Relationship between time to treatment and mortality among patients undergoing primary percutaneous coronary intervention according to Korea Acute Myocardial Infarction Registry

The Busan Regional CardioCerebroVascular Center Project��s Experience Over a Decade in the Treatment of ST-segment Elevation Myocardial Infarction

Objectives

The Regional CardioCerebroVascular Center (RCCVC) project was initiated to improve clinical outcomes for patients with acute myocardial infarction or stroke in non-capital areas of Korea. The purpose of this study was to evaluate the outcomes and issues identified by the Busan RCCVC project in the treatment of ST-segment elevation myocardial infarction (STEMI).

Methods

Among the patients who were registered in the Korean Registry of Acute Myocardial Infarction for the RCCVC project between 2007 and 2019, those who underwent percutaneous coronary intervention (PCI) for STEMI at the Busan RCCVC were selected, and their medical data were compared with a historical cohort.

Results

In total, 1161 patients were selected for the analysis. Ten years after the implementation of the Busan RCCVC project, the median door-to-balloon time was reduced from 86 (interquartile range [IQR], 64–116) to 54 (IQR, 44–61) minutes, and the median symptom-to-balloon time was reduced from 256 (IQR, 180–407) to 189 (IQR, 118–305) minutes (p<0.001). Inversely, the false-positive PCI team activation rate increased from 0.6% to 21.4% (p<0.001). However, the 1-year cardiovascular death and major adverse cardiac event rates did not change. Even after 10 years, approximately 75% of the patients had a symptom-to-balloon time over 120 minutes, and approximately 50% of the patients underwent inter-hospital transfer for primary PCI.

Conclusions

A decade after the implementation of the Busan RCCVC project, although time parameters for early reperfusion therapy for STEMI improved, at the cost of an increased false-positive PCI team activation rate, survival outcomes were unchanged.

Impact of Total Ischemic Time on Clinical Outcomes in Patients With ST-Elevation Myocardial Infarction: Lost Time Is Never Found Again

Introduction

A dedicated relationship between total ischemic time (TIT) and clinical outcomes has been reported in ST-elevation myocardial infarction (STEMI) patients undergoing percutaneous coronary intervention (PCI); however, this claim is yet to be clarified. Accordingly, this study was carried out to determine the association of TIT with in-hospital and one-year follow-up outcomes in STEMI patients undergoing primary PCI.

Material and methodology

Between December 2020 and December 2021, a total of 113 consecutive STEMI patients undergoing primary PCI were prospectively included. According to TIT, all patients were categorized into two groups: (a) shorter TIT (<180 minutes) and (b) prolonged TIT (≥180 minutes). Data regarding baseline, clinical, and angiographic characteristics, as well as in-hospital and one-year follow-up outcomes were noted among the two groups.

Results

A total of 113 STEMI patients with a mean age of 69.3 ± 13.6 years were studied, and males [92 (81.4%)] were predominately affected with STEMI. A median TIT was 348 minutes. Of 113, 30 (23.0%) patients had a TIT of <180 minutes and 83 (73.5%) had a TIT of ≥180 minutes. Prolonged ischemia duration was significantly associated with composite of death, rehospitalization, and revascularization (p=0.02) at one-year follow-up.

Conclusion

TIT can be considered a good quality indicator, together with door-to-balloon time and other clinical determinants, in order to improve survival in STEMI patients.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Time to think beyond door to balloon time: significance of total ischemic time in STEMI

Background

Significance of total ischemic time (TIT) in the context of ST-segment elevation myocardial infarction (STEMI) is still controversial. Therefore, in this study, we have evaluate the association of TIT with immediate outcomes in STEMI patients in whom recommended door to balloon (DTB) time of less than 90 min was achieved.

Results

A total of 5730 patients were included in this study, out of which 80.9% were male and median age was 55 [61–48] years. The median DTB was observed to be 60 [75–45] min and onset of chest pain to emergency room (ER) arrival time was 180 [300–120] min. Prolonged TIT was associated with poor pre-procedure thrombolysis in myocardial infarction (TIMI) flow grade (p = 0.022), number of diseased vessels (p = 0.002), use of intra-aortic balloon pump (p = 0.003), and in-hospital mortality (p = 0.002). Mortality rate was 4.5%, 5.7%, and 7.8% for the patients with TIT of ≤ 120 min, 121 to 240 min, and > 240 min, respectively. Thirty days’ risk of mortality on TIMI score was 4.97 ± 7.09%, 5.01 ± 6.99%, and 7.12 ± 8.64% for the patients with TIT of ≤ 120 min, 121 to 240 min, and > 240 min, respectively.

Conclusions

Prolonged total ischemic was associated with higher in-hospital mortality. Therefore, TIT can also be considered in the matrix of focus, along with DTB time and other clinical determinants to improve the survival from STEMI.

The risk score for in-hospital mortality in patients with ST-segment elevation myocardial infarction

Aim    To develop a scale (score system) for predicting the individual risk of in-hospital death in patients with ST segment elevation acute myocardial infarction (STEMI) with an account of results of percutaneous coronary intervention (PCI).Material and methods    The analysis used data of 1 649 sequential patients with STEMI included into the hospital registry of PCI from 2006 through 2017. To test the model predictability, the original sample was divided into two groups: a training group consisting of 1150 (70 %) patients and a test group consisting of 499 (30 %) patients. The training sample was used for computing an individual score. To this purpose, β-coefficients of each variable obtained at the last stage of the multivariate logistic regression model were subjected to linear transformation. The scale was verified using the test sample.Results    Seven independent predictors of in-hospital death were determined: age ≥65 years, acute heart failure (Killip class III-IV), total myocardial ischemia time ≥180 min, anterior localization of myocardial infarction, failure of PCI, SYNTAX scale score ≥16, glycemia on admission ≥7.78 mmol/l for patients without a history of diabetes mellitus and ≥14.35 mmol/l for patients with a history of diabetes mellitus. The contribution of each value to the risk of in-hospital death was ranked from 0 to 7. A threshold total score of 10 was determined; a score ≥10 corresponded to a high probability of in-hospital death (18.2 %). In the training sample, the sensitivity was 81 %, the specificity was 80.6 %, and the area under the curve (AUC) was 0.902. In the test sample, the sensitivity was 96.2 %, the specificity was 83.3 %, and the AUC was 0.924.Conclusion    The developed scale has a good predictive accuracy in identifying patients with acute STEMI who have a high risk of fatal outcome at the hospital stage.

Analysis of the hospitalization time impact on hospital mortality from acute myocardial infarction

Diseases of the circulatory system and their most severe form – acute myocardial infarction (AMI) – is one of the most important problems of modern medicine due to the steady increase in morbidity, negative impact on quality of life, early disability of patients. 19.5 % of patients die from AMI, 50 % among which die 90-120 minutes after the first symptoms of the disease. The aim of the research was to analyse the impact of hospitalization on the mortality of patients with AMI and predict the risk of death in case of untimely hospitalization of this category of patients. Materials and methods. We have conducted a retrospective analysis of 876 medical records of patients diagnosed with AMI who were treated in the cardiology department of Kharkiv Regional Clinical Hospital in 2019. During the study, we have used retrospective, logical, medical and statistical methods. Odds ratios and a 95 % confidence interval were also calculated. Results and discussion. The research revealed the impact of hospitalization on the organization of medical care and hospital mortality of patients with AMI. It was found that the largest share of patients with AMI, both among the dead and those who left the hospital, were hospitalized in the period from 2 to 12 hours from the onset of the disease (49.6 % and 52.33 %, respectively), as well as in period after 24 hours – 28.00 % and 21.70 %, respectively. The largest share of patients with AMI, regardless of the time of hospitalization were persons older than 60 years. The results of the analysis showed that in the period up to 2 h from the onset of the disease, the share of hospitalized patients with more severe heart muscle damage (presence of Q wave) was 91.35 % against 8.65 % of patients with AMI without ST segment elevation. It should be noted that in almost 50 % of cases, patients with AMI without ST segment elevation were hospitalized after 24 h from the onset of the disease. At the same time, the largest share of deaths in this group of patients was observed in the hospital stay from 12 to 24 hours. According to the results of the research, risk factors for fatal outcome in AMI were identified, in particular male gender, the presence of an established ECG diagnosis of NSTEMI, conducting SKA in patients with AMI. It was also found that timely hospitalization of patients within the therapeutic window reduces the chances of hospital mortality by 52 %. Conclusions. The obtained data indicate a strong relationship between the time of hospitalization and the organization of medical care and hospital mortality of patients with AMI. It is reliably established that timely hospitalization of patients within the therapeutic window reduces the chances of hospital mortality by 52 %: HS is 0.483 (95 % CI 0.238 – 0.981), p=0.175.

Patient delay and benefit of timely reperfusion in ST-segment elevation myocardial infarction

BACKGROUND

In patients with ST-segment elevation myocardial infarction (STEMI), it is unknown how patient delay modulates the beneficial effects of timely reperfusion.

AIMS

To assess the prognostic significance of a contact-to-balloon time of less than 90 min on in-hospital mortality in different categories of symptom-onset-to-first-medical-contact (S2C) times.

METHODS

A total of 20 005 consecutive patients from the Feedback Intervention and Treatment Times in ST-segment Elevation Myocardial Infarction (FITT-STEMI) programme treated with primary percutaneous coronary intervention (PCI) were included.

RESULTS

There were 1554 deaths (7.8%) with a J-shaped relationship between mortality and S2C time. Mortality was 10.0% in patients presenting within 1 hour, and 4.9%, 6.0% and 7.3% in patient groups with longer S2C intervals of 1-2 hours, 2-6 hours and 6-24 hours, respectively. Patients with a short S2C interval of less than 1 hour (S2C<60 min) had the highest survival benefit from timely reperfusion with PCI within 90 min (OR 0.27, 95% CI 0.23 to 0.31, p<0.0001) as compared with the three groups with longer S2C intervals of 1 hour

CONCLUSIONS

Timely reperfusion with a contact-to-balloon time of less than 90 min is most effective in patients presenting with short S2C intervals of less than 1 hour, but has also beneficial effects in patients with S2C intervals of up to 24 hours.

TRIAL REGISTRATION NUMBER

NCT00794001.

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Key Words

• acute coronary syndrome
• chest pain
• myocardial infarction

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MESH Headings

• Aged
• Emergency Medical Services/methods
• Female
• Hospital Mortality/trends
• Humans
• Incidence
• Male
• Percutaneous Coronary Intervention/methods
• Risk Factors
• ST Elevation Myocardial Infarction/epidemiology
• ST Elevation Myocardial Infarction/surgery
• Survival Rate/trends
• Time Factors
• Time-to-Treatment
• Treatment Outcome

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Grants

• Deutsche Herzstiftung

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Affiliation(s)

Karl Heinrich Scholz Department of Cardiology and Intensive Care, St Bernward Hospital, Hildesheim, Germany
Thomas Meyer Department of Psychosomatic Medicine and Psychotherapy, University of Göttingen, Göttingen, Germany, and DZHK (German Centre for Cardiovascular Research), partner site Göttingen, Göttingen, Germany
Björn Lengenfelder Department of Cardiology, University of Würzburg, Würzburg, Germany
Christian Vahlhaus Department of Cardiology and Angiology, University Hospital Münster, Münster, Germany
Jörn Tongers Department of Cardiology, Medizinische Hochschule Hannover, Hannover, Germany
Steffen Schnupp Department of Cardiology, Klinikum Coburg, Coburg, Germany
Rainer Burckhard Department of Cardiology, Donauisar Klinikum Deggendorf, Deggendorf, Germany
Nicolas von Beckerath Department of Cardiology, Allgemeines Krankenhaus Viersen, Viersen, Germany
Hans-Martin Grusnick Department of Cardiology, Sana Kliniken Lübeck, Lübeck, Germany
Andreas Jeron Department of Cardiology, Rems-Murr-Kliniken, Winnenden, Germany
Klaus Dieter Winter Department of Cardiology, Hermann-Josef-Hospital, Erkelenz, Germany
Sebastian K G Maier Department of Cardiology, Klinikum Sankt Elisabeth Straubing, Straubing, Germany
Michael Danner Department of Cardiology, Städtisches Klinikum, München Neuperlach, Munich, Germany
Jürgen Vom Dahl Department of Cardiology, Kliniken Maria Hilf, Mönchengladbach, Germany
Stefan Neef Department of Cardiology, University Hospital Regensburg, Regensburg, Germany
Stefan Stefanow Department of Cardiology, Klinikum Ludwigsburg, Ludwigsburg, Ludwigsburg, Germany
Tim Friede Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany, and DZHK (German Centre for Cardiovascular Research), partner site Göttingen, Göttingen, Germany

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Cardiac mortality benefit of direct admission to percutaneous coronary intervention-capable hospital in acute myocardial infarction: Community registry-based study

ABSTRACT

Appropriate risk stratification and timely revascularization of acute myocardial infarction (AMI) are available in percutaneous coronary intervention (PCI) - capable hospitals (PCHs). This study evaluated whether direct admission vs inter-hospital transfer influences cardiac mortality in patients with AMI. This study was conducted in the PCH where the patients were able to arrive within an hour. The inclusion criteria were AMI with a symptom onset time within 24 hours and having undergone PCI within 24 hours after admission. The cumulative incidence of cardiac death after percutaneous coronary intervention was evaluated in the direct admission versus inter-hospital transfer groups. Among the 3178 patients, 2165 (68.1%) were admitted via inter-hospital transfer. Patients with ST-segment elevation myocardial infarction (STEMI) in the direct admission group had a reduced symptom onset-to-balloon time (121 minutes, P < .001). With a median period of 28.4 (interquartile range, 12.0-45.6) months, the cumulative incidence of 2-year cardiac death was lower in the direct admission group (NSTEMI, 9.0% vs 11.0%, P = .136; STEMI, 9.7% vs 13.7%, P = .040; AMI, 9.3% vs 12.3%, P = .014, respectively). After the adjustment for clinical variables, inter-hospital transfer was the determinant of cardiac death (hazard ratio, 1.59; 95% confidence interval, 1.08-2.33; P = .016). Direct PCH admission should be recommended for patients with suspected AMI and could be a target for reducing cardiac mortality.

Influence of Total Ischemic Time on Clinical Outcomes in Patients with ST-Segment Elevation Myocardial Infarction

Aim      To evaluate the effect of the total time of myocardial ischemia on results of the treatment of patients with ST segment elevation acute myocardial infarction (STEMI) who underwent percutaneous coronary interventions (PCI).Material and methods This study used data from a hospital register for PCI in STEMI from 2006 through 2017. 1649 patients were included. Group 1 consisted of 604 (36.6 %) patients with a total time of myocardial ischemia not exceeding 1880 min; group 2 included 531 (32.2 %) patients with a duration of myocardial ischemia from 180 to 360 min; and group 3 included 514 (31.2 %) patients with a duration of myocardial ischemia longer than 360 min.Results Mortality was lower in group 1 (2.3 %) than in groups 2 and 3 (6.2 and 7.2 %, respectively; p1-2=0.001; p1-3&lt;0.001; p2-3=0.520). The incidence of major cardiac complications ("adverse cardiac events", MACE) was lower in group 1 (4.1 %) than in groups 2 and 3 (7.3 and 9.5 %, respectively, p1-2=0.020; p1-3&lt;0.001; p2-3=0.200). The incidence of no-reflow phenomenon was higher in group 3 (9.7 %) than in groups 2 and 3 (4.5 and 5.3 %, respectively (p1-2=0.539; p1-3=0.001; p2-3=0.005). The major factors associated with the increased total time of myocardial ischemia &gt;180 min were age (odd ratio, OR, 1.01 at 95 % confidence interval, CI, 1.0 to 1.02; р=0.044), female gender (OR, 1.64 at 95 % CI 1.26 to 2.13; р&lt;0.001), chronic kidney disease (OR 1.82 at 95 % CI 1.21 to 2.74; р=0.004). Performing prehospital thrombolysis was associated with a decrease in the total time of myocardial ischemia (OR 0.4 at 95 % CI 0.31 to 0.51; р&lt;0.001). A strong direct correlation was observed between the total time of myocardial ischemia and the time from the onset of pain syndrome to hospitalization (r=0.759; р&lt;0.001).Conclusion      The total time of myocardial ischemia &gt;180 min was associated with increased mortality and development of MACE. The total time of myocardial ischemia &gt; 360 min was associated with increased incidence of the no-reflow phenomenon. The major predictors for the time of myocardial ischemia &gt;180 min included age, female gender, and chronic kidney disease. The use of pharmacoinvasive strategy was associated with an increased number of patients with a total duration of myocardial ischemia &lt;180 min. The contribution of the time of prehospital delay to the total time of myocardial ischemia was greater than the contribution of the "door-to-balloon" time. The time of prehospital delay showed a strong direct correlation with the total time of myocardial ischemia.

Time to Treatment and In-Hospital Major Adverse Cardiac Events Among Patients With ST-Segment Elevation Myocardial Infarction Who Underwent Primary Percutaneous Coronary Intervention (PCI) According to the 24/7 Primary PCI Service Registry in Iran: Cross-Sectional Study

Background

Performing primary percutaneous coronary intervention (PCI) as a preferred reperfusion strategy for patients with ST-segment elevation myocardial infarction (STEMI) may be associated with major adverse cardiocerebrovascular events (MACCEs). Thus, timely primary PCI has been emphasized in order to improve outcomes. Despite guideline recommendations on trying to reduce the door-to-balloon time to <90 minutes in order to reduce mortality, less attention has been paid to other components of time to treatment, such as the symptom-to-balloon time, as an indicator of the total ischemic time, which includes the symptom-to-door time and door-to-balloon time, in terms of clinical outcomes of patients with STEMI undergoing primary PCI.

Objective

We aimed to determine the association between each component of time to treatment (ie, symptom-to-door time, door-to-balloon time, and symptom-to-balloon time) and in-hospital MACCEs among patients with STEMI who underwent primary PCI.

Methods

In this observational study, according to a prospective primary PCI 24/7 service registry, adult patients with STEMI who underwent primary PCI in one of six catheterization laboratories of Tehran Heart Center from November 2015 to August 2019, were studied. The primary outcome was in-hospital MACCEs, which was a composite index consisting of cardiac death, revascularization (ie, target vessel revascularization/target lesion revascularization), myocardial infarction, and stroke. It was compared at different levels of time to treatment (ie, symptom-to-door and door-to-balloon time <90 and ≥90 minutes, and symptom-to-balloon time <180 and ≥180 minutes). Data were analyzed using SPSS software version 24 (IBM Corp), with descriptive statistics, such as frequency, percentage, mean, and standard deviation, and statistical tests, such as chi-square test, t test, and univariate and multivariate logistic regression analyses, and with a significance level of <.05 and 95% CIs for odds ratios (ORs).

Results

Data from 2823 out of 3204 patients were analyzed (mean age of 59.6 years, SD 11.6 years; 79.5% male [n=2243]; completion rate: 88.1%). Low proportions of symptom-to-door time ≤90 minutes and symptom-to-balloon time ≤180 minutes were observed among the study patients (579/2823, 20.5% and 691/2823, 24.5%, respectively). Overall, 2.4% (69/2823) of the patients experienced in-hospital MACCEs, and cardiac death (45/2823, 1.6%) was the most common cardiac outcome. In the univariate analysis, the symptom-to-balloon time predicted in-hospital MACCEs (OR 2.2, 95% CI 1.1-4.4; P=.03), while the symptom-to-door time (OR 1.4, 95% CI 0.7-2.6; P=.34) and door-to-balloon time (OR 1.1, 95% CI 0.6-1.8, P=.77) were not associated with in-hospital MACCEs. In the multivariate analysis, only symptom-to-balloon time ≥180 minutes was associated with in-hospital MACCEs and was a predictor of in-hospital MACCEs (OR 2.3, 95% CI 1.1-5.2; P=.04).

Conclusions

A longer symptom-to-balloon time was the only component associated with higher in-hospital MACCEs in the present study. Efforts should be made to shorten the symptom-to-balloon time in order to improve in-hospital MACCEs.

International Registered Report Identifier (IRRID)

RR2-10.2196/13161

Community-Based Pre-Hospital Electrocardiogram Transmission Program for Reducing Systemic Time Delay in Acute ST-Segment Elevation Myocardial Infarction

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.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

DISCUSSION

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

Effect of percutaneous coronary intervention team prenotification based on real time electrocardiogram transmission in interhospital transfer of ST elevation myocardial infarction patients: pilot trial of Preparing Revascularization Effort before Patients' Arrival via Regionalization Engagement protocol

Objective

Prompt reperfusion is important for patients with ST elevation myocardial infarction (STEMI). However, patients often require interhospital transfer for percutaneous coronary intervention (PCI) because not all hospitals can provide. The purpose of this study is to reduce the PCI delay using a regionalization protocol in patients with STEMI following transfer from another hospital lacking PCI facility.

Methods

We established a revascularization protocol designated as Preparing Revascularization Effort before Patients’ Arrival via Regionalization Engagement (PREPARE) for the STEMI patients transferred from an outside regional hospital. The protocol included immediate referral acceptance by an emergency physician, real-time electrocardiogram sharing via mobile phone and early activation of the PCI team. We analyzed the differences between the PREPARE and the non-PREPARE groups.

Results

In the PREPARE group, the median time from the first hospital visit to the ballooning procedure via PCI at the receiving facility (D1-to-B time) was 111.0 (interquartile range 97.0– 130.0) minutes, which was significantly shorter than in the non-PREPARE group 134.0 (interquartile range 115.0–182.0) minutes. The proportion of D1-to-B time within 120 minutes was 30.4% in the group and 60.0% in the PREPARE group, which represents a significant difference (P=0.004). Multivariate logistic regression analysis revealed that patient transfer via PREPARE protocol (odds ratio, 3.399; 95% confidence interval, 1.150–10.050, P=0.027) was related to adequate D1-to-B time. No statistically significant differences were found in the hospital length of stay or major adverse cardiac events within 4 weeks.

Conclusion

The PREPARE protocol is an effective strategy to reduce the time to revascularization of the transferred STEMI patients.

Pre-hospital delay and emergency medical services in acute myocardial infarction

BACKGROUND/AIMS

Minimising total ischemic time (TIT) is important for improving clinical outcomes in patients with ST-segment elevation myocardial infarction who have undergone percutaneous coronary intervention (PCI). TIT has not shown a significant improvement due to persistent pre-hospital delay. This study aimed to investigate the risk factors associated with pre-hospital delay.

METHODS

Individuals enrolled in the Korea Acute Myocardial Infarction Registry-National Institutes of Health between 2011 and 2015 were included in this study. The study population was analyzed according to the symptom-to-door time (STDT; within 60 or > 60 minutes), and according to the type of hospital visit (emergency medical services [EMS], non-PCI center, or PCI center).

RESULTS

A total of 4,874 patients were included in the analysis, of whom 28.4% arrived at the hospital within 60 minutes of symptom-onset. Old age (> 65 years), female gender, and renewed ischemia were independent predictors of delayed STDT. Utilising EMS was the only factor shown to reduce STDT within 60 minutes, even when cardiogenic shock was evident. The overall frequency of EMS utilisation was low (21.7%). Female gender was associated with not utilising EMS, whereas cardiogenic shock, previous myocardial infarction, familial history of ischemic heart disease, and off-hour visits were associated with utilising EMS.

CONCLUSION

Factors associated with delayed STDT and not utilising EMS could be targets for preventive intervention to improve STDT and TIT.

The Current Status of Percutaneous Coronary Intervention in Korea: Based on Year 2014 & 2016 Cohort of Korean Percutaneous Coronary Intervention (K-PCI) Registry

BACKGROUND AND OBJECTIVES

In this second report from Korean percutaneous coronary intervention (K-PCI) registry, we sought to describe the updated information of PCI practices and Korean practice pattern of PCI (KP3).

METHODS

In addition to K-PCI registry of 2014, new cohort of 2016 from 92 participating centers was appended. Demographic and procedural information, as well as in-hospital outcomes, of PCI was collected using a web-based reporting system. KP3 class C was defined as any strategy with less evidence from randomized trials and more aggressive for PCI than medical therapy or bypass-surgery.

RESULTS

In 2016, total 48,823 PCI procedures were performed at 92 participating centers. Mean age of the patients was 65.7±11.6 years, and 71.7% were males. Overall patient characteristics and PCI practices in 2016 were similar to those in 2014. The biggest change was the decrease in the in-hospital occurrence of myocardial infarction (MI;1.6%→0.7%, p<0.001). Many associations between PCI volumes and demographic/procedural characteristics observed in 2014 have disappeared. The median of door-to-balloon time was 62 minutes, and 83.3% of ST-elevation MI patients received primary PCI within 90 minutes, while the median of total ischemic time was 168 minutes and patients who had total ischemic time within 120 and 180 minutes were 29.1% and 54.1%, respectively. The proportion of KP3 class C cases in non-acute coronary syndrome patients decreased from 13.5% in 2014 to 12.1% in 2016 (p<0.001).

CONCLUSIONS

In this second report from K-PCI registry, we described the current practices of PCI and changes from 2014 to 2016 in Korea.

Time to Treatment and In-Hospital Major Adverse Cardiac Events Among Patients With ST-Segment Elevation Myocardial Infarction Who Underwent Primary Percutaneous Coronary Intervention (PCI) According to the 24/7 Primary PCI Service Registry in Iran: Protocol for a Cross-Sectional Study

Background

Patients with ST-segment elevation myocardial infarction (STEMI) experience major adverse cardiac events (MACEs) following primary percutaneous coronary intervention (PCI). Although the relationship between time to treatment (eg, door-to-balloon time, symptom onset-to-balloon time, and symptom onset-to-door time) and 1-month all-cause mortality was assessed previously, its relationship with in-hospital MACEs and the effect of some clinical characteristics on this relationship were not considered. Furthermore, previous studies that were conducted in developed countries with a different quality of care cannot be applied in Iran, as Iran is a developing country and the studies were not performed according to the 24/7 primary PCI service registry.

Objective

The objective of this study protocol is to determine the relationship between time to treatment and in-hospital MACEs.

Methods

This cross-sectional study will take place at the Tehran Heart Center (THC), which is affiliated with Tehran University of Medical Sciences (TUMS) in Tehran, Iran. Data related to patients with STEMI, who underwent primary PCI between March 2015 and March 2019, that have been prospectively recorded in the THC’s 24/7 primary PCI service registry will be analyzed. The study outcome is the occurrence of in-hospital MACEs. Data analysis will be conducted using SPSS for Windows, version 16.0 (SPSS Inc). We will perform chi-square tests, independent-samples t tests, or the Mann-Whitney U test, as well as univariate and multivariate binary logistic regression with a significance level of less than .05 and 95% CI for odds ratios.

Results

From March 2015 to September 2017, 1586 patients were included in the THC service registry, consecutively. We will conduct a retrospective analysis of this registry on patient entries between March 2015 and March 2019 and data will be analyzed and published by the end of 2019.

Conclusions

To our knowledge, this is the first observational study based on the 24/7 primary PCI service registry in Iran. The findings of this study may reveal current problems regarding time to treatment in STEMI management in the THC. Results from this study may help determine appropriate preventive strategies that need to be applied in order to reduce time-to-treatment delays and improve patients’ outcomes following primary PCI in the setting of STEMI at the THC and similar clinical centers.

International Registered Report Identifier (IRRID)

DERR1-10.2196/13161

Current status of acute myocardial infarction in Korea

Coronary artery disease, especially acute myocardial infarction (AMI), is a leading cause of death in the Asia-Pacific region. The Korea Acute Myocardial Infarction Registry (KAMIR) is the first nationwide, prospective, multicenter registry of Korean patients with AMI. Since the KAMIR first began in November 2005, more than 70,000 patients have been enrolled, and 230 papers have been published (as of October 2018). Moreover, published data from the KAMIR have revealed different characteristics from those of Western AMI registries regarding risk factors, interventional strategies, and clinical outcomes. As a result, the KAMIR study has improved the outcomes of percutaneous coronary intervention and reduced mortality. We propose the use of the KAMIR score in the prediction of 1-year mortality. Using data from the KAMIR, we provide an overview of the current status of AMI in Korea, including trends in demographic characteristics, risk factors, medications, treatment strategies, and clinical outcomes.

Results of a 10-Year Experience in Korea Using Drug-Eluting Stents During Percutaneous Coronary Intervention for Acute Myocardial Infarction (from the Korea Acute Myocardial Infarction Registry)

Limited information exists about characteristics of patients with acute myocardial infarction (AMI) in Asia. We examined trends in interventional treatment and clinical outcomes for AMI from the Korea Acute Myocardial Infarction Registry (KAMIR). The study population was derived from patients in the KAMIR from November 2005 to December 2016. We identified 54,402 patients with ST-elevation myocardial infarction (STEMI) (n = 29,222) and non-ST-elevation myocardial infarction (NSTEMI) (n = 25,180). The rate of percutaneous coronary intervention (PCI) increased to 96.2% of STEMI group and 84.3% of NSTEMI group in 2016, respectively (All p_trend <0.001). Furthermore, the rate of successful PCI was 97.3% in STEMI and 97.9% in NSTEMI. The rate of primary PCI increased from 67.8% in 2005 to 96.9% in 2016 (p_trend <0.001). Moreover, in patients with STEMI, the proportion of drug-eluting stent implantation increased from 88.8% in 2005 to 97.9% in 2016 (p_trend <0.001). Regarding 1-year clinical outcomes, incidence of definite stent thrombosis was 0.5%, 0.6%, and 0.4% in patients with AMI, STEMI, and NSTEMI, respectively. Moreover, 1-year mortality of AMI improved almost 40% compared with in 2005 (11.4% in 2005 and 6.7% in 2015, p_trend <0.001). In Korean patients with AMI, the rate of primary PCI and drug-eluting stent implantation in STEMI was evidently higher than in the Western registries. In 1-year clinical outcomes, the incidence of stent thrombosis was low and mortality of AMI gradually improved and was lower than in the Western registries.

Differences in the Korea Acute Myocardial Infarction Registry Compared with Western Registries

The Korea Acute Myocardial Infarction Registry (KAMIR) is the first nationwide registry that reflects current therapeutic approaches and acute myocardial infarction (AMI) management in Korea. The results of the KAMIR demonstrated different risk factors and responses to medical and interventional treatments. The results indicated that the incidence of ST-elevation myocardial infarction (STEMI) was relatively high, and that the prevalence of dyslipidemia was relatively low with higher triglyceride and lower high-density lipoprotein cholesterol levels. Percutaneous coronary intervention (PCI) rates were high for both STEMI and non-ST-elevation myocardial infarction (NSTEMI) with higher use of drug-eluting stents (DESs). DES were effective and safe without increased risk of stent thrombosis in Korean AMI patients. Triple antiplatelet therapy, consisting of aspirin, clopidogrel, and cilostazol, was effective in preventing adverse clinical outcomes after PCI. Statin therapy was effective in Korean AMI patients, including those with very low levels of low-density lipoprotein cholesterol and those with cardiogenic shock. The KAMIR score had a greater predictive value than Thrombolysis in Myocardial Infarction (TIMI) and Global Registry of Acute Coronary Events (GRACE) scores for long-term mortality in AMI patients. Based on these results, the KAMIR will be instrumental for establishing new therapeutic strategies and effective methods for secondary prevention of AMI and guidelines for Asian patients.