Factors associated with prehospital delay in patients with ST-segment elevation acute myocardial infarction in China

Development and validation of a nomogram model for predicting the risk of pre-hospital delay in patients with acute myocardial infarction

BACKGROUND

Acute myocardial infarction (AMI) is a severe cardiovascular disease caused by the blockage of coronary arteries that leads to ischemic necrosis of the myocardium. Timely medical contact is critical for successful AMI treatment, and delays increase the risk of death for patients. Pre-hospital delay time (PDT) is a significant challenge for reducing treatment times, as identifying high-risk patients with AMI remains difficult. This study aims to construct a risk prediction model to identify high-risk patients and develop targeted strategies for effective and prompt care, ultimately reducing PDT and improving treatment outcomes.

AIM

To construct a nomogram model for forecasting pre-hospital delay (PHD) likelihood in patients with AMI and to assess the precision of the nomogram model in predicting PHD risk.

METHODS

A retrospective cohort design was employed to investigate predictive factors for PHD in patients with AMI diagnosed between January 2022 and September 2022. The study included 252 patients, with 180 randomly assigned to the development group and the remaining 72 to the validation group in a 7:3 ratio. Independent risk factors influencing PHD were identified in the development group, leading to the establishment of a nomogram model for predicting PHD in patients with AMI. The model's predictive performance was evaluated using the receiver operating characteristic curve in both the development and validation groups.

RESULTS

Independent risk factors for PHD in patients with AMI included living alone, hyperlipidemia, age, diabetes mellitus, and digestive system diseases (P < 0.05). A nomogram model incorporating these five predictors accurately predicted PHD occurrence. The receiver operating characteristic curve analysis indicated area under the receiver operating characteristic curve values of 0.787 (95% confidence interval: 0.716-0.858) and 0.770 (95% confidence interval: 0.660-0.879) in the development and validation groups, respectively, demonstrating the model's good discriminatory ability. The Hosmer-Lemeshow goodness-of-fit test revealed no statistically significant disparity between the anticipated and observed incidence of PHD in both development and validation cohorts (P > 0.05), indicating satisfactory model calibration.

CONCLUSION

The nomogram model, developed with independent risk factors, accurately forecasts PHD likelihood in AMI individuals, enabling efficient identification of PHD risk in these patients.

Shortening Door-to-Balloon Time: The Use of Ambulance versus Private Vehicle for Patients with ST-Segment Elevation Acute Myocardial Infarction

Purpose

Time is critical when dealing with acute myocardial infarction (AMI) patients in the Emergency Department (ED), as 90 min is crucial for overall health. Using non-EMS transportation for critical patients, such as patients with acute myocardial infarction, to a hospital might delay the rapid identification of the underlying medical disease and initiating definitive treatment. We aim to evaluate the association between the mode of transportation and the D2B time in patients presenting at the ED with AMI.

Patients and Methods

We conducted a retrospective cohort study with patients who presented at ED with AMI and underwent percutaneous coronary intervention (PCI). The participants were patients with confirmed AMI at the ED of King Abdullah Medical City (KAMC) from January 2019 to December 2019.

Results

In total, 162 AMI patients were enrolled in the study and divided based on the method of transportation. Less than half (n=65, 40.1%) were transported with an ambulance and 97 (59.9%) patients with a private car. The door-to-balloon (D2B) time for the ambulance group was 93.6±38.31 minutes, and the private car group was 93.8±30.88 minutes.

Conclusion

There was no statistical significance when comparing the D2B time between the private car group and the ambulance group (P = 0.1870). Finally, ambulance transport significantly shortened the time to first ED physician contact. However, it was not associated with shortened D2B time when compared to private vehicle transport.

"We are in the forgotten corner!" a qualitative study of experiences and challenges among Chinese older women at the onset of acute myocardial infarction

Background

Acute myocardial infarction (AMI) is a common and serious cardiovascular disease (CVD) that is one of the leading causes of death among women globally and in China. However, there are sex-associated differences and inequalities in the detection and management of AMI, especially in older people. There is little research demonstrating how challenges and barriers affect older women's help-seeking behavior and health-related procedures in China.

Purpose

The objective of this study was to explore the experiences of older women with AMI, focusing on their perception, challenges, and coping strategies at the onset of AMI in Wuhan, China.

Methods

This study utilized a qualitative research design approach and conducted semi-structured, in-depth, and audio-recorded interviews with 18 women aged 65-84 years, purposively selected from two tertiary hospitals in Wuhan City from November 2021 to April 2022.

Results

Interpretative Phenomenological Analysis (IPA) was used in this study to analyze the data on 18 participants and three major themes were generated: disease perception disorder, negative coping strategies, and barriers due to social-environmental contexts.

Conclusion

To reduce older women's delay in seeking help, healthcare professionals should provide public health education that emphasizes sex-related disparities, and age-specific knowledge-attitude aspects to high-risk groups. Policy-based and health administration recommendations, including e-health information support, access to care, and social-environmental factors, should be highlighted to promote women's health behavior.

Factors Associated with Symptom-to-Door Delay in Patients with ST-Segment Myocardial Infarction: A Systematic Review

BACKGROUND

Decreasing symptom-to-door (S2D) delay is of vital importance for reducing morbidity and mortality in patients with ST-segment elevation myocardial infarction (STEMI). The factors associated with S2D delay in STEMI patients have not been well-characterized.

OBJECTIVES

The aim of this study was to identify factors associated with S2D delay in patients with STEMI.

METHODS

The PubMed, CINAHL, and Embase databases were searched for data. References from the selected articles and relevant background papers were also manually searched to identify additional eligible studies. The included articles were reviewed and assessed for risk of bias. The level of evidence for each identified factor was evaluated using a semiquantitative synthesis.

RESULTS

Twelve (12) papers were included in the review. Factors associated with S2D delay were complex and could be divided into sociodemographic, clinical history, and onset characteristics. The level of evidence regarding female sex and diabetes was strong, and the evidence was moderate regarding older age, smoking, history of hypertension, self-transport, or referral.

CONCLUSIONS

Female sex, older age, previous diabetes, previous hypertension, smoking, and self-transport are all strong or moderate risk factors for S2D time delay in patients with ST-segment myocardial infarction. More efforts should be made to educate at-risk populations concerning symptoms of STEMI and the importance of seeking early medical assistance.

In-hospital major adverse cardiovascular events after primary percutaneous coronary intervention in patients with acute ST-segment elevation myocardial infarction: a retrospective study under the China chest pain center (standard center) treatment system

BACKGROUND

Patients with acute ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) are at high risk of major adverse cardiovascular events (MACE) despite timely treatment. This study aimed to investigate the independent predictors and their predictive value of in-hospital MACE after primary PCI in patients with acute STEMI under the China chest pain center (standard center) treatment system.

METHODS

We performed a single-center, retrospective study of 151 patients with acute STEMI undergoing primary PCI. All patients were treated under the China chest pain center (standard center) treatment system. The data collected included general data, vital signs, auxiliary examination results, data related to interventional therapy, and various treatment delays. The primary endpoint was the in-hospital MACE defined as the composite of all-cause death, stroke, nonfatal recurrent myocardial infarction, new-onset heart failure, and malignant arrhythmias.

RESULTS

In-hospital MACE occurred in 71 of 151 patients with acute STEMI undergoing primary PCI. Logistic regression analysis showed that age, cardiac troponin I (cTnI), serum creatinine (sCr), multivessel coronary artery disease, and Killip class III/IV were risk factors for in-hospital MACE, whereas estimated glomerular filtration rate (eGFR), left ventricular ejection fraction (LVEF), systolic blood pressure (SBP), diastolic blood pressure (DBP), were protective factors, with eGFR, LVEF, cTnI, SBP, and Killip class III/IV being independent predictors of in-hospital MACE. The prediction model had good discrimination with an area under the curve = 0. 778 (95%CI: 0.690-0.865). Good calibration and clinical utility were observed through the calibration and decision curves, respectively.

CONCLUSIONS

Our data suggest that eGFR, LVEF, cTnI, SBP, and Killip class III/IV independently predict in-hospital MACE after primary PCI in patients with acute STEMI, and the prediction model constructed based on the above factors could be useful for individual risk assessment and early management guidance.

Health Inequalities of STEMI Care Before Implementation of a New Regional Network: A Prefecture-Level Analysis of Social Determinants of Healthcare in Yunnan, China

BACKGROUND

As one of the most serious types of coronary heart disease, ST-elevation myocardial infarction (STEMI) faces huge challenges in the equal management and care of patients due to its life-threatening and time-critical condition. Health inequalities such as sex and age differences in STEMI care have been reported from developed countries. However, limited outcomes have been investigated and the major drivers of inequality are still unclear, especially in under-developed areas. This study aimed to explore the major drivers of health inequalities in STEMI care before implementation of a new regional network in the south-west of China.

METHODS

Prefecture-level data of STEMI patients before the implementation of a regional network were analysed retrospectively. Drivers of inequality were identified from six social determinants of health, namely area of residence, ethnicity, sex, age, education and occupation. Outcomes of STEMI care included timely presentation, reperfusion therapy, timely reperfusion therapy, heart failure, inpatient mortality, length of hospital stay, hospital costs, and various intervals of ischaemic time.

RESULTS

A total of 376 STEMI patients in the research area before implementation of the STEMI network were included. Compared with urban residents, rural patients were significantly less likely to have timely presentation (odds ratio [OR]=0.47, 95% CI: 0.28-0.80, P=.004) and timely reperfusion therapy (OR=0.32, 95% CI: 0.14-0.70, P=.005). Rural residents were less likely to present to hospital promptly than urban residents (HR=0.65, 95% CI=0.52-0.82, P<.001). In the first 3 hours of percutaneous coronary intervention (PCI) reperfusion delay and first 6 hours of total ischaemic time, rural patients had a significantly lower probability to receive prompt PCI (hazard ratio [HR]=0.40, 95% CI: 0.29-0.54, P<.001) and reperfusion therapy (HR=0.37, 95% CI: 0.25-0.56, P<.001) compared to urban patients.

CONCLUSION

Rural residents were a major vulnerable group before implementation of the regional STEMI network. No obvious inequalities in ethnicity, sex, age, education or occupation existed in STEMI care in Chuxiong Prefecture of China.

Before the door: Comparing factors affecting symptom onset to first medical contact for STEMI patients between a high and low-middle income country

Background

Early reperfusion in patients with ST-segment elevation myocardial infarction (STEMI) has been associated with preservation of left ventricular function and decrease in mortality. Symptom onset to first medical contact (FMC) time consumes the majority of total ischemic time, and remains one of the main reasons that patients do not receive timely care. With FMC to reperfusion time being effectively reduced in many parts of the world, the focus is now shifting to reducing symptom onset to FMC times.

Methods

This mixed-methods observational study was designed to elucidate factors affecting symptom onset to FMC time at a regional cardiac center in a low-middle income country (LMIC) and a high-income country (HIC). A review of the Aswan Heart Center and Hamilton General Hospital STEMI registry in Egypt and Canada was conducted, and retrospective semi-structured questionnaires carried out for a convenience sample of 158 patients.

Results

Gender, symptom type and severity were none-modifiable factors found between early and late presenters. Modifiable factors found were actions of bystanders, actions of patients, transportation method and time. Emotional factors also showed differences between the two groups.

Conclusion

While some concepts are generalizable, contextual differences in demographics, risk factors, access and knowledge are identified. These factors can be used to inform tailored knowledge translation strategies to help reduce symptom onset to FMC in both LMIC and HIC.

The relationship between symptom onset-to-needle time and ischemic outcomes in patients with acute myocardial infarction treated with primary PCI: Observations from Prague-18 Study

OBJECTIVES

Based on previous studies with clopidogrel, the time between acute myocardial infarction (AMI) symptoms onset and primary percutaneous coronary intervention (PCI) was proven as important prognostic factor. Our aim was to assess the relationship between symptoms onset to needle time (SNT) and procedural results and the occurrence of ischemic endpoints in primary angioplasty patients treated with potent P2Y12 inhibitors.

METHODS

A total of 1,131 out of 1,230 patients randomized to the Prague-18 study (prasugrel vs. ticagrelor in primary PCI) were divided into a high and a low-risk group. The effect of defined SNT on patients' ischemic endpoints and prognosis by their risk status at admission was tested.

RESULTS

The median SNT was 3.2 hours. Longer SNTs resulted in a more frequent incidence of TIMI flow <3 post PCI (p=0.015). There were significant differences in the occurrence of the combined ischemic endpoint among the compared SNT groups at 30 days (p=0.032), and 1 year (p=0.011), with the highest incidence in the ≤1 h SNT group of patients. "Latecomers" (SNT>4 hs) in the high-risk group experienced more reinfarction within 1 year [OR (95% CI) 3.23 (1.09-9.62) p=0.035]; no difference was found in the low-risk group.

CONCLUSIONS

In the era of intense antithrombotic medication, stratification of MI patients undergoing primary angioplasty, based on initial ischemic risk assessment affected prognosis more than symptom onset to needle time. Longer time delay was significantly related to increased incidence of ischemic events and all-cause mortality only in patients with high ischemic risk.

Analysis of potential factors contributing to refusal of invasive strategy after ST-segment elevation myocardial infarction in China

Background:

Reduced application of percutaneous coronary intervention (PCI) is associated with higher mortality rates after ST-segment elevation myocardial infarction (STEMI). We aimed to evaluate potential factors contributing to the refusal of PCI in STEMI patients in China.

Methods:

We studied 957 patients diagnosed with STEMI in the emergency departments (EDs) of six public hospitals in China. The differences in baseline characteristics and 30-day outcome were investigated between patients who refused PCI and those who underwent PCI. Multivariable logistic regression was used to evaluate the potential factors associated with refusing PCI.

Results:

The potential factors contributing to refusing PCI were older than 65 years (odds ratio [OR] 2.66, 95% confidence interval [CI] 1.56–4.52, P < 0.001), low body mass index (BMI) (OR 0.91, 95% CI 0.84–0.98, P = 0.013), not being married (OR 0.29, 95% CI 0.17–0.49, P < 0.001), history of myocardial infarction (MI) (OR 2.59, 95% CI 1.33–5.04, P = 0.005), higher heart rate (HR) (OR 1.02, 95% CI 1.01–1.03, P = 0.002), cardiac shock in the ED (OR 5.03, 95% CI 1.48–17.08, P = 0.010), pre-hospital delay (>12 h) (OR 3.31, 95% CI 1.83–6.02, P < 0.001) and not being hospitalized in a tertiary hospital (OR 0.45, 95% CI 0.27–0.75, P = 0.002). Compared to men, women were older, were less often married, had a lower BMI and were less often hospitalized in tertiary hospitals.

Conclusions:

Patients who were older, had lower economic or social status, and had poorer health status were more likely to refuse PCI after STEMI. There was a sex difference in the potential predictors of refusing PCI. Targeted efforts should be made to improve the acceptance of PCI among patients with STEMI in China.

Time-to-Treatment and Its Association With Complications and Mortality Rate in Patients With Acute Myocardial Infarction: A Prospective Cohort Study

INTRODUCTION

Time-to-treatment is one of the most important factors affecting the complications and mortality rate in patients with acute myocardial infarction. The purpose of this study was to determine time-to-treatment and its association with complications and mortality rates in patients with acute myocardial infarction in selected hospitals in Zanjan, Iran.

METHODS

This prospective cohort study was performed with 200 patients suffering from acute myocardial infarction in selected educational hospitals of Zanjan from June 2016 to March 2017. Parameters including the interval between pain onset and treatment, myocardial infarction complications, in-hospital mortality, and 30-day mortality after the occurrence of myocardial infarction were collected through a special questionnaire and phone calls. The data were analyzed using descriptive statistics and logistic regression models.

RESULTS

The longest time-to-treatment delay is related to prehospital time (mean, 330.68 [SD=411.55] minutes). Based on the results, the increase in the interval time between onset of pain and treatment (odds ratio: 1.001; 95% confidence interval, 1.000-1.002; P = 0.01), hypertension (odds ratio: 2.96; 95% confidence interval, 1.14-7.68; P = 0.02), and left coronary artery complete occlusion (odds ratio: 2.78; 95% confidence interval, 1.57-4.94; P < 0.001) were mortality predictor factors. Furthermore, the increase in the interval time between onset of pain and treatment (odds ratio: 1.001; 95% confidence interval, 1.000-1.002; P = 0.03), current smoking (odds ratio: 5.53; 95% confidence interval, 1.75-17.43; P = 0.004), and right coronary artery complete occlusion (odds ratio: 5.87; 95% confidence interval, 1.34-25.82; P = 0.02) were highly associated with the occurrence of heart failure.

DISCUSSION

Hypertension, smoking history, and delay in treatment time were highly associated with the occurrence of heart failure and mortality. Therefore, in Iranian society, education on primary and secondary prevention of myocardial infarction is recommended to reduce patient mortality.

The role of late reperfusion in ST-segment elevation myocardial infarction: a real-world retrospective cohort study

Background

Early reperfusion of the coronary artery has become the first choice for patients with ST-segment elevation myocardial infarction (STEMI). How to deal with patients who miss the time window for early reperfusion is still controversial. Based on real-world data, this study was conducted to explore whether percutaneous coronary intervention (PCI) has an advantage over standard drug therapy in patients who miss the optimal treatment window.

Methods

Consecutive patients who were diagnosed with STEMI and met the inclusion criteria between 2009 and 2018 in our center were retrospectively included in this cohort study. The primary endpoint events were major adverse cardiac events (MACEs), including heart failure, sudden cardiac death, malignant arrhythmia, thrombi and bleeding events during the period of admission. Secondary endpoint events were components of MACEs. At the same time, we also evaluated angina pectoris at admission and discharge through Canadian Cardiovascular Society (CCS) grading.

Results

This study enrolled 417 STEMI patients and divided them into four groups (PCI < 3 days, 14.87%; 3 days<PCI < 7 days, 21.104%; PCI > 7 days, 34.29%; MED, 29.74%). During the period of admission, MACEs occurred in 52 cases. The incidence of MACEs was 11.29, 7.95, 4.20 and 25.81% in the four respective groups (p < 0.0001). The MED group had higher rates of MACEs (OR = 3.074; 95% CI 0.1.116–8.469, p = 0.03) and cardiac death (OR = 3.027; 95% CI 1.121–8.169, p = 0.029) compared to the PCI group. Although both treatments were effective in improving CCS grade at discharge, the PCI group improved more significantly (p < 0.0001).

Conclusions

In the real world, delayed PCI can be more effective in patients with angina symptoms at discharge and reduce the incidence of MACEs and cardiac death during hospitalization. The timing of intervention was independent of the occurrence of MACEs during hospitalization and of improvement in symptoms.

Prehospital and in-hospital delays to care and associated factors in patients with STEMI: an observational study in 101 non-PCI hospitals in China

OBJECTIVES

To describe the prehospital and in-hospital delays to care and factors associated with the delays among patients with ST-segment elevation myocardial infarction (STEMI) in non-percutaneous coronary intervention (PCI) hospitals in China.

DESIGN, SETTING AND PARTICIPANTS

We analysed data from a large registry-based quality of care improvement trial conducted from 2011 to 2014 among 101 non-PCI hospitals in China. A total of 7312 patients with STEMI were included. Prehospital delay was defined as time from symptom onset to hospital arrival >120 min, first ECG delay as time from arrival to first ECG >10 min, thrombolytic therapy delay as time from first ECG to thrombolytic therapy >10 min and in-hospital delay as time from arrival to thrombolytic therapy >30 min. Logistic regressions with generalised estimating equations were preformed to identify the factors associated with each delay.

RESULTS

The rates of prehospital delay, first ECG delay, thrombolytic therapy delay and in-hospital delay were 67.1%, 31.4%, 85.8% and 67.8%, respectively. Patients who were female, older than 65 years old, illiterate, farmers, onset during late night and forenoon, had heart rate ≥100 beats/m at admission were more likely and patients who had history of myocardial infarction, hypertension or SBP <90 mm Hg at admission were less likely to have prehospital delay. First ECG delay was more likely to take place in patients arriving on regular hours. Thrombolytic therapy delay rate was lower in patients who had prehospital delay or first ECG delay but higher in those with heart rate ≥100 beats/m at admission. In-hospital delay rate was lower in patients with a history of dyslipidaemia and those who arrived during regular hours.

CONCLUSION

Chinese patients with STEMI in low medical resource areas suffered severe prehospital and in-hospital delays to care. Future efforts should be made to improve the prehospital delay among vulnerable populations with low socioeconomic status.

TRIAL REGISTRATION NUMBER

NCT01398228; Post-results.

The MEDEA FAR-EAST Study: Conceptual framework, methods and first findings of a multicenter cross-sectional observational study

BACKGROUND

The substantial increase in cardiovascular diseases (CVD) in China over the last three decades warrants comprehensive preventive primary and secondary strategies. Prolonged prehospital delay (PHD) has been identified as a substantial barrier to timely therapeutic interventions for acute myocardial infarction (AMI). Despite worldwide efforts to decrease the patient's decision-making time, minimal change has been achieved so far. Here, we aim to describe the conceptual framework and methods and outline key data of the MEDEA FAR-EAST Study, which aimed to elucidate in-depth barriers contributing to delay in Chinese AMI-patients.

METHODS

Data sources of this multicenter cross-sectional observational study are a standardized bedside interview, a self-administered tailored questionnaire tool and the patient chart. PHD was defined as the main outcome and triangulated at bedside. Standard operation procedures ensured uniform data collection by trained study personnel. The study was ethically approved by Tongji-Hospital and applied to all participating hospitals.

RESULTS

Among 379 consecutively screened patients, 296 (78.1%) fulfilled eligibility criteria. A total of 241 (81.4%) AMI-patients were male and 55 (18.6%) female. Mean age was 62.9 years. Prehospital delay time was assessed for 294 (99.3%) patients. Overall median PHD was 151 min with no significant sex difference. Symptom mismatch was present in 200 (69.7%) patients and 106 (39.0%) patients did not attribute their symptoms to cardiac origin. A total of 33 (12.4%) patients suffered from depression, 31 (11.7%) from anxiety and 141 (53.2%) patients employed denial as their major coping style.

CONCLUSION

This is the first study on prehospital delay with emphasis on psychological variables in Chinese AMI-patients. A comprehensive assessment tool to measure clinical and psychological factors was successfully implemented. Socio-demographic key data proved a good fit into preexisting Chinese literature. Potential barriers including cardiac denial and symptom-mismatch were assessed for the first time in Chinese AMI-patients. The pretested selection of instruments allows future in depth investigations into barriers to delay of Chinese AMI-patients and enables inter-cultural comparisons.

Pre-Hospital Factors Influencing Time of Arrival at Emergency Departments for Patients with Acute ST-Elevation Myocardial Infarction

Background

Pre-hospital delay is currently a major factor limiting early reperfusion among ST-elevation myocardial infarction (STEMI) patients worldwide. This study aims to determine pre-hospital factors affecting symptom-to-door time among STEMI patients in Malaysia.

Methods

This cross-sectional study included 222 STEMI patients admitted to two tertiary hospitals in Malaysia. By determining symptom-to-door time, the study population was categorised into two definitive treatment seeking groups: early (≤ 3 h) and delayed (> 3 h). Data was collected focusing on socio-demographical data, risk factors and comorbidities, clinical presentation, situational factors and action taken by patients.

Results

The mean age of our patients was 58.0 (SD = 11.9) years old, and the population consisted of 186 (83.8%) males and 36 (16.2%) females. Our study found that the median symptom-to-door time was 130.5 (IQR 240) min, with 64% of subjects arriving early and 36% arriving late. Pre-hospital delays were found to be significant among females (adj OR = 2.42; 95% CI: 1.02, 5.76; P = 0.046), patients with recurrence of similar clinical presentations (adj OR = 2.74; 95% CI: 1.37, 5.46; P = 0.004), patients experiencing atypical symptoms (adj OR = 2.64; 95% CI: 1.11, 6.31; P = 0.029) and patients who chose to have their first medical contact (FMC) for their symptoms with a general practitioner (adj OR = 2.80; 95% CI: 1.20, 6.56; P = 0.018). However, patients with hyperlipidaemia (adj OR = 0.46; 95% CI: 0.23, 0.93; P = 0.030), self-perceived cardiac symptoms (adj OR = 0.36; 95% CI: 0.17, 0.73; P = 0.005) and symptoms that began in public places (adj OR = 0.21; 95% CI: 0.06, 0.69; P = 0.010) tended to seek treatment earlier.

Conclusion

The symptom-to-door time among the Malaysian population is shorter in comparison to other developing countries. Nevertheless, identified, modifiable pre-hospital factors can be addressed to further shorten symptom-to-door time among STEMI patients.

Psychometric Evaluation of the Major Depression Inventory (MDI) as a Depression Severity Scale in Chinese Patients With Coronary Artery Disease. Findings From the MEDEA FAR-EAST Study

Background: It is highly recommended that all patients with coronary artery disease should be screened for depression. The Major Depression Inventory (MDI) is a widely used self-rating scale for the assessment of depression but is not valid in Chinese language. The present study was designed to assess the reliability and validity of a version of the MDI translated into Chinese among patients with acute myocardial infarction (AMI). Methods: Data were derived from the "Multicenter Delay in Patients Experiencing Acute Myocardial Infarction in Shanghai" (MEDEA FAR-EAST) study. Using a cross-sectional study design, the Chinese version of the MDI was administered to a total of 267 inpatients. The internal consistency reliability of the MDI scale was evaluated based on the Cronbach's coefficient and the binary coefficient for the whole scale. Exploratory factor analysis was performed to assess the internal consistency of the MDI. To examine discriminant validity, we analyzed the correlation of the MDI score with the General Anxiety Disorder-7 (GAD-7) and World Health Organization-5 Well-Being Index (WHO-5) scale scores. Results: The Chinese version of the MDI showed high reliability (Cronbach's alpha = 0.909, split-half reliability = 0.866). We identified one factor that explained 52% of the variance, which indicated that the MDI has satisfactory structural validity. The correlations of the MDI scores with the GAD-7 scores (r = 0.425) and the WHO-5 scores (r = -0.365) were moderate, suggesting that the MDI has acceptable discriminant validity. Conclusions: The MDI was proved to be a highly reliable and satisfactory valid diagnostic screening tool to assess depression in Chinese cardiac patients.

Gender disparities in first medical contact and delay in ST-elevation myocardial infarction: a prospective multicentre Swedish survey study

OBJECTIVES

Compare gender disparities in ST-elevation myocardial infarction (STEMI) regarding first medical contact (FMC) and prehospital delay times and explore factors associated with prehospital delay in men and women separately.

DESIGN

Cross-sectional study based on medical records and a validated questionnaire. Eligible patients were enrolled within 24 hours after admittance to hospital.

SETTING

Patients were included from November 2012 to January 2014 from five Swedish hospitals with catheterisation facilities 24/7.

PARTICIPANTS

340 men and 109 women aged between 31 and 95 years completed the survey.

MAIN OUTCOME MEASURES

FMC were divided into five possible contacts: primary healthcare centre by phone or directly, national advisory nurse by phone, emergency medical services (EMS) and emergency room directly. Two parts of prehospital delay times were studied: time from symptom onset to FMC and time from symptom onset to diagnostic ECG.

RESULTS

Women more often called an advisory nurse as FMC (28% vs 18%, p=0.02). They had a longer delay until FMC, 90 (IQR 39-221) vs 66 (28-161) min, p=0.04 and until ECG, 146 (68-316) vs 103 (61-221) min, p=0.03. Men went to hospital because of believing they were stricken by an MI to a higher extent than women did (25% vs 15%, p=0.04) and were more often recommended to call EMS by bystanders (38% vs 22%, p<0.01). Hesitating about going to hospital and experiencing pain in the stomach/back/shoulders were factors associated with longer delays in women. Believing the symptoms would disappear or interpreting them as nothing serious were corresponding factors in men. In both genders bystanders acting by contacting EMS explained shorter prehospital delays.

CONCLUSIONS

In STEMI, women differed from men in FMC and they had longer delays. This was partly due to atypical symptoms and a longer decision time. Bystanders acted more promptly when men than when women fell ill. Public knowledge of MI symptoms, and how to act properly, still seems insufficient.

Symptom clusters and treatment time delay in Korean patients with ST-elevation myocardial infarction on admission

Most patients with acute myocardial infarction (AMI) experience more than one symptom at onset. Although symptoms are an important early indicator, patients and physicians may have difficulty interpreting symptoms and detecting AMI at an early stage. This study aimed to identify symptom clusters among Korean patients with ST-elevation myocardial infarction (STEMI), to examine the relationship between symptom clusters and patient-related variables, and to investigate the influence of symptom clusters on treatment time delay (decision time [DT], onset-to-balloon time [OTB]). This was a prospective multicenter study with a descriptive design that used face-to-face interviews. A total of 342 patients with STEMI were included in this study. To identify symptom clusters, two-step cluster analysis was performed using SPSS software. Multinomial logistic regression to explore factors related to each cluster and multiple logistic regression to determine the effect of symptom clusters on treatment time delay were conducted. Three symptom clusters were identified: cluster 1 (classic MI; characterized by chest pain); cluster 2 (stress symptoms; sweating and chest pain); and cluster 3 (multiple symptoms; dizziness, sweating, chest pain, weakness, and dyspnea). Compared with patients in clusters 2 and 3, those in cluster 1 were more likely to have diabetes or prior MI. Patients in clusters 2 and 3, who predominantly showed other symptoms in addition to chest pain, had a significantly shorter DT and OTB than those in cluster 1. In conclusion, to decrease treatment time delay, it seems important that patients and clinicians recognize symptom clusters, rather than relying on chest pain alone. Further research is necessary to translate our findings into clinical practice and to improve patient education and public education campaigns.

Clinical characteristics and improvement of the guideline-based management of acute myocardial infarction in China: a national retrospective analysis

Objective

This study is to document the clinical characteristics and improvement in management of acute myocardial infarction (AMI) in Chinese population.

Results

This study included 64,654 patients (23,805 patients in 2011, 40,849 patients in 2013), of which STEMI and NSTEMI account for 85.09% and 14.91%, respectively. From 2011 to 2013, significant improvement has been achieved in the recanalization rate of PCI (96.01% vs. 98.63%, P < 0.001) and in-hospital deaths (4.52% vs. 3.55%, P = 0.038). Although the time of door-to-balloon and the duration of PCI were satisfactorily controlled within 90min and 60min, respectively, the onset-to-FMC time (≈3.5h) and door-to-thrombolysis time (≈1.1h) limited the efficiency of management. The total cost of medical care showed no increase from 2011 to 2013, but the patient's paid Portion decreased from 20.33% to 13.96%.

Materials and Methods

The AMI patients admitted in the general hospitals in 2011 and 2013 were retrospectively analyzed according to the data reported to the Single Disease Quality Control Information Systemissued by Chinese Hospital Association.

Conclusion

Compared to the Western countries, STEMI accounted for a larger portion of AMI, and the AMI management in China basically meets the standards of the quality control of guidelines. With improvement of management, there was no increase in the total medical cost, while the patient's paid portion was actually reduced. In future, improvement of transportation strategy and the public medical education are recommended to shorten the onset-to-FMC time to further improve the outcome of AMI patients.

Low level of knowledge of heart attack symptoms and inappropriate anticipated treatment-seeking behaviour among older Chinese: a cross-sectional survey

BACKGROUND

Prehospital delay of acute myocardial infarction (AMI) is common globally, and Hong Kong-home of a rapidly ageing Chinese population-is not an exception. Seeking emergency medical care promptly is important for patients. Treatment-seeking behaviours have been shown to be associated with knowledge of AMI symptoms and specific cultural beliefs. This study aimed to assess the level of knowledge of AMI symptoms and expected treatment-seeking behaviour among older Chinese in Hong Kong.

METHODS

A cross-sectional population-based survey was conducted at the Elderly Health Centres in Hong Kong from March to September 2016. Face-to-face interviews were conducted with a structured questionnaire based on previous studies and local adaptations.

RESULTS

Among 1804 people aged 65 years and above who completed the questionnaire, chest pain (80.2%), palpitations (75.8%) and fainting (71.9%) were the major symptoms recognised as AMI related. Meanwhile, stomach ache (46.9%), coughing (45.4%) and neck pain (40.8%) were recognised as not AMI related. The mean expected discomfort intensity during AMI onset was 7.7 out of 10 (SD=2.1). Regarding the expected treatment-seeking behaviour, seeking non-emergent medical care was the most popular action when AMI symptoms emerged during the day, without chest pain or with lower discomfort intensity, whereas calling an ambulance was the most common option when AMI symptoms emerged at night or with high discomfort intensity.

CONCLUSIONS

To minimise delays in seeking treatment, future health education should focus on increasing the public knowledge of AMI symptoms and the need to call an ambulance during an emergency.

Coronary intervention door-to-balloon time and outcomes in ST-elevation myocardial infarction: a meta-analysis

OBJECTIVE

This study aims to determine the relationship between door-to-balloon delay in primary percutaneous coronary intervention and ST-elevation myocardial infarction (MI) outcomes and examine for potential effect modifiers.

METHODS

We conducted a systematic review and meta-analysis of prospective observational studies that have investigated the relationship of door-to-balloon delay and clinical outcomes. The main outcomes include mortality and heart failure.

RESULTS

32 studies involving 299 320 patients contained adequate data for quantitative reporting. Patients with ST-elevation MI who experienced longer (>90 min) door-to-balloon delay had a higher risk of short-term mortality (pooled OR 1.52, 95% CI 1.40 to 1.65) and medium-term to long-term mortality (pooled OR 1.53, 95% CI 1.13 to 2.06). A non-linear time-risk relation was observed (P=0.004 for non-linearity). The association between longer door-to-balloon delay and short-term mortality differed between those presented early and late after symptom onset (Cochran's Q 3.88, P value 0.049) with a stronger relationship among those with shorter prehospital delays.

CONCLUSION

Longer door-to-balloon delay in primary percutaneous coronary intervention for ST-elevation MI is related to higher risk of adverse outcomes. Prehospital delays modified this effect. The non-linearity of the time-risk relation might explain the lack of population effect despite an improved door-to-balloon time in the USA.

CLINICAL TRIAL REGISTRATION

PROSPERO (CRD42015026069).

Gender Differences in Factors Related to Prehospital Delay in Patients with ST-Segment Elevation Myocardial Infarction

PURPOSE

The aim of our study was to investigate gender differences in factors related to prehospital delay and identify whether the knowledge of acute myocardial infarction symptoms affects this delay in Korean patients with ST-elevation myocardial infarction (STEMI).

MATERIALS AND METHODS

A total of 350 patients (286 men, 64 women) with confirmed STEMI were interviewed to investigate socio-demographics, history of disease, symptom onset time, and factors that contributed to delayed decision time in seeking treatment and hospital arrival time from symptom onset. Factors associated with prehospital delay were examined separately by gender using univariate and multivariate analyses.

RESULTS

Female patients had higher proportions of ≥60-minute decision time and ≥120-minute arrival time compared to male patients (33.9% vs. 23.1%, 60.9% vs. 52.1%, respectively). However, the difference was not statistically significant (p=0.093 and 0.214, respectively). Previous cardiovascular disease (CVD) was associated with increased decision time in men, whereas, in women, lower educational status caused a greater delay in decision time. Factors associated with hospital arrival time excluding delayed decision time were referral from another hospital, previous CVD, and percutaneous coronary intervention in men, and referral from another hospital in women.

CONCLUSION

Gender differences exist in factors related to prehospital delay. Therefore, public education to reduce prehospital delay should be conducted according to gender with a focus on the pertinent factors.

Predictors of pre-hospital delay in Hong Kong Chinese patients with acute myocardial infarction

BACKGROUND

The pre-hospital delay to seek care remains the most significant barrier for effective management of acute myocardial infarction. Many of the previous studies mainly took place in Western countries. Few data are available about the care-seeking behavior of Hong Kong Chinese.

AIM

The purpose of this study was to identify the predictors of pre-hospital delay in care seeking among Hong Kong Chinese patients with acute myocardial infarction.

METHODS

Adult Chinese patients ( n=301) with a confirmed diagnosis of acute myocardial infarction were recruited from the cardiac units of three regional hospitals in Hong Kong. Various socio-demographic, clinical, symptom presentation characteristics and patient perceptual factors were considered as potential predictors. Multivariate analysis was conducted to identify the independent predictors with pre-hospital delay in care-seeking among acute myocardial infarction patients.

RESULTS

Perceived barriers to care seeking constituted the most significant predictor for longer pre-hospital delay in acute myocardial infarction patients. Female gender was also significant in predicting longer delay, whereas a greater extent of symptom congruence and a greater extent of typical symptom presentation were significantly associated with a shorter delay. The final model accounted for 49.6% of the variance in pre-hospital delay as a whole.

CONCLUSION

The most prominent predictors of pre-hospital delay are modifiable in nature, including the perceived barriers to care seeking and symptom congruence. Other sociodemographic and clinical factors also influence patients' decision. Although these are non-modifiable, our findings provide important insight for educating high-risk individuals.

Symptom-to-door delay among patients with ST-segment elevation myocardial infarction in Singapore

OBJECTIVES

Symptom-to-door time (S2D) is one of the important components of ischaemic time, which might affect the infarct size and outcomes of acute myocardial infarction. The aim of the present study was to identify patients' characteristics associated with delayed symptom-onset-to-arrival at EDs in ST-segment elevation myocardial infarction (STEMI) patients in Singapore.

METHODS

Retrospective data of STEMI patients presenting to the ED of all public hospitals with onsite primary percutaneous coronary intervention facilities between 2010 and 2012 were obtained from the Singapore Myocardial Infarction Registry. Based on the S2D of 120 min, characteristics of patients were compared between short S2D (≤120 min) and long S2D (>120 min). Multivariate logistic and linear regression analyses were performed.

RESULTS

Out of 3848 patients, 1682 patients had an S2D of ≤120 min, and 2166 had an S2D >120 min. In the multivariate analyses, older age, Malay ethnicity, diabetes mellitus, presenting symptoms of back and epigastric pain were independently associated with long S2D. Patients who utilised the emergency medical services, presented after office hours and with symptoms of chest pain, breathlessness, diaphoresis and past history of percutaneous transluminal coronary angioplasty/primary percutaneous coronary intervention, were independently associated with short S2D. Patients with long S2D had lower probability of receiving reperfusion treatment with delayed symptom-to-balloon and door-to-balloon time and higher probabilities of complications and mortality.

CONCLUSION

The present study shows that longer S2D was associated with older age, ethnicity, diabetes mellitus, delay in receiving early reperfusion treatment and poorer prognosis.

The China Acute Myocardial Infarction (CAMI) Registry: A national long-term registry-research-education integrated platform for exploring acute myocardial infarction in China

BACKGROUND

Acute myocardial infarction (AMI) has become a major cause of hospitalization and mortality in China. There has been limited data to date available to characterize AMI presentation, contemporary patterns of medical care, and outcomes in China.

AIMS

The CAMI Registry is a national project with the objectives to timely obtain real-world knowledge about AMI patients and to provide the platform for clinical research, guide preventive measures and care quality improvement efforts in China.

METHODS AND PROGRESS

The CAMI registry is a prospective, nationwide, multicenter observational study for AMI patients. The registry includes three levels of hospitals (representing typical Chinese governmental and administrative models) from all provinces and municipalities throughout Mainland China except Hong Kong and Macau. Sites were instructed to enroll consecutive patients with a primary diagnosis of AMI. Clinical data, treatments, outcomes and cost are collected by local investigators and captured electronically, with a standardized set of variables and standard definitions, and rigorous data quality control. Post-discharge patient follow-up to 2 years is planned. The CAMI Registry was launched in January 2013. A total of 108 hospitals have participated in the registry so far. As of September 2014, 26,103 patients with AMI were registered.

CONCLUSIONS

The CAMI registry represents a well-supported and the largest national long-term registry-research-education platform for surveillance, research, prevention and care improvement for AMI in China, the world's most populous nation. The broad representation of all provinces and different-level hospitals will allow for the exploration of AMI across diverse geographic regions and economic circumstances.

Predictors of delay in seeking treatment by Jordanian patients with acute coronary syndrome

BACKGROUND

ACS management aims for early coronary reperfusion, which should be within one hour from symptoms onset. This time was found to be relatively long, and many patients died before hospital arrival. In Jordan, this phenomenon is not clearly understood with a discrepancy between the reported durations of delay time.

AIMS

To evaluate Jordanian ACS patients' delay time in seeking medical care, along with predictors of delay.

METHODS

A descriptive, cross-sectional design was utilized to conveniently recruit 160 Jordanian ACS patients. Data were collected using chart review and the Modified ACS Response Questionnaire.

RESULTS

The mean delay time was 7.8 hours (SD =3.5), with none of participants presenting within one hour. Delay time correlated negatively with ACS history, knowledge, attitudes, beliefs, and perceived risk (r = -0.448, r = -0.400, r = -0.408, r = -0.261, r = -0.411, respectively) and positively with health perception (r = 0.469). A 4-predictor model (history, beliefs, health perception, STEMI diagnosis) was revealed explaining 40% of variance in delay time (R(2)=.400, F (14,145) = 6.908, P < .001).

CONCLUSION

Improving ACS patients' health seeking behaviors can be achieved when all components of care are considered together.

Predictors of prehospital delay in patients with acute myocardial infarction in kashan city

Background:

The prehospital delay might result in death in patients with acute myocardial infarction (AMI).

Objectives:

This study aimed to investigate the prehospital delay and its related factors in patients with AMI admitted to Kashan’s Shahid Beheshti Hospital.

Patients and Methods:

This cross-sectional study was conducted on 117 patients with AMI in the second half of 2013. The interval between the onset of symptoms and arrival at the hospital was noted and in cases of delay, the factors leading to the delay were investigated using a questionnaire. The content validity of the questionnaire was confirmed through content validity method and its internal consistency was confirmed using Cronbach's alpha coefficient. Chi-square test, odds ratio, and logistic regression analysis were used in data analysis.

Results:

The median delay was 129 minutes (mean ± SD, 240.44 ± 295.30). Overall, 32.5% of patients were admitted within 90 minutes of symptom onset. The long distance between living locations to the hospital was the most common cause of delay to hospital admission (31.7%). Significant associations were observed between the delay time and location of residency (P = 0.00) and type of transportation vehicle (P = 0.003). Multivariate logistic regression analysis showed that the location of residency and type of transportation vehicle could significantly predict the delay time in patients with AMI (P = 0.039 and 0.036, respectively).

Conclusions:

The delay time from symptom onset to hospital admission was high in patients with AMI. It is necessary to create emergency medical system (EMS) stations in suburbs and train the public on the importance of quick contact with the EMS when the symptoms of an AMI are observed.

Gender and Age Differences Associated With Prehospital Delay in Chinese Patients Presenting With ST-Elevation Myocardial Infarction

BACKGROUND AND OBJECTIVES

A limited number of studies have examined the interaction between gender and age with regard to extent of prehospital delay. Our aim was to examine gender and age differences associated with prehospital delay in Chinese patients presenting with ST-elevation myocardial infarction (STEMI).

METHODS

A total of consecutive 1429 records from patients presenting with STEMI were analyzed between June 1, 2009, and June 1, 2010. We compared hospital care data by gender and age for inpatients with acute STEMI presenting within 24 hours of symptom onset.

RESULTS

The overall median duration of prehospital delay was 150 minutes (mean, 266 minutes). For patients 54 years or younger, 55 to 64 years old, and 75 years or older, women were more likely to experience longer delays compared with men (P < .05) even after controlling for medical history and risk factors. For male patients, compared with groups 54 years or younger, with the exception of men 55 to 64 years old, older male patients were more likely to have greater delays (P < .05) even after controlling for medical history and risk factors. However, after controlling for other variables, these gender and age differences in prehospital delay were no longer statistically significant. Among patients 65 to 74 years old, there were no gender differences in prehospital delay. Among female patients, there were no age differences in prehospital delay.

CONCLUSIONS

Male elderly patients (aged ≥65 years) and women (aged ≤64 and ≥75 years) with STEMI were more likely to delay seeking timely medical care. These gender and age differences were explained by different education, stable income, medical insurance, typical chest pain, and cognition toward heart diseases.