Impact of time to treatment with tissue plasminogen activator on morbidity and mortality following acute myocardial infarction (The second National Registry of Myocardial Infarction)

Fibrinolytic uses in the emergency department: a narrative review

INTRODUCTION

Several life-threatening conditions associated with thrombosis include acute ischemic stroke (AIS), acute myocardial infarction (AMI), and acute pulmonary embolism (PE). Fibrinolytics are among the treatment algorithms for these conditions.

OBJECTIVE

This narrative review provides emergency clinicians with an overview of fibrinolytics for AIS, AMI, and PE in the emergency department (ED) setting.

DISCUSSION

Pathologic thrombosis can result in vascular occlusion and embolism, ultimately leading to end-organ injury. Fibrinolytics are medications utilized to lyse a blood clot, improving vascular flow. One of the first agents utilized was streptokinase, though this is not as often used with the availability of fibrin-specific agents including alteplase (tPA), tenecteplase (TNK), and reteplase (rPA). These agents are integral components in the management of several conditions, including AIS, AMI, and PE. Patients with AIS who present within 3-4.5 h of measurable neurologic deficit with no evidence of intracerebral hemorrhage (ICH) or other contraindications may be eligible to receive tPA or TNK. In the absence of percutaneous coronary intervention (PCI), fibrinolytics should be considered in patients with AMI presenting with chest pain for at least 30 min but less than 12 h, though it may be considered up to 24 h. Unlike in AIS and PE, anticoagulation and antiplatelet medications should be administered in those with AMI receiving fibrinolytics. Following fibrinolytics, PCI is typically necessary. Fibrinolytics are recommended in patients with high-risk PE (hemodynamic instability), as they reduce the risk of mortality. The most significant complication following fibrinolytic administration includes major bleeding such as ICH, which occurs most frequently in those with AIS compared to AMI and PE. Thus, close patient monitoring is necessary following fibrinolytic administration.

CONCLUSIONS

An understanding of fibrinolytics in the ED setting is essential, including the indications, contraindications, and dosing.

Computed tomography for the detection of myocardial hypoperfusion in acute myocardial infarction and the associated CT-to-catheter time

Emergency computed tomography (CT) often does not allow for comprehensive coronary artery assessment. However, CT may reveal pathological myocardial hypoperfusion suggestive of acute myocardial infarction (AMI), especially in patients presenting with a different diagnostic hypothesis. CT hypoperfusion is known to be associated with myocardial infarction, however the diagnostic value of CT hypoperfusion for the detection of AMI is still not well evaluated. This was a single-centre retrospective study including patients who underwent invasive coronary angiography (ICA) due to suspected AMI based on incidental perfusion defects upon emergency CT imaging between 2018 and 2023. A total of 22 patients (mean age 66.3 ± 10.8 years, 11 female) were included in this analysis. The diagnosis of AMI was established in all cases leading to ICA. Culprit coronary artery lesions with an indication of percutaneous coronary intervention were detected in all patients who underwent ICA. Spearmann correlation for hypoperfused segments on CT imaging and the corresponding vascular territory upon ICA was significantly substantial (ρ = 0.73, p = < 0.001). The higher the number of affected myocardial segments, the faster ICA was initiated. Mean time between the suspicion of AMI on CT imaging and ICA was 196 (29-4044) minutes. Myocardial hypoperfusion on emergency CT imaging should be considered as AMI until proven otherwise, independent of the clinical scenario leading to performance of CT imaging and whether imaging was performed for the exclusion of non-cardiac pathologies. Early initiation of further diagnostic workup may potentially avoid delays to invasive treatment and reduce the CT-to-catheter-time. Our study explicitly underlines that myocardial hypoperfusion upon contrast enhanced CT imaging needs to be considered as sign of acute myocardial infarction and indicates targeted clinical workup to rule out this diagnosis and to shorten the timeframe from imaging diagnosis to interventional treatment.

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.

Fibrinolytic Therapy in Patients with Acute ST-elevation Myocardial Infarction

Fibrinolytic agents provide an important alternative therapeutic strategy in individuals presenting with ST-elevation myocardial infarction (STEMI). Ultimately, primary percutaneous coronary intervention (PCI) is the preferred reperfusion strategy for most patients with STEMI, including elderly patients and patients with coronavirus disease 2019 (COVID-19) infection. Fibrinolytic therapy should always be considered when timely primary PCI cannot be delivered appropriately. Clinicians should promptly recognize the signs of fibrinolytic therapy failure and consider rescue PCI. When fibrinolytics are used, coronary angiography and revascularization should not be conducted within the initial 3 hours after fibrinolytic administration.

Clinical significance of prehospital 12-lead electrocardiography in patients with ST-segment elevation myocardial infarction presenting with syncope: from a multicenter observational registry (K-ACTIVE study)

Patients with acute myocardial infarction (AMI) presenting with syncope have poor clinical outcomes partly due to a delay in the diagnosis. Although the impact of prehospital 12-lead electrocardiography (PHECG) on the reduction of first medical contact (FMC)-to-device time and subsequent adverse clinical events in patients with AMI has been demonstrated, the impact of PHECG for the patients presenting with syncope remains to be elucidated. This study aimed to explore the impact of PHECG on 30-day mortality in patients with ST-segment elevation myocardial infarction (STEMI) presenting with syncope. From a cohort of multi-center registry [Kanagawa-ACuTe cardIoVascular rEgistry (K-ACTIVE)], a total of 90 consecutive patients with STEMI presenting with syncope were included. The 30-day mortality were compared between patients with PHECG (PHECG group, n = 25) and those without PHECG (non-PHECG group, n = 65). There was no significant difference in the baseline clinical characteristics between the 2 groups. FMC-to-device time was significantly shorter in the PHECG group than in the non-PHECG group (122 [86, 128] vs. 131 [102, 153] min, p = 0.03) due to the shorter door-to-device time. Thirty-day mortality was significantly lower in the PHECG group than in the non-PHECG group (16.0 vs. 44.6%, p = 0.03). In conclusion, PHECG was associated with shorter FMC-to-device time and lower 30-day mortality in patients with STEMI presenting with syncope.

Prevalence and Predictors of Delay in Seeking Emergency Care in Patients Who Call 9-1-1 for Chest Pain

BACKGROUND

Delay in seeking medical treatment for suspected acute coronary syndrome can lead to negative patient outcomes.

OBJECTIVE

Our aim was to evaluate the prevalence and predictors of delay in seeking care in high-risk chest pain patients with or without acute coronary syndrome (ACS).

METHODS

This was a secondary analysis of an observational cohort study of patients transported by Emergency Medical Services for a chief complaint of chest pain. Important demographic and clinical characteristics were extracted from electronic health records. Two independent reviewers adjudicated the presence of ACS. Logistic regression was used to model the predictors of delay in seeking care.

RESULTS

The final sample included 743 patients (99% non-Hispanic). Overall, 24% presented > 12 h from onset of symptoms. Among those with ACS (n = 115), 14% presented > 12 h after onset of symptoms. Race, smoking, diabetes, and related symptoms were associated with delayed seeking behavior. In multivariate analysis, non-Caucasian race (black or others) was the only independent predictor of > 12 h delay in seeking care (odds ratio 1.4; 95% confidence interval 1.0-1.9).

CONCLUSIONS

One in four patients with chest pain, including 14% of those with ACS, wait more than 12 h before seeking care. Compared to non-blacks, black patients are 40% more likely to delay seeking care > 12 h.

Numeracy Predicts Risk of Pre-Hospital Decision Delay: a Retrospective Study of Acute Coronary Syndrome Survival

BACKGROUND

Many patients delay seeking medical attention during acute coronary syndromes (ACS), profoundly increasing their risk for death and major disability. Although research has identified several risk factors, efforts to improve patient decision making have generally been unsuccessful, prompting a call for more research into psychological factors.

PURPOSE

The purpose of this study is to estimate the relationship between ACS decision delay and numeracy, a factor closely related to general decision making skill and risk literacy.

METHODS

About 5 days after experiencing ACS, 102 survivors (mean age = 58, 32-74) completed a questionnaire including measures of numeracy, decision delay, and other relevant factors (e.g., anxiety, depression, symptom severity, knowledge, demographics).

RESULTS

Low patient numeracy was related to longer decision delay, OR = 0.64 [95 % confidence interval (CI) 0.44, 0.92], which was in turn related to higher odds of positive troponin on arrival at the hospital, OR = 1.37 [95 % CI 1.01, 2.01]. Independent of the influence of all other assessed factors, a patient with high (vs. low) numeracy was about four times more likely to seek medical attention within the critical first hour after symptom onset (i.e., OR_high-low = 3.84 [1.127, 11.65]).

CONCLUSIONS

Numeracy may be one of the largest decision delay risk factors identified to date. Results accord with theories emphasizing potentially pivotal roles of patient deliberation, denial, and outcome understanding during decision making. Findings suggest that brief numeracy assessments may predict which patients are at greater risk for life-threatening decision delay and may also facilitate the design of risk communications that are appropriate for diverse patients who vary in risk literacy.

Electrocardiographic indicators of acute coronary syndrome are more common in patients with ambulance transport compared to those who self-transport to the emergency department journal of electrocardiology

INTRODUCTION

The American Heart Association recommends individuals with symptoms suggestive of acute coronary syndrome (ACS) activate the Emergency Medical Services' (EMS) 911 system for ambulance transport to the emergency department (ED), which enables treatment to begin prior to hospital arrival. Despite this recommendation, the majority of patients with symptoms suspicious of ACS continue to self-transport to the ED. The IMMEDIATE AIM study was a prospective study that enrolled individuals who presented to the ED with ischemic symptoms.

OBJECTIVES

The purpose of this secondary analysis was to determine differences in patients presenting the ED for possible ACS who arrive by ambulance versus self-transport on: 1) time-to-initial hospital electrocardiogram (ECG), 2) presence of ischemic ECG changes, and 3) patient characteristics.

METHODS

Initial 12-lead ECGs acquired upon patient arrival to the ED were evaluated for ST-elevation, ST-depression, and T-wave inversion. ECG signs of ischemia were analyzed both individually and collapsed into an independent dichotomous variable (ED ECG ischemia yes/no) for statistical analysis. Patient characteristics tested included: gender, age, race, ethnicity, English speaking, living alone, mode of transport, and presenting symptoms (chest pain, jaw pain, shortness of breath, nausea/vomiting, syncope, and clinical history).

RESULTS

In 1299 patients (mean age 63.9, 46.7% male), 384 (29.6%) patients arrived by ambulance to the ED. The mean time-to-initial ECG was 47minutes for ambulance patients versus 53minutes for self-transport patients (p<0.001). Mode of transport was found to be an independent predictor for time-to-initial ECG controlling for age, gender, and race (p=0.004). There were significantly higher rates of ECG changes of ischemia for patients who arrived by ambulance versus self-transport (p=0.02), and patient characteristics differed by mode of transport to the ED.

DISCUSSION

Our findings indicate that less than 30% of individuals with symptoms of ACS activate the EMS '911' system for ambulance transport to the ED. Individuals more likely to activate 911 have timelier ECG but higher rates of ischemic changes, specifically ST-depression and T-wave inversion. Individuals least likely to activate 911 are women, younger individuals, Latino ethnicity, live with a significant other, and those experiencing chest or jaw pain.

The History of Primary Angioplasty and Stenting for Acute Myocardial Infarction

The evolution of the management of acute myocardial infarction (MI) has been one of the crowning achievements of modern medicine. At the turn of the twentieth century, MI was an often-fatal condition. Prolonged bed rest served as the principal treatment modality. Over the past century, insights into the pathophysiology of MI revolutionized approaches to management, with the sequential use of surgical coronary artery revascularization, thrombolytic therapy, and percutaneous coronary intervention (PCI) with primary coronary angioplasty, and placement of intracoronary stents. The benefits of prompt revascularization inspired systems of care to provide rapid access to PCI. This review provides a historical context for our current approach to primary PCI for acute MI.

International Comparison of Factors Associated with Delay in Presentation for AMI Treatment

BACKGROUND

Prehospital delay in response to acute myocardial infarction (AMI) symptoms is well documented in the US and Europe, but little is known about it in Asian countries where cardiovascular disease is increasing.

AIMS

We conducted an observational study of delay times and factors associated with hospital presentation times in 595 patients with AMI from the US, England, Japan and South Korea.

METHODS

Patients were interviewed about responses to symptoms within 72 h of hospital admission and the medical records were reviewed.

RESULTS

The proportions of patients with delay times of 1 h or less were: US--23%, Korea--18%, England--15% and Japan--8%. In the US and England when others present at symptom onset called an ambulance patients presented two to three times sooner. Independent predictors of presentation within an hour of symptom onset were attribution of symptoms to the heart and not waiting for symptoms to go away.

CONCLUSION

Similar education about the need to seek treatment early in response to AMI symptoms may be applicable in Western and Eastern industrialised populations.

Pre-hospital delay in patients with first time myocardial infarction: an observational study in a northern Swedish population

Background

In myocardial infarction (MI), pre-hospital delay is associated with increased mortality and decreased possibility of revascularisation. We assessed pre-hospital delay in patients with first time MI in a northern Swedish population and identified determinants of a pre-hospital delay ≥ 2 h.

Methods

A total of 89 women (mean age 72.6 years) and 176 men (mean age 65.8 years) from a secondary prevention study were enrolled in an observational study after first time MI between November 2009 and March 2012. Total pre-hospital delay was defined as the time from the onset of symptoms suggestive of MI to admission to the hospital. Decision time was defined as the time from the onset of symptoms until the call to Emergency Medical Services (EMS). The time of symptom onset was assessed during the episode of care, and the time of call to EMS and admission to the hospital was based on recorded data. The first medical contact was determined from a mailed questionnaire. Determinants associated with pre-hospital delay ≥ 2 h were identified by multivariable logistic regression.

Results

The median total pre-hospital delay was 5.1 h (IQR 18.1), decision time 3.1 h (IQR 10.4), and transport time 1.2 h (IQR 1.0). The first medical contact was to primary care in 52.3 % of cases (22.3 % as a visit to a general practitioner and 30 % by telephone counselling), 37.3 % called the EMS, and 10.4 % self-referred to the hospital. Determinants of a pre-hospital delay ≥ 2 h were a visit to a general practitioner (OR 10.77, 95 % CI 2.39–48.59), call to primary care telephone counselling (OR 3.82, 95 % CI 1.68–8.68), chest pain as the predominant presenting symptom (OR 0.24, 95 % CI 0.08–0.77), and distance from the hospital (OR 1.03, 95 % CI 1.02–1.04). Among patients with primary care as the first medical contact, 67.0 % had a decision time ≥ 2 h, compared to 44.7 % of patients who called EMS or self-referred (p = 0.002).

Conclusions

Pre-hospital delay in patients with first time MI is prolonged considerably, particularly when primary care is the first medical contact. Actions to shorten decision time and increase the use of EMS are still necessary.

Electronic supplementary material

The online version of this article (doi:10.1186/s12872-016-0271-x) contains supplementary material, which is available to authorized users.

Percutaneous coronary intervention in the elderly

Our population dynamics are changing. The number of octogenarians and older people in the general population is increasing and therefore the number of older patients presenting with acute coronary syndrome or stable angina is increasing. This group has a larger burden of coronary disease and also a greater number of concomitant comorbidities when compared to younger patients. Many of the studies assessing percutaneous coronary intervention (PCI) to date have actively excluded octogenarians. However, a number of studies, both retrospective and prospective, are now being undertaken to reflect the, "real" population. Despite being a higher risk group for both elective and emergency PCIs, octogenarians have the greatest to gain in terms of prognosis, symptomatic relief, and arguably more importantly, quality of life. Important future development will include assessment of patient frailty, encouraging early presentation, addressing gender differences on treatment strategies, identification of culprit lesion(s) and vascular access to minimise vascular complications. We are now appreciating that the new frontier is perhaps recognising and risk stratifying those elderly patients who have the most to gain from PCI. This review article summarises the most relevant trials and studies.

First medical contact in patients with STEMI and its impact on time to diagnosis; an explorative cross-sectional study

OBJECTIVE

It is unknown into what extent patients with ST-elevation myocardial infarction (STEMI) utilise a joint service number (Swedish Healthcare Direct, SHD) as first medical contact (FMC) instead of Emergency Medical Services (EMS) and how this impact time to diagnosis. We aimed to (1) describe patients' FMC; (2) find explanatory factors influencing their FMC (ie, EMS and SHD) and (3) explore the time interval from symptom onset to diagnosis.

SETTING

Multicentred study, Sweden.

METHODS

Cross-sectional, enrolling patients with consecutive STEMI admitted within 24 h from admission.

RESULTS

We included 109 women and 336 men (mean age 66±11 years). Although 83% arrived by ambulance to the hospital, just half of the patients (51%) called EMS as their FMC. Other utilised SHD (21%), contacted their primary healthcare centre (14%), or went directly to the emergency room (14%). Reasons for not contacting EMS were predominantly; (1) my transport mode was faster (40%), (2) did not consider myself sick enough (30%), and (3) it was easier to be driven or taking a taxi (25%). Predictors associated with contacting SHD as FMC were female gender (OR 1.92), higher education (OR 2.40), history of diabetes (OR 2.10), pain in throat/neck (OR 2.24) and pain intensity (OR 0.85). Predictors associated with contacting EMS as FMC were history of MI (OR 2.18), atrial fibrillation (OR 3.81), abdominal pain (OR 0.35) and believing the symptoms originating from the heart (OR 1.60). Symptom onset to diagnosis time was significantly longer when turning to the SHD instead of the EMS as FMC (1:59 vs 1:21 h, p<0.001).

CONCLUSIONS

Using other forms of contacts than EMS, significantly prolong delay times, and could adversely affect patient prognosis. Nevertheless, having the opportunity to call the SHD might also, in some instances, lower the threshold for taking contact with the healthcare system, and thus lowers the number that would otherwise have delayed even longer.

Prodromal symptoms associated with acute coronary syndrome acute symptom presentation

OBJECTIVE

Prodromal symptoms (PS), indicative of myocardial ischemia, are frequently unrecognized by individuals prior to an acute coronary syndrome (ACS). ACSs are the leading cause of death worldwide. This study describes (1) the prevalence and association of PS with patients' baseline ACS-related acute symptoms of pain intensity and state anxiety and (2) the relationship of PS to co-morbidity.

METHODS

An exploratory sub-analysis was performed. Cross sectional data identified prodromal predictors of ACS pain intensity (numeric rating scale 0-10 (NRS)) and state anxiety (Speilberger state-trait anxiety personality inventory (STAI)). ACS patients (n=121) admitted to a community rural emergency department completed the prodromal symptom screening scale (PS-SS) and reported baseline cardiac pain intensity, state, and trait anxiety.

RESULTS

Increased ACS pain intensity was associated with PS. Median pain scores were higher by two points for those with prodromal headache, p=0.006, and anxiety, p=0.017, and one point higher for those with sleep disturbances, p=0.012. PS were not associated with state or trait anxiety. Hypertensive individuals were 7.5 times more likely to experience prodromal fatigue prior to their ACS event.

CONCLUSION

Results extend current knowledge of the predictive value that prodromal headache, sleep disturbance and anxiety may have on individuals' acute symptom presentation. A prospective, prognostic study is required in order to determine whether PS are predictive of adverse cardiac events and if PS are a stronger predictor of ACS acute symptom presentation, compared with typical ACS-related co-morbidities.

Patient awareness and perception of stroke symptoms and the use of 911

BACKGROUND

Response to stroke symptoms and the use of 911 can vary by race/ethnicity. The quickness with which a patient responds to such symptoms has implications for the outcome and treatment. We sought to examine a sample of patients receiving a Remote Evaluation of Acute isCHemic stroke (REACH) telestroke consult in South Carolina regarding their awareness and perception of stroke symptoms related to the use of 911 and to assess possible racial/ethnic disparities.

METHODS

As of September 2013, 2325 REACH telestroke consults were conducted in 13 centers throughout South Carolina. Telephone surveys assessing use of 911 were administered from March 2012-January 2013 among 197 patients receiving REACH consults. Univariate and multivariate logistic regression was performed to assess factors associated with use of 911.

RESULTS

Most participants (73%) were Caucasian (27% were African-American) and male (54%). The mean age was 66 ± 14.3 years. Factors associated with use of 911 included National Institutes of Health Stroke Scale scores >4 (odds ratio [OR], 5.4; 95% confidence interval [CI], 2.63-11.25), unknown insurance which includes self-pay or not charged (OR, 2.90; 95% CI, 1.15-7.28), and perception of stroke-like symptoms as an emergency (OR, 4.58; 95% CI, 1.65-12.67). African-Americans were significantly more likely than Caucasians to call 911 (62% vs. 43%, P = .02).

CONCLUSIONS

African-Americans used 911 at a significantly higher rate. Use of 911 may be related to access to transportation, lack of insurance, or proximity to the hospital although this information was not available. Interventions are needed to improve patient arrival times to telemedicine equipped emergency departments after stroke.

Site of hospital readmission and mortality: a population-based retrospective cohort study

BACKGROUND

Unplanned hospital readmission is a complex process, particularly if the patient is readmitted to an acute care institution other than the original hospital. This study tested the hypothesis that readmission to an alternative hospital is associated with increased mortality compared with readmission to the original hospital.

METHODS

We performed a population-based retrospective cohort analysis set between 1995 and 2010 for all 21 acute care adult general hospitals in the Greater Toronto and Hamilton Area. Participants were consecutive adults (age ≥ 18 yr) readmitted through the emergency department within 30 days after hospital discharge. The primary outcome measure was all-cause mortality within 30 days after readmission.

RESULTS

Of the 198 149 patients included in the study, 38 134 (19.2%) died within 30 days after readmission. Patients readmitted to an alternative hospital were more likely than those readmitted to the original hospital to be older, reside in a chronic-care facility and arrive by ambulance. Alternative-hospital readmission was associated with a higher risk of death within 30 days (22.3% v. 18.6%, p < 0.001; odds ratio [OR] 1.26, 95% confidence interval [CI] 1.23-1.30). The increased risk was substantially less after adjustment for patient- and hospital-level covariables (adjusted OR 1.06, 95% CI 1.02-1.10). Unadjusted Kaplan-Meier survival curves separated early and the absolute difference in mortality continued throughout the entire 1-year follow-up period, but no difference between groups was observed based on adjusted survival analyses.

INTERPRETATION

Among patients readmitted within 30 days after discharge, readmission to an alternative hospital was associated with a higher risk of death than readmission to the original hospital. Whether this adverse prognosis reflects a true causal relation or residual confounding is unknown.

Inconsistent measurement of acute coronary syndrome patients' pre-hospital delay in research: a review of the literature

BACKGROUND

Patients' treatment-seeking delay remains a significant barrier to timely initiation of reperfusion therapy. Measurement of treatment-seeking delay is central to the large body of research that has focused on pre-hospital delay (PHD), which is primarily patient-related. This research has aimed to quantify PHD and its effects on morbidity and mortality, identify contributing factors, and evaluate interventions to reduce such delay. A definite time of symptom onset in acute coronary syndrome (ACS) is essential for determining delay, but difficult to establish. This literature review aimed to explore the variety of operational definitions of both PHD and symptom onset in published research.

METHODS AND RESULTS

We reviewed the English-language literature from 1998-2013 for operational definitions of PHD and symptom onset. Of 626 papers of possible interest, 175 were deemed relevant. Ninety-seven percent reported a delay time and 84% provided an operational definition of PHD. Three definitions predominated: (a) symptom onset to decision to seek help (18%); (b) symptom onset to hospital arrival (67%), (c) total delay, incorporating two or more intervals (11%). Of those that measured delay, 8% provided a definition of which symptoms triggered the start of timing.

CONCLUSION

We found few and variable operational definitions of PHD, despite American College of Cardiology/American Heart Association recommendations to report specific intervals. Worryingly, definitions of symptom onset, the most elusive component of PHD to establish, are uncommon. We recommend that researchers (a) report two PHD delay intervals (onset to decision to seek care, and decision to seek care to hospital arrival), and (b) develop, validate and use a definition of symptom onset. This will increase clarity and confidence in the conclusions from, and comparisons within and between studies.

Longer pre-hospital delay in first myocardial infarction among patients with diabetes: an analysis of 4266 patients in the northern Sweden MONICA Study

Background

Reperfusion therapy reduces both morbidity and mortality in myocardial infarction, but the effectiveness depends on how fast the patient receives treatment. Despite the time-dependent effectiveness of reperfusion therapy, many patients with myocardial infarction have delays in seeking medical care. The aim of this study was to describe pre-hospital delay in a first myocardial infarction among men and women with and without diabetes and to describe the association between pre-hospital delay time and diabetes, sex, age, symptoms and size of residential area as a proxy for distance to hospital.

Methods

This population based study was based on data from 4266 people aged 25–74 years, with a first myocardial infarction registered in the Northern Sweden MONICA myocardial infarction registry between 2000 and 2008.

Results

The proportion of patients with delay times ≥ 2 h was 64% for patients with diabetes and 58% for patients without diabetes. There was no difference in delay time ≥ 2 h between men and women with diabetes. Diabetes, older age and living in a town or rural areas were factors associated with pre-hospital delay times ≥ 2 h. Atypical symptoms were not a predictor for pre-hospital delay times ≥ 2 h, OR 0.59 (0.47; 0.75).

Conclusions

A higher proportion of patients with diabetes have longer pre-hospital delay in myocardial infarction than patients without diabetes. There are no differences in pre-hospital delay between men and women with diabetes. The largest risk difference for pre-hospital delay ≥ 2 h is between women with and without diabetes. Diabetes, older age and living in a town or rural area are predictors for pre-hospital delay ≥ 2 h.

Impact of type of thrombolytic agent on in-hospital outcomes in ST-segment elevation myocardial infarction patients in the Middle East

Little is known about the impact of thrombolytic agents on in-hospital outcomes in the Middle East. The objective of this study was to evaluate the impact of thrombolytic agents on in-hospital outcomes in ST-segment elevation myocardial infarction (STEMI) patients in six Middle Eastern countries. Gulf Registry of Acute Coronary Events was a prospective, multinational, multicentre, observational survey of consecutive acute coronary syndrome patients admitted to 65 hospitals in 2006 and 2007. Out of 1,765 STEMI patients admitted to hospitals within 12 h of symptoms onset, 25, 43, and 30% were treated with streptokinase, reteplase, and tenecteplase, respectively. Median age of the study cohort was 50 (45-59) years and majority were males (89%). The overall median symptom onset-to-presentation and median door-to-needle times were 130 min (65-240) and 45 min (30-75), respectively. Streptokinase patients had worse GRACE risk scores compared to patients who received fibrin specific thrombolytics. Academic hospitals and cardiologists as admitting physicians were associated with the use of fibrin specific thrombolytics. After significant covariate adjustment, both reteplase [odds ratio (OR), 0.38; 95% CI: 0.18-0.79; P = 0.009] and tenecteplase (OR, 0.30; 95% CI: 0.12-0.77; P = 0.012) were associated with lower all-cause in-hospital mortality compared with streptokinase. No significant differences in other in-hospital outcomes were noted between the thrombolytic agents. In conclusion, in light of the study's limitations, fibrin specific agents, reteplase and tenecteplase, were associated with lower all-cause in-hospital mortality compared to the non-specific fibrin agent, streptokinase. However, the type of thrombolytic agent used did not influence other in-hospital outcomes.

Coronary collateral circulation: Effects on outcomes of acute anterior myocardial infarction after primary percutaneous coronary intervention

Background

To investigate the effects of collateral coronary circulation on the outcome of the patients with anterior myocardial infarction (MI) with left anterior desending artery occlusion abruptly.

Methods

Data of 189 patients with acute anterior MI who had a primary percutaneous coronary intervention (PCI) in the first 12 h from the onset of symptoms between January 2004 and December 2008 were retrospective analyzed. Left anterior descending arteries (LAD) of all patients were occluded. LADs were reopened with primary PCI. According to the collateral circulation, all patients were classified to two groups: no collateral group (n = 111), patients without angiographic collateral filling of LAD or side branches (collateral index 0) and collateral group (n = 78), and patients with angiographic collateral filling of LAD or side branches (collateral index 1, 2 or 3). At one year's follow-up, the occurrence of death, reinfarction, stent thrombosis (ST), target vessel revascularization and readmission because of heart failure were observed.

Results

At one year, the mortality was lower in patients with collateral circulation compared with those without collateral circulation (1% vs. 8%, P = 0.049), whereas there were no differences in the occurrence of reinfarction, ST, target vessel revascularization and readmission because of heart failure. The occurrence of composite of endpoint was lower in patients with collateral circulation compared with those without collateral circulation (12% vs. 26%; P = 0.014).

Conclusions

Pre-exist collateral circulation may prefigure the satisfactory prognosis to the patients with acute anterior MI after primary PCI in the first 12 h of MI onset.

First episode psychosis and the trail to secondary care: help-seeking and health-system delays

BACKGROUND

People experience delays in receiving effective treatment for many illnesses including psychosis. These delays have adverse consequences in heart disease and cancer, and their causes have been the subject of much research but only in recent years have pathways to care in psychosis received such attention. We sought to establish if, when and where people seek help in the early phase of psychosis in a representative sample.

METHODS

One hundred and sixty-five people with first episode psychosis, referred from community-based psychiatric services and a private psychiatric facility to an early intervention service over 18 months, were interviewed with the Structured Clinical Interview for DSM-IV diagnoses. Symptoms were measured using the Schedule for the Assessment of Positive Symptoms, Schedule for the Assessment of Negative Symptoms and the Calgary Scale. Duration of untreated illness (DUI) and duration of untreated psychosis (DUP) were established using the Beiser Scale. Pathways to mental health services were systematically detailed through interviews with patients and their families.

RESULTS

The final sample consisted of 142 (88M, 54F) cases after those with psychosis due to a general medical condition and those without pathway and DUP data were excluded. Less than half of participants initiated help seeking themselves. Of those who did seek help (n = 57) 25% did so during the DUI. Those who had a positive family history of mental illness and poorer premorbid adjustment were significantly less likely to seek help for themselves and those who did not seek help were more likely to require hospitalisation. Families were involved in help seeking for 50% of cases and in 1/3 of cases did so without the affected individual participating in the contact. Being younger and having more negative symptoms were associated with having one's family involved in help seeking. Delays to effective treatment from the onset of psychosis were evenly split between "help-seeking delays" and "health-system delays". Having a family member involved in help seeking and better premorbid adjustment were independently associated with shorter help-seeking delays when measured from the onset of psychosis. Being female, having better premorbid adjustment and fewer negative symptoms were associated with shorter help-seeking delays from the onset of illness. Those with a non-affective psychosis had significantly longer system delays.

CONCLUSION

Many people with first episode psychosis do not initiate help-seeking for themselves particularly those with a relative affected by mental illness. Those with poor premorbid adjustment are at particular risk of longer delays. Poor premorbid adjustment compounded by long delays to effective treatment reduces the likelihood of a good outcome. Families play a vital role in hastening receipt of effective treatment.

Trends in reperfusion strategies, door-to-needle and door-to-balloon times, and in-hospital mortality among patients with ST-segment elevation myocardial infarction enrolled in the National Registry of Myocardial Infarction from 1990 to 2006

BACKGROUND

Among patients with ST-segment elevation myocardial infarction (STEMI), rapid reperfusion is associated with improved mortality. As such, door-to-needle (D2N) and door-to-balloon (D2B) times have become metrics of quality of care and targets for intense quality improvement.

METHODS

The National Registry of Myocardial Infarction (NRMI) collected data regarding reperfusion therapy, its timing and in-hospital mortality among STEMI patients from 1990 through 2006.

RESULTS

Since 1990, NRMI has enrolled 1,374,232 STEMI patients at 2,157 hospitals. Among those, 774,279 (56.3%) were eligible for reperfusion upon arrival. The proportion receiving fibrinolytic therapy fell from 52.5% in 1990 to 27.6% in 2006 (P < .001), while the proportion undergoing primary percutaneous coronary intervention (pPCI) increased from 2.6% to 43.2%. Among reperfusion-eligible patients who received fibrinolytic therapy, there was a nearly linear decline in median D2N time from 59 minutes in 1990 to 29 minutes in 2006 (P < .001 for trend) as well as a decrease in mortality from 7.0% in 1994 to 6.0% in 2006 (P < .001). Among those undergoing pPCI, D2B time among nontransfer patients declined linearly from 111 minutes in 1994 to 79 minutes in 2006 (P < .001) with a decline in mortality from 8.6% to 3.1% (P < .001). The relative improvement in mortality attributable to improvements in D2N time was 16.3% and to D2B time was 7.5%.

CONCLUSIONS

Since 1990, there has been a progressive decline in D2N and D2B time among reperfusion-eligible STEMI patients. These improvements have contributed, at least in part, to a progressive decline in mortality.

Impact of delayed presentation on management and outcome of non-ST-elevation acute coronary syndromes

BACKGROUND

The impact of delayed presentation on the management and outcomes of patients with non-ST-elevation acute coronary syndromes (NSTE-ACS) has not been well studied. Furthermore, the prognostic value of initial biomarker level in relation to the time of presentation has not been determined.

METHODS

The Canadian ACS II registry was a national, multicenter, prospective observational study of 1,956 patients with NSTE-ACS (October 2002-December 2003). We compared the baseline characteristics, treatment, and outcomes in early (within 6 hours of symptom onset) versus late presenters (>6 hours). A logistic regression model was developed to examine the independent association of late presentation with 1-year mortality. We also evaluated the prognostic value of initial biomarker level in relation to early versus late presentation.

RESULTS

A total of 1,219 (62.3%) patients presented early, whereas 727 (37.7%) presented late; their rates of in-hospital revascularization were similar (40.5% vs 42.5%, respectively, P = .39). There was also no significant difference in hospital mortality (1.6% vs 2.2%, P = .30) or 1-year mortality (7.6% vs 5.7%, P = .13) between early and late presenters. After adjusting for other prognosticators, late presentation was not an independent predictor of 1-year mortality (adjusted odds ratio 0.78, 95% confidence interval 0.48-1.26, P = .3). Elevated initial biomarker was independently associated with higher 1-year mortality (adjusted odds ratio 2.17, 95% CI 1.31-3.58, P = .002) regardless of whether hospital presentation was early or late (P for interaction = .74).

CONCLUSIONS

There is still considerable delay between symptom onset of NSTE-ACS and hospital presentation in the contemporary era. In contrast to studies of ST-elevation myocardial infarction, we found no significant differences in the management and outcome of early presenters as compared with late presenters with NSTE-ACS. Nevertheless, measures to reduce patient delay time should continue to be implemented. Initial biomarker status is a useful prognosticator irrespective of the delay time.

The impact of initial treatment delay using primary angioplasty on mortality among patients with acute myocardial infarction: from the Korea acute myocardial infarction registry

The impact of treatment delays to reperfusion on patient mortality after primary percutaneous coronary intervention (PCI) for ST elevation myocardial infarction (STEMI) is controversial. We analyzed 5,069 patients included in the Korea Acute Myocardial Infarction Registry (KAMIR) between November 2005 and January 2007. We selected 1,416 patients who presented within 12 hr of symptom onset and who were treated with primary PCI. The overall mortality at one month was 4.4%. The medians of door-to-balloon time, symptom onset-to-balloon time, and symptom onset-to-door time were 90 (interquartile range, 65-136), 274 (185-442), and 163 min (90-285), respectively. One-month mortality was not increased significantly with any increasing delay in door-to-balloon time (4.3% for < or =90 min, 4.4% for >90 min; p=0.94), symptom onset-to-balloon time (3.9% for < or =240 min, 4.8% for >240 min; p=0.41), and symptom onset-to-door time (3.3% for < or =120 min, 5.0% for >120 min; p=0.13). These time variables had no impact on one-month mortality in any subgroup. Thus, this first nationwide registry data in Korea showed a good result of primary PCI, and the patient prognosis may not depend on the initial treatment delay using the current protocols.

Symptom-to-door time in ST segment elevation myocardial infarction: overemphasized or overlooked? Results from the AMI-McGill study

BACKGROUND

Ischemic time is a major determinant of infarct size in ST segment elevation myocardial infarction (STEMI). Emphasis is placed on reducing the door-to-reperfusion therapy time component, whereas the symptom-to-door time is often overlooked.

OBJECTIVES

To correlate the symptom-to-door time with left ventricular ejection fraction (LVEF) in patients with STEMI.

METHODS

Acute Myocardial Infarction (AMI)-McGill was a cohort study of consecutive patients with STEMI who presented to three adult university hospitals. Multivariate linear regression was performed to correlate the symptom-to-door time with postinfarction LVEF adjusted for reperfusion method, prior myocardial infarction and components of the Thrombolysis In Myocardial Infarction (TIMI) risk score.

RESULTS

There were 188 patients, with a mean age of 66 years. On arrival to hospital, 23% of patients were in Killip class II to IV and 87% received reperfusion therapy (20% fibrinolytic therapy and 67% primary percutaneous coronary intervention). The median symptom-to-door time was 120 min (first quartile: 60 min, third quartile: 290 min) and the median door-to-reperfusion therapy time was 93 min (first quartile: 54 min, third quartile: 155 min). Three variables were independently correlated with LVEF in the study's regression model: symptom-to-door time (beta: -0.66, 95% CI -1.18 to -0.14; P=0.01), Killip class II to IV on arrival (beta: -6.43, 95% CI -11.87 to -0.99; P=0.02) and anterior territory of the infarction (beta: -5.86, 95% CI -10.55 to -1.18; P=0.02).

CONCLUSIONS

Symptom-to-door time was negatively correlated with postinfarction LVEF in patients with STEMI. Strategies to shorten this delay, such as educating high-risk patients about the symptoms of AMI, should be considered.

Factors associated with longer time from symptom onset to hospital presentation for patients with ST-elevation myocardial infarction

BACKGROUND

Previous studies have demonstrated the effects of single factors, such as age, sex, and race, with longer delays from symptom onset to hospital presentation in patients with ST-elevation myocardial infarction.

METHODS

We studied risk factors individually and in combination to determine the cumulative effect on delay times in 482,327 patients with ST-elevation myocardial infarction enrolled in the National Registry of Myocardial Infarction between January 1, 1995, and December 31, 2004. We analyzed patient subgroups with the following risk factors in combination: younger than 70 years vs 70 years and older, race/ethnicity, men vs women, and nondiabetic vs diabetic.

RESULTS

The geometric mean for delay time was 114 minutes, with a decreasing trend from 123 minutes in 1995 to 113 minutes in 2004 (P < .001). Nearly half of the patients (45.5%) presented more than 2 hours and 8.7% presented more than 12 hours after the onset of symptoms. Compared with the reference group (those < 70 years, men, white, and did not have diabetes mellitus [DM]), subgroups with longer delay times (P < .01 for all) included those younger than 70 years, men, black, and had DM (+43 minutes); those younger than 70 years, women, black, and had DM (+55 minutes); those 70 years and older, men, black, and had DM (+60 minutes); and those 70 years and older, women, black, and had DM (+63 minutes).

CONCLUSIONS

Patient subgroups with a combination of factors (older age, women, Hispanic or black race, and DM) have particularly long delay times that may be 60 minutes longer than subgroups without those characteristics. Improving patient responsiveness in these subgroups represents an important opportunity to improve quality of care and minimize disparities in care.

Delay in presentation and reperfusion therapy in ST-elevation myocardial infarction

BACKGROUND

We studied the relationship between longer delays from symptom onset to hospital presentation and the use of any reperfusion therapy, door-to-balloon time, and door-to-drug time.

METHODS

Cohort study of patients with ST-elevation myocardial infarction enrolled in the National Registry of Myocardial Infarction from January 1, 1995 to December 31, 2004. Delay in hospital presentation was categorized into 1-hour intervals as < or =1 hour, >1-2 hours, >2-3 hours, etc, up to >11-12 hours. The study analyzed 3 groups: 440,398 patients for the association between delay and use of any reperfusion therapy; 67,207 patients for the association between delay and door-to-balloon time; 183,441 patients for the association between delay and door-to-drug time.

RESULTS

In adjusted analyses, patients with longer delays between symptom onset and hospital presentation were less likely to receive any reperfusion therapy, had longer door-to-balloon times, and had longer door-to-needle times (all P <.0001 for linear trend). For patients presenting < or =1 hour, >1-2 hours, >2-3 hours, >9-10 hours, >10-11 hours, and >11-12 hours after symptom onset, the use of any reperfusion therapy were 77%, 77%, 73%, 53%, 50%, and 46%, respectively. Door-to-balloon times were 99, 101, 106, 123, 125, and 123 minutes, respectively, and door-to-drug times were 33, 34, 36, 46, 44, and 47 minutes, respectively.

CONCLUSIONS

Longer delays from symptom onset to hospital presentation were associated with reduced likelihood of receiving primary reperfusion therapy, and even among those treated, late presenters had significantly longer door-to-balloon and door-to-drug times.

Impact of delay in door-to-needle time on mortality in patients with ST-segment elevation myocardial infarction

Fibrinolytic therapy is the most common reperfusion strategy for patients with ST-segment elevation myocardial infarction (STEMI), particularly in smaller centers. Previous studies evaluated the relation between time to treatment and outcomes when few patients were treated within 30 minutes of hospital arrival and many did not receive modern adjunctive medications. To quantify the impact of a delay in door-to-needle time on mortality in a recent and representative cohort of patients with STEMI, a cohort of 62,470 patients with STEMI treated using fibrinolytic therapy at 973 hospitals that participated in the National Registry of Myocardial Infarction from 1999 to 2002 was analyzed. Hierarchical models were used to evaluate the independent effect of door-to-needle time on in-hospital mortality. In-hospital mortality was lower with shorter door-to-needle times (2.9% for < or =30 minutes, 4.1% for 31 to 45 minutes, and 6.2% for >45 minutes; p <0.001 for trend). Compared with those experiencing door-to-needle times < or =30 minutes, adjusted odd ratios (ORs) of dying were 1.17 (95% confidence interval [CI] 1.04 to 1.31) and 1.37 (95% CI 1.23 to 1.52; p for trend <0.001) for patients with door-to-needle times of 31 to 45 and >45 minutes, respectively. This relation was particularly pronounced in those presenting within 1 hour of symptom onset to presentation time (OR 1.25, 95% CI 1.01 to 1.54; OR 1.54, 95% CI 1.27 to 1.87, respectively; p for trend <0.001). In conclusion, timely administration of fibrinolytic therapy continues to significantly impact on mortality in the modern era, particularly in patients presenting early after symptom onset.

Expedited transfer for primary percutaneous coronary intervention: a program evaluation

BACKGROUND

A shorter time from symptom onset to reperfusion is associated with improved outcomes for patients with ST-segment elevation myocardial infarction (MI). Primary percutaneous coronary intervention is a favourable method of reperfusion if performed effectively and expeditiously. We sought to evaluate the impact of an expedited pre-hospital diagnosis and transfer pathway developed by a multidisciplinary team on the door-to-balloon time in a large urban community.

METHODS

We included all patients with ST-segment elevation MI who presented within 12 hours after symptom onset and who sought medical attention through Emergency Medical Services within the boundaries of the city of Calgary in the 16 months following the introduction of the pathway in June 2004. The primary aim was to determine the proportion of patients who received percutaneous coronary intervention within the recommended door-to-balloon time of 90 minutes.

RESULTS

The 358 patients (268 men) in the study cohort had a mean age of 63.2 (standard deviation 12.7) years; 140 (39.1%) had an anterior MI; and 23 (6.4%) had cardiogenic shock. The introduction of the pathway resulted in a median door-to-balloon time of 62 (interquartile range 45-84) minutes. A door-to-balloon time within 60 minutes and within the currently recommended 90 minutes was achieved in 48.9% and 78.8% of the patients respectively. The in-hospital and 30-day mortality rates were both 3.1%.

INTERPRETATION

In a community with multiple regional hospitals and a single facility for percutaneous coronary intervention, the implementation of a multidisciplinary pre-hospital diagnosis and transfer pathway was feasible and resulted in most patients in the study cohort receiving primary percutaneous coronary intervention within the recommended door-to-balloon time of 90 minutes.

Reducing delay in seeking treatment by patients with acute coronary syndrome and stroke: a scientific statement from the American Heart Association Council on Cardiovascular Nursing and Stroke Council

Patient delay in seeking treatment for acute coronary syndrome and stroke symptoms is the major factor limiting delivery of definitive treatment in these conditions. Despite decades of research and public education campaigns aimed at decreasing patient delay times, most patients still do not seek treatment in a timely manner. In this scientific statement, we summarize the evidence that (1) demonstrates the benefits of early treatment, (2) describes the extent of the problem of patient delay, (3) identifies the factors related to patient delay in seeking timely treatment, and (4) reveals the inadequacies of our current approaches to decreasing patient delay. Finally, we offer suggestions for clinical practice and future research.

"Patient-time", "doctor-time", and "institution-time": perceptions and definitions of time among doctors who become patients

OBJECTIVE

To examine views and experiences of conflicts concerning time in healthcare, from the perspective of physicians who have become patients.

METHODS

We conducted two in-depth semi-structured 2-h interviews concerning experiences of being health care workers, and becoming a patient, with each of 50 doctors who had serious illnesses.

RESULTS

These doctor-patients often came to realize as they had not before how patients experience time differently, and how "patient-time", "doctor-time", and "institution-time" exist and can conflict. Differences arose in both the long and short term, regarding historical time (prior eras/decades in medicine), prognosis (months/years), scheduling delays (days/weeks), daily medical events and tasks (hours), and periods in waiting rooms (minutes/hours). Definitions of periods of time (e.g., "fast", "slow", "plenty", and "soon") also varied widely, and could clash. Professional socialization had heretofore impeded awareness of these differences. Physicians tried to address these conflicts in several ways (e.g., trying to provide test results more promptly), though full resolution remained difficult.

CONCLUSIONS

Doctors who became patients often now realized how physicians and patients differ in subjective experiences of time. Medical education and research have not adequately considered these issues, which can affect patient satisfaction, doctor-patient relationships and communication, and care.

PRACTICE IMPLICATIONS

Physicians need to be more sensitive to how their definitions, perceptions, and experiences concerning time can differ from those of patients.

Current incidence and clinical outcomes of bivalirudin administration among patients undergoing primary coronary intervention for stent thrombosis elevation acute myocardial infarction

BACKGROUND

Multiple antithrombotic options are available for patients undergoing primary percutaneous coronary interventions for stent thrombosis elevation acute myocardial infarction. Current utilization and outcomes of antithrombotic agents for primary percutaneous coronary intervention, including bivalirudin, have not been defined.

METHODS

A total of 84 471 patients were reported from 439 hospitals to the National Registry of Myocardial Infarction-5 registry between April 2004 and June 2005. Consecutive patients undergoing primary percutaneous coronary interventions for stent thrombosis elevation acute myocardial infarction (n=7629 at 231 United States percutaneous coronary intervention capable hospitals) comprised the population analyzed. We examined antithrombotic strategies and the occurrence of adverse cardiac events stratified according to the use of bivalirudin. Logistic regression was performed to control for differences between three antithrombotic therapy treatment groups.

RESULTS

Glycoprotein IIbIIIa inhibitors were used nearly ubiquitously, but given prior to percutaneous coronary interventions in only 36% of patients. Less than one-quarter of patients received clopidogrel prior to percutaneous coronary interventions. Bivalirudin was used in 4.2% of patients (n=320) undergoing primary percutaneous coronary intervention during this time period. Patients treated with bivalirudin were more likely to be elderly (P=0.03), have a history of prior bleeding (P=0.003) and stroke (P=0.06). Major adverse events and bleeding complications were similar in antithrombotic therapy groups (bleeding: bivalirudin 7.8% versus nonbivalirudin 7.5%, P=0.85). The adjusted outcomes were also similar after confining the analysis to bivalirudin patients who had not received any glycoprotein IIbIIIa inhibitors (n=143).

CONCLUSIONS

Contemporary primary percutaneous coronary intervention includes mainly clopidogrel and eptifibatide initiated at the time of percutaneous coronary intervention. Patients who received bivalirudin were at higher risk and had similar adjusted outcomes as patients in the nonbivalirudin group. Optimization of primary percutaneous coronary intervention pharmacology requires future randomized clinical trials, examining the timing and type of adjunctive antithrombotic agents.

Delays to reperfusion therapy in acute ST-segment elevation myocardial infarction: results from the AMI-QUEBEC Study

BACKGROUND

Through the AMI-QUEBEC Study we sought to describe delays to reperfusion therapy for ST-segment elevation myocardial infarction (STEMI) and to identify factors associated with prolonged delays.

METHODS

We reviewed the charts of all consecutive patients with STEMI admitted to 17 hospitals in the province of Quebec in 2003 to obtain data on the time from presentation to reperfusion therapy. Data were available for 1189 (83.0%) of 1432 patients.

RESULTS

The median delay to reperfusion therapy was 32 minutes (first and third quartile [Q1, Q3] 20, 49) for 535 patients who received fibrinolytic therapy, 109 minutes (Q1, Q3 79, 150) for 455 patients who underwent primary percutaneous coronary intervention (PCI) at the initial hospital of presentation and 142 minutes (Q1, Q3 115, 194) for 199 patients who underwent primary PCI after an interhospital transfer. Patients who presented outside daytime working hours, those who received primary PCI and those who required interhospital transfer for primary PCI were less likely to receive reperfusion therapy within current recommended times (odds ratios [ORs] 0.49, 0.56 and 0.15, respectively). Increased age was associated with prolonged delays only among patients who received fibrinolytic therapy (OR for each 10-year increase in age 0.95, 95% credible interval [CrI] 0.93-0.99 for fibrinolytic therapy and 0.99, 95% CrI 0.95-1.05, for primary PCI).

INTERPRETATION

In 2003, many patients with STEMI in Quebec were not treated within the recommended times. Delays may be reduced by reorganizing pre-and in-hospital care for patients with STEMI to expedite delivery of reperfusion therapy.

Trends in acute myocardial infarction complicated by cardiogenic shock, 1979-2003, United States

BACKGROUND

Acute myocardial infarction (AMI) complicated by cardiogenic shock is associated with high morbidity and mortality.

METHODS

Using the National Hospital Discharge Survey data from 1979 to 2003, we measured trends in the incidence of AMI complicated by cardiogenic shock, the use of percutaneous transluminal coronary angioplasty (PTCA), and the inhospital death.

RESULTS

Age-adjusted hospitalization rates (per 100,000 populations) in 1979 and 2003, respectively, were 213 and 261 for AMI, and 8.6 and 4.3 for AMI complicated by cardiogenic shock. Among patients with AMI, the proportion with cardiogenic shock was 3.9% (n = 17,000) in 1979 and 1.7% (n = 13,000) in 2003. Patients with acute myocardial infarction with cardiogenic shock, compared with those without cardiogenic shock, were more likely to be women (48% vs 43%, P < .0001), more likely to have anterior wall AMI (33% vs 14%, P < .0001), and had much higher inhospital mortality (43% vs 7%, P < .0001). Over the years, among AMI complicated by cardiogenic shock, PTCA use increased substantially from 0% to 28%. During this period, inhospital death decreased from 84% to 43%. After adjustment for age, sex, location of AMI, health insurance, and survey year, PTCA use was significantly associated with decreased inhospital deaths among patients with AMI with cardiogenic shock.

CONCLUSIONS

Although hospitalization for AMI has increased over the past 25 years, the hospitalization rate of AMI complicated by cardiogenic shock has decreased by 50%. At the same time, PTCA use and hospital survival have increased substantially among cardiogenic shock patients.

Reducing Delay in Seeking Treatment by Patients With Acute Coronary Syndrome and Stroke

Patient delay in seeking treatment for acute coronary syndrome and stroke symptoms is the major factor limiting delivery of definitive treatment in these conditions. Despite decades of research and public education campaigns aimed at decreasing patient delay times, most patients still do not seek treatment in a timely manner. In this scientific statement, we summarize the evidence that (1) demonstrates the benefits of early treatment, (2) describes the extent of the problem of patient delay, (3) identifies the factors related to patient delay in seeking timely treatment, and (4) reveals the inadequacies of our current approaches to decreasing patient delay. Finally, we offer suggestions for clinical practice and future research.

Impact of treatment delays on outcomes of primary percutaneous coronary intervention for acute myocardial infarction: analysis from the CADILLAC trial

BACKGROUND

The impact of treatment delays on outcomes after primary percutaneous coronary intervention for acute myocardial infarction is controversial.

METHODS

The CADILLAC trial randomized 2082 patients with acute myocardial infarction to stenting versus percutaneous transluminal coronary angioplasty, each with or without abciximab.

RESULTS

Earlier reperfusion (<3 vs 3-6 vs >6 hours) was associated with lower 1-year mortality (2.6% vs 4.3% vs 4.8%, P = .046 for <3 vs > or = 3 hours), more frequent grade 2 to 3 myocardial blush (55% vs 53% vs 44%, P = .003), more frequent complete ST-segment resolution (64% vs 68% vs 47%, P = .006), and greater improvement in left ventricular function. Early reperfusion (<3 vs 3-6 vs > or = 3 hours) was associated with lower mortality in high-risk patients (3.8% vs 6.9% vs 7.0%, P = .051 for <3 vs > or = 3 hours) but not in low-risk patients (1.4% vs 0.6% vs 1.0%, P = .63). Door-to-balloon times were independently correlated with mortality in patients presenting early after the onset of symptoms (< or = 2 hours, hazard ratio 1.24, P = .013) but not late (>2 hours, heart rate 0.88, P = .33).

CONCLUSIONS

Early reperfusion results in superior clinical outcomes, enhanced microvascular reperfusion, and better recovery of left ventricular function. Incremental treatment delays impact mortality more in high-risk versus low-risk patients and more in patients presenting early versus late after the onset of symptoms. These data emphasize the importance of minimizing treatment delays and have implications regarding patient triage for primary percutaneous coronary intervention.

Effect of door-to-balloon time on mortality in patients with ST-segment elevation myocardial infarction

OBJECTIVES

We sought to determine the effect of door-to-balloon time on mortality for patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI).

BACKGROUND

Studies have found conflicting results regarding this relationship.

METHODS

We conducted a cohort study of 29,222 STEMI patients treated with PCI within 6 h of presentation at 395 hospitals that participated in the National Registry of Myocardial Infarction (NRMI)-3 and -4 from 1999 to 2002. We used hierarchical models to evaluate the effect of door-to-balloon time on in-hospital mortality adjusted for patient characteristics in the entire cohort and in different subgroups of patients based on symptom onset-to-door time and baseline risk status.

RESULTS

Longer door-to-balloon time was associated with increased in-hospital mortality (mortality rate of 3.0%, 4.2%, 5.7%, and 7.4% for door-to-balloon times of < or =90 min, 91 to 120 min, 121 to 150 min, and >150 min, respectively; p for trend <0.01). Adjusted for patient characteristics, patients with door-to-balloon time >90 min had increased mortality (odds ratio 1.42; 95% confidence interval [CI] 1.24 to 1.62) compared with those who had door-to-balloon time < or =90 min. In subgroup analyses, increasing mortality with increasing door-to-balloon time was seen regardless of symptom onset-to-door time (< or =1 h, >1 to 2 h, >2 h) and regardless of the presence or absence of high-risk factors.

CONCLUSIONS

Time to primary PCI is strongly associated with mortality risk and is important regardless of time from symptom onset to presentation and regardless of baseline risk of mortality. Efforts to shorten door-to-balloon time should apply to all patients.

Revascularization and cardioprotective drug treatment in myocardial infarction patients: how do they impact on patients' survival when delivered as usual care

Background

Randomized clinical trials showed the benefit of pharmacological and revascularization treatments in secondary prevention of myocardial infarction (MI), in selected population with highly controlled interventions. The objective of this study is to measure these treatments' impact on the cardiovascular (CV) mortality rate among patients receiving usual care in the province of Quebec.

Methods

The study population consisted of a "naturalistic" cohort of all patients ≥ 65 years old living in the Quebec province, who survived a MI (ICD-9: 410) in 1998. The studied dependant variable was time to death from a CV disease. Independent variables were revascularization procedure and cardioprotective drugs. Death from a non CV disease was also studied for comparison. Revascularization procedure was defined as percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass graft (CABG). The exposure to cardioprotective drugs was defined as the number of cardioprotective drug classes (Acetylsalicylic Acid (ASA), Beta-Blockers, Angiotensin-Converting Enzyme (ACE) Inhibitors, Statins) claimed within the index period (first 30 days after the index hospitalization). Age, gender and a comorbidity index were used as covariates. Kaplan-Meier survival curves, Cox proportional hazard models, logistic regressions and regression trees were used.

Results

The study population totaled 5596 patients (3206 men; 2390 women). We observed 1128 deaths (20%) within two years following index hospitalization, of them 603 from CV disease. The CV survival rate at two years is much greater for patients with revascularization, regardless of pharmacological treatments. For patients without revascularization, the CV survival rate increases with the number of cardioprotective drug classes claimed. Finally, Cox proportional hazard models, regression tree and logistic regression analyses all revealed that the absence of revascularization and, to a lower extent, absence of cardioprotective drugs were major predictors for CV death, even after adjusting for age, gender and comorbidity.

Conclusion

Considering usual care management of MI in the province of Quebec in 1998, CV survival is positively correlated to the presence of a revascularization procedure and to the intensity of cardioprotective pharmacological treatment. These results are coherent with data from randomized control trials.