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

The additive impact of reduced symptom-to-door and door-to-balloon times on survival rates in acute ST-elevation myocardial infarction patients

BACKGROUND

Shortened door-to-balloon time (D2B) has been documented to confer cardiovascular benefits for ST-elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PPCI). However, prolonged myocardial ischemic duration usually negates the beneficial effects due to delayed symptom-to-door time (S2D). In this study, we sought to investigate the joint effect of S2D-D2B in predicting clinical outcomes.

METHODS

This study retrospectively enrolled 342 consecutive STEMI patients receiving PPCI. The baseline demographic data, clinical features, S2D, D2B, and S2B were compared between survivors and non-survivors. We further analyzed the relationships between mortality rates and S2D/D2B in patients with different age categories.

RESULTS

The receiver-operating characteristic curves analysis revealed D2B time 65. Mins, S2D time 125 min, and S2B time 170 min had the greatest predictive power for mortality rate. Patients with D2B < 65min and S2D time <125 min had the lowest mortality rate (1.62%). Whereas, patients with a D2B ≥ 65 min and S2D ≥ 125 min had the highest mortality rate (21%, P = 0.0004). Multiple variate analyses showed that combined D2B ≥ 65 min and S2D ≥ 125 min was an independent predictor for a higher mortality rate (HR 9.44, P = 0.0111). Shorter S2B time was also associated with a lower mortality rate in overall and younger populations.

CONCLUSIONS

The reductions of both D2B and S2D were associated with improved mortality rates in STEMI patients receiving PPCI, especially in younger populations. The findings call for community and healthcare system efforts to address these critical time intervals to enhance survival rates in STEMI patients.

The Role of QRS Complex and ST-Segment in Major Adverse Cardiovascular Events Prediction in Patients with ST Elevated Myocardial Infarction: A 6-Year Follow-Up Study

BACKGROUND

as a relatively high number of ST-segment elevation myocardial infarction (STEMI) patients develop major adverse cardiovascular events (MACE) following percutaneous coronary intervention (PCI), our aim was to determine the significance, and possible predictive value of QRS complex width and ST-segment elevation.

METHODS

our patient sample included 200 PCI-treated STEMI patients, which were divided into two groups based on the following duration of symptoms: (I) less than 6 h, and (II) 6 to 12 h. For every patient, an ECG was performed at six different time points, patients were followed for up to six years for the occurrence of MACE.

RESULTS

the mean age was 60.6 ± 11.39 years, and 142 (71%) were male. The 6-12 h group had significantly wider QRS complex, higher ST-segment elevation, lower prevalence of ST-segment resolution as well as MACE prevalence (p < 0.05). ECG parameters, QRS width, and magnitude of ST-segment elevation were proved to be independent significant predictors of MACE in all measured time points (p < 0.05). Even after controlling for biomarkers of myocardial injury, these ECG parameters remained statistically significant predictors of MACE (p < 0.05).

CONCLUSION

our study highlights that wider QRS complex and a more pronounced ST-segment elevation are associated with longer total ischemic time and higher risk of long-term MACE.

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Diagnostic Performance of a Mnemonic for Warning Symptoms in Predicting Acute Coronary Syndrome Diagnosis: A Retrospective Cross-Sectional Study

Objectives: We aimed to create a mnemonic for acute coronary syndrome (ACS) warning symptoms and determine its diagnostic performance. Methods: This retrospective cross-sectional study included patients visiting the emergency room with symptoms of suspected ACS during 2020-2021. The mnemonic was created using symptoms with an odds ratio (OR) for predicting ACS >1.0. The mnemonic with the highest OR and sensitivity was identified. Sensitivity analysis was performed to test the diagnostic performance of the mnemonic by patient subgroups commonly exhibiting atypical symptoms. Results: ACS prevalence was 12.2% (415/3,400 patients). The mnemonic, "RUSH ChesT" [if you experience referred pain (R), unexplained sweating (U), shortness of breath (S), or heart fluttering (H) together with chest pain (C), visit the hospital in a timely (T) manner] had the best OR [7.81 (5.93-10.44)] and sensitivity [0.81 (0.77-0.85)]. This mnemonic had equal sensitivity in men and women, the elderly and adults, smokers and non-smokers, and those with and without diabetes or hypertension. Conclusion: The "RUSH ChesT" mnemonic shows good diagnostic performance for patient suspected ACS. It may effectively help people memorize ACS warning symptoms.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Symptom recognition and treatment-seeking behaviors in women experiencing acute coronary syndrome for the first time: a qualitative study

BACKGROUND

Women are more likely to delay medical help-seeking for ACS symptoms. Understanding patients' experience of the symptoms and their response is essential in improving help-seeking behaviors and timely diagnosis and treatment for ACS. This study aimed to explore women's experience of ACS, their response to the symptoms, and treatment-seeking decisions.

METHODS

This qualitative descriptive study was conducted in a tertiary referral specialized heart hospital affiliated with Tabriz University of Medical Sciences, Iran. Participants included 39 women who had experienced ACS for the first time.

RESULTS

Four main themes emerged from the analysis of interview transcripts: (1) the onset of symptoms, (2) the types of symptoms, (3) response to symptoms and (4) arriving at the hospital. These themes and associated sub-themes explained women's experience of ACS symptoms, their response to the symptoms, and decision to seek medical help.

CONCLUSIONS

This study identified and discussed factors contributing to the prehospital delay in women and their decision-making to seek medical care for ACS symptoms. The results are consistent with previous research indicating that ACS symptoms in women are somewhat different from men, and women tend to underestimate their symptoms and attribute them to non-cardiac causes. Women should be supported to develop awareness and understanding of ACS symptoms and appreciate the importance of early treatment-seeking in the disease outcomes.

Comparison of Prognosis According to the Use of Emergency Medical Services in Patients with ST-Segment Elevation Myocardial Infarction

PURPOSE

This study aimed to compare long-term clinical outcomes according to the use of emergency medical services (EMS) in patients with ST-segment elevation myocardial infarction (STEMI) who arrived at the hospital within 12 hr of symptom onset.

MATERIALS AND METHODS

A total of 13104 patients with acute myocardial infarction were enrolled in the Korea Acute Myocardial Infarction Registry-National Institutes of Health from October 2011 to December 2015. Of them, 2416 patients with STEMI who arrived at the hospital within 12 hr were divided into two groups: 987 patients in the EMS group and 1429 in the non-EMS group. Propensity score matching (PSM) was performed to reduce bias from confounding variables. After PSM, 796 patients in the EMS group and 796 patients in the non-EMS group were analyzed. The clinical outcomes during 3 years of clinical follow-up were compared between the two groups according to the use of EMS.

RESULTS

The symptom-to-door time was significantly shorter in the EMS group than in the non-EMS group. The EMS group had more patients with high Killip class compared to the non-EMS group. The rates of all-cause death and major adverse cardiac events (MACE) were not significantly different between the two groups. After PSM, the rate of all-cause death and MACE were still not significantly different between the EMS and non-EMS groups. The predictors of mortality were high Killip class, renal dysfunction, old age, long door-to-balloon time, long symptom-to-door time, and heart failure.

CONCLUSION

EMS utilization was more frequent in high-risk patients. The use of EMS shortened the symptom-to-door time, but did not improve the prognosis in this cohort.

Correlates of Delayed Initial Contact to Emergency Services among Patients with Suspected ST-Elevation Myocardial Infarction

Background

Early diagnosis and treatment of a patient displaying symptoms of myocardial ischemia is paramount in preventing detrimental tissue damage, arrhythmias, and death. Patient-related hospital delay is the greatest considerable cause of total delay in treatment for acute myocardial infarction.

Objective

To identify patient characteristics contributing to prehospital delay and ultimately developing health interventions to prevent future delay and improve health outcomes.

Methods

A retrospective chart review of 287 patients diagnosed with ST-elevation myocardial infarction (STEMI) was evaluated to examine correlates of patient-related delays to care.

Results

Stepwise logistic regression modeling with forward selection (likelihood ratio) was performed to identify predictors of first medical contact (FMC) within 120 minutes of symptom onset and door-to-balloon (DTB) time within 90 minutes. Distance from the hospital, being unmarried, self-medicating, disability, and hemodynamic stability emerged as variables that were found to be predictive of FMC within the first 120 minutes after symptom onset. Similarly, patient characteristics of gender and disability and having an initial nondiagnostic electrocardiogram emerged as significant predictors of DTB within 90 minutes.

Conclusions

Individual attention to high-risk patients and public education campaigns using printed materials, public lectures, and entertainment mediums are likely needed to disseminate information to improve prevention strategies. Future research should focus on identifying the strengths of prehospital predictors and finding other variables that can be established as forecasters of delay. Interventions to enhance survival in acute STEMI should continue as to provide substantial advances in overall health outcomes.

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.

Collapse

Key Words

• acute coronary syndrome
• chest pain
• myocardial infarction

Collapse

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

Collapse

Grants

• Deutsche Herzstiftung

Collapse

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

Collapse

Emergency medical services use and its association with acute ischaemic stroke evaluation and treatment in Singapore

Background

Emergency medical services (EMS) is a critical link in the chain of stroke survival. We aimed to assess EMS use for stroke in Singapore, identify characteristics associated with EMS use and the association of EMS use with stroke evaluation and treatment.

Methods

The Singapore Stroke Registry combines nationwide EMS and public hospital data for stroke cases in Singapore. Multivariate regressions with the generalised estimating equations were performed to examine the association between EMS use and timely stroke evaluation and treatment.

Results

Of 3555 acute ischaemic patients with symptom onset within 24 hours admitted to all five public hospitals between 2015 and 2016, 68% arrived via EMS. Patients who used EMS were older, were less likely to be female, had higher stroke severity by National Institute of Health Stroke Scale and had a higher prevalence of atrial fibrillation or peripheral arterial disease. Patients transported by EMS were more likely to receive rapid evaluation (door-to-imaging time ≤25 min 34.3% vs 11.1%, OR=2.74 (95% CI 1.40 to 5.38)) and were more likely to receive intravenous tissue plasminogen activator (tPA, 22.8% vs 4.6%, OR=4.61 (95% CI 3.52 to 6.03)). Among patients treated with tPA, patients who arrived via EMS were more likely to receive timely treatment than self-transported patients (door-to-needle time ≤60 min 52.6% vs 29.4%, OR=2.58 (95% CI 1.35 to 4.92)).

Conclusions

EMS use is associated with timely stroke evaluation and treatment in Singapore. Seamless EMS-Hospital stroke pathways and targeted public campaigns to advocate for appropriate EMS use have the potential to improve acute stroke care.

Presentation Times of Myocardial Infarctions to the Emergency Department: Disappearance of the Morning Predominance

BACKGROUND

Previous studies show that myocardial infarctions (MIs) occur most frequently in the morning.

OBJECTIVES

We hypothesized that there no longer is a morning predominance of MI, and that the timing of ST-elevation myocardial infarction (STEMI) vs. non-ST-elevation myocardial infarction (NSTEMI) presentation differs.

METHODS

We reviewed MI, STEMI, and NSTEMI patients (2013-2017) from a multiple-hospital system, identified by diagnostic codes. Daily emergency department arrival times were categorized into variable time intervals for count and proportional analysis, then examined for differences.

RESULTS

There were 18,663 MI patients from 12 hospitals included in the analysis. Most MIs occurred between 12:00 pm and 5:59 pm (35.7%), and least between 12:00 am-5:59 am (16.3%). After subdividing all MIs into STEMIs and NSTEMIs, both groups continued to have the greatest presentation between 12:00 pm and 5:59 pm (33.1% and 36.0%, respectively). STEMIs (17.2%) and NSTEMIs (16.2%) were least frequent between 12:00 am and 5:59 am. We found the second most common presentation time for MIs was in the 6 pm-11:59 pm time period, which held true for both subtypes (MI 26.7%, STEMI 26.4%, NSTEMI 26.7%).

CONCLUSIONS

These data suggest a potential shift in the circadian pattern of MI, revealing an afternoon predominance for both STEMI and NSTEMI subtypes.

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

OBJECTIVES

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

DESIGN, SETTING AND PARTICIPANTS

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

RESULTS

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

CONCLUSION

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

TRIAL REGISTRATION NUMBER

NCT01398228; Post-results.

The association between symptom onset characteristics and prehospital delay in women and men with acute coronary syndrome

BACKGROUND

A decision to delay seeking treatment for symptoms of acute coronary syndrome increases the risk of serious complications, disability, and death.

AIMS

The purpose of this study was to determine if there was an association between gradual vs abrupt symptom onset and prehospital delay for patients with acute coronary syndrome and to examine the relationship between activities at symptom onset and gradual vs abrupt symptom onset.

METHODS

This was a secondary analysis of a large prospective multi-center study. Altogether, 474 patients presenting to the emergency department with symptoms of acute coronary syndrome were included in the study. Symptom characteristics, activity at symptom onset, and prehospital delay were measured with the ACS Patient Questionnaire.

RESULTS

Median prehospital delay time was four hours. Being uninsured (β=0.120, p=0.031) and having a gradual onset of symptoms (β=0.138, p=0.003) were associated with longer delay. A diagnosis of ST-elevation myocardial infarction (β=-0.205, p=0.001) and arrival by ambulance (β=-0.317, p<0.001) were associated with shorter delay. Delay times were shorter for patients who experienced an abrupt vs gradual symptom onset (2.57 h vs 8 h, p<0.001). Among men with an abrupt onset of symptoms and a ST-elevation myocardial infarction diagnosis, 54% reported that symptoms were triggered by exertion (p=0.046).

CONCLUSION

Patients should be counselled that a gradual onset of symptoms for potential acute coronary syndrome is an emergency and that they should call 911. Men with ischemic heart disease or with multiple risk factors should be cautioned that symptom onset following exertion may represent acute coronary syndrome.

The impact of door-to-electrocardiogram time on door-to-balloon time after achieving the guideline-recommended target rate

Background

Little is known about the components and contributing factors of door-to-balloon time after implementation of Door-to-Balloon Alliance quality-improving (QI) strategies, including the impact of door-to-ECG time on door-to-balloon time.

Objective

We investigated whether modification of emergency department (ED) triage processes could improve door-to-ECG and door-to-balloon times after implementation of QI strategies.

Methods

This was a retrospective before-and-after study of a prospectively collected database. From June 2014 to October 2014, interventions were implemented in our ED, including a protocol-driven ECG initiation and moving an ECG station and technician to the triage area. The primary outcome was the percentage of patients with ST-elevation myocardial infarction (STEMI) who received ECG within 10 min of arrival; the secondary outcome was the percentage of patients with door-to-balloon times of <90 min from arrival. Patients from the year pre- and post-QI initiative were defined as the control and intervention groups, respectively.

Results

Enrollment comprised 214 patients with STEMI: 109 before the intervention and 105 after the intervention. We analyzed the components of the door-to-balloon process and found the door-to-ECG process was the most critical interval of delay (20.8%). Unrecognized symptoms were the most common cause of delay in the door-to-ECG process resulting in a significant impact on the door-to-balloon time. The intervention group had a higher percentage of patients with door-to-ECG times <10 min than did the control group (93.3% vs. 79.8%, p = 0.005), with a corresponding improvement in door-to-balloon times <90 min (91.1% vs. 76.2%, p = 0.007). In subgroup analysis, the intervention benefits occurred only in non-transferred or walk-in patients. After adjustment for possible co-variates, the QI interventions remained a significant contributing factor for achieving the door-to-ECG and door-to-balloon targets.

Conclusions

The modification of ED triage processes through implementation of QI strategies are effective in achieving better door-to-ECG times and thus, achieving door-to-balloon times <90 min. In patients presenting with ambiguous symptoms, improved door-to ECG target achievement rates, through a protocol-driven and multidisciplinary approach allows for earlier identification of STEMI.

ST-elevation myocardial infarction in a migrant population: a registry-based study of patient treatment and outcomes

BACKGROUND

Internationally, a growing number of studies has identified race-related disparities in the presentation, treatment and outcomes of patients with ST-elevation myocardial infarction (STEMI). With a large migrant population, Australia presents a unique microcosm in which to study the impact of migrant status and ethnicity in STEMI patients.

AIM

To investigate if first-generation migrants differed in presentation, treatment or outcomes following STEMI compared with the Australian-born population.

METHODS

We conducted a retrospective observational study using data from a clinician-initiated registry. The study involved 2154 patients who presented to 12 hospitals between 2004 and 2012. Our main outcome measures included time to reperfusion, 30-day mortality and complications.

RESULTS

Migrants (n = 1035, 48.8%) were more likely to be older (61 vs 58 years, P < 0.001), diabetic (29.3 vs 21.5%, P < 0.001) and have a prolonged symptom to door time (102 vs 91 min, P = 0.04). Despite lower rates of previous known ischaemic heart disease (22.5 vs 26.6%, P = 0.03), migrants had more diffuse disease (triple vessel or left main (3VD/LM): 29.8 vs 22.0%, P < 0.001) and higher troponin values (3.77 vs 3.22 μg/L, P = 0.01). We found no significant differences in hospital treatment times, intervention types or rates. Multivariate regression identified age, diabetes, female gender and multi-vessel disease as predictors of complications and death at 30 days.

CONCLUSIONS

Migrants had longer pre-hospital delays and exhibited different cardiovascular risk profiles than Australian-born patients but received comparable treatment in the acute hospital setting. Higher rates of diabetes and multi-vessel coronary artery disease were seen among migrant patients, indicating a relatively higher risk population.