1
|
Price J, Rudman J, Schoenfeld D, Thomas SA, Rees P, Bloom B, McCartin M, Blumen I, Thomas SH. Survivorship With Incrementally Faster Times to Primary Percutaneous Coronary Intervention (SWIFT-PPCI): A Systematic Review and Meta-Analysis. Am J Cardiol 2023; 207:356-362. [PMID: 37776583 DOI: 10.1016/j.amjcard.2023.08.178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 08/27/2023] [Accepted: 08/27/2023] [Indexed: 10/02/2023]
Abstract
In the United States, there are approximately 750,000 ST-elevation myocardial infarction cases each year. Streamlined care and rapid delivery for primary percutaneous coronary intervention (PPCI) is associated with improved survival. This systematic review and meta-analysis aimed to generate a practical estimate of mortality savings for every notional 30-minute decrease in the time to achieving PPCI. Included studies were those that provided a specific absolute risk reduction for a specific reduction in pre-PPCI time. The eligible studies evaluated the survival benefit from pre-PPCI time savings measured in any interval ending with PPCI and commencing with objectively recorded timing, such as initial emergency call, first medical contact, or hospital arrival. Study planning called for the reporting of data as individual study results, with a pooled effect estimate of relative risk calculated with random-effects meta-analysis. A total of 1,088 records were eligible for review; 52 were reviewed in full text, with 4 studies (total patient n = 235,814, overall mortality 4.7% to 7.8%) included in the final analysis. All 4 studies reported significant time-related survival benefit over the study focus window of 60 to 180 minutes pre-PPCI. The number of lives saved per 100 cases for each 30-minute pre-PPCI time savings ranged from 0.8 to 1.9. The overall effect estimate generated was 0.753 (95% confidence interval 0.712 to 0.796), with acceptable heterogeneity (I2 = 36%). In conclusion, a pooled effect calculation estimated a 24.7% relative risk reduction for each 30 minutes of time savings. For cases that underwent PPCI within 60 to 180 minutes of initial presentation with known baseline mortality risk, the time savings in 30-minute epochs can be leveraged to estimate a specific number of lives saved; this may be useful for those involved in the organization of medical care who make systemwide plans and individual patient triage decisions.
Collapse
Affiliation(s)
- James Price
- Department of Emergency Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom; Department of Research, Audit, Innovation & Development, East Anglian Air Ambulance, Norwich, United Kingdom.
| | - Jordan Rudman
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center & Harvard Medical School, Boston, Massachusetts
| | - David Schoenfeld
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center & Harvard Medical School, Boston, Massachusetts
| | - Sarah Alice Thomas
- Department of Molecular Microbiology & Immunology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Paul Rees
- Department of Research, Audit, Innovation & Development, East Anglian Air Ambulance, Norwich, United Kingdom; Blizard Institute for Neuroscience, Surgery, & Trauma, Barts & the London School of Medicine, London, United Kingdom; Department of Cardiology, St Bartholomew's Hospital and Barts Health NHS Trust, London, United Kingdom
| | - Ben Bloom
- Blizard Institute for Neuroscience, Surgery, & Trauma, Barts & the London School of Medicine, London, United Kingdom; Department of Emergency Medicine, The Royal London Hospital and Barts Health NHS Trust, London, United Kingdom
| | - Michael McCartin
- Section of Emergency Medicine, University of Chicago, Chicago, Illinois
| | - Ira Blumen
- Section of Emergency Medicine, University of Chicago, Chicago, Illinois
| | - Stephen H Thomas
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center & Harvard Medical School, Boston, Massachusetts; Blizard Institute for Neuroscience, Surgery, & Trauma, Barts & the London School of Medicine, London, United Kingdom
| |
Collapse
|
2
|
Najafi H, Bahramali E, Bijan M, Dehghan A, Amirkhani M, Balaghi inaloo M. Comparison of the outcomes of EMS vs. Non-EMS transport of patients with ST-segment elevation myocardial infarction (STEMI) in Southern Iran: a population-based study. BMC Emerg Med 2022; 22:46. [PMID: 35331145 PMCID: PMC8944078 DOI: 10.1186/s12873-022-00603-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 03/08/2022] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND In the medical management of acute myocardial infarction, the transport of patients and primary care provided by emergency medical technicians (EMTs) and paramedics are effective in reducing the mortality and disabilities. Therefore, the present study aimed to compare the outcomes of emergency medical services (EMS) vs. non-EMS transport of patients with ST-segment elevation myocardial infarction (STEMI) in southern Iran. METHODS This is an analytical, cross-sectional study. The study population consisted of the individuals registered in Fasa Registry on Acute Myocardial Infarction (FaRMI) in the south of Iran. 2244 patients with STEMI were included in the study. Statistical analyses were performed using Chi-Square test and independent t-test at a significance level of P < 0.05 in SPSS 22. RESULTS Out of the 2244 patients with STEMI, 1552 (69.16%) were male and 672 patients (29.94%) were female. 934(41.62%) patients used EMS transport to the hospital, while 1310 (58.37%) patients used non-EMS transport to the hospital. A total of 169 patients with STEMI (7.26%) expired (out-of-hospital cardiac arrest); of them, 113 (66.86%) patients did not use EMS transport to the hospital. Successful cardiopulmonary resuscitation (CPR) was performed on 52 patients who used EMS transport. 27 patients also received an effective DC shock due to ventricular fibrillation (VF). Of the total number of patients, 49 had a stroke; among them, 37(75.51%) patients did not use EMS transport. CONCLUSION In the present study, the death rate in patients with acute myocardial infarction who used EMS transport was lower than those who used non-EMS transport. The health system managers and policymakers in the healthcare systems are recommended to take the necessary measures to increase public health awareness and knowledge about the use of EMS and consequently reduce the death rate and complications of acute myocardial infarction.
Collapse
Affiliation(s)
- Hjatolah Najafi
- Department of Health in Disasters and Emergencies, School of Management and Medical Information, Health Human Resources Research Center, University of Medical Sciences, ShirazShiraz, Iran
| | - Ehsan Bahramali
- Noncommunicable Diseases Research Center (NCDRC), Fasa University of Medical Sciences, Fasa, Iran
| | - Mostafa Bijan
- Department of Medical Surgical Nursing, Fasa University of Medical Sciences, 81936-13119 Fasa, Iran
| | - Azizallah Dehghan
- Noncommunicable Diseases Research Center (NCDRC), Fasa University of Medical Sciences, Fasa, Iran
| | - Mehdi Amirkhani
- Department of Health in Disasters and Emergencies, School of Management and Medical Information, Health Human Resources Research Center, University of Medical Sciences, ShirazShiraz, Iran
| | - Maryam Balaghi inaloo
- Noncommunicable Diseases Research Center (NCDRC), Fasa University of Medical Sciences, Fasa, Iran
| |
Collapse
|
3
|
Mahadevan K, Sharma D, Walker C, Maznyczka A, Hobson A, Strike P, Griffiths H, Dana A. Impact of paramedic education on door-to-balloon times and appropriate use of the primary PCI pathway in ST-elevation myocardial infarction. BMJ Open 2022; 12:e046231. [PMID: 35210332 PMCID: PMC8883211 DOI: 10.1136/bmjopen-2020-046231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE Evidence supports improved outcomes and reduced mortality with rapid reperfusion through primary percutaneous coronary intervention (PPCI) for ST-elevation myocardial infarction (STEMI). UK national audit data (Myocardial Ischaemia National Audit Project [MINAP]) demonstrates minor improvements in door-to-balloon times (DTB) of <90 min but increasing call-to-balloon times (CTB). We evaluate the effect of a regional Cardiologist delivered paramedic education programme (PEP) on DTB times and appropriate use of the PPCI pathway. METHODS This was a prospective single-centre study of patients with STEMI brought directly to hospital via ambulance services. Data sources included ambulance charts, in-patient notes, British Cardiovascular Interventional Society (BCIS) database and local MINAP data. All DTB breaches were investigated. A local PEP was implemented with focus on ECG interpretation, STEMI diagnosis and appropriate use of the PPCI pathway. Non-parametric Wilcoxon rank test was used for comparisons of DTB and CTB times between direct versus ED-associated cath lab transfer. RESULTS A total of 728 patients with STEMI were admitted directly to our centre via ambulance, 66% (n=484) directly to the Catheterisation Laboratory (Cath Lab) and 34% (n=244) via the Emergency Department (ED). There was a significant increase in median DTB, 83 vs 37 min (p<0.001) and median CTB 144 vs 97.5 min (p<0.001) when transfer to the Cath Lab occurred via the ED versus direct transfer. The PEP increased direct cath lab transfers (52%-85%) and generated annual reductions in median DTB times, with sustained improvement seen throughout the 7-year study period. CONCLUSIONS Paramedic education increases direct transfer of STEMI patients to the Cath Lab, and reduces DTB times. This is an effective and reproducible intervention to facilitate timely reperfusion in STEMI.
Collapse
Affiliation(s)
- Kalaivani Mahadevan
- Department of Cardiology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Divyesh Sharma
- Department of Cardiology, Altnagelvin Hospitals Health and Social Services Trust, Londonderry, UK
| | - Christopher Walker
- Department of Cardiology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Annette Maznyczka
- Department of Cardiology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Alex Hobson
- Department of Cardiology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Philip Strike
- Department of Cardiology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Huw Griffiths
- Department of Cardiology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Ali Dana
- Department of Cardiology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| |
Collapse
|
4
|
Mughal LH, Sastry S. Advances in the treatment of ST Elevation Myocardial Infarction in the UK. JRSM Cardiovasc Dis 2022; 11:20480040221075519. [PMID: 35186283 PMCID: PMC8855403 DOI: 10.1177/20480040221075519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 12/13/2021] [Accepted: 01/04/2022] [Indexed: 11/17/2022] Open
Abstract
The treatment of acute coronary occlusion with Primary PCI has been a major factor in improving outcomes of patients suffering STEMI in the last 15 years, and is the standard treatment for patients suffering STEMI in the UK. Treatment is beneficial for patients presenting within 12 hours of the onset of symptoms, with the goal being opening of the occluded artery within 150 min of the call for help. Opening of the occluded artery is typically completed with a drug-eluting stent followed by administration of antiplatelet medications for 12 months. Procedures are performed using the radial artery which is associated with improved outcomes compared to vascular access via the femoral artery. Evidence is growing to support full revascularisation including the treatment of severe narrowing in other blood vessels as well as the culprit vessel.
Collapse
Affiliation(s)
- Lal Hussain Mughal
- Senior Clinical Fellow in Interventional Cardiology, Wythenshawe Hospital, Manchester University Foundation Trust, UK
| | - Sanjay Sastry
- Consultant Interventional Cardiologist, Wythenshawe Hospital, Manchester University Foundation Trust, UK
| |
Collapse
|
5
|
Alrawashdeh A, Nehme Z, Williams B, Smith K, Brennan A, Dinh DT, Liew D, Lefkovits J, Stub D. Impact of emergency medical service delays on time to reperfusion and mortality in STEMI. Open Heart 2021; 8:openhrt-2021-001654. [PMID: 33963080 PMCID: PMC8108686 DOI: 10.1136/openhrt-2021-001654] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 04/14/2021] [Accepted: 04/16/2021] [Indexed: 12/30/2022] Open
Abstract
Objectives To explore the relationship between emergency medical service (EMS) delay time, overall time to reperfusion and clinical outcome in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI). Methods This was a retrospective observational study of 2976 patients with STEMI who presented to EMS and underwent PPCI between January 2014 and December 2017. We performed multivariable logistic models to assess the relationship between EMS delay time and 30-day mortality and to identify factors associated with system delay time. Results EMS delay time accounted for the first half of total system delay (median=59 min (IQR=48–77)). Compared with those who survived, those who died had longer median EMS delay times (59 (IQR=11–74) vs 74 (IQR=57–98), p<0.001). EMS delay time was independently associated with a higher risk of mortality (adjusted OR 1.20; 95% CI 1.02 to 1.40, for every 30 min increase), largely driven by complicated patients with cardiogenic shock or cardiac arrest. Independent predictors of longer EMS delay times were older age, women, cardiogenic shock, cardiac arrest, prehospital notification and intensive care management. Although longer EMS delay times were associated with shorter door-to-balloon times, total system delay times increased with increasing EMS delay times. Conclusion Increasing EMS delay times, particularly those result from haemodynamic complications, increase total time to reperfusion and are associated with 30-day mortality after STEMI. All efforts should be made to monitor and reduce EMS delay times for timely reperfusion and better outcome.
Collapse
Affiliation(s)
- Ahmad Alrawashdeh
- Department of Paramedicine, Monash University, Frankston, Victoria, Australia.,Department of Allied Medical Sciences, Jordan University of Science and Technology, Irbid, Jordan
| | - Ziad Nehme
- Department of Paramedicine, Monash University, Frankston, Victoria, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Ambulance Victoria, Blackburn North, Victoria, Australia
| | - Brett Williams
- Department of Paramedicine, Monash University, Frankston, Victoria, Australia
| | - Karen Smith
- Department of Paramedicine, Monash University, Frankston, Victoria, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Ambulance Victoria, Blackburn North, Victoria, Australia
| | - Angela Brennan
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Alfred Hospital, Prahran, Victoria, Australia
| | - Diem T Dinh
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Danny Liew
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Jeffrey Lefkovits
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Dion Stub
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia .,Alfred Hospital, Prahran, Victoria, Australia.,Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Baker IDI Heart and Diabetes Institute, Melbourne, Victoria, Australia
| |
Collapse
|
6
|
Huang C, Liu Y, Beenken A, Jiang L, Gao X, Huang Z, Hsu A, Gross GJ, Wang YG, Mohammadi M, Schultz JEJ. A novel fibroblast growth factor-1 ligand with reduced heparin binding protects the heart against ischemia-reperfusion injury in the presence of heparin co-administration. Cardiovasc Res 2017; 113:1585-1602. [PMID: 29016740 PMCID: PMC5852627 DOI: 10.1093/cvr/cvx165] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 03/20/2017] [Accepted: 08/10/2017] [Indexed: 12/12/2022] Open
Abstract
AIMS Fibroblast growth factor 1 (FGF1), a heparin/heparan sulfate-binding growth factor, is a potent cardioprotective agent against myocardial infarction (MI). The impact of heparin, the standard of care for MI patients entering the emergency room, on cardioprotective effects of FGF1 is unknown, however. METHODS AND RESULTS To address this, a rat model of MI was employed to compare cardioprotective potentials (lower infarct size and improve post-ischemic function) of native FGF1 and an engineered FGF1 (FGF1ΔHBS) with reduced heparin-binding affinity when given at the onset of reperfusion in the absence or presence of heparin. FGF1 and FGF1ΔHBS did not alter heparin's anticoagulant properties. Treatment with heparin alone or native FGF1 significantly reduced infarct size compared to saline (P < 0.05). Surprisingly, treatment with FGF1ΔHBS markedly lowered infarct size compared to FGF1 (P < 0.05). Both native and modified FGF1 restored contractile and relaxation function (P < 0.05 versus saline or heparin). Furthermore, FGF1ΔHBS had greater improvement in cardiac function compared to FGF1 (P < 0.05). Heparin negatively impacted the cardioprotective effects (infarct size, post-ischemic recovery of function) of FGF1 (P < 0.05) but not of FGF1ΔHBS. Heparin also reduced the biodistribution of FGF1, but not FGF1ΔHBS, to the left ventricle. FGF1 and FGF1ΔHBS bound and triggered FGFR1-induced downstream activation of ERK1/2 (P < 0.05); yet, heparin co-treatment decreased FGF1-produced ERK1/2 activation, but not that activated by FGF1ΔHBS. CONCLUSION These findings demonstrate that modification of the heparin-binding region of FGF1 significantly improves the cardioprotective efficacy, even in the presence of heparin, identifying a novel FGF ligand available for therapeutic use in ischemic heart disease.
Collapse
Affiliation(s)
- Chahua Huang
- Department of Pharmacology and Cell Biophysics, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
- Department of Cardiology, Second Affiliated Hospital, Nanchang University, Nanchang 330006, China
| | - Yang Liu
- Department of Biochemistry and Molecular Pharmacology, New York University School of Medicine, New York, NY 10016, USA
| | - Andrew Beenken
- Department of Biochemistry and Molecular Pharmacology, New York University School of Medicine, New York, NY 10016, USA
| | - Lin Jiang
- Department of Pathology and Laboratory Medicine, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
| | - Xiang Gao
- Department of Pathology and Laboratory Medicine, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
| | - Zhifeng Huang
- School of Pharmacy and Center for Structural Biology, Wenzhou Medical University, Zhejiang 325035, China
| | - Anna Hsu
- Department of Pharmacology and Toxicology, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Garrett J. Gross
- Department of Pharmacology and Toxicology, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Yi-Gang Wang
- Department of Pathology and Laboratory Medicine, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
| | - Moosa Mohammadi
- Department of Biochemistry and Molecular Pharmacology, New York University School of Medicine, New York, NY 10016, USA
| | - Jo El J. Schultz
- Department of Pharmacology and Cell Biophysics, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
| |
Collapse
|
7
|
Tiulim J, Mak K, Shavelle DM. ST segment elevation myocardial infarction in patients hospitalized for non-cardiac conditions. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2017; 19:17-20. [PMID: 28600021 DOI: 10.1016/j.carrev.2017.05.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 05/18/2017] [Accepted: 05/26/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Timely use of primary percutaneous coronary intervention (PCI) is the standard of care for patients with ST segment elevation myocardial infarction (STEMI). Most patients with STEMI present via emergency medical services or self-transport to the emergency department (ED) and relatively little is known about the minority of patients that develop STEMI while hospitalized for non-cardiac conditions. The objective of this study was to analyze treatment times and clinical outcome for in-hospital STEMI patients. METHODS Two-hundred fifty-five patients with STEMI treated at Keck Medical Center of USC and Los Angeles County USC Medical Center from January, 2009 to December, 2013 were retrospectively analyzed. Demographics, treatment time intervals and clinical outcome were collected. Patients arriving via the ED (ED STEMI Group, n=228; 89%) were compared to patients that developed in-hospital STEMI (In-hospital STEMI Group, n=27; 11%). RESULTS Patients with in-hospital STEMI were similar in age, gender and associated medical conditions to ED STEMI patients. In-hospital STEMI patients were less likely to present with chest pain compared to ED STEMI patients, 5% vs. 79%, respectively, p<0.0001. Time from first abnormal electrocardiogram to device was 195±202min for in-hospital STEMI Group compared to door to device time of 88±64min for ED STEMI Group, p<0.001. Length of hospital stay was significantly longer for in-hospital STEMI Group compared to ED STEMI Group, 13±10 vs. 6.8±7.8days, respectively, p<0.001. In-hospital mortality was significantly higher for the in-hospital STEMI Group compared to the ED STEMI Group, 37% vs. 7%, respectively, p<0.001. CONCLUSIONS In-hospital STEMI patients have significant treatment delays and worse clinical outcome compared to STEMI patients that present via the emergency department. Additional efforts are required to promptly identify in-hospital patients that develop STEMI.
Collapse
Affiliation(s)
- Justin Tiulim
- Division of Cardiovascular Medicine, University of Southern California, Los Angeles, CA
| | - Kevin Mak
- Division of Cardiovascular Medicine, University of Southern California, Los Angeles, CA
| | - David M Shavelle
- Division of Cardiovascular Medicine, University of Southern California, Los Angeles, CA.
| |
Collapse
|
8
|
Oldroyd KG. Time is still muscle and there is still room for improvement. BRITISH HEART JOURNAL 2017; 103:96-97. [DOI: 10.1136/heartjnl-2016-310167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
|