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Yiadom MYAB, Gong W, Patterson BW, Baugh CW, Mills AM, Gavin N, Podolsky SR, Mumma BE, Tanski M, Salazar G, Azzo C, Dorner SC, Hadley K, Bloos SM, Bunney G, Vogus TJ, Liu D. Influence of time-to-diagnosis on time-to-percutaneous coronary intervention for emergency department ST-elevation myocardial infarction patients: Time-to-electrocardiogram matters. J Am Coll Emerg Physicians Open 2024; 5:e13174. [PMID: 38726468 PMCID: PMC11079543 DOI: 10.1002/emp2.13174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 02/28/2024] [Accepted: 03/15/2024] [Indexed: 05/12/2024] Open
Abstract
Objectives Earlier electrocardiogram (ECG) acquisition for ST-elevation myocardial infarction (STEMI) is associated with earlier percutaneous coronary intervention (PCI) and better patient outcomes. However, the exact relationship between timely ECG and timely PCI is unclear. Methods We quantified the influence of door-to-ECG (D2E) time on ECG-to-PCI balloon (E2B) intervention in this three-year retrospective cohort study, including patients from 10 geographically diverse emergency departments (EDs) co-located with a PCI center. The study included 576 STEMI patients excluding those with a screening ECG before ED arrival or non-diagnostic initial ED ECG. We used a linear mixed-effects model to evaluate D2E's influence on E2B with piecewise linear terms for D2E times associated with time intervals designated as ED intake (0-10 min), triage (11-30 min), and main ED (>30 min). We adjusted for demographic and visit characteristics, past medical history, and included ED location as a random effect. Results The median E2B interval was longer (76 vs 68 min, p < 0.001) in patients with D2E >10 min than in those with timely D2E. The proportion of patients identified at the intake, triage, and main ED intervals was 65.8%, 24.9%, and 9.7%, respectively. The D2E and E2B association was statistically significant in the triage phase, where a 1-minute change in D2E was associated with a 1.24-minute change in E2B (95% confidence interval [CI]: 0.44-2.05, p = 0.003). Conclusion Reducing D2E is associated with a shorter E2B. Targeting D2E reduction in patients currently diagnosed during triage (11-30 min) may be the greatest opportunity to improve D2B and could enable 24.9% more ED STEMI patients to achieve timely D2E.
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Affiliation(s)
| | - Wu Gong
- Department of Biostatistics, Vanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Brian W. Patterson
- Department of Emergency MedicineUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
| | - Christopher W. Baugh
- Department of Emergency MedicineBrigham and Women's Hospital–Harvard UniversityBostonMassachusettsUSA
| | - Angela M. Mills
- Department of Emergency MedicineColumbia University College of Physicians and SurgeonsNew YorkNew YorkUSA
| | - Nicholas Gavin
- Department of Emergency MedicineIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Seth R. Podolsky
- Legacy HealthPortlandOregonUSA
- Oregon Health & Science UniversityCollege of MedicinePortlandOregonUSA
- Elson S. Floyd College of MedicineWashington State UniversitySpokaneWashingtonUSA
| | - Bryn E. Mumma
- Department of Emergency MedicineUniversity of California–DavisDavisCaliforniaUSA
| | - Mary Tanski
- Department of Emergency MedicineOregon Health & Science UniversityPortlandOregonUSA
| | - Gilberto Salazar
- Department of Emergency MedicineUniversity of Texas SouthwesternDallasTexasUSA
| | - Caitlin Azzo
- Department of Emergency MedicineMassachusetts General Hospital, Harvard School of MedicineBostonMassachusettsUSA
| | - Stephen C. Dorner
- Department of Emergency MedicineMassachusetts General Hospital, Harvard School of MedicineBostonMassachusettsUSA
| | - Kelsea Hadley
- School of MedicineAmerican University of AntiguaOsbournAntigua and Barbuda
| | - Sean M. Bloos
- Department of Emergency MedicineStanford UniversityStanfordCaliforniaUSA
- Tulane University, School of MedicineNew OrleansLouisianaUSA
| | - Gabrielle Bunney
- Department of Emergency MedicineStanford UniversityStanfordCaliforniaUSA
| | - Timothy J. Vogus
- Owen Graduate School of ManagementVanderbilt UniversityNashvilleTennesseeUSA
| | - Dandan Liu
- Department of Biostatistics, Vanderbilt University Medical CenterNashvilleTennesseeUSA
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de Diego O, Rueda F, Carrillo X, Oliveras T, Andrea R, El Ouaddi N, Serra J, Labata C, Ferrer M, Martínez-Membrive MJ, Montero S, Mauri J, García-Picart J, Rojas S, Ariza A, Tizón-Marcos H, Faiges M, Cárdenas M, Lidón RM, Muñoz-Camacho JF, Jiménez Fàbrega X, Lupón J, Bayés-Genís A, García-García C. Performance analysis of a STEMI network: prognostic impact of the type of first medical contact facility. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2023; 76:708-718. [PMID: 36623690 DOI: 10.1016/j.rec.2022.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 12/21/2022] [Indexed: 06/17/2023]
Abstract
INTRODUCTION AND OBJECTIVES Prognosis in ST-elevation myocardial infarction (STEMI) is determined by delay in primary percutaneous coronary intervention (PPCI). The impact of first medical contact (FMC) facility type on reperfusion delays and mortality remains controversial. METHODS We performed a prospective registry of primary coronary intervention (PCI)-treated STEMI patients (2010-2020) in the Codi Infart STEMI network. We analyzed 1-year all-cause mortality depending on the FMC facility type: emergency medical service (EMS), community hospital (CH), PCI hospital (PCI-H), or primary care center (PCC). RESULTS We included 18 332 patients (EMS 34.3%; CH 33.5%; PCI-H 12.3%; PCC 20.0%). Patients with Killip-Kimball classes III-IV were: EMS 8.43%, CH 5.54%, PCI-H 7.51%, PCC 3.76% (P <.001). All comorbidities and first medical assistance complications were more frequent in the EMS and PCI-H groups (P <.05) and were less frequent in the PCC group (P <.05 for most variables). The PCI-H group had the shortest FMC-to-PCI delay (median 82 minutes); the EMS group achieved the shortest total ischemic time (median 151 minutes); CH had the longest reperfusion delays (P <.001). In an adjusted logistic regression model, the PCI-H and CH groups were associated with higher 1-year mortality, OR, 1.22 (95%CI, 1.00-1.48; P=.048), and OR, 1.17 (95%CI 1.02-1.36; P=.030), respectively, while the PCC group was associated with lower 1-year mortality than the EMS group, OR, 0.71 (95%CI 0.58-0.86; P <.001). CONCLUSIONS FMC with PCI-H and CH was associated with higher adjusted 1-year mortality than FMC with EMS. The PCC group had a much lower intrinsic risk and was associated with better outcomes despite longer revascularization delays.
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Affiliation(s)
- Oriol de Diego
- Servicio de Cardiología, Institut Clínic Cardiovascular, Hospital Clínic Barcelona, Barcelona, Spain; Institut D'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Doctorando, Programa de doctorado, Department de Medicina, Universitat Autònoma de Barcelona, Spain.
| | - Ferran Rueda
- Servicio de Cardiología, Institut del Cor, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Xavier Carrillo
- Servicio de Cardiología, Institut del Cor, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Teresa Oliveras
- Servicio de Cardiología, Institut del Cor, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Rut Andrea
- Servicio de Cardiología, Institut Clínic Cardiovascular, Hospital Clínic Barcelona, Barcelona, Spain; Institut D'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Nabil El Ouaddi
- Servicio de Cardiología, Institut del Cor, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Jordi Serra
- Servicio de Cardiología, Institut del Cor, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Carlos Labata
- Servicio de Cardiología, Institut del Cor, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Marc Ferrer
- Servicio de Cardiología, Institut del Cor, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - María J Martínez-Membrive
- Servicio de Cardiología, Institut del Cor, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Santiago Montero
- Servicio de Cardiología, Institut del Cor, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Josepa Mauri
- Servicio de Cardiología, Institut del Cor, Hospital Universitari Germans Trias i Pujol, Badalona, Spain; Servei Català de Salut, Generalitat de Catalunya, Registre del Codi Infart, Barecelona, Spain
| | - Joan García-Picart
- Servicio de Cardiología, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Sergio Rojas
- Servicio de Cardiología, Hospital Joan XXIII, Tarragona, Spain
| | - Albert Ariza
- Servicio de Cardiología, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Helena Tizón-Marcos
- Servicio de Cardiología, Hospital del Mar, Barcelona, Spain; Heart Diseases Biomedical Research Group, Instituto de investigaciones Hospital del Mar (IMIM), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Marta Faiges
- Servicio de Cardiología, Hospital de Tortosa Verge de la Cinta, IISPV, Tarragona, Spain
| | - Mérida Cárdenas
- Servicio de Cardiología, Hospital Universitari Josep Trueta, Girona, Spain
| | - Rosa María Lidón
- Servicio de Cardiología, Hospital Vall d'Hebron, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | | | | | - Josep Lupón
- Servicio de Cardiología, Institut del Cor, Hospital Universitari Germans Trias i Pujol, Badalona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Departamento de Medicina, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Antoni Bayés-Genís
- Servicio de Cardiología, Institut del Cor, Hospital Universitari Germans Trias i Pujol, Badalona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Departamento de Medicina, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Cosme García-García
- Servicio de Cardiología, Institut del Cor, Hospital Universitari Germans Trias i Pujol, Badalona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Departamento de Medicina, Universidad Autónoma de Barcelona, Barcelona, Spain
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Herscovici DM, Boggs KM, Cash RE, Espinola JA, Sullivan AF, Hasegawa K, Nagurney JT, Camargo CA. Development of a unified national database of primary percutaneous coronary intervention centers with co-located emergency departments, 2020. Am Heart J 2022; 254:149-155. [PMID: 36099978 DOI: 10.1016/j.ahj.2022.08.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 08/18/2022] [Accepted: 08/21/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Although primary percutaneous coronary intervention (pPCI) is the preferred intervention for ST-elevation myocardial infarction (STEMI), not all patients are admitted directly to an emergency department (ED) with 24/7/365 pPCI capabilities. This is partly due to a lack of a national system of known pPCI-capable EDs. Our objective was to create a unified, national database of confirmed 24/7/365 pPCI centers co-located in hospitals with EDs. METHODS We compiled all hospitals designated as Chest Pain Centers with Primary PCI by the American College of Cardiology's (ACC) National Clinical Data Registry (NCDR), all STEMI Receiving Centers designated by the American Heart Association's (AHA) Mission: Lifeline registry, and all state-designated pPCI-capable hospitals and designation criteria from state departments of health. We matched ACC, AHA, and state-designated facilities to those in the 2019 National ED Inventory (NEDI)-USA database to identify all EDs in pPCI-capable hospitals. RESULTS Overall, 467 hospitals were recognized as Chest Pain Centers with Primary PCI by ACC, 293 hospitals were recognized as being STEMI Receiving Centers by AHA, and 827 hospitals were confirmed to be pPCI-capable by state designations and operated 24/7/365. Together, there were 1,178 EDs (21% of 5,587 total) co-located in pPCI-capable hospitals operating 24/7/365. CONCLUSIONS There is substantial heterogeneity in cardiac systems of care, with large regional systems existing alongside local state-led initiatives. We created a unified national database of confirmed 24/7/365 pPCI centers co-located in hospitals with EDs. This data set will be valuable for future cardiac systems research and improving access to pPCI.
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Affiliation(s)
- Darya M Herscovici
- From the Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - Krislyn M Boggs
- From the Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - Rebecca E Cash
- From the Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - Janice A Espinola
- From the Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - Ashley F Sullivan
- From the Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - Kohei Hasegawa
- From the Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - John T Nagurney
- From the Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - Carlos A Camargo
- From the Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA.
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Primary Percutaneous Coronary Intervention and Application of the Pharmacoinvasive Approach Within ST-Elevation Myocardial Infarction Care Networks. Can J Cardiol 2022; 38:S5-S16. [PMID: 33838227 DOI: 10.1016/j.cjca.2021.02.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 02/12/2021] [Accepted: 02/13/2021] [Indexed: 12/30/2022] Open
Abstract
The management of acute ST-elevation myocardial infarction (STEMI) has transitioned from observation and reactive treatment of hemodynamic and arrhythmic complications to accelerated reperfusion and application of evidence-based treatment to minimize morbidity and mortality. International research established the importance of timely reperfusion therapy and the application of fibrinolysis, primary percutaneous coronary intervention (PCI), and subsequent development of the pharmacoinvasive approach. Clinician thought leaders developed and investigated comprehensive systems of care to optimize the outcomes of patients with STEMI, with a key focus in Canada being the integration of prehospital paramedics in diagnosis, triage, and treatment. This article will review highlights of these interventions and identify future challenges and opportunities in STEMI patient care.
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5
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Allana A, Tavares W, Pinto AD, Kuluski K. Designing and Governing Responsive Local Care Systems - Insights from a Scoping Review of Paramedics in Integrated Models of Care. Int J Integr Care 2022; 22:5. [PMID: 35509960 PMCID: PMC9009364 DOI: 10.5334/ijic.6418] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Accepted: 03/28/2022] [Indexed: 11/20/2022] Open
Abstract
Introduction Programs that fill gaps in fractured health and social services in response to local needs can provide insight on enacting integrated care. Grassroots programs and the changing roles of paramedics within them were analyzed to explore how the health workforce, organizations and governance could support integrated care. Methods A study was conducted following Arksey and O'Malley's method for scoping reviews, using Valentijn's Rainbow Model of Integrated Care as an organizing framework. Qualitative content analysis was done on clinical, professional, organizational, system, functional and normative aspects of integration. Common patterns, challenges and gaps were documented. Results After literature search and screening, 137 documents with 108 unique programs were analysed. Paramedics bridge reactive and preventative care for a spectrum of population needs through partnerships with hospitals, social services, primary care and public health. Programs encountered challenges with role delineation, segregated organizations, regulation and tensions in professional norms. Discussion Five concepts were identified for fostering integrated care in local systems: single point-of-entry care pathways; flexible and mobile workforce; geographically-based cross-cutting organizations; permissive regulation; and assessing system-level value. Conclusion Integrated care may be supported by a generalist health workforce, through cross-cutting organizations that work across silos, and legislation that balances standardization with flexibility.
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Affiliation(s)
- Amir Allana
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, CA
- McNally Project for Paramedicine Research, CA
- Upstream Lab, MAP/Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, Unity Health Toronto, CA
| | - Walter Tavares
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, CA
- McNally Project for Paramedicine Research, CA
- The Wilson Centre and Temerty Faculty of Medicine, University of Toronto|University Health Network, CA
- York Region Paramedic Services, Community and Health Services Department, The Regional Municipality of York, CA
| | - Andrew D. Pinto
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, CA
- Upstream Lab, MAP/Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, Unity Health Toronto, CA
- Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, CA
| | - Kerry Kuluski
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, CA
- Institute for Better Health, Trillium Health Partners, CA
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Fratta KA, Fishe JN, Schenk E, Anders JF. Emergency Medical Services Clinicians' Pediatric Destination Decision-Making: A Qualitative Study. Cureus 2021; 13:e17443. [PMID: 34589349 PMCID: PMC8462747 DOI: 10.7759/cureus.17443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2021] [Indexed: 11/05/2022] Open
Abstract
Objective This study sought to identify factors that influence emergency medical services (EMS) clinicians' destination decision-making for pediatric patients. We also sought EMS clinicians' opinions on potential systems improvements, such as protocol changes and the use of evidence-based transport guidelines. Methods Thirty-six in-depth phone interviews were conducted using a semi-structured format. We utilized a modified Grounded Theory approach to understand the complicated decision-making processes of EMS personnel. Memo writing was used throughout the data collection and analysis processes in order to identify emerging themes. The research team utilized hierarchical coding of interview transcripts to organize data into sub-categories for final analysis. Results EMS clinicians cited the perceived need for specialty care, the presence of a medical home, a desire for improved continuity of care, and the availability of aeromedical transport as factors that promoted transport to a pediatric specialty center. They voiced that children with emergent stabilization needs should be transported to the closest facility, however, they did not identify any specific medical conditions suitable for transport to non-specialty centers. EMS clinicians recommended improvements in pediatric-specific education, improved clarity of hospitals' pediatric capabilities, and the creation of a pediatric-specific destination decision-making tool. Conclusion This study describes specific factors that influence EMS clinicians' transport destination decision-making for pediatric patients. It also describes potential systems and educational improvements that may increase pediatric transport directly to definitive care. EMS clinicians are in support of specific designations for hospitals' pediatric capabilities and were in favor of the creation of a formal destination decision-making tool.
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Affiliation(s)
- Kyle A Fratta
- Emergency Medicine, University of Pittsburgh Medical Center, Harrisburg, USA
| | - Jennifer N Fishe
- Pediatric Emergency Medicine, University of Florida College of Medicine, Jacksonville, USA
| | - Ellen Schenk
- Epidemiology and Public Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Jennifer F Anders
- Pediatric Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
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7
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Anders JF, Fishe JN, Fratta KA, Katznelson JH, Levy MJ, Lichenstein R, Milin MG, Simpson JN, Walls TA, Winger HL. Creating a Pediatric Prehospital Destination Decision Tool Using a Modified Delphi Method. CHILDREN-BASEL 2021; 8:children8080658. [PMID: 34438548 PMCID: PMC8394584 DOI: 10.3390/children8080658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 07/26/2021] [Accepted: 07/26/2021] [Indexed: 11/16/2022]
Abstract
Decisions for patient transport by emergency medical services (EMS) are individualized; while established guidelines help direct adult patients to specialty hospitals, no such pediatric equivalents are in wide use. When children are transported to a hospital that cannot provide definitive care, care is delayed and may cause adverse events. Therefore, we created a novel evidence-based decision tool to support EMS destination choice. A multidisciplinary expert panel (EP) of stakeholders reviewed published literature. Four facility capability levels for pediatric care were defined. Using a modified Delphi method, the EP matched specific conditions to a facility pediatric-capability level in a draft tool. The literature review and EP recommendations identified seventeen pediatric medical conditions at risk for secondary transport. In the first voting round, two were rejected, nine met consensus for a specific facility capability level, and six did not reach consensus on the destination facility level. A second round reached consensus on a facility level for the six conditions as well as revision of one previously rejected condition. In the third round, the panel selected a visual display format. Finally, the panel unanimously approved the PDTree. Using a modified Delphi technique, we developed the PDTree EMS destination decision tool by incorporating existing evidence and the expertise of a multidisciplinary panel.
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Affiliation(s)
- Jennifer F. Anders
- Department of Pediatrics, Johns Hopkins University, Baltimore, MD 21287, USA; (K.A.F.); (J.H.K.)
- Correspondence: ; Tel.: +1-410-955-6143
| | - Jennifer N. Fishe
- Department of Emergency Medicine, University of Florida–Jacksonville, Jacksonville, FL 32224, USA;
| | - Kyle A. Fratta
- Department of Pediatrics, Johns Hopkins University, Baltimore, MD 21287, USA; (K.A.F.); (J.H.K.)
- Department of Emergency Medicine, University of Pittsburgh Medical Center-Harrisburg, Harrisburg, PA 15213, USA
| | - Jessica H. Katznelson
- Department of Pediatrics, Johns Hopkins University, Baltimore, MD 21287, USA; (K.A.F.); (J.H.K.)
| | - Matthew J. Levy
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD 21287, USA; (M.J.L.); (M.G.M.)
| | - Richard Lichenstein
- Division of Pediatric Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA;
| | - Michael G. Milin
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD 21287, USA; (M.J.L.); (M.G.M.)
| | - Joelle N. Simpson
- Department of Emergency Medicine, Children’s National Hospital, Washington, DC 20010, USA;
| | - Theresa A. Walls
- Division of Emergency Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA;
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Fang HY, Lee WC. Warning system improve the clinical outcomes in transfer patients with ST-segment elevation myocardial infarction. Medicine (Baltimore) 2021; 100:e26558. [PMID: 34190194 PMCID: PMC8257831 DOI: 10.1097/md.0000000000026558] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 06/12/2021] [Indexed: 01/04/2023] Open
Abstract
A warning system included directly faxing electrocardiography information to the mobile phone immediately after an ST-segment elevation myocardial infarction (STEMI) diagnosis was made at a non-percutaneous coronary intervention (PCI) capable hospital. This study aimed to explore the outcomes after using a warning system in transfer STEMI patients.From October 2013 to December 2016, 667 patients experienced a STEMI event and received primary PCI at our institution. 274 patients who were divided into transfer group were transferred from non-PCI capable hospitals and connected to a first-line cardiovascular doctor by the warning system. Other 393 patients were divided into the non-transfer group.The transfer group still had a longer pain-to-reperfusion time and presented higher troponin-I level when compared with non-transfer group. There was no significant difference in the use of drug-eluting stent and procedural devices between non-transfer and transfer groups. The prevalence of different anti-platelet agents loading did not differ between non-transfer and transfer groups. Non-significant trend about higher prevalence of statin use was noted in transfer group (78.9% vs 86.1%, P = .058). The transfer group presented similar clinical short-term results regarding both cardiovascular and all-cause mortality when comparing with non-transfer group. The transfer group provided non-significant trend about lower one-year cardiovascular mortality (10.7% vs 6.2%, P = .052) and lower all-cause mortality (12.2% vs 6.9%, P = .026) when compared with non-transfer group. There was a significant difference in the Kaplan-Meier curve of 1-year cardiovascular mortality between the transfer group and the non-transfer group (P = .049).After using the warning system, the inter-facility transfer group had comparable outcomes even though a longer pain-to-reperfusion time and a higher peak troponin-I level when comparing with non-transfer group.
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Hudzik B, Budaj A, Gierlotka M, Witkowski A, Wojakowski W, Zdrojewski T, Gil R, Legutko J, Bartuś S, Buszman P, Dudek D, Gąsior M. Assessment of quality of care of patients with ST-segment elevation myocardial infarction. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2020; 9:893-901. [DOI: 10.1177/2048872619882360] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Aims:
The 2017 European Society of Cardiology guidelines for the management of ST-elevation myocardial infarction recommended assessing quality of care to establish measurable quality indicators in order to ensure that every ST-elevation myocardial infarction patient receives the best possible care. We investigated the quality indicators of healthcare services in Poland provided to ST-elevation myocardial infarction patients.
Methods and results:
The Polish Registry of Acute Coronary Syndromes is a nationwide, multicentre, prospective study of acute coronary syndrome patients in Poland. For the purpose of assessing quality indicators, we included 8279 patients from the Polish Registry of Acute Coronary Syndromes hospitalised with ST-elevation myocardial infarction in 2018. Four hundred and eight of 8279 patients (4.9%) arrived at percutaneous coronary intervention centre by self-transport, 4791 (57.9%) arrived at percutaneous coronary intervention centre by direct emergency medical system transport, and 2900 (37.2%) were transferred from non-percutaneous coronary intervention facilities. Whilst 95.1% of ST-elevation myocardial infarction patients arriving in the first 12 h received reperfusion therapy, the rates of timely reperfusion were much lower (ranging from 39.4% to 55.0% for various ST-elevation myocardial infarction pathways). The median left ventricular ejection fraction was 46% and was assessed before discharge in 86.0% of patients. Four hundred and eighty-nine of 8279 patients (5.9%) died during hospital stay. Optimal medical therapy is prescribed in 50–85% of patients depending on various clinical settings. Only one in two ST-elevation myocardial infarction patients is enrolled in a cardiac rehabilitation program at discharge. No patient-reported outcomes were recorded in the Polish Registry of Acute Coronary Syndromes.
Conclusions:
The results of this study identified areas of healthcare system that require solid improvement. These include direct transport to percutaneous coronary intervention centre, timely reperfusion, guidelines-based medical therapy (in particular in patients with heart failure), referral to cardiac rehabilitation/secondary prevention programs. Also, there is a need for recording quality indicators associated with patient-reported outcomes.
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Affiliation(s)
- Bartosz Hudzik
- 3rd Department of Cardiology, Silesian Centre for Heart Disease, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
- Department of Cardiovascular Disease Prevention, Faculty of Health Sciences in Bytom, Medical University of Silesia, Katowice, Poland
| | - Andrzej Budaj
- Centre of Postgraduate Medical Education, Department of Cardiology, Grochowski Hospital, Warsaw, Poland
| | | | - Adam Witkowski
- Department of Interventional Cardiology and Angiology, Institute of Cardiology, Poland
| | - Wojciech Wojakowski
- 3rd Department of Cardiology, Upper Silesian Cardiology Centre, Faculty of Medical Sciences in Katowice, Medical University of Silesia, Katowice, Poland
| | - Tomasz Zdrojewski
- Department of Preventive Medicine and Education, Medical University of Gdansk, Poland
| | - Robert Gil
- Department of Invasive Cardiology, Central Clinical Hospital of the Ministry of Interior and Administration, Poland
| | - Jacek Legutko
- Department of Interventional Cardiology, Jagiellonian University Medical College, Poland
| | - Stanisław Bartuś
- Second Department of Cardiology, Jagiellonian University Medical College, Poland
| | - Paweł Buszman
- Centre for Cardiovascular Research and Development, American Heart of Poland, Poland
| | - Dariusz Dudek
- Second Department of Cardiology, Jagiellonian University Medical College, Poland
| | - Mariusz Gąsior
- 3rd Department of Cardiology, Silesian Centre for Heart Disease, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
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10
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Marbach JA, Alhassani S, Chong AY, MacPhee E, Le May M. A Novel Protocol for Very Early Hospital Discharge After STEMI. Can J Cardiol 2020; 36:1826-1829. [PMID: 32841675 PMCID: PMC7443159 DOI: 10.1016/j.cjca.2020.08.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 07/22/2020] [Accepted: 08/11/2020] [Indexed: 11/28/2022] Open
Abstract
Although the incidence of ST-elevation myocardial infarction (STEMI) is on the decline, management of patients who present with STEMI continues to require significant health care resources. Earlier hospital discharge in low-risk patients who present with STEMI has been an area of focus in an attempt to reduce health care costs. As a result, discharge within 48-72 hours after successful primary percutaneous coronary intervention has increasingly become routine practice. Moreover, the current COVID-19 pandemic has led to enormous pressure on health care systems to find ways to increase bed capacity, preserve resources, and reduce the risk of exposure to patients and health care workers. In response to this goal, the Ottawa Heart Institute has developed and implemented a novel Very Early Hospital Discharge (VEHD) protocol. The VEHD protocol is a simple, 4-step algorithm designed to accurately and efficiently identify low-risk STEMI patients who can be safely discharged between 20 and 36 hours after successful primary percutaneous coronary intervention. When deemed eligible for VEHD predischarge tasks are completed by the treating medical and nursing team and the patient is discharged home. Follow-up is completed remotely via virtual care (48 hours, 7 days, 30 days), and in the outpatient cardiology clinic (4-6 weeks). Amid a worldwide COVID-19 pandemic we believe the VEHD protocol is a crucial step in maintaining exceptional quality of care, in terms of patient satisfaction and clinical outcomes, while concurrently decreasing the risk of nosocomial infections, and reducing resource utilization.
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Affiliation(s)
- Jeffrey A Marbach
- Capital Research Group, Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Saad Alhassani
- Capital Research Group, Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Aun-Yeong Chong
- Capital Research Group, Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Erika MacPhee
- Capital Research Group, Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Michel Le May
- Capital Research Group, Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada.
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11
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Park K, Park JS, Cho YR, Park TH, Kim MH, Yang TH, Kim DI, Kim JH, Lee YH, Lee DW, Seo J, Lee GY, Kim YD. Community-Based Pre-Hospital Electrocardiogram Transmission Program for Reducing Systemic Time Delay in Acute ST-Segment Elevation Myocardial Infarction. Korean Circ J 2020; 50:709-719. [PMID: 32725978 PMCID: PMC7390714 DOI: 10.4070/kcj.2019.0337] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 03/29/2020] [Accepted: 04/06/2020] [Indexed: 12/31/2022] Open
Abstract
Background and Objectives In acute ST-segment elevation myocardial infarction (STEMI), on-site transmission of electrocardiogram (ECG) has been shown to reduce systemic time delay to reperfusion and improve outcomes. However, it has not been adopted in community-based emergency transport system in Korea. Methods Busan Regional Cardio-cerebrovascular Center and Busan Metropolitan City Fire and Safety Headquarters (BMFSH) jointly developed and conducted a pre-hospital ECG transmission program. Seven tertiary hospitals and 22 safety stations of BMFSH participated. Systemic time delay to reperfusion of STEMI patients in the program was compared with that of 95 patients transported by 119 emergency medical system (EMS) before the program was implemented. Results During the study period, 289 ECG transmissions were made by 119 EMS personnel, executed within 5 minutes in 88.1% of cases. Of these, 42 ECGs were interpreted as ST-segment elevation. Final diagnosis of STEMI was made in 20 patients who underwent primary percutaneous coronary intervention. With the program, systemic time delay to reperfusion was significantly reduced (median [interquartile range; IQR], 76.0 [62.2–98.7] vs. 90.0 [75.0–112.0], p<0.01). Significant reduction of door-to-balloon time was also observed (median [IQR], 45.0 [34.0–69.5] vs. 58.0 [51.0–68.0], p=0.03). The proportion of patients with systemic time delay shorter than 90 minutes rose (51.6% vs. 75.0%, p=0.08) with pre-hospital ECG transmission. Conclusions We developed and implemented a community-based pre-hospital ECG transmission program for expeditious triage of STEMI patients. Significant reductions of systemic time delay and door-to-balloon time were observed. The expanded use of pre-hospital ECG transmission should be encouraged to realize the full potential of this program.
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Affiliation(s)
- Kyungil Park
- Department of Cardiology, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Korea.,Cardiovascular Center, Busan Regional Cardio-cerebrovascular Center, Dong-A University Hospital, Busan, Korea
| | - Jong Sung Park
- Department of Cardiology, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Korea.,Cardiovascular Center, Busan Regional Cardio-cerebrovascular Center, Dong-A University Hospital, Busan, Korea
| | - Young Rak Cho
- Department of Cardiology, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Korea.,Cardiovascular Center, Busan Regional Cardio-cerebrovascular Center, Dong-A University Hospital, Busan, Korea
| | - Tae Ho Park
- Department of Cardiology, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Korea.,Cardiovascular Center, Busan Regional Cardio-cerebrovascular Center, Dong-A University Hospital, Busan, Korea
| | - Moo Hyun Kim
- Department of Cardiology, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Korea.,Cardiovascular Center, Busan Regional Cardio-cerebrovascular Center, Dong-A University Hospital, Busan, Korea
| | - Tae Hyun Yang
- Department of Inje University Baek Hospital, Inje University College of Medicine, Busan, Korea
| | - Doo Il Kim
- Department of Cardiology, Inje University Haeundae Baek Hospital, Inje University College of Medicine, Busan, Korea
| | - Jung Hwan Kim
- Department of Cardiology, Dong-Eui Medical Center, Busan, Korea
| | - Yong Hwan Lee
- Department of Cardiology, Dong Rae Bong Seng Hospital, Busan, Korea
| | - Dong Won Lee
- Department of Cardiology, Gupo Sungshim Hospital, Busan, Korea
| | - Jeongkee Seo
- Department of Cardiology, BHS Hanseo Hospital, Busan, Korea
| | - Geun Young Lee
- Metropolitan City Fire and Safety Headquarters, Busan, Korea
| | - Young Dae Kim
- Department of Cardiology, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Korea.,Cardiovascular Center, Busan Regional Cardio-cerebrovascular Center, Dong-A University Hospital, Busan, Korea.
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12
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Saberian P, Tavakoli N, Hasani-Sharamin P, Sezavar SH, Dadashi F, Vahidi E. The effect of prehospital telecardiology on the mortality and morbidity of ST-segment elevated myocardial infarction patients undergoing primary percutaneous coronary intervention: A cross-sectional study. Turk J Emerg Med 2020; 20:28-34. [PMID: 32355899 PMCID: PMC7189824 DOI: 10.4103/2452-2473.276380] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 11/03/2019] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVES The sooner the primary percutaneous coronary intervention (PPCI) is performed, the better prognosis is expected in patients with acute myocardial infarction. The objective is to evaluate the effect of prehospital triage based on electrocardiogram (ECG) and telecardiology on the mortality and morbidity of ST-segment elevated myocardial infarction (STEMI) patients undergoing PPCI. METHODS This cross-sectional study was conducted based on the data extracted from the hospital information system (HIS) of one general hospital, which had the capability of performing PPCI 24 h a day, 7 days a week. All patients with STEMI who undergone PPCI during 1 year, transferred by emergency medical service (EMS) and their data were registered in the HIS were eligible. Besides the baseline characteristics, first medical contact (FMC)-to-balloon time was recorded. Morbidity based on predischarge left ventricular ejection fraction (LVEF) and mortality based on Global Registry of Acute Cardiac Events (GRACE) score were also recorded. Patients who were referred to the hospital by EMS with prehospital ECG and telecardiology were compared with those without prehospital ECG. RESULTS Totally, 298 patients with STEMI were enrolled, of whom 183 patients (61.4%) had prehospital ECG (telecardiology), and 115 patients (38.6%) had not. The means of predischarge LVEF of the patients in the first and the second groups were 40.7 ± 10.4 and 40.6 ± 11.2, respectively (P = 0.946). The mean of the probability of 6-month mortality based on GRACE score in the first group was significantly less than that of the second group (P = 0.004). Analyses of multivariable ordinal logistic regression showed that 6-month mortality severity risk in the second group was 1.5 times more than the first group (95% confidence interval 0.8-2.6), although this difference was not statistically significant (P = 0.199). CONCLUSIONS It is likely that prehospital telecardiology, with shortening FMC to balloon time result in reducing probability 6-month mortality in STEMI patients who undergone PPCI. However, the process of telecardiology had no effect on predischarge LVEF in the current study.
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Affiliation(s)
- Peyman Saberian
- Prehospital and Hospital Emergency Research Center, Tehran University of Medical Sciences, Tehran, Iran.,Department of Anesthesiology, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Nader Tavakoli
- Trauma and Injury Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Parisa Hasani-Sharamin
- Tehran Emergency Medical Service Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Hashem Sezavar
- Research Center for Prevention of Cardiovascular Disease, Institute of Endocrinology and Metabolism, Iran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Dadashi
- Tehran Emergency Medical Service Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Elnaz Vahidi
- Prehospital and Hospital Emergency Research Center, Tehran University of Medical Sciences, Tehran, Iran.,Department of Emergency Medicine, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
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13
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Ferreira AS, Costa J, Braga CG, Marques J. Impacto na mortalidade da admissão direta versus transferência inter‐hospitalar nos doentes com enfarte agudo do miocárdio com elevação do segmento ST submetidos a intervenção coronária percutânea primária. Rev Port Cardiol 2019; 38:621-631. [DOI: 10.1016/j.repc.2019.02.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 01/16/2019] [Accepted: 02/03/2019] [Indexed: 01/10/2023] Open
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14
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Impact on mortality of direct admission versus interhospital transfer in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2019. [DOI: 10.1016/j.repce.2019.11.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
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15
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Borowicz A, Nadolny K, Bujak K, Cieśla D, Gąsior M, Hudzik B. Paramedic versus physician-staffed ambulances and prehospital delays in the management of patients with ST-segment elevation myocardial infarction. Cardiol J 2019; 28:110-117. [PMID: 31313273 DOI: 10.5603/cj.a2019.0072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Revised: 06/03/2019] [Accepted: 06/23/2019] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Time delays to reperfusion therapy in ST-segment elevation myocardial infarction (STEMI) still remain a considerable drawback in many healthcare systems. Emergency medical service (EMS) has a critical role in the early management of STEMI. Under investigation herein, was whether the use of physician-staffed ambulances leads to shorter pre-hospital delays in STEMI patients. METHODS This was an observational and retrospective study, using data from the registry of the Silesian regional EMS system in Katowice, Poland and the Polish Registry on Acute Coronary Syndromes (PL-ACS) for a study period of January 1, 2013 to December 31, 2016. The study population (n = 717) was divided into two groups: group 1 (n = 546 patients) - physician-staffed ambulances and group 2 (n = 171 patients) - paramedic-staffed ambulances. RESULTS Responses during the day and night shifts were similar. Paramedic-led ambulances more often transmitted 12-lead electrocardiogram (ECG) to the percutaneous coronary intervention centers. All EMS time intervals were similar in both groups. The type of EMS dispatched to patients (physicianstaffed vs. paramedic/nurse-only staffed ambulance) was adjusted for ECG transmission, sex had no impact on in-hospital mortality (odds ratio [OR] 1.41; 95% confidence interval [CI] 0.79-1.95; p = 0.4). However, service time exceeding 42 min was an independent predictor of in-hospital mortality (OR 4.19; 95% CI 1.27-13.89; p = 0.019). In-hospital mortality rate was higher in the two upper quartiles of service time in the entire study population. CONCLUSIONS These findings suggest that both physician-led and paramedic-led ambulances meet the criteria set out by the Polish and European authorities. All EMS time intervals are similar regardless of the type of EMS unit dispatched. A physician being present on board did not have a prognostic impact on outcomes.
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Affiliation(s)
- Artur Borowicz
- Voivodeship Rescue Service in Katowice, Katowice, Poland
| | - Klaudiusz Nadolny
- Voivodeship Rescue Service in Katowice, Katowice, Poland.,Department of Emergency Medicine, Medical University of Bialystok, Bialystok.,University of Strategic Planning in Dabrowa Gornicza, Poland
| | - Kamil Bujak
- 3rd Department of Cardiology, Silesian Center for Heart Disease, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Sil
| | - Daniel Cieśla
- Department of Science, Biostatistics and New Technologies, Silesian Center for Heart Disease, Zabrze, Poland
| | - Mariusz Gąsior
- 3rd Department of Cardiology, Silesian Center for Heart Disease, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Sil
| | - Bartosz Hudzik
- 3rd Department of Cardiology, Silesian Center for Heart Disease, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Sil. .,Department of Cardiovascular Disease Prevention, School of Public Health in Bytom, Medical University of Silesia.
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16
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Froats M, Reed A, Dionne R, Maloney J, Duncan S, Burns R, Sinclair J, Austin M. The Safety of Bypass to Percutaneous Coronary Intervention Facility by Basic Life Support Providers in Patients with ST-Elevation Myocardial Infarction in Prehospital Setting. J Emerg Med 2018; 55:792-798. [DOI: 10.1016/j.jemermed.2018.09.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 04/24/2018] [Accepted: 09/01/2018] [Indexed: 10/28/2022]
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17
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Safety and clinically important events in PCP-initiated STEMI bypass in Ottawa. CAN J EMERG MED 2018; 20:865-873. [DOI: 10.1017/cem.2018.452] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
CLINICIAN’S CAPSULEWhat is known about the topic?Transport of STEMI patients directly to the cath lab (STEMI bypass) by advanced care paramedics (ACPs) is common practice. The safety of this practice with primary care paramedics (PCPs) is unknown.What did this study ask?What is the prevalence and breakdown of events during PCP STEMI bypass?What did this study find?Clinically important events are common in STEMI bypass patients. A smaller proportion of events would be addressed differently by ACP compared to PCP protocols.Why does this study matter to clinicians?This study adds to the evidence that PCP STEMI bypass is safe.
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18
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Keys to Achieving Target First Medical Contact to Balloon Times and Bypassing Emergency Department More Important Than Distance. Cardiol Res Pract 2018; 2018:2951860. [PMID: 29951310 PMCID: PMC5987289 DOI: 10.1155/2018/2951860] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 03/27/2018] [Accepted: 04/30/2018] [Indexed: 11/26/2022] Open
Abstract
Background Australian guidelines advocate primary percutaneous coronary intervention (PPCI) as the reperfusion strategy of choice for ST elevation myocardial infarction (STEMI) in patients in whom it can be performed within 90 minutes of first medical contact; otherwise, fibrinolytic therapy is preferred. In a large health district, the reperfusion strategy is often chosen in the prehospital setting. We sought to identify a distance from a PCI centre, which made it unlikely first medical contact to balloon time (FMCTB) of less than 90 minutes could be achieved in the Hunter New England health district and to identify causes of delay in patients who were triaged to a PPCI strategy. Methods and Results We studied 116 patients presenting via the ambulance service with STEMI from January 2016 to December 2016. In patients who were taken directly to the cardiac catheterisation lab, a maximum distance of 50 km from hospital resulted in 75% of patients receiving PCI within 90 minutes and approximately 95% of patients receiving PCI within 120 minutes. Patients who bypassed the emergency department (ED) were significantly more likely to have FMCTB of less than 90 minutes (p < 0.001) despite having a longer travel distance (28.5 km versus 17.4 km, p < 0.001). Patients transiting via the ED were significantly more likely to present out of hours (60 versus 24.2% p < 0.001). Conclusions Patients who do not bypass the ED have a longer FMCTB across all spectrum of distances from the PCI centre; therefore, bypassing the ED is key to achieving target FMCTB times. Using a cutoff distance of 50 km may reduce human error in estimating travel time to our PCI centre and thereby identifying patients who should receive prehospital thrombolysis.
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19
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Harris DG, Olson SB, Rosen CB, Kalsi R, Taylor BS, Diaz JJ, Flohr TR, Crawford RS. Early Treatment at a Referral Center Improves Outcomes for Patients with Acute Vascular Disease. Ann Vasc Surg 2018. [PMID: 29518507 DOI: 10.1016/j.avsg.2018.01.088] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Patients with acute vascular disease frequently need specialized management that may require transfer to a vascular referral center. Although transfer may be medically necessary, it can delay definitive care and is an indicator of incorrect triage to the initial hospital. Regionalization of acute vascular care could improve patient triage and subsequent outcomes. To evaluate the potential benefit from regionalization, we analyzed outcomes of patients treated for acute vascular disease at vascular referral centers. METHODS Using a statewide database capturing all inpatient admissions in Maryland during 2013-2015, patients undergoing noncardiac vascular procedures on an acute basis were identified. Patients admitted to a vascular referral center were stratified by admission status as direct or transfer. The primary outcome was inpatient mortality, and the secondary outcome was resource use. Patient groups were compared by univariable analyses, and the effect of admission status on mortality was assessed by multivariable logistic regression. RESULTS Of 4,873 patients with acute vascular disease managed at vascular referral centers, 2,713 (56%) were admitted directly, whereas 2,160 (44%) were transferred. Transfers to referral centers accounted for 71% of all interhospital transfers. The transfer-group patients were older, had more comorbidities, and higher illness severities. Patients who were transferred had higher mortality (14% vs. 9%, P < 0.0001), longer hospital lengths of stay, greater critical care-resource utilization, and higher costs. After adjusting for demographics, comorbidities, and illness severity, transfer status was independently associated with higher inpatient mortality. CONCLUSIONS Primary treatment at a referral center is independently associated with improved outcomes for patients with acute vascular disease. Direct admission or earlier triage to a specialty center may improve patient and system outcomes and could be facilitated by standardization and regionalization of complex acute vascular care.
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Affiliation(s)
- Donald G Harris
- Department of Surgery, Division of Vascular Surgery, University of Maryland School of Medicine, Baltimore, MD.
| | - Sarah B Olson
- Department of Surgery, Division of Vascular Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Claire B Rosen
- Department of Surgery, Division of Vascular Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Richa Kalsi
- Department of Surgery, Division of Vascular Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Bradley S Taylor
- Department of Surgery, Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD; Center for Aortic Disease, University of Maryland Medical Center, Baltimore, MD
| | - Jose J Diaz
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD
| | - Tanya R Flohr
- Department of Surgery, Division of Vascular Surgery, University of Maryland School of Medicine, Baltimore, MD; Center for Aortic Disease, University of Maryland Medical Center, Baltimore, MD
| | - Robert S Crawford
- Department of Surgery, Division of Vascular Surgery, University of Maryland School of Medicine, Baltimore, MD; Center for Aortic Disease, University of Maryland Medical Center, Baltimore, MD
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Abstract
OBJECTIVE Limited evidence supports primary care paramedic (PCP) direct transport of ST-segment elevation myocardial infarction (STEMI) patients for percutaneous coronary intervention (PCI). The goal of this study was to evaluate an urban-based PCP STEMI bypass guideline. METHODS We reviewed consecutive Toronto Paramedic Services call reports between April 7, 2015, and May 31, 2016, regarding STEMI patients identified by PCPs. The primary outcome was patient assignment (stable versus unstable) according to guideline criteria. Secondary outcomes were the proportion of PCP-transported patients who had an indication for an advanced care intervention (ACI) or who received an ACI when PCPs rendezvoused with an advanced care paramedic (ACP). Lastly, we reviewed prehospital outcomes of cardiac arrest patients and calculated the difference in transport intervals between direct PCP bypass and a PCI-centre and predicted transport interval to the closest emergency department (ED). RESULTS Of 361 patients, 232 were PCP transports and 129 were ACP-rendezvous transports. There was a significant difference in the distribution of stable and unstable patients between PCPs and ACPs (p<0.001). For PCP patients, 21/232 (9.1%) had indications for an ACI, whereas 34/129 (26.4%) ACP patients received an ACI. Eleven patients experienced cardiac arrest; 10 were successfully resuscitated (5 of these by PCPs). The median difference between direct PCP bypass and a PCI-centre versus transport to the closest ED was 5.53 minutes (IQR=6.71). CONCLUSIONS We found a significant difference in the distribution of stable and unstable patients and fewer patients with indications for an ACI in PCP patients. This PCP STEMI bypass guideline appears feasible.
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van Diepen S, Katz JN, Albert NM, Henry TD, Jacobs AK, Kapur NK, Kilic A, Menon V, Ohman EM, Sweitzer NK, Thiele H, Washam JB, Cohen MG. Contemporary Management of Cardiogenic Shock: A Scientific Statement From the American Heart Association. Circulation 2017; 136:e232-e268. [PMID: 28923988 DOI: 10.1161/cir.0000000000000525] [Citation(s) in RCA: 985] [Impact Index Per Article: 140.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Cardiogenic shock is a high-acuity, potentially complex, and hemodynamically diverse state of end-organ hypoperfusion that is frequently associated with multisystem organ failure. Despite improving survival in recent years, patient morbidity and mortality remain high, and there are few evidence-based therapeutic interventions known to clearly improve patient outcomes. This scientific statement on cardiogenic shock summarizes the epidemiology, pathophysiology, causes, and outcomes of cardiogenic shock; reviews contemporary best medical, surgical, mechanical circulatory support, and palliative care practices; advocates for the development of regionalized systems of care; and outlines future research priorities.
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22
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Almawiri A, Jan V, Ziad A, Martin J, Josef S. Mortality benefit of primary transportation to a PCI-capable center persists through an eight-year follow-up in patients with ST-segment elevation myocardial infarction. J Interv Cardiol 2017; 30:522-526. [DOI: 10.1111/joic.12419] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 07/11/2017] [Accepted: 07/18/2017] [Indexed: 11/30/2022] Open
Affiliation(s)
- Abdulwasya Almawiri
- Department of Cardiovascular Medicine; University Hospital in Hradec Kralove; Charles University; Hradec Kralove Czech Republic
| | - Vojacek Jan
- Department of Cardiovascular Medicine; University Hospital in Hradec Kralove; Charles University; Hradec Kralove Czech Republic
| | - Albahri Ziad
- Department of Pediatrics; University Hospital in Hradec Kralove; Hradec Kralove Czech Republic
| | - Jakl Martin
- Department of Emergency Medicine; University Hospital in Hradec Kralove; Hradec Kralove Czech Republic
- Department of Internal Medicine; University of Defense; Faculty of Military Health Sciences; Hradec Kralove Czech Republic
| | - Stasek Josef
- Department of Cardiovascular Medicine; University Hospital in Hradec Kralove; Charles University; Hradec Kralove Czech Republic
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23
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Fishe JN, Psoter KJ, Klein BL, Anders JF. Retrospective Evaluation of Risk Factors for Pediatric Secondary Transport. PREHOSP EMERG CARE 2017; 22:41-49. [PMID: 28657816 DOI: 10.1080/10903127.2017.1339748] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Emergency medical services (EMS) typically transports patients to the nearest emergency department (ED). After initial presentation, children who require specialized care must undergo secondary transport, exposing them to additional risks and delaying definitive treatment. EMS direct transport protocols exist for major trauma and certain adult medical conditions, however the same cannot be said for pediatric medical conditions or injuries that do not meet trauma center criteria ('minor trauma'). To explore the utility of such future protocols, we sought to first describe the pediatric secondary transport population and examine prehospital risk factors for secondary transport. METHODS Pediatric secondary transport patients aged 0-18 years were identified. Patients meeting state EMS trauma protocol criteria or who were clinically unstable were excluded. Data were abstracted by chart review of EMS, community hospital ED, and specialty hospital records. Patients were compared to control patients with similar conditions who did not require secondary transport. RESULTS This study identified 211 medical or minor trauma pediatric secondary transport patients between 2013 and 2014. The three most prevalent conditions were seizure (n = 52), isolated orthopedic injury (n = 49), and asthma/respiratory distress (n = 27). Increased odds of secondary transport for seizure patients were associated with administration of supplemental oxygen, glucose measurement, and online medical direction; for isolated orthopedic injuries, online medical direction; and for asthma/respiratory distress, administration of supplemental oxygen, and online medical direction. Decreased odds of secondary transport for seizure patients were associated with a higher GCS; for isolated orthopedic injuries, increased age and oxygen saturation; and for asthma/respiratory distress, administration of albuterol only. CONCLUSIONS Children with seizures, isolated orthopedic injuries, and asthma/respiratory distress comprised the majority of the medical or minor trauma pediatric secondary transport population. Each of those conditions had specific risk factors for secondary transport. This study's results provide information to guide future prospective studies and the development of direct transport protocols for those populations.
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24
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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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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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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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Kaul P, Welsh RC, Liu W, Savu A, Weiss DR, Armstrong PW. Temporal and Provincial Variation in Ambulance Use Among Patients Who Present to Acute Care Hospitals With ST-Elevation Myocardial Infarction. Can J Cardiol 2016; 32:949-55. [DOI: 10.1016/j.cjca.2015.09.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Revised: 09/03/2015] [Accepted: 09/03/2015] [Indexed: 11/24/2022] Open
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Nakatsuma K, Shiomi H, Morimoto T, Furukawa Y, Nakagawa Y, Ando K, Kadota K, Yamamoto T, Suwa S, Horie M, Kimura T. Inter-Facility Transfer vs. Direct Admission of Patients With ST-Segment Elevation Acute Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention. Circ J 2016; 80:1764-72. [PMID: 27350014 DOI: 10.1253/circj.cj-16-0204] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Inter-facility transfer for primary percutaneous coronary intervention (PCI) from referring facilities to PCI centers causes a significant delay in treatment of ST-segment elevation acute myocardial infarction (STEMI) patients undergoing primary PCI. However, little is known about the clinical outcomes of STEMI patients undergoing inter-facility transfer in Japan. METHODS AND RESULTS In the CREDO-Kyoto acute myocardial infarction (AMI) registry that enrolled 5,429 consecutive AMI patients in 26 centers in Japan, the current study population consisted of 3,820 STEMI patients who underwent primary PCI within 24 h of symptom onset. We compared long-term clinical outcomes between inter-facility transfer patients and those directly admitted to PCI centers. The primary outcome measure was a composite of all-cause death or heart failure (HF) hospitalization. There were 1,725 (45.2%) inter-facility transfer patients, and 2,095 patients (54.8%) with direct admission to PCI centers. The cumulative 5-year incidence of death/HF hospitalization was significantly higher in the inter-facility transfer patients than in those with direct admission (26.9% vs. 22.2%; log-rank P<0.001). After adjusting for potential confounders, the risk for death/HF hospitalization was significantly higher (adjusted hazard ratio: 1.22, 95% confidence interval: 1.07-1.40, P<0.001) in the inter-facility transfer patients than in those directly admitted. CONCLUSIONS Inter-facility transfer was associated with significantly worse long-term clinical outcomes for patients with STEMI undergoing primary PCI. (Circ J 2016; 80: 1764-1772).
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Affiliation(s)
- Kenji Nakatsuma
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
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Direct admission to stroke centers reduces treatment delay and improves clinical outcome after intravenous thrombolysis. J Clin Neurosci 2016; 27:74-9. [DOI: 10.1016/j.jocn.2015.06.038] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Revised: 06/01/2015] [Accepted: 06/04/2015] [Indexed: 01/07/2023]
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Outcomes of non-STEMI patients transported by emergency medical services vs private vehicle. Am J Emerg Med 2016; 34:531-5. [PMID: 26809927 DOI: 10.1016/j.ajem.2015.12.070] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Revised: 12/22/2015] [Accepted: 12/22/2015] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Non-ST-segment elevation myocardial infarctions (NSTEMIs) are more common but less studied than ST-segment elevation myocardial infarctions (STEMIs) treated by emergency medical services (EMS). OBJECTIVE The purpose of this study was to evaluate the differences in baseline characteristics and outcomes of NSTEMI patients when arriving by EMS vs self-transport. METHODS We performed a retrospective medical record review of 96 EMS patients and 96 self-transport patients with the diagnosis of NSTEMI based on billing code. RESULTS The mean age of patients arriving by EMS was 75 vs 65 years for self-transport patients (P≤ .000). Patients arriving by self-transport received cardiac catheterization more often than patients arriving by EMS (84% vs 49%, P≤ .001). Emergency medical services patients had significantly longer average hospital length of stay and intensive care unit length of stay than did patients arriving by self-transport (6.5 vs 4 days [P≤ .001] and 4.1 vs 2.7 days [P= .019]). Significantly more EMS patients were discharged to a new extended care facility (25% vs 3.1%, P≤ .001). Finally, more EMS patients died in the hospital (18.8 vs 4.2%, P= .002). CONCLUSIONS Patients with NSTEMI who arrived by EMS are older, are more ill, and have worse outcomes compared with patients who arrived by self-transport. Further research into patient reasoning for mode of transportation to the ED may influence public health interventions, public policy development, and EMS and hospital protocols for management of NSTEMIs. The high mortality in prehospital cohort should prompt further investigation to develop evidence-based protocols.
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Impact of pre-hospital electrocardiogram teletransmission on time delays in ST segment elevation myocardial infarction patients: a single-centre experience. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2015; 11:212-7. [PMID: 26677362 PMCID: PMC4631736 DOI: 10.5114/pwki.2015.54016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Revised: 11/12/2014] [Accepted: 03/16/2015] [Indexed: 12/05/2022] Open
Abstract
Introduction Delay in diagnosis and treatment has a great influence on morbidity and mortality of ST-segment elevation myocardial infarction (STEMI) patients. Every 30 min of delay in reperfusion is associated with an 8% increase in mortality. ECG teletransmission was proved to effectively shorten time delays in STEMI treatment. In 2012 an ECG teletransmission program was introduced in the Lower Silesia region. Aim To assess the frequency of ECG teletransmission in STEMI patients and its influence on time delays. Material and methods We conducted a retrospective analysis of all patients admitted to our hospital with STEMI in 2013. Time delays, treatment and clinical characteristics of patients with and without teletransmission performed were compared. Results The study included 137 patients, of whom 49 (36%) had teletransmission performed. Direct transport to a percutaneous coronary intervention (PCI)-capable hospital was more frequent in patients with ECG teletransmission performed (88% vs. 63%, p = 0.002). In patients with teletransmission pain-emergency room time and total ischemic time were shorter (respectively 125 (91–184) min vs. 201 (113–339) min, p = 0.001 and 159 (136–244) min vs. 259 (170–389) min, p < 0.001). There were no differences in in-hospital delay, patients’ characteristics, or applied therapy. Conclusions The percentage of STEMI patients who had ECG teletransmission performed was low. Patients with ECG teletransmission had a shorter total ischemic time and lower percentage of indirect transport to a PCI-capable hospital.
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Green JL, Nallamothu BK. Direct emergency medical services transport in STEMI: breaking the bank for non-PCI capable hospitals? Open Heart 2015; 2:e000139. [PMID: 26167289 PMCID: PMC4493164 DOI: 10.1136/openhrt-2014-000139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/21/2014] [Indexed: 11/30/2022] Open
Affiliation(s)
- Jacqueline L Green
- Division of Cardiovascular Medicine , University of Michigan , Ann Arbor, Michigan , USA
| | - Brahmajee K Nallamothu
- Division of Cardiovascular Medicine , University of Michigan , Ann Arbor, Michigan , USA
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Leshem-Rubinow E, Assa EB, Shacham Y, Zatelman A, Oren-Shamir A, Malov N, Golovner M, Roth A. Expediting Time from Symptoms to Medical Contact Utilizing a Telemedicine Call Center. Telemed J E Health 2015; 21:801-7. [PMID: 26431259 DOI: 10.1089/tmj.2014.0227] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND No definitive solution has been forthcoming for the often dangerously long interval between symptom onset and seeking medical care in the prehospital setting. We examined the implementation of telemedicine technology and characterization of its utilizers for its efficacy in reducing this possibly life-threatening time lag. MATERIALS AND METHODS A retrospective observational study was performed on the working database of an operational telemedicine facility that included all subscribers. Time-to-contact measurements throughout 2012 were retrieved from its medical files, and data on age, gender, medical history, and main complaint were analyzed. RESULTS Throughout 2012, 22,274 of a total of 46,556 calls (47.8%) were made ≤60 min from symptom onset. It is important that 26.9% of all calls (12,522/46,556) were made in <15 min. Significantly more males (10,794/22,229 [49%]) contacted in ≤60 min compared with females (11,480/24,327 [47%], p<0.03). Subjects <60 years of age (2,889/5,717 [51%]) called earlier than those >60 years (19,386/40,839 [47%], p<0.001). Patients with prior resuscitation and/or myocardial infarction contacted significantly more rapidly than those with other cardiac diseases. Over one-half of patients with cardiac complaints contacted the call center ≤60 min from symptom onset, as did those who suffered physical trauma, but not patients with gastrointestinal symptoms or pain elsewhere. CONCLUSIONS A telemedicine system with rapid accessibility to a professional call center and prompt triage thereafter could be an additional promising strategy for shortening the interval between symptom onset and call for medical assistance. Implementation of a widespread telemedicine infrastructure may bridge the unmet gap between occurrence of symptoms to initiation of medical treatment.
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Affiliation(s)
- Eran Leshem-Rubinow
- 1 Department of Cardiology, Tel Aviv Sourasky Medical Center, Affiliated with the Sackler Faculty of Medicine, Tel Aviv University , Tel Aviv, Israel
| | - Eyal Ben Assa
- 1 Department of Cardiology, Tel Aviv Sourasky Medical Center, Affiliated with the Sackler Faculty of Medicine, Tel Aviv University , Tel Aviv, Israel
| | - Yacov Shacham
- 1 Department of Cardiology, Tel Aviv Sourasky Medical Center, Affiliated with the Sackler Faculty of Medicine, Tel Aviv University , Tel Aviv, Israel
| | | | | | - Nomi Malov
- 2 'SHL'-Telemedicine, Israel, Tel Aviv, Israel
| | | | - Arie Roth
- 1 Department of Cardiology, Tel Aviv Sourasky Medical Center, Affiliated with the Sackler Faculty of Medicine, Tel Aviv University , Tel Aviv, Israel
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Pre-hospital ticagrelor in ST-segment elevation myocardial infarction: Ready for prime time? Int J Cardiol 2015; 194:41-3. [PMID: 26011263 DOI: 10.1016/j.ijcard.2015.05.064] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Revised: 04/26/2015] [Accepted: 05/09/2015] [Indexed: 11/21/2022]
Abstract
In ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI) peri-procedural P2Y12 antagonism - although of great importance - is often suboptimal, even with the novel oral antiplatelet agents prasugrel and ticagrelor. The concept of pre-hospital ticagrelor loading, investigated in the recently published Administration of Ticagrelor in the Cath Lab or in the Ambulance for New ST Elevation Myocardial Infarction to Open the Coronary Artery (ATLANTIC) trial, appears quite a promising strategy to optimize peri-procedural platelet inhibition and potentially clinical outcome. Implementation of such an approach when treating low risk STEMI patients in 'real life' practice might prove even more beneficial than expected from the ATLANTIC results, given the reported delays from first medical contact to primary PCI performance.
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Singh K, Hibbert B, Singh B, Carson K, Premaratne M, Le May M, Chong AY, Arstall M, So D. Meta-analysis of admission hyperglycaemia in acute myocardial infarction patients treated with primary angioplasty: a cause or a marker of mortality? EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2015; 1:220-8. [PMID: 27532445 DOI: 10.1093/ehjcvp/pvv023] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2015] [Accepted: 04/21/2015] [Indexed: 01/08/2023]
Abstract
AIMS Admission hyperglycaemia (AH) has been associated with worse outcomes in acute myocardial infarction (AMI). In the current review, we evaluated the impact of primary angioplasty (pPCI) on mortality in AMI patients with AH. Our second aim was to evaluate if AH is a marker of baseline risk or an independent predictor of mortality. METHODS AND RESULTS A comprehensive search of four major databases was performed. We included original research studies reporting data on mortality in AMI patients with AH (mean plasma glucose >156 mg/dL/8.7 mmol) and euglycaemia who were treated with pPCI. Of 481 citations, 12 studies were included in the analysis. Admission hyperglycaemia was associated with a higher 30-day [risk ratio (RR) 4.30, P < 0.0001] and 1- to 3-year mortality (RR 2.26, P < 0.0001). As well, AH was more prevalent in women and in patients with an increasing number of cardiac risk factors or angiographic predictors of mortality, such as previous AMI (RR 0.89, P = 0.01), multivessel coronary disease (RR 0.72, P = 0.0001), and involvement of left anterior descending artery (RR 0.92, P < 0.0001). Moreover, patients with AH had larger infarcts (higher creatine kinase-MB; P = 0.004) and more frequent ventricular arrhythmias (P = 0.002). CONCLUSION Despite rapid revascularization and treatment of hyperglycaemia, patients with AH continue to have a higher mortality. Admission hyperglycaemia occurs more commonly in patients who have traditional predictors of worse outcomes-specifically prior infarction, anterior wall infarctions, and multivessel disease. Likely, AH is a predictor of rather than a bona fide therapeutic target in AMI.
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Affiliation(s)
- Kuljit Singh
- University of Ottawa Heart Institute, Ottawa, ON, Canada K1Y 1J7 Basil Hetzel Institute, University of Adelaide, Adelaide, SA 5000, Australia
| | - Benjamin Hibbert
- University of Ottawa Heart Institute, Ottawa, ON, Canada K1Y 1J7
| | - Balwinder Singh
- Department of Clinical Neurosciences, University of North Dakota School of Medicine & Health Sciences, Fargo, ND, USA
| | - Kristin Carson
- Basil Hetzel Institute, University of Adelaide, Adelaide, SA 5000, Australia
| | | | - Michel Le May
- University of Ottawa Heart Institute, Ottawa, ON, Canada K1Y 1J7
| | - Aun-Yeong Chong
- University of Ottawa Heart Institute, Ottawa, ON, Canada K1Y 1J7
| | - Margaret Arstall
- Department of Cardiology, Lyell McEwin Hospital, University of Adelaide, Adelaide, SA 5000, Australia
| | - Derek So
- University of Ottawa Heart Institute, Ottawa, ON, Canada K1Y 1J7
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Thang ND, Karlson BW, Sundström BW, Karlsson T, Herlitz J. Pre-hospital prediction of death or cardiovascular complications during hospitalisation and death within one year in suspected acute coronary syndrome patients. Int J Cardiol 2015; 185:308-12. [DOI: 10.1016/j.ijcard.2015.03.143] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Revised: 03/11/2015] [Accepted: 03/15/2015] [Indexed: 10/23/2022]
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Mercuri M, Welsford M, Schwalm JD, Mehta SR, Rao-Melacini P, Sheth T, Rokoss M, Jolly SS, Velianou JL, Natarajan MK. Providing optimal regional care for ST-segment elevation myocardial infarction: a prospective cohort study of patients in the Hamilton Niagara Haldimand Brant Local Health Integration Network. CMAJ Open 2015; 3:E1-7. [PMID: 25844361 PMCID: PMC4382034 DOI: 10.9778/cmajo.20140035] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Although considered the evidence-based best therapy for ST-segment elevation myocardial infarction (STEMI), many patients do not receive primary percutaneous coronary intervention (PCI) because of health care resource distribution and constraints. This study describes the clinical management and outcomes of all patients identified with STEMI within a region, including those who did not receive primary PCI. METHODS This study used a prospective cohort design. Patients presenting with STEMI to PCI- and non-PCI-capable hospitals in one integrated health region in Ontario were included in the study. The primary objective was to examine use of reperfusion strategies and timeliness of care. Secondary objectives included determining (through regression models) which variables were associated with mortality within 90 days, and describing patient uptake of risk-reducing therapies and activities post-STEMI. RESULTS Between Apr. 1, 2010, and Mar. 31, 2013, data were collected on 2247 consecutive patients presenting with STEMI. Patients presenting to the PCI-capable hospital were more likely to receive primary PCI (82.5% v. 65.2%, p < 0.001) and be treated within optimal treatment times. However, there was no appreciable difference in mortality at 90 days post-STEMI between patients presenting to PCI- and non-PCI-capable hospitals (7.8% v. 7.5%, p = 0.82), even after adjustment for acuity on presentation. Despite recognized risk factors, many patients were not taking evidence-based medications for risk factor modification before STEMI. INTERPRETATION A systematic approach to regional STEMI care focusing on timely access to the best available therapies, rather than the type of reperfusion provided alone, can yield favourable outcomes.
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Affiliation(s)
- Mathew Mercuri
- Department of Medicine, Division of Cardiology, Columbia University, New York ; Department of Medicine, Division of Cardiology, McMaster University, Hamilton, Ont
| | - Michelle Welsford
- Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, Ont. ; Hamilton Health Sciences, Hamilton Ontario, Hamilton, Ont
| | - Jon-David Schwalm
- Department of Medicine, Division of Cardiology, McMaster University, Hamilton, Ont. ; Hamilton Health Sciences, Hamilton Ontario, Hamilton, Ont. ; Population Health Research Institute, Hamilton, Ont
| | - Shamir R Mehta
- Department of Medicine, Division of Cardiology, McMaster University, Hamilton, Ont. ; Hamilton Health Sciences, Hamilton Ontario, Hamilton, Ont. ; Population Health Research Institute, Hamilton, Ont
| | | | - Tej Sheth
- Department of Medicine, Division of Cardiology, McMaster University, Hamilton, Ont. ; Hamilton Health Sciences, Hamilton Ontario, Hamilton, Ont. ; Population Health Research Institute, Hamilton, Ont
| | - Michael Rokoss
- Department of Medicine, Division of Cardiology, McMaster University, Hamilton, Ont. ; Hamilton Health Sciences, Hamilton Ontario, Hamilton, Ont
| | - Sanjit S Jolly
- Department of Medicine, Division of Cardiology, McMaster University, Hamilton, Ont. ; Hamilton Health Sciences, Hamilton Ontario, Hamilton, Ont. ; Population Health Research Institute, Hamilton, Ont
| | - James L Velianou
- Department of Medicine, Division of Cardiology, McMaster University, Hamilton, Ont. ; Hamilton Health Sciences, Hamilton Ontario, Hamilton, Ont
| | - Madhu K Natarajan
- Department of Medicine, Division of Cardiology, McMaster University, Hamilton, Ont. ; Hamilton Health Sciences, Hamilton Ontario, Hamilton, Ont. ; Population Health Research Institute, Hamilton, Ont
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Imori Y, Akasaka T, Shishido K, Ochiai T, Tobita K, Yamanaka F, Mizuno S, Saito S. Prehospital Transfer Pathway and Mortality in Patients Undergoing Primary Percutaneous Coronary Intervention. Circ J 2015; 79:2000-8. [DOI: 10.1253/circj.cj-14-0678] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Yoichi Imori
- Department of Cardiovascular Medicine, Shonan Kamakura General Hospital
| | - Takeshi Akasaka
- Department of Cardiovascular Medicine, Shonan Kamakura General Hospital
| | - Koki Shishido
- Department of Cardiovascular Medicine, Shonan Kamakura General Hospital
| | - Tomoki Ochiai
- Department of Cardiovascular Medicine, Shonan Kamakura General Hospital
| | - Kazuki Tobita
- Department of Cardiovascular Medicine, Shonan Kamakura General Hospital
| | - Futoshi Yamanaka
- Department of Cardiovascular Medicine, Shonan Kamakura General Hospital
| | - Shingo Mizuno
- Department of Cardiovascular Medicine, Shonan Kamakura General Hospital
| | - Shigeru Saito
- Department of Cardiovascular Medicine, Shonan Kamakura General Hospital
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Ross G, Alsayed T, Turner L, Olynyk C, Thurston A, Verbeek PR. Assessment of the Safety and Effectiveness of Emergency Department STEMI Bypass by Defibrillation-only Emergency Medical Technicians/Primary Care Paramedics. PREHOSP EMERG CARE 2014; 19:191-201. [DOI: 10.3109/10903127.2014.959226] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Farshid A, Allada C, Chandrasekhar J, Marley P, McGill D, O'Connor S, Rahman M, Tan R, Shadbolt B. Shorter ischaemic time and improved survival with pre-hospital STEMI diagnosis and direct transfer for primary PCI. Heart Lung Circ 2014; 24:234-40. [PMID: 25456507 DOI: 10.1016/j.hlc.2014.09.015] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2014] [Revised: 09/15/2014] [Accepted: 09/20/2014] [Indexed: 12/26/2022]
Abstract
BACKGROUND We sought to determine if our regional program for pre-hospital STEMI diagnosis and direct transfer for primary PCI (PPCI) was associated with shorter ischaemic times and improved survival compared with ED diagnosis. METHODS STEMI diagnosis was made at the scene by pre-hospital ECG or in local EDs depending on patient presentation. Ambulance ECGs were transmitted to our ED for cath lab activation. Patient variables and outcomes at 12 months were recorded. RESULTS We treated 782 consecutive patients with PPCI during January 2008-June 2013. Cath lab activation was initiated prior to hospital arrival (pre-hospital) in 24% of cases and by ED in 76% of cases. Median total ischaemic time was 154 min for pre-hospital and 211 minutes for ED patients (p<0.0001). Mortality at 12 months was 7.9% in the ED group compared with 3.7% in the pre-hospital group (p=0.036). On multivariate Cox regression analysis including baseline and procedural variables, pre-hospital activation remained an independent predictor of mortality (HR 0.45, 95% CI 0.20-1.0, p=0.03). CONCLUSIONS Pre-hospital diagnosis of STEMI and direct transfer to the cath lab reduced total ischaemic time by 57 minutes and mortality by >50% following PPCI. Further efforts are needed to increase the proportion of STEMI patients treated using this strategy.
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Affiliation(s)
- Ahmad Farshid
- Cardiology Unit, The Canberra Hospital, Yamba Drive, Garran, Australian Capital Territory, Australia; College of Medicine, Biology and Environment, Australian National University, Canberra, ACT 2601, Australia.
| | - Chris Allada
- Cardiology Unit, The Canberra Hospital, Yamba Drive, Garran, Australian Capital Territory, Australia
| | - Jaya Chandrasekhar
- Cardiology Unit, The Canberra Hospital, Yamba Drive, Garran, Australian Capital Territory, Australia
| | - Paul Marley
- Cardiology Unit, The Canberra Hospital, Yamba Drive, Garran, Australian Capital Territory, Australia
| | - Darryl McGill
- Cardiology Unit, The Canberra Hospital, Yamba Drive, Garran, Australian Capital Territory, Australia
| | - Simon O'Connor
- Cardiology Unit, The Canberra Hospital, Yamba Drive, Garran, Australian Capital Territory, Australia
| | - Moyazur Rahman
- Cardiology Unit, The Canberra Hospital, Yamba Drive, Garran, Australian Capital Territory, Australia
| | - Ren Tan
- Cardiology Unit, The Canberra Hospital, Yamba Drive, Garran, Australian Capital Territory, Australia
| | - Bruce Shadbolt
- College of Medicine, Biology and Environment, Australian National University, Canberra, ACT 2601, Australia; Centre for Advances in Epidemiology and Information Technology, The Canberra Hospital, Yamba Drive, Garran, Australian Capital Territory, Australia
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STOP STEMI©-a novel medical application to improve the coordination of STEMI care: a brief report on door-to-balloon times after initiating the application. Crit Pathw Cardiol 2014; 13:85-8. [PMID: 25062390 PMCID: PMC4132040 DOI: 10.1097/hpc.0000000000000019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Objective: The objective of our study was to evaluate the effect of the STOP STEMI© medical application on door-to-balloon (D2B) time in patients arriving to our emergency department with an acute ST Elevation Myocardial Infarction (STEMI). STOP STEMI© is a novel medical application developed by physicians to improve the coordination and communication tasks essential to rapid assessment and care of the patients suffering from a STEMI. Methods: We conducted a retrospective before and after review of the Good Shepherd Health System STEMI quality assurance/improvement dashboard for a 10-month period between November, 2012 and September, 2013 (4 months before STOP STEMI© and 6 months after). Data was collected using a standard data collection form and entered on the dashboard by a STEMI coordinator blinded to study objectives. We calculated the average D2B times before and after initiation of STOP STEMI© along with the improvement in the benchmarks of D2B less than 90 min and D2B less than 60 minutes. A subgroup analysis of Center for Medicare and Medicaid services (CMS) reportable cases was conducted to evaluate these benchmarks in the subset of patients meeting the criteria for CMS reporting by our facility. Results: During the study period, we received 155 STEMI patients, average 0.5 patients per day. One hundred twelve of the patients underwent percutaneous coronary intervention (PCI), 37 preSTOP STEMI©, and 75 postSTOP STEMI©. Of the 112 PCI cases, 7 were excluded leaving 105 cases for analysis, 36 preapplication and 69 postapplication. We found a 22% reduction in the average door-to-balloon time after implementing the STOP STEMI© application (91–71 minutes) respectively, the average difference of 20 minutes P = 0.05 (95% CI, -1–40minutes). In the analysis of CMS reportable cases (n = 64 cases), we observed a decrease in the average D2B of 15 minutes (68–53 minutes), a 22% reduction P = 0.03 (95% CI 1–29min). In the CMS reportable cases, we saw an improvement in the D2B time less than 90 minutes from 78–95% and less than 60 minutes D2B improvement from 56–80%. We also observed an appropriate absolute reduction in PCI resource utilization by 11%. Conclusions: In this cohort of patients, the utilization of STOP STEMI© decreased the average door-to-balloon times by 22% in the patients with acute STEMI arriving at our emergency department. This effect was maintained when looking at the subset of all STEMI cases reportable to CMS. We also observed modest improvements in meeting the less than 60-minute, less than 90-minute benchmarks, and improvements in the resource utilization.
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Estévez-Loureiro R, López-Sainz &A, Pérez de Prado A, Cuellas C, Calviño Santos R, Alonso-Orcajo N, Salgado Fernández J, Vázquez-Rodríguez JM, López-Benito M, Fernández-Vázquez F. Timely reperfusion for ST-segment elevation myocardial infarction: Effect of direct transfer to primary angioplasty on time delays and clinical outcomes. World J Cardiol 2014; 6:424-433. [PMID: 24976914 PMCID: PMC4072832 DOI: 10.4330/wjc.v6.i6.424] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Accepted: 04/09/2014] [Indexed: 02/07/2023] Open
Abstract
Primary percutaneous coronary intervention (PPCI) is the preferred reperfusion therapy for patients presenting with ST-segment elevation myocardial infarction (STEMI) when it can be performed expeditiously and by experienced operators. In spite of excellent clinical results this technique is associated with longer delays than thrombolysis and this fact may nullify the benefit of selecting this therapeutic option. Several strategies have been proposed to decrease the temporal delays to deliver PPCI. Among them, prehospital diagnosis and direct transfer to the cath lab, by-passing the emergency department of hospitals, has emerged as an attractive way of diminishing delays. The purpose of this review is to address the effect of direct transfer on time delays and clinical events of patients with STEMI treated by PPCI.
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Mumma BE, Kontos MC, Peng SA, Diercks DB. Association between prehospital electrocardiogram use and patient home distance from the percutaneous coronary intervention center on total reperfusion time in ST-segment-elevation myocardial infarction patients: a retrospective analysis from the national cardiovascular data registry. Am Heart J 2014; 167:915-20. [PMID: 24890543 DOI: 10.1016/j.ahj.2014.03.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Accepted: 03/19/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Current guidelines recommend ≤90 minutes from first medical contact to percutaneous coronary intervention (FMC2B) for ST-segment-elevation myocardial infarction (STEMI) patients. We evaluated the relationship between patient home distance from a percutaneous coronary intervention (PCI) center, prehospital electrocardiogram (ECG) use, and FMC2B time among patients with STEMI. METHODS We performed a retrospective cohort study including all STEMI patients in the ACTION-Get With The Guidelines registry from July 1, 2008, to September 30, 2012, who were transported by ambulance to a PCI center. Patient home distance was defined as the driving distance from the patient's home zip code to the PCI center address. Distance was classified into tertiles, and linear regression was used to characterize the interaction between prehospital ECG use and patient home distance with respect to FMC2B time. RESULTS Of the 29,506 STEMI patients, 19,690 (67%) received a prehospital ECG. The median patient home distance to the PCI center was 11.0 miles among patients with and 9.9 miles among those without a prehospital ECG. Prehospital ECGs were associated with a 10-minute reduction in the FMC2B time (P < .0001), which was consistent across distance tertiles (11 vs 11 vs 10 minutes). The association between prehospital ECGs and shorter FMC2B was attenuated by 0.8 minute for every 10-mile increase in distance (interaction P = .0002). CONCLUSIONS Prehospital ECGs are associated with a 10-minute reduction in the FMC2B time. However, patient home distance from a PCI center does not substantially change this association.
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Hibbert B, Maze R, Pourdjabbar A, Simard T, Ramirez FD, Moudgil R, Blondeau M, Labinaz M, Dick A, Glover C, Froeschl M, Marquis JF, So DYF, Le May MR. A comparative pharmacodynamic study of ticagrelor versus clopidogrel and ticagrelor in patients undergoing primary percutaneous coronary intervention: the CAPITAL RELOAD study. PLoS One 2014; 9:e92078. [PMID: 24651043 PMCID: PMC3961303 DOI: 10.1371/journal.pone.0092078] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2013] [Accepted: 02/17/2014] [Indexed: 11/19/2022] Open
Abstract
Background In patients undergoing primary percutaneous coronary intervention (PPCI) ticagrelor is superior to clopidogrel in reducing cardiovascular events. This study sought to evaluate the effect of clopidogrel pretreatment on the pharmacodynamics of ticagrelor in patients undergoing PPCI. Methods We measured platelet reactivity using the VerifyNow P2Y12 assay at baseline, 1, 2, 4, 6, 12, 24, and 48 hours following ticagrelor bolus in patients previously loaded with clopidogrel (C+T) and in thienopyridine-naive patients (T) referred to our centre for PPCI. Results In total, 52 consecutive eligible patients with ST-elevation myocardial infarction (STEMI) were enrolled (27 C+T and 25 T). Baseline characteristics and mean baseline platelet reactivity units (PRUs) were similar between the groups. The primary endpoint, the proportion of patients achieving a PRU<208 at 2 hours, was more frequently achieved in the C+T group compared to T treatment (76.0% vs 44.4%, p = 0.026). Notably, C+T therapy resulted in fewer patients with high platelet reactivity at 1 hour (56.0% vs. 14.8%), 4 hours (100.0% vs. 61.5%) and 6 hours (100.0% vs. 64%, p<0.01 for all comparisons). Furthermore, C+T therapy was associated with lower PRU values from 2 to 48 hours. Conclusions In patients referred for PPCI, ticagrelor bolus following clopidogrel resulted in more rapid and profound platelet inhibition, demonstrating a positive pharmacodynamic interaction. Further study is needed to determine if this pharmacodynamic effect translates into reduced clinical events.
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Affiliation(s)
- Benjamin Hibbert
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Ronnen Maze
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Ali Pourdjabbar
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Trevor Simard
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - F. Daniel Ramirez
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Rohit Moudgil
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Melissa Blondeau
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Marino Labinaz
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Alexander Dick
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Christopher Glover
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Michael Froeschl
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Jean-François Marquis
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Derek Y. F. So
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Michel R. Le May
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- * E-mail:
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Austin D, Yan AT, Spratt JC, Kunadian V, Edwards RJ, Egred M, Bagnall AJ. Patient characteristics associated with self-presentation, treatment delay and survival following primary percutaneous coronary intervention. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2014; 3:214-22. [DOI: 10.1177/2048872614527011] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- David Austin
- Cardiothoracic Division, The James Cook University Hospital, Middlesbrough, UK
| | - Andrew T Yan
- Department of Cardiology, St Michael’s Hospital, University of Toronto, Canada
| | - James C Spratt
- Department of Cardiology, Forth Valley Hospital, Larbert, UK
| | - Vijay Kunadian
- Department of Cardiology, Freeman Hospital, Newcastle upon Tyne, UK
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Richard J Edwards
- Department of Cardiology, Freeman Hospital, Newcastle upon Tyne, UK
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Mohaned Egred
- Department of Cardiology, Freeman Hospital, Newcastle upon Tyne, UK
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Alan J Bagnall
- Department of Cardiology, Freeman Hospital, Newcastle upon Tyne, UK
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
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Aggarwal B, Menon V. Recent advances in treatment of acute coronary syndromes. F1000PRIME REPORTS 2013; 5:56. [PMID: 24381731 PMCID: PMC3854689 DOI: 10.12703/p5-56] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
In this manuscript we highlight recent advances in the management of acute coronary syndromes. Efforts to minimize myocardial ischemia time through improved health care systems have resulted in significant success. In addition, new evidence in the areas of reperfusion therapy and pharmacological intervention has emerged. Percutaneous coronary intervention continues to evolve and new data concerning the superiority of the radial route, the use of improved stents and adjunctive therapy will be presented. We will highlight the changes that were made in international guidelines (from the American College of Cardiology/American Heart Association and the European Society of Cardiology) in the last 18 months in order to incorporate the latest evidence. Although significant advancements have been made in the management of acute coronary syndromes, the morbidity and mortality associated with this condition remains high, necessitating continued research in this field of cardiovascular medicine.
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Affiliation(s)
- Bhuvnesh Aggarwal
- Departments of Internal Medicine9500 Euclid Avenue, Cleveland, Ohio 44114USA
| | - Venu Menon
- Cardiovascular Medicine Cleveland Clinic9500 Euclid Avenue, Cleveland, Ohio 44114USA
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Dietrich MWD, Le May PM, Lundbye JB, Adams MP. Therapeutic Hypothermia in Post Cardiac Arrest. Ther Hypothermia Temp Manag 2013; 3:161-5. [DOI: 10.1089/ther.2013.1515] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | | | - Justin B. Lundbye
- Department of Cardiology, The Hospital of Central Connecticut, New Britain, Connecticut
| | - Mark Preston Adams
- Coronary Care Unit, University of Virginia Health System, Charlottesville, Virginia
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A Review of JACC Journal Articles on the Topic of Interventional Cardiology: 2011–2012. J Am Coll Cardiol 2013. [DOI: 10.1016/j.jacc.2013.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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49
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AlHabib KF, Alfaleh H, Hersi A, Kashour T, Alsheikh-Ali AA, Suwaidi JA, Sulaiman K, Saif SA, Almahmeed W, Asaad N, Amin H, Al-Motarreb A, Thalib L. Use of emergency medical services in the second gulf registry of acute coronary events. Angiology 2013; 65:703-9. [PMID: 24019088 DOI: 10.1177/0003319713502846] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Data are scarce regarding emergency medical service (EMS) usage by patients with acute coronary syndrome (ACS) in the Arabian Gulf region. This 9-month in-hospital prospective ACS registry was conducted in Arabian Gulf countries, with 30-day and 1-year follow-up mortality rates. Of 5184 patients with ACS, 1293 (25%) arrived at the hospital by EMS. The EMS group (vs non-EMS) was more likely to be male, have cardiac arrest on presentation, be current or exsmokers, and have moderate or severe left ventricular dysfunction and ST-segment elevation myocardial infarction (STEMI). The EMS group had higher crude mortality rates during hospitalization and after hospital discharge but not after adjustment for clinical factors and treatments. The EMSs are underused in the Arabian Gulf region. Short- and long-term mortality rates in patients with ACS are similar between those who used and did not use EMS. Quality improvement in the EMS infrastructure and establishment of integrated STEMI networks are urgently needed.
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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
| | - Hussam 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
| | - Alawi A Alsheikh-Ali
- Division of Cardiology, Institute of Cardiac Sciences, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates Tufts Clinical and Translational Science Institute, Tufts Medical Center, Boston, MA, USA
| | - Jassim Al Suwaidi
- Department of Cardiology, Hamad Medical Corporation (HMC), Doha, Qatar
| | | | - Shukri Al Saif
- Saud AlBabtain Cardiac Center, Dammam, Kingdom of Saudi Arabia
| | - Wael Almahmeed
- Department of Cardiology, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
| | - Nidal Asaad
- Department of Cardiology, Hamad Medical Corporation (HMC), Doha, Qatar
| | - Haitham Amin
- Mohammed Bin Khalifa Cardiac Center, Manama, Bahrain
| | | | - Lukman Thalib
- Faculty of Medicine, Health Sciences Centre, Kuwait University, Kuwait
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Kurz MC. We cannot improve that which we do not measure. Resuscitation 2013; 84:1015-6. [DOI: 10.1016/j.resuscitation.2013.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2013] [Accepted: 05/12/2013] [Indexed: 10/26/2022]
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