Time to treatment and the impact of a physician on prehospital management of acute ST elevation myocardial infarction: insights from the ASSENT-3 PLUS trial

Pretreatment with P2Y12 Receptor Inhibitors in Acute Coronary Syndromes-Is the Current Standpoint of ESC Experts Sufficiently Supported?

Excessive platelet reactivity plays a pivotal role in the pathogenesis of acute myocardial infarction. Today, the vast majority of patients presenting with acute coronary syndromes qualify for invasive treatment strategy and thus require fast and efficient platelet inhibition. Since 2008, in cases of ST-elevation myocardial infarction, the European Society of Cardiology guidelines have recommended pretreatment with a P2Y₁₂ inhibitor. This approach has become the standard of care in the majority of centers worldwide. Nevertheless, the latest guidelines for the management of patients presenting with acute coronary syndrome without persisting ST-elevation preclude routine pretreatment with the P2Y₁₂ receptor inhibitor. Those who oppose pretreatment support their stance with trials failing to prove the benefits of this strategy at the cost of an increased risk of major bleeding, especially in individuals inappropriately diagnosed with an acute coronary syndrome, thus having no indication for platelet inhibition. However, adequate platelet inhibition requires even up to several hours after application of a loading dose of P2Y₁₂ receptor inhibitors. Omission of data from pharmacokinetic and pharmacodynamic studies in the absence of data from clinical studies makes generalization of the pretreatment recommendations difficult to accept. We aimed to review the scientific evidence supporting the current recommendations regarding pretreatment with P2Y₁₂ inhibitors.

The Evolution of Anticoagulation for Percutaneous Coronary Intervention: A 40-Year Journey

The selection of antithrombotic strategies continue to be of utmost importance during percutaneous coronary intervention (PCI) and have evolved over the past 40 years. Although the backbone of therapy during PCI continues to be a combination of oral antiplatelets and parenteral anticoagulants, a variety of different approaches have been tested over time. In particular, different choices of anticoagulation management have been tested in the stable ischemic heart disease and acute coronary syndrome setting. Evaluation of alternative regimens in the quest to balance ischemic and bleeding risk have undoubtedly improved patient care with PCI. In the current review we highlight the evolution of evidence-based therapeutic options over the past 40 years from the beginning of coronary angioplasty to contemporary PCI. We provide insight into future therapeutic options and provide a contemporary overview of anticoagulation choices for patients who require PCI on the basis of up-to-date evidence balancing ischemic and bleeding risk and according to clinical presentation.

Primary Percutaneous Coronary Intervention and Application of the Pharmacoinvasive Approach Within ST-Elevation Myocardial Infarction Care Networks

The management of acute ST-elevation myocardial infarction (STEMI) has transitioned from observation and reactive treatment of hemodynamic and arrhythmic complications to accelerated reperfusion and application of evidence-based treatment to minimize morbidity and mortality. International research established the importance of timely reperfusion therapy and the application of fibrinolysis, primary percutaneous coronary intervention (PCI), and subsequent development of the pharmacoinvasive approach. Clinician thought leaders developed and investigated comprehensive systems of care to optimize the outcomes of patients with STEMI, with a key focus in Canada being the integration of prehospital paramedics in diagnosis, triage, and treatment. This article will review highlights of these interventions and identify future challenges and opportunities in STEMI patient care.

Effect of Health Literacy on Decision Delay in Patients With Acute Myocardial Infarction

Background: Health literacy (HL) is a risk factor for adverse outcomes in patients with cardiovascular disease, and shorter pre-hospital delay time is crucial for successful treatment of acute myocardial infraction (AMI) patients. Most previous studies focused on the influencing factors of pre-hospital delay but ignore the essential contribution of decision delay.

Aims: Therefore, the purpose of this study was to explore the effect of HL on decision delay.

Methods: Continuously included AMI patients admitted to a grade A class three hospital in Chongqing. HL level was assessed using Brief Health Literacy Screen and categorized as adequate or inadequate. Mann-Whitney U-test and Chi-square test were used to compare the differences between groups, and binary logistic regression was used to analyze the association between HL and decision delay.

Results: A total of 217 AMI patients were enrolled in this study, including 166 males (76.5%) and 51 females (23.5%), with the median age was 68 years old; 135 (62.2%) patients had delayed decision-making while 82 (37.8%) did not; 157 (72.7%) patients had inadequate HL and 59 (27.3%) had adequate HL. The total HL score of non-delayed group was higher than that in delayed group (9.22 vs. 7.02, P < 0.000).

Conclusion: After adjusting for covariates, HL was significantly negatively associated with decision time. AMI patients with inadequate HL were more likely to delay seeking timely medical care.

Collaborative Heart Attack Management Program (CHAMP): use of prehospital thrombolytics to improve timeliness of STEMI management in British Columbia

Coronary artery disease is the second leading cause of death in Canada. Time to treatment in ST-elevation myocardial infarction (STEMI) is directly related to morbidity and mortality. Thrombolysis is the primary treatment for STEMI in many regions of Canada because of prolonged transport times to percutaneous coronary intervention-capable centres. To reduce time from first medical contact (FMC) to thrombolysis, some emergency medical services (EMS) systems have implemented prehospital thrombolysis (PHT). PHT is not a novel concept and has a strong evidence base showing reduced mortality.

Here, we describe a quality improvement initiative to decrease time from FMC to thrombolysis using PHT and aim to describe our methods and challenges during implementation. We used a quality improvement framework to collaborate with hospitals, EMS, cardiology, emergency medicine and other stakeholders during implementation. We trained advanced care paramedics to administer thrombolysis in STEMI with remote cardiologist support and aimed to achieve a guideline-recommended median FMC to needle time of <30 min in 80% of patients.

Overall, we reduced our median FMC to needle time by 70%. Our baseline patients undergoing in-hospital thrombolysis had a median time of 84 min (IQR 62–116 min), while patients after implementation of PHT had a median time of 25 min (IQR 23–39 min). Patients treated within the guideline-recommended time from FMC to needle of <30 min increased from 0% at baseline to 61% with PHT. Return on investment analysis showed $2.80 saved in acute care costs for every $1.00 spent on the intervention.

While we did not achieve our goal of 80% compliance with FMC to needle time of <30 min, our results show that the intervention substantially reduced the FMC to needle time and overall cost. We plan to continue with ongoing implementation of PHT through expansion to other communities in our province.

Changes in ST segment elevation myocardial infarction hospitalisations in China from 2011 to 2015

Objective

Access to acute cardiovascular care has improved and health services capacity has increased over the past decades. We assessed national changes in (1) patient characteristics, (2) in-hospital management and (3) patient outcomes among patients presenting with ST segment elevation myocardial infarction (STEMI) in 2011–2015 in China.

Methods

In a nationally representative sample of hospitals in China, we created two random cohorts of patients in 2011 and 2015 separately. We weighted our findings to estimate nationally representative numbers and assessed changes from 2011 to 2015. Data were abstracted from medical charts centrally using standardised definitions.

Results

While the proportion of patients with STEMI among all patients with acute myocardial infarction decreased over time from 82.5% (95% CI 81.7 to 83.3) in 2011 to 68.5% (95% CI 67.7 to 69.3) in 2015 (p<0.0001), the weighted national estimate of patients with STEMI increased from 210 000 to 380 000. The rate of reperfusion eligibility among patients with STEMI decreased from 49.3% (95% CI 48.1 to 50.5) to 42.2% (95% CI 41.1 to 43.4) in 2015 (p<0.0001); ineligibility was principally driven by larger proportions with prehospital delay exceeding 12 hours (67.4%–76.7%, p<0.0001). Among eligible patients, the proportion receiving reperfusion therapies increased from 54% (95% CI 52.3 to 55.7) to 59.7% (95% CI 57.9 to 61.4) (p<0.0001). Crude and risk-adjusted rates of in-hospital death did not differ significantly between 2011 and 2015.

Conclusions

In this most recent nationally representative study of STEMI in China, the use of acute reperfusion increased, but no significant improvement occurred in outcomes. There is a need to continue efforts to prevent cardiovascular diseases, to monitor changes in in-hospital treatments and outcomes, and to reduce prehospital delay.

Data quality of Glasgow Coma Scale and Systolic Blood Pressure in scientific studies involving physician-staffed emergency medical services: Systematic review

BACKGROUND

Emergency physicians on-scene provide highly specialized care to severely sick or injured patients. High-quality research relies on the quality of data, but no commonly accepted definition of EMS data quality exits. Glasgow Coma Score (GCS) and Systolic Blood Pressure (SBP) are core physiological variables, but little is known about the quality of these data when reported in p-EMS research. This systematic review aims to describe the quality of pre-hospital reporting of GCS and SBP data in studies where emergency physicians are present on-scene.

METHODS

A systematic literature search was performed using CINAHL, Cochrane, Embase, Medline, Norart, Scopus, SweMed + and Web of Science, in accordance with the PRISMA guidelines. Reported data on accuracy of reporting, completeness and capture were extracted to describe the quality of documentation of GCS and SBP. External and internal validity assessment was performed by extracting a set of predefined variables.

RESULTS

We included 137 articles describing data collection for GCS, SBP or both. Most studies (81%) were conducted in Europe and 59% of studies reported trauma cases. Reporting of GCS and SBP data were not uniform and may be improved to enable comparisons. Of the predefined external and internal validity data items, 26%-45% of data were possible to extract from the included papers.

CONCLUSIONS

Reporting of GCS and SBP is variable in scientific papers. We recommend standardized reporting to enable comparisons of p-EMS.

Predictors of transportation delay in patients with suspected ST-elevation-myocardial infarction in the VIENNA-STEMI network

OBJECTIVE

The emergency medical service (EMS) provides rapid pre-hospital diagnosis and transportation in ST-elevation myocardial infarction (STEMI) systems of care. Aim of the study was to assess temporal and regional characteristics of EMS-related delays in a metropolitan STEMI network.

METHODS

Patient call-to-arrival of EMS at site (call-to-site), transportation time from site to hospital (site-to-door), call-to-door, patient's location, month, weekday, and hour of EMS activation were recorded in 4751 patients referred to a tertiary center with suspicion of STEMI.

RESULTS

Median call-to-site, site-to-door, and call-to-door times were 9 (7-12), 39 (31-48), and 49 (41-59) minutes, respectively. The shortest transportation times were noted between 08:00 and 16:00 and in general on Sundays. They were significantly prolonged between midnight and 04:00, whereby the longest difference did not exceed 4 min in median. Patient's site of call had a major impact on transportation times, which were shorter in Central and Western districts as compared to Southern and Eastern districts of Vienna (p < 0.001 between-group difference for call-to-site, site-to-door, and call-to-door). After multivariable adjustment, patient's site of call was an independent predictor of call-to-site delay (p < 0.001). Moreover, age and hour of EMS activation were the strongest predictors of call-to-site, site-to-door, and call-to-door delays (p < 0.05).

CONCLUSION

In our Viennese STEMI network, the strongest determinants of pre-hospital EMS-related transportation delays were patient's site of call, patient's age, and hour of EMS activation. Due to the significant but small median time delays, which are within the guideline-recommended time intervals, no impact on clinical outcome can be expected.

Emergency medical service delays in ST-elevation myocardial infarction: a meta-analysis

OBJECTIVES

To evaluate emergency medical services (EMS) delays and their impact on time to treatment and mortality in patients with ST-elevation myocardial infarction (STEMI).

METHOD

We collected data on EMS time intervals from published studies across five electronic databases. The primary EMS interval was the time in minutes between first medical contact and arrival at hospital door (FMC-to-door time). Secondary intervals were other components of EMS delay. Weighted means were measured using random-effects models. Meta-regression was used to identify factors associated with EMS delays and to assess the impact of EMS delay on the proportion of patients treated within90 min and mortality.

RESULTS

Two independent reviewers included 100 studies (125 343 patients) conducted in 20 countries. The weighted mean FMC-to-door time was 41 min (n=101 646; 95% CI 39 to 43, range 21-88). However, substantial heterogeneity was observed with each interval, which could be explained by region and urban classification, distance to hospital and method of ECG interpretation. In a meta-regression adjusted for door-to-balloon time, a 10 min increase in FMC-to-door time was associated with a 10.6% (95% CI 7.6% to 13.5%; p<0.001) reduction in the proportion of patients treated within 90 min. Shorter EMS delay was significantly associated with lower short-term mortality in patients receiving prehospital thrombolysis (p=0.018).

CONCLUSION

EMS delays account for half of the total system delay in STEMI. There is a fourfold global variation in EMS delays, which are not completely explained by differences in system characteristics. Reducing unexplained variation could yield improvements in the time to treatment and outcome of STEMI patients.

PROSPERO REGISTRATION NUMBER

CRD42017074118.

Time to hospital arrival among patients with acute myocardial infarction in China: a report from China PEACE prospective study

Aims

Few contemporary studies have reported the time between acute myocardial infarction (AMI) symptoms onset and hospital arrival, associated factors, and patient perceptions of AMI symptoms and care seeking. We sought to study these issues using data from China, where AMI hospitalizations are increasing.

Methods and results

We used data from the China PEACE prospective AMI study of 53 hospitals across 21 provinces in China. Patients were interviewed during index hospitalization for information of symptom onset, and perceived barriers to accessing care. Regression analyses were conducted to explore factors associated with the time between symptom onset and hospital arrival. The final sample included 3434 patients (mean age 61 years). The median time from symptom onset to hospital arrival was 4 h (interquartile range 2–7.5 h). While 94% of patients reported chest pain or chest discomfort, only 43% perceived symptoms as heart-related. In multivariable analyses, time to hospital arrival was longer by 14% and 39% for patients failing to recognize symptoms as cardiac and those with rural medical insurance, respectively (both P < 0.001). Compared with patients with household income over 100 000 RMB, those with income of 10 000–50 000 RMB, and <10 000 RMB had 16% and 23% longer times, respectively (both P = 0.03).

Conclusion

We reported an average time to hospital arrival of 4 h for AMI in China, with longer time associated with rural medical insurance, failing to recognize symptoms as cardiac, and low household income. Strategies to improve the timeliness of presentation may be essential to improving outcomes for AMI in China.

Clinical trial registration

https://clinicaltrials.gov/ct2/show/NCT01624909.

A Long-Forgotten Tale: The Management of Cardiogenic Shock in Acute Myocardial Infarction

Patients with acute myocardial infarction (AMI) complicated with cardiogenic shock (CS) present one of the highest mortality rates recorded in critical care. Mortality rate in this setting is reported around 45-50% even in the most experienced and well-equipped medical centers. The continuous development of ST-segment elevation acute myocardial infarction (STEMI) networks has led not only to a dramatic decrease in STEMI-related mortality, but also to an increase in the frequency of severely complicated cases who survive to be transferred to tertiary centers for life-saving treatments. The reduced effectiveness of vasoactive drugs on a severely altered hemodynamic status led to the development of new devices dedicated to advanced cardiac support. What’s more, efforts are being made to reduce time from first medical contact to initiation of mechanical support in this particular clinical context. This review aims to summarize the most recent advances in mechanical support devices, in the setting of CS-complicated AMI. At the same time, the review presents several modern concepts in the organization of complex CS centers. These specialized hubs could improve survival in this critical condition.

Review. Regional Networks in Acute Cardiac Care

In acute cardiac care, the timely initiation of life-saving measures proved to be life-saving and requires many organizational and logistic measures. One of such measures is represented by the development and implementation of a regional network dedicated for the treatment of major cardiovascular emergencies, a strategy that proved to significantly reduce mortality rates on short and long term. This review aims to describe the current status in the development of regional networks in three of the main cardiovascular emergencies: acute myocardial infarction, out-of-hospital cardiac arrest, and acute stroke. The concepts demonstrating the utility of such networks, together with their results in reducing cardiac events, are presented in this paper.

The Emergency Medical Care of Patients With Acute Myocardial Infarction

BACKGROUND

Optimizing the emergency medical care chain might shorten the time to treatment of patients with ST-elevation myocardial infarction (STEMI). The initial care by a physician, and, in particular, correct ECG interpretation, are critically important factors.

METHODS

From 1999 onward, data on the care of patients with myocardial infarction have been recorded and analyzed in the Berlin Myocardial Infarction Registry. In the First Medical Contact Study, data on initial emergency medical care were obtained on 1038 patients who had been initially treated by emergency physicians in 2012. Their pre-hospital ECGs were re-evaluated in a blinded fashion according to the criteria of the European Society of Cardiology.

RESULTS

The retrospective re-evaluation of pre-hospital ECGs revealed that 756 of the 1038 patients had sustained a STEMI. The emergency physicians had correctly diagnosed STEMI in 472 patients (62.4%), and they had correctly diagnosed ventricular fibrillation in 85 patients (11.2%); in 199 patients (26.3%), the ECG interpretation was unclear. The pre-hospital ECG interpretation was significantly associated with the site of initial hospitalization and the ensuing times to treatment. In particular, the time from hospital admission to cardiac catheterization was longer in patients with an unclear initial ECG interpretation than in those with correctly diagnosed STEMI (121 [54; 705] vs. 36 [19; 60] minutes, p <0.001). After multivariate adjustment, this corresponded to a hazard ratio* of 2.67 [2.21; 3.24].

CONCLUSION

Pre-hospital ECG interpretation in patients with STEMI was a trigger factor with a major influence on the time to treatment in the hospital. The considerable percentage of pre-hospital ECGs whose interpretation was unclear implies that there is much room for improvement.

Treatment-seeking delays in patients with acute myocardial infarction and use of the emergency medical service

OBJECTIVES

To investigate treatment-seeking delays in Chinese patients with acute myocardial infarction (AMI) and to compare sex differences in this behaviour.

METHODS

A descriptive cross-sectional study was undertaken in patients with AMI, admitted to one of three hospitals in Shanghai, China. A treatment-seeking behaviour questionnaire was administered to each patient within 48 h of hospital admission.

RESULTS

In total, 250 patients were included: 159 men and 91 women. The median time for patients with AMI to make a treatment-seeking decision was 130 min. Women took significantly longer to seek treatment than men (240 min versus 120 min). The majority of patients (70.8%) took >1 h to decide to seek treatment. The emergency medical service (EMS) was used by 77 (30.8%) of patients, and these patients had a significantly shorter prehospital delay time than those who transported themselves to hospital. Predictive factors for using the EMS were pain level and rating AMI symptoms as severe.

CONCLUSIONS

Chinese patients with AMI had a significant prehospital delay time and women took longer than men to seek treatment. Public awareness of the importance of seeking immediate medical assistance for AMI via the EMS needs to be increased in China.

Belimumab: a technological advance for systemic lupus erythematosus patients? Report of a systematic review and meta-analysis

OBJECTIVES

To undertake a systematic review and meta-analysis to investigate clinical effectiveness of belimumab for patients with systemic lupus erythematosus (SLE) and antinuclear and/or anti-double-stranded DNA (dsDNA) autoantibodies.

METHODS

We searched eight electronic databases and reference lists for randomised controlled trials (RCTs) of belimumab against placebo or best supportive care. Quality assessment and random effects meta-analysis were undertaken.

DESIGN

A meta-analysis of RCTs.

PARTICIPANTS

2133 SLE patients.

PRIMARY AND SECONDARY OUTCOME MEASURES

SLE Responder Index (SRI) at week 52.

RESULTS

Three double-blind placebo-controlled RCTs (L02, BLISS-52 BLISS-76) investigated 2133 SLE patients. BLISS-52 and BLISS-76 trials recruited patients with antinuclear and/or anti-dsDNA autoantibodies and demonstrated belimumab effectiveness for the SRI at week 52. Ethnicity and geographical location of participants varied considerably between BLISS trials. Although tests for statistical heterogeneity were negative, BLISS-52 results were systematically more favourable for all measured outcomes. Meta-analysis of pooled 52-week SRI BLISS results showed benefit for belimumab (OR 1.63, 95% CI 1.27 to 2.09). By week 76, the primary SRI outcome in BLISS-76 was not statistically significant (OR 1.31, 95% CI 0.919 to 1.855).

An organized system of emergency care for patients with myocardial infarction: a reality?

An organized system of emergency care is an essential requirement for the modern treatment of ST-elevation acute myocardial infarction. There is a strong need to deliver reperfusion therapy as soon as possible, with primary percutaneous coronary intervention being the preferred option if performed in a timely manner and thrombolytic therapy, particularly in the prehospital setting, being a good alternative if the primary percutaneous coronary intervention-related delay exceeds the equipoise. In this situation, emergency medical services have a primary role in rescuing patients from cardiac arrest, performing prehospital diagnosis, triage and treatment and safely transporting them to the most appropriate cardiological center, including interhospital transfer. A complete reorganization of the healthcare systems in different countries is frequently needed to build an ST-elevation acute myocardial infarction system of care, focusing on fast transport, use of telemedicine and diversion protocols to skip the unsuited centers.

Time from first medical contact to reperfusion in ST elevation myocardial infarction: a Which Early ST Elevation Myocardial Infarction Therapy (WEST) substudy

BACKGROUND

Recent research and contemporary ST elevation myocardial infarction guidelines emphasize the importance of prompt reperfusion and have redefined the traditional time to treatment metric to include prehospital paramedical staff as the point of first medical contact. However, an important knowledge gap exists relating to data systematically addressing the impact of arrival at the hospital by ambulance and the delays inherent in transfer from a community hospital to tertiary centres for percutaneous coronary intervention (PCI).

METHODS

The Which Early ST Elevation Myocardial Infarction Therapy (WEST) study initiated treatment at the point of first medical contact, including prehospital contact. Patients were randomly assigned to receive fibrinolysis with usual care or coupled with mechanical cointervention, or primary PCI. To assess the impact of this strategy on time to treatment, the following randomly assigned patient groups were compared: prehospital versus in-hospital; those arriving at the hospital by ambulance versus ambulatory self transport; and those whose initial hospital care was a community versus PCI centre.

RESULTS

Of the 328 patients enrolled in the study, 221 received fibrinolysis and 107 received primary PCI. Compared with the in-hospital group, patients who underwent prehospital random assignment (44%, n=145) experienced a 48 min reduction in median (interquartile range) time from symptom onset to first study medication (87 min [65 min to 147 min] versus 135 min [95 min to 186 min]; P<0.001) and a 56 min reduction in time to first balloon inflation (148 min [117 min to 214 min] versus 204 min [166 min to 290 min]; P<0.001). Arrival by ambulance without prehospital random assignment (n=90) incurred a substantial delay from first medical contact to reperfusion (fibrinolysis 76 min [63 min to 105 min] and PCI 160 min [141 min to 212 min]) compared with prehospital random assignment (n=145; fibrinolysis 43 min [33 min to 54 min] and PCI 105 min [90 min to 127 min]) or ambulatory patients (n=93; fibrinolysis 47 min [32 min to 68 min] and PCI 108 min [85 min to 150 min]). Community (n=165) versus PCI hospital (n=163) random assignment was associated with a longer delay from first medical contact to reperfusion: fibrinolysis, 56 min versus 47 min (P=0.008) and primary PCI, 139 min versus 105 min (P=0.001).

DISCUSSION

Prehospital diagnosis, random assignment and treatment substantially reduced treatment delay with both pharmacological and mechanical reperfusion. Those activating the prehospital medical response system without receiving prehospital random assignment experienced the longest delay from first medical contact to reperfusion, indicating a lost opportunity to enhance ST elevation myocardial infarction patient outcomes.

Evaluating the views of paramedics, cardiologists, emergency department physicians and nurses on advanced prehospital management of acute ST elevation myocardial infarction

BACKGROUND

Although advanced prehospital management (PHM) in ST elevation myocardial infarction (STEMI) reduces reperfusion delay and improves patient outcomes, its use in North America remains uncommon. Understanding perceived barriers to and facilitators of PHM implementation may support the expansion of programs, with associated patient benefit.

OBJECTIVE

To explore the attitudes and beliefs of paramedics, cardiologists, emergency physicians and nurses regarding these issues.

METHODS

To maximize the potential to identify unpredictable issues within each of the four groups, focus group sessions were recorded, transcribed and analyzed for themes using the constant comparative method.

RESULTS

All 18 participants believed that PHM of STEMI decreased time to treatment and improved health outcomes. Despite agreeing that most paramedics were capable of providing PHM, regular maintenance of competence and medical overview were emphasized. Significant variations in perceptions were revealed regarding practical aspects of the PHM process and protocol, as well as ownership and responsibility of the patient. Success and failures of technology were also expressed. Varying arguments against a signed 'informed consent' were presented by the majority.

CONCLUSIONS

Focus group discussions provided key insights into potential barriers to and facilitators of PHM in STEMI. Although all groups were supportive of the concept and its benefits, concerns were expressed and potential barriers identified. This novel body of knowledge will help elucidate future educational programs and protocol development, and identify future challenges to ensure successful PHM of STEMI, thereby reducing reperfusion delay and improving patient outcomes.

Paramedic transtelephonic communication to cardiologist of clinical and electrocardiographic assessment for rapid reperfusion of ST-elevation myocardial infarction

BACKGROUND/PURPOSE

We tested the hypothesis that paramedic recognition of ST-elevation myocardial infarction (STEMI) and cardiologist activation of the cardiac catheterization laboratory without transmission of the electrocardiogram reduces door-to-balloon times.

METHODS

We studied a consecutive series of patients suspected to have STEMI who were taken to the cardiac catheterization laboratory in the 6-month period before hotline implementation (historical controls) and during the first year of hotline use (intervention group, hotline; emergency medical service patients without hotline, concurrent controls).

RESULTS

Emergency medical services activated the hotline 47 times, and 25 patients were subsequently taken to the catheterization laboratory. Patients who received PCI involving hotline use (n = 20) had significantly shorter door-to-balloon times (58 minutes; 25th-75th percentile, 52-73 minutes) than historical controls (n = 15) (112 minutes; 25th-75th percentile, 81-137; P < .0001) and concurrent controls (n = 15) (92 minutes; 25th-75th percentile, 76-112; P = .019).

CONCLUSIONS

Paramedic transtelephonic communication to cardiologist of clinical and electrocardiogram assessment resulted in a 54-minute reduction in door-to-balloon time for patients with STEMI.

Feasibility and applicability of paramedic-based prehospital fibrinolysis in a large North American center

BACKGROUND

Although considered the highest level of evidence and critical-to-test novel therapies, clinical trials are unrepresentative of the "real world" as they lack a true patient denominator, which limits general applicability of results. Accordingly, in conjunction with the Assessment of the Safety and Efficacy of a New Thrombolytic Regimen 3+ trial, we evaluated a comprehensive contemporary cohort of patients with ST segment elevation myocardial infarction (STEMI) to investigate: feasibility, applicability, safety, and efficacy of de novo paramedic-based prehospital fibrinolysis (PHF) program.

METHODS

Prospective observational comparative cohort of all patients with STEMI encountered during the Assessment of the Safety and Efficacy of a New Thrombolytic Regimen 3+ enrollment period. Time-to-treatment, systematic electrocardiographic (ECG) analysis, peak creatine kinase, inhospital clinical events, and mortality were assessed.

RESULTS

During the 22-month study period, 1095 patients with STEMI were admitted to hospital; 46% (119/258) of eligible patients received PHF (< or = 6 hours of symptom onset by ambulance). Paramedics contacted the study physician 3.6 times per week: 33% (119/357) of patients enrolled, and ECG transmission failure is 6%. Time-to-treatment was reduced with PHF versus inhospital (1 hour 43 minutes vs 2 hours 38 minutes; P < .001). Despite higher baseline Thrombolysis in Myocardial Infarction Scores and greater ECG territory at risk (ST), prehospital patients achieved more favorable outcomes: peak creatine kinase (1413 vs 1549 U/L; P = .122), Q wave at discharge (56.3% vs 70.7%; P = .003), and intracranial hemorrhage (0% vs 0.8%; P < 1.0), respectively. Inhospital mortality for PHF versus inhospital patients was 3.4% versus 4.8% (P = .627), with an adjusted odds ratio of 0.60 (confidence interval, 0.19-1.87).

CONCLUSION

Feasibility and applicability of PHF was demonstrated with a substantial reduction in treatment delay and favorable clinical outcomes. Extending the unrealized potential of paramedic-based PHF programs in North America is feasible and desirable.

Prehospital fibrinolysis

Reperfusion therapy for ST-elevation acute coronary syndromes aims at early and complete recanalization of the infarct-related artery to salvage myocardium and improve both early and late clinical outcomes. Prehospital diagnosis of ST-elevation acute coronary syndrome can be made by electrocardiography with or without transtelephonic transmission, and subsequent fibrinolytic therapy can be instituted at home or in the ambulance. Prehospital fibrinolysis decreases time to treatment by approximately 1 hour compared with in-hospital therapy resulting in a significant 15% relative risk reduction in early mortality. This may compare well with primary angioplasty for ST-elevation acute coronary syndrome, although more studies are necessary.

Bypassing the emergency room reduces delays and mortality in ST elevation myocardial infarction: the USIC 2000 registry

OBJECTIVE

To study the impact on outcomes of direct admission versus emergency room (ER) admission in patients with ST-segment elevation myocardial infarction (STEMI) DESIGN: Nationwide observational registry of STEMI patients

SETTING

369 intensive care units in France.

INTERVENTIONS

Patients were categorised on the basis of the initial management pathway (direct transfer to the coronary care unit or catheterisation laboratory versus transfer via the ER).

MAIN OUTCOME MEASURES

Delays between symptom onset, admission and reperfusion therapy. Mortality at five days and one year.

RESULTS

Of 1204 patients enrolled, 66.9% were admitted direct and 33.1% via the ER. Bypassing the ER was associated with more frequent use of reperfusion (61.7% v 53.1%; p = 0.001) and shorter delays between symptom onset and admission (244 (interquartile range 158) v 292 (172) min; p < 0.001), thrombolysis (204 (150) v 258 (240) min; p < 0.01), hospital thrombolysis (228 (156) v 256 (227) min, p = 0.22), and primary percutaneous coronary intervention (294 (246) v 402 (312) min; p < 0.005). Five day mortality rates were lower in patients who bypassed the ER (4.9% v 8.6%; p = 0.01), regardless of the use and type of reperfusion therapy. After adjusting for the simplified Thrombolysis in Myocardial Infarction (TIMI) risk score, admission via the ER was an independent predictor of five day mortality (odds ratio 1.67, 95% confidence interval 1.01 to 2.75).

CONCLUSIONS

In this observational analysis, bypassing the ER was associated with more frequent and earlier use of reperfusion therapy, and with an apparent survival benefit compared with admission via the ER.