled 2,928 patients; mean age, 52.7 (SD ±11.8) years; 90% men; and 61.7% non-Arabian Gulf citizens. Only 753 patients (25.7%) used EMS; which was mostly via Inter-Hospital EMS (22%) rather than direct transfer from the scene to the hospital by the Red Crescent (3.7%). Compared to the non-EMS group, the EMS group was more likely to arrive initially at a primary or secondary health care facility; thus, they had longer median symptom-onset-to-emergency department arrival times (218 vs. 158 min; p˂.001); they were more likely to receive primary percutaneous coronary interventions (62% vs. 40.5%, p = 0.02); they had shorter door-to-needle times (38 vs. 42 min; p = .04); and shorter door-to-balloon times (47 vs. 83 min; p˂.001). High EMS use was independently predicted mostly by primary/secondary school educational levels and low or moderate socioeconomic status. Low EMS use was predicted by a history of angina and history of percutaneous coronary intervention. The groups had similar in-hospital deaths and outcomes. Conclusion Most acute STEMI patients in the Arabian Gulf region did not use EMS services. Improving Red Crescent infrastructure, establishing integrated STEMI networks, and launching educational public campaigns are top health care system priorities.
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Affiliation(s)
- Khalid F. AlHabib
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
- * E-mail:
| | | | - Jassim Al Suwaidi
- Department of Cardiology, Hamad Medical Corporation (HMC), Doha, Qatar
| | - Wael Almahmeed
- Heart and Vascular Institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates
| | - Alawi A. Alsheikh-Ali
- College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, United Arab Emirates
- Institute of Cardiac Sciences, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
- Tufts Clinical and Translational Science Institute, Tufts Medical Center, Boston, MA, United States of America
| | - Haitham Amin
- Mohammed Bin Khalifa Cardiac Center, Manama, Bahrain
| | | | - Hussam F. Alfaleh
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | | | - Ahmad Hersi
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Tarek Kashour
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Zohair Al Aseri
- Emergency Department, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Anhar Ullah
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Hani B. Altaradi
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Kazi Nur Asfina
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Robert C. Welsh
- Division of Cardiology, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada
| | - Salim Yusuf
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, Canada
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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
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Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, Das SR, de Ferranti S, Després JP, Fullerton HJ, Howard VJ, Huffman MD, Isasi CR, Jiménez MC, Judd SE, Kissela BM, Lichtman JH, Lisabeth LD, Liu S, Mackey RH, Magid DJ, McGuire DK, Mohler ER, Moy CS, Muntner P, Mussolino ME, Nasir K, Neumar RW, Nichol G, Palaniappan L, Pandey DK, Reeves MJ, Rodriguez CJ, Rosamond W, Sorlie PD, Stein J, Towfighi A, Turan TN, Virani SS, Woo D, Yeh RW, Turner MB. Heart Disease and Stroke Statistics-2016 Update: A Report From the American Heart Association. Circulation 2015; 133:e38-360. [PMID: 26673558 DOI: 10.1161/cir.0000000000000350] [Citation(s) in RCA: 3736] [Impact Index Per Article: 415.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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245
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Bates ER. Limiting Infarct Size in ST-Segment Myocardial Infarction. JACC-HEART FAILURE 2015; 3:883-5. [DOI: 10.1016/j.jchf.2015.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 08/14/2015] [Indexed: 11/25/2022]
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Herzer KR, Pronovost PJ. Physician Motivation: Listening to What Pay-for-Performance Programs and Quality Improvement Collaboratives Are Telling Us. Jt Comm J Qual Patient Saf 2015; 41:522-8. [PMID: 26484685 PMCID: PMC5099521 DOI: 10.1016/s1553-7250(15)41069-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Kurt R Herzer
- Medical Scientist Training Program, Johns Hopkins School of Medicine, Baltimore, USA
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247
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Jiang L, Krumholz HM, Li X, Li J, Hu S. Achieving best outcomes for patients with cardiovascular disease in China by enhancing the quality of medical care and establishing a learning health-care system. Lancet 2015; 386:1493-505. [PMID: 26466053 PMCID: PMC5323019 DOI: 10.1016/s0140-6736(15)00343-8] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
China has an immediate need to address the rapidly growing population with cardiovascular disease events and the increasing number of people living with this illness. Despite progress in increasing access to services, China faces the dual challenge of addressing gaps in quality of care and producing more evidence to support clinical practice. In this Review, we address opportunities to strengthen performance measurement, programmes to improve quality of care, and national capacity to produce high-impact knowledge for clinical practice. Moreover, we propose recommendations, with implications for other diseases, for how China can immediately make use of its Hospital Quality-Monitoring System and other existing national platforms to assess and improve performance of medical care, and to generate new knowledge to inform clinical decisions and national policies.
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Affiliation(s)
- Lixin Jiang
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Harlan M Krumholz
- Section of Cardiovascular Medicine and the Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA; Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT, USA
| | - Xi Li
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jing Li
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shengshou Hu
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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Solhpour A, Chang KW, Arain SA, Balan P, Loghin C, McCarthy JJ, Vernon Anderson H, Smalling RW. Ischemic time is a better predictor than door-to-balloon time for mortality and infarct size in ST-elevation myocardial infarction. Catheter Cardiovasc Interv 2015; 87:1194-200. [DOI: 10.1002/ccd.26230] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 08/15/2015] [Indexed: 11/08/2022]
Affiliation(s)
- Amirreza Solhpour
- University of Texas Health Science Center and Memorial Hermann Heart and Vascular Institute; Houston Texas
| | - Kay-Won Chang
- University of Texas Health Science Center and Memorial Hermann Heart and Vascular Institute; Houston Texas
| | - Salman A. Arain
- University of Texas Health Science Center and Memorial Hermann Heart and Vascular Institute; Houston Texas
| | - Prakash Balan
- University of Texas Health Science Center and Memorial Hermann Heart and Vascular Institute; Houston Texas
| | - Catalin Loghin
- University of Texas Health Science Center and Memorial Hermann Heart and Vascular Institute; Houston Texas
| | - James J. McCarthy
- University of Texas Health Science Center and Memorial Hermann Heart and Vascular Institute; Houston Texas
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249
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Affiliation(s)
- Zoran S Nedeljkovic
- From Evans Department of Medicine, Boston University School of Medicine, and Section of Cardiology, Boston Medical Center, Boston, MA
| | - Alice K Jacobs
- From Evans Department of Medicine, Boston University School of Medicine, and Section of Cardiology, Boston Medical Center, Boston, MA.
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250
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Dauerman HL. Anticoagulation Strategies for Primary Percutaneous Coronary Intervention. Circ Cardiovasc Interv 2015; 8:CIRCINTERVENTIONS.115.001947. [DOI: 10.1161/circinterventions.115.001947] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Harold L. Dauerman
- From the Department of Medicine and the Cardiovascular Research Institute, University of Vermont College of Medicine, Burlington
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