Factors associated with delay in transfer of patients with ST-segment elevation myocardial infarction from first medical contact to catheterization laboratory: Lessons from CRAC, a French prospective multicentre registry

Evaluation of the ODISEA APP for improving a STEMI regional network

BACKGROUND

The use of technological innovations in ST elevation myocardial infarction (STEMI) care networks has been shown to be effective in improving information flow and coordination, and thus reducing the time to reperfusion. We developed a smartphone application called ODISEA to improve our STEMI care network and evaluated the results of its use.

METHOD

Quasi-experimental study that compared the outcomes of STEMI suspected patients with an alert and indication for transfer to a cath lab during a previous period and a period in which the ODISEA APP was used. The main objective was to examine differences in reperfusion time and the proportion of patients with a final diagnosis other than acute coronary syndrome.

RESULTS

A total of 699 patients were included (415 before and 284 during the ODISEA-APP period). No differences were observed in patient characteristics, infarct type, or acute complications. We observed a reduction in the time from diagnostic ECG to wire crossing with the use of the ODISEA APP (117 vs 102 min, p < 0.001) and a reduction in the percentage of patients with a final diagnosis other than acute coronary syndrome (17.1% vs 9.5%, p = 0.004).

CONCLUSIONS

The use of the ODISEA APP in the management of patients with suspected STEMI may be useful for reducing the time from diagnostic ECG to wire crossing and the percentage of patients with a final diagnosis other than acute coronary syndrome.

Performance of the 2019 ESC/EASD guideline strategy for the screening of silent coronary artery disease in patients with diabetes

BACKGROUND

The 2019 guidelines for cardiovascular risk stratification by the European Society of Cardiology and European Association for the Study of Diabetes (ESC-EASD) suggested screening for silent coronary disease in very high risk patients with severe target organ damage (TOD) (i.e. peripheral occlusive arterial disease or severe nephropathy) or high coronary artery calcium (CAC) score. This study aimed to test the validity of this strategy.

METHODS

In this retrospective study, we included 385 asymptomatic patients with diabetes and no history of coronary disease but with TOD or ≥ 3 risk factors in addition to diabetes. CAC score was measured using computed tomography scan and a stress myocardial scintigraphy was performed to detect silent myocardial ischemia (SMI), with subsequent coronary angiography in those with SMI. Various strategies to select patients to be screened for SMI were tested.

RESULTS

CAC score was ≥ 100 Agatston units (AU) in 175 patients (45.5%). SMI was present in 39 patients (10.1%) and among the 30 patients who underwent angiography, 15 had coronary stenoses and 12 had a revascularization procedure. The most effective strategy consisted in performing myocardial scintigraphy in the 146 patients with severe TOD and, among the 239 other patients without severe TOD, in those with CAC ≥ 100 AU: this strategy provided 82% sensitivity for SMI diagnosis, and identified all the patients with stenoses.

CONCLUSION

The ESC-EASD guidelines suggesting SMI screening in asymptomatic patients with very high risk assessed by severe TOD or high CAC score appears effective and could identify all the patients with stenoses eligible for revascularization.

Early survival after acute myocardial infarction with ST-segment elevation: What could be improved? Insights from France PCI French registry

Early mortality post-ST-segment elevation myocardial infarction (STEMI) in France remains high. The multicentre France Percutaneous Coronary Intervention Registry includes every patient undergoing coronary angiography in France. We analyzed the prevalence and impact of unmodifiable and modifiable risk factors on 30-day survival in patients experiencing STEMI. Patients admitted for STEMI between 01/2014 and 12/2016 were included in the analysis. Patients with nonobstructive coronary artery disease, with cardiogenic shock or cardiac arrest without STEMI, were excluded. Prehospital, clinical and procedural data were collected prospectively by the cardiologist in the cath lab using medical reporting software. Information on outcomes, including mortality, was obtained by a dedicated research technician by phone calls or from medical records. Marginal Cox proportional hazards regression was used to test the predictive value for survival at 30 days in a multivariable analysis. Included were 2590 patients (74% men) aged 63 ± 14 years. During the first month, 174 patients (6.7%) died. After adjustment, unmodifiable variables significantly associated with reduced 30-day survival were: age > 80 years (prevalence 15%; hazard ratio [HR] 2.7; 95% confidence interval [CI] 1.5-4.7), chronic kidney disease (2%; HR 5.3; 95% CI 2.6-11.1), diabetes mellitus (14%; HR 1.6; 95% CI 1.0-2.5), anterior or circumferential electrical localization (39%; HR 2.0; 95% CI 1.4-2.9), and Killip class 2, 3, or 4 (7%; HR 3.4; 95% CI 1.9-5.9; 2%; HR 10.1; 95% CI 5.3-19.4; 4%; HR 18; 95% CI 10.8-29.8, respectively). Among modifiable variables, total ischemic time > 3 hours (68%; HR 1.8; 95% CI 1.1-3.0), lack of appropriate premedication (18%; HR 2.2; 95% CI 1.5-3.3), and post-PCI TIMI < 3 (6%; HR 4.9; 95% CI 3.2-7.6) were significantly associated with reduced 30-day survival. Most predictors of 30-day survival post-STEMI are unmodifiable, but outcomes might be improved by optimizing modifiable factors, most importantly ischemic time and appropriate premedication.

Cross-sectional study of healthcare accessibility in rural regions among patients with acute myocardial infarction

BACKGROUND

Patients suffering from acute myocardial infarction (AMI), mainly with ST elevation (STEMI), are at a great disadvantage in rural regions due to the lack of nearby hospitals with percutaneous coronary intervention (PCI).

OBJECTIVE

This study aimed to analyse AMI patients' interhospital referrals in a rural emergency department (ED), as well as the factors contributing to its system delay METHODS: A cross-sectional observational study was carried out. An analysis of hospital referral was conducted as well for time intervals: from the first medical contact (FMC), first electrocardiogram (ECG), contact with the PCI hospital, ED exit, and arrival at the catheterization laboratory ward.

RESULTS

Of the 48 eligible patients, 62.5% suffered from STEMI, and 50.0% were transferred to a PCI hospital. The median time to coronary intervention facilities was 214 min. The median time spent in the ED was 131 min, and time spent in transport was 101 min. The time interval to the first ECG was 6 to 10 min.

CONCLUSIONS

Interhospital referral of AMI patients in rural settings is inconsistent and often not in compliance with international guidelines. A long system delay time is related mainly to organizational issues. STEMI patients still experience significant delays in healthcare accessibility. Nurses' timely execution and interpretation of ECG can improve healthcare accessibility.

Is coronary multivessel disease in acute myocardial infarction patients still associated with worse clinical outcomes at 1-year?

Background

ST‐elevation myocardial infarction (STEMI) patients with multivessel disease (MVD) are associated with a worse prognosis. However, few comparisons are available according to coronary status in the era of modern reperfusion and optimized secondary prevention.

Hypothesis

We hypothesized that the difference in prognosis according to number of vessel disease in STEMI patients has reduced.

Methods

All consecutive STEMI patients undergoing primary percutaneous coronary intervention (PCI) within 24 h of symptoms onset between January 1, 2014 and June 30, 2016 enrolled in the CRAC (Club Régional des Angioplasticiens de la région Centre) France PCI registry were analyzed. Baseline characteristics, management, and outcomes at 1‐year were analyzed according to coronary status (one‐, two‐, and three‐VD).

Results

A total of 1886 patients (mean age 62.2 ± 14.0 year; 74% of male) were included. Patients with MVD (two or three‐VD) represented 53.7%. They were older with higher cardiovascular risk factor profile. At 1 year, the rate of major adverse cardiovascular events (MACE, defined as all‐cause death, stroke or re‐MI) was 10%, 12%, and 12% in one‐, two, and three‐VD respectively (p = .28). In multivariable adjusted Cox proportional hazard regression model, two‐ and three‐VD were not associated with higher rate of MACE compared to patients with single VD (HR, 1.09; 95%CI 0.76–1.56 for two‐VD; HR, 0.74; 95%CI 0.48–1.14 for three‐VD).

Conclusions

MVD still represents an important proportion of STEMI patients but their prognoses were not associated with worse clinical outcomes at 1‐year compared with one‐VD patients in a modern reperfusion area and secondary medication prevention.

Characteristics associated with patient delay during the management of ST-segment elevated myocardial infarction, and the influence of awareness campaigns

BACKGROUND

The delay between the occurrence of symptoms and the call seeking medical assistance is an important component of the pain-to-balloon delay in patients with ST-segment elevation myocardial infarction (STEMI). Factors affecting this "patient delay" have been poorly studied, and campaigns to raise emergency call awareness have barely been evaluated.

AIMS

To evaluate the factors related to patient delay, and the effects of public awareness campaigns undertaken in our region.

METHODS

Data from the regional registry of STEMI in Limousin, France, were analysed, and we performed a survey to assess medical history, clinical signs, context, socioeconomic situation and perception and behaviour of the patient. "Late callers" (i.e. third tertile,>154minutes) were compared with "early callers" (i.e. first and second tertiles,≤154minutes) using univariate and multivariable statistical methods. The influence of public awareness campaigns was studied by comparing the patient delays before and after a regional campaign.

RESULTS

Among 481 patients, the median patient delay was 87minutes. "Late callers" were older (odds ratio [OR] 1.02 per year, 95% confidence interval [CI] 1.00 to 1.03), more often had symptom onset between 00:00 and 05:59 a.m. (OR 1.86, 95% CI 1.10 to 3.12) and more often sought assistance from a general practitioner (OR 2.58, 95% CI 1.66 to 4.04) or attended the emergency room (OR 4.10, 95% CI 2.04 to 8.32). Sweats and considering the situation to be severe were factors associated with a reduced delay. After awareness campaigns, there was no change in patient delay, but the proportion of patients calling the Emergency Medical Services increased from 55% to 62% (P<0.001).

CONCLUSIONS

Patient delay is multifactorial. The impact of previous campaigns is mixed. Psychological and behavioural aspects are determinant, and should be taken into consideration to develop awareness messages that target specific groups.