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Abstract
AIMS Despite recent progress in coronary artery disease treatment, ST-segment elevation myocardial infarction (STEMI) remains a very high-risk medical condition. Whether recent patients' outcomes, following implementation of the 2012 European Society of Cardiology (ESC) STEMI guidelines have improved, is yet unclear. METHODS AND RESULTS The study was based on a prospective detailed registry of 2004 consecutive patients with STEMI treated with primary percutaneous coronary intervention (pPCI). We compared trends during two different time periods (2006-2012 vs. 2012-2018). Endpoints included mortality and major adverse cardiac events (MACE: death, repeat myocardial infarction, target vessel revascularization and coronary artery bypass surgery) at 1 month, 1 and 2 years. Rates of transradial interventions have risen significantly (67.3 vs. 42.0%; P < 0.01), as have rates of prasugrel administration (69.8 vs. 4.5%; P < 0.01) and use of drug eluting stents (75.5 vs. 56.5%; P < 0.01). Both at 1 and at 2 years, MACE was significantly lower in the later period (11.6 vs. 20.9%; P < 0.01 and 18.9 vs. 25.4%; P < 0.01 respectively), whereas mortality was only significantly lower after 1 year (5.8 vs. 8.6%; P = 0.02). Cox regression identified the later period (2012-2018) to independently and favorably impact MACE (hazard ratio, -0.69; 95% CI, 0.56-0.85; P < 0.01) but not mortality (hazard ratio, -0.76; 95% CI, 0.54-1.05; P = 0.09). CONCLUSION Among patients treated with pPCI for STEMI, adoption of the contemporary evidence-based treatments is associated with better MACE derived outcomes, following the inception of the 2012 ESC guidelines. Nonetheless, the long-term mortality was marginally (but not significantly) lower, which indicates an unmet need for further improvement.
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Pong JZ, Ho AFW, Tan TXZ, Zheng H, Pek PP, Sia CH, Hausenloy DJ, Ong MEH. ST-segment elevation myocardial infarction with non-chest pain presentation at the Emergency Department: Insights from the Singapore Myocardial Infarction Registry. Intern Emerg Med 2019; 14:989-997. [PMID: 31165979 DOI: 10.1007/s11739-019-02122-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 05/28/2019] [Indexed: 12/12/2022]
Abstract
ST-segment elevation myocardial infarction (STEMI) often presents acutely at the Emergency Department (ED). Although chest pain is a classical symptom, a significant proportion of patients do not present with chest pain. The impact of a non-chest pain (NCP) presentation on ED processes-of-care and outcomes is not fully understood. We utilised a national registry to characterise predictors, processes-of-care, and outcomes of NCP STEMI presentations. Retrospective data for all STEMI cases occurring between 2010 and 2012 were analysed from the Singapore Myocardial Infarction Registry. Cases of inpatient onset, inter-facility transfers, and out-of-hospital cardiac arrests were excluded. Univariable analysis of demographic, clinical, processes-of-care, and outcome variables was conducted. Multivariable logistic regression ascertained independent predictors of a NCP presentation and 28-day mortality. Of 4667 STEMI cases, 12.9% presented without chest pain. Patients with NCP presentation were older (median, years = 74 vs. 58; p < 0.001), more likely to be female (39.1% vs. 15.7%; p < 0.001), of the Chinese race (72.5% vs. 62.7%; p < 0.001), and with diabetes (48.6% vs. 36.7%; p < 0.001). These patients were more likely to present with syncope (6.0% vs. 1.9%; p < 0.001) or epigastric pain (10.6% vs. 4.9%; p < 0.001). Patients with NCP presentation were less likely to receive percutaneous coronary intervention (27.0% vs. 75.6%; p < 0.001), had longer door-to-balloon time (median, minutes = 83 vs. 63; p < 0.001), and experienced greater mortality at 28 days (31.2% vs. 4.5%; p < 0.001). On multivariable logistic regression, independent predictors of a NCP presentation included age (adjusted odds ratio [aOR] = 1.05, 95% confidence interval [CI] 1.04-1.07), diabetes (aOR = 1.76, 95% CI 1.40-2.19), BMI (aOR = 0.93, 95% CI 0.91-0.96), and dyslipidemia (aOR = 0.73, 95% CI 0.58-0.91). Absence of chest pain was an independent predictor for 28-day mortality (aOR = 3.46, 95% CI 2.64-4.52). Patients who presented with a NCP STEMI had a distinct clinical profile and experienced poorer outcomes. Routine triage ECG could be considered for patients with high-risk factors and non-classical symptoms.
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Affiliation(s)
- Jeremy Zhenwen Pong
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
| | - Andrew Fu Wah Ho
- SingHealth Duke-NUS Emergency Medicine Academic Clinical Programme, Singapore, Singapore
- Signature Programme in Cardiovascular and Metabolic Disorders, Duke-NUS Medical School, Singapore, Singapore
- National Heart Research Institute Singapore, National Heart Centre, Singapore, Singapore
| | | | - Huili Zheng
- National Registry of Diseases Office, Health Promotion Board, Singapore, Singapore
| | - Pin Pin Pek
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
| | - Ching-Hui Sia
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Derek John Hausenloy
- Signature Programme in Cardiovascular and Metabolic Disorders, Duke-NUS Medical School, Singapore, Singapore
- National Heart Research Institute Singapore, National Heart Centre, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- The Hatter Cardiovascular Institute, University College London, London, UK
- The National Institute of Health Research University College London Hospitals Biomedical Research Centre, Research and Development, London, UK
- Tecnologico de Monterrey, Centro de Biotecnologia-FEMSA, Nuevo León, Mexico
| | - Marcus Eng Hock Ong
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore.
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore.
- Health Service Research Centre, Singapore Health Services, Academia, 20 College Road, Singapore, 169856, Singapore.
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Hong Y, Graham MM, Rosychuk RJ, Southern D, McMurtry MS. The Effects of Acute Atmospheric Pressure Changes on the Occurrence of ST-Elevation Myocardial Infarction: A Case-Crossover Study. Can J Cardiol 2019; 35:753-760. [PMID: 31151711 DOI: 10.1016/j.cjca.2019.02.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 02/07/2019] [Accepted: 02/07/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Few studies have explored the influence of short-term exposure to atmospheric pressure changes on the abrupt onset of ST-elevation myocardial infarction (STEMI). We sought to evaluate the association between acute atmospheric pressure changes and the occurrence of STEMI. METHODS We studied STEMI patients from the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH) from March 1, 2002 to December 31, 2016 in a case-crossover study design. Each case was matched with control intervals according to the same day of week, month, and year. All STEMI patients were linked with the nearest weather station within a 40-km radius according to residential postal code. The effect of exposure to air pressure changes, rate of air pressure changes, acute air pressure increase, and acute air pressure decrease 1 day to 7 days earlier on the onset of STEMI were analyzed with conditional logistic regression. All models were adjusted with daily average temperature, relative humidity, and average levels of 5 air pollutants. RESULTS In 11,379 STEMI patients, positive associations with the onset of STEMI were only found at 7 days after exposure to acute air pressure decrease (odds ratio, 1.12; 95% confidence interval, 1.03-1.21), which was consistent in sensitivity and subgroup analyses. All the other models showed no evidence of statistically significant associations. CONCLUSIONS Acute air pressure decrease is associated with higher odds of a STEMI event 7 days after exposure. Weather advisories might be issued when atmospheric pressure decrease occurs.
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Affiliation(s)
- Yongzhe Hong
- Department of Medicine and Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada; The Second Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, China
| | - Michelle M Graham
- Department of Medicine and Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Rhonda J Rosychuk
- O'Brien Institute for Public Health and Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Danielle Southern
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Michael Sean McMurtry
- Department of Medicine and Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada.
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Wang Z, Zhan B, Bao H, Huang X, Wu Y, Liang Q, Zhang W, Jiang L, Cheng X. Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting in Unprotected Left Main Coronary Artery Stenosis. Am J Med Sci 2019; 357:230-241. [DOI: 10.1016/j.amjms.2018.12.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Revised: 12/15/2018] [Accepted: 12/18/2018] [Indexed: 01/23/2023]
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