Impact of Time to Treatment on Mortality After Prehospital Fibrinolysis or Primary Angioplasty

CVIT expert consensus document on primary percutaneous coronary intervention (PCI) for acute coronary syndromes (ACS) in 2024

Primary Percutaneous Coronary Intervention (PCI) has significantly contributed to reducing the mortality of patients with ST-segment elevation myocardial infarction (STEMI) even in cardiogenic shock and is now the standard of care in most of Japanese institutions. The Task Force on Primary PCI of the Japanese Association of Cardiovascular Intervention and Therapeutics (CVIT) proposed an expert consensus document for the management of acute myocardial infarction (AMI) focusing on procedural aspects of primary PCI in 2018 and updated in 2022. Recently, the European Society of Cardiology (ESC) published the guidelines for the management of acute coronary syndrome in 2023. Major new updates in the 2023 ESC guideline include: (1) intravascular imaging should be considered to guide PCI (Class IIa); (2) timing of complete revascularization; (3) antiplatelet therapy in patient with high-bleeding risk. Reflecting rapid advances in the field, the Task Force on Primary PCI of the CVIT group has now proposed an updated expert consensus document for the management of ACS focusing on procedural aspects of primary PCI in 2024 version.

Prevalence and Predictors of Emergency Medical Service Use in Patients Undergoing Primary Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction

AIM

We aim to describe prevalence of Emergency Medical Service (EMS) use, investigate factors predictive of EMS use, and determine if EMS use predicts treatment delay and mortality in our ST-elevation myocardial infarction (STEMI) cohort.

METHOD

We prospectively collected data on 5,602 patients presenting with STEMI for primary percutaneous coronary intervention (PCI) transported to PCI-capable hospitals in Victoria, Australia, from 2013-2018 who were entered into the Victorian Cardiac Outcomes Registry (VCOR). We linked this dataset to the Ambulance Victoria and National Death Index (NDI) datasets. We excluded late presentation, thrombolysed, and in-hospital STEMI, as well as patients presenting with cardiogenic shock and out-of-hospital cardiac arrest.

RESULTS

In total, 74% of patients undergoing primary PCI for STEMI used EMS. Older age, female gender, higher socioeconomic status, and a history of prior ischaemic heart disease were independent predictors of using EMS. EMS use was associated with shorter adjusted door-to-balloon (53 vs 72 minutes, p<0.001) and symptom-to-balloon (183 vs 212 minutes, p<0.001) times. Mode of transport was not predictive of 30-day or 12-month mortality.

CONCLUSIONS

EMS use in Victoria is relatively high compared with internationally reported data. EMS use reduces treatment delay. Predictors of EMS use in our cohort are consistent with those prevalent in prior literature. Understanding the patients who are less likely to use EMS might inform more targeted education campaigns in the future.

Clinical Research in Prehospital Care: Current and Future Challenges

Prehospital care plays a critical role in improving patient outcomes, particularly in cases of time-sensitive emergencies such as trauma, cardiac failure, stroke, bleeding, breathing difficulties, systemic infections, etc. In recent years, there has been a growing interest in clinical research in prehospital care, and several challenges and opportunities have emerged. There is an urgent need to adapt clinical research methodology to a context of prehospital care. At the same time, there are many barriers in prehospital research due to the complex context, posing unique challenges for research, development, and evaluation. Among these, this review allows the highlighting of limited resources and infrastructure, ethical and regulatory considerations, time constraints, privacy, safety concerns, data collection and analysis, selection of a homogeneous study group, etc. The analysis of the literature also highlights solutions such as strong collaboration between emergency medical services (EMS) and hospital care, use of (mobile) health technologies and artificial intelligence, use of standardized protocols and guidelines, etc. Overall, the purpose of this narrative review is to examine the current state of clinical research in prehospital care and identify gaps in knowledge, including the challenges and opportunities for future research.

The Efficacy of Drug-Coated Balloon for Acute Coronary Syndrome

Background

Percutaneous coronary intervention using a drug-eluting stent (DES) is a common therapeutic option for acute coronary syndrome (ACS). However, stent-associated complications, such as bleeding associated with dual antiplatelet therapy, in-stent restenosis, stent thrombosis, and neoatherosclerosis, remain. Drug-coated balloons (DCBs) are expected to reduce stent-associated complications. This study aimed to assess the efficacy of DCB therapy and compare it with that of DES therapy in patients with ACS.

Materials and Methods

In this single-center, retrospective, observational study, we examined all patients with ACS treated with DCB or DES between July 2014 and November 2020. Patients with left main trunk lesions were excluded. The primary outcome was a composite of major adverse cardiovascular events (MACE: cardiac death, myocardial infarction, and target lesion revascularization) at one year.

Results

Three hundred and seventy-two patients were treated with DES, and 83 patients were treated with DCB. MACE occurred in 10 (12.0%) patients in the DCB group and in 50 (13.4%) patients in the DES group (P=0.73).

Conclusions

DCB is a valuable and effective therapy for patients with ACS. Moreover, DCB may become an alternative therapy for DES in patients with ACS.

Impact of lifting the mandatory evacuation order after the Fukushima Daiichi Nuclear Power Plant accident on the emergency medical system: a retrospective observational study at Minamisoma City with machine learning analysis

OBJECTIVES

This study aimed to identify factors that delayed emergency medical services (EMS) in evacuation order zones after the 2011 Great East Japan Earthquake and Fukushima Daiichi Nuclear Power Plant accident and to investigate how the lifting of the evacuation affected these factors over time.

DESIGN

This research was a retrospective observational study. The primary outcome measure was onsite EMS time. A gradient boosting model and a decision tree were used to find the boundary values for factors that reduce EMS.

SETTING

The target area was Minamisoma City, Fukushima, Japan that was partly designated as an evacuation order zone after the 2011 Fukushima disaster, which was lifted due to decreased radiation.

PARTICIPANTS

This study included patients transferred by EMS from 1 January 2013 through 31 October 2018. Patients who were not transported and those transported for community events, interhospital patient transfer and natural disasters were excluded.

OUTCOME MEASURES

This study evaluated the total EMS time using on-site time which is the time from arrival at the scene to departure to the destination, and other independent factors.

RESULTS

The total number of transports was 12 043. The decision tree revealed that the major factors that prolonged onsite time were time of day and latitude, except for differences by year. While latitude was a major factor in extending on-site time until 2016, the effect of latitude decreased and that of time of day became more significant since 2017. The boundary was located at N37.695° latitude.

CONCLUSIONS

The onsite time delay in EMS in evacuation order zones is largely due to regional factors from north to south and the time of day. However, the north-south regional factor decreased with the lifting of evacuation orders.

Development of Prediction Models for Acute Myocardial Infarction at Prehospital Stage with Machine Learning Based on a Nationwide Database

Models for predicting acute myocardial infarction (AMI) at the prehospital stage were developed and their efficacy compared, based on variables identified from a nationwide systematic emergency medical service (EMS) registry using conventional statistical methods and machine learning algorithms. Patients in the EMS cardiovascular registry aged >15 years who were transferred from the public EMS to emergency departments in Korea from January 2016 to December 2018 were enrolled. Two datasets were constructed according to the hierarchical structure of the registry. A total of 184,577 patients (Dataset 1) were included in the final analysis. Among them, 72,439 patients (Dataset 2) were suspected to have AMI at prehospital stage. Between the models derived using the conventional logistic regression method, the B-type model incorporated AMI-specific variables from the A-type model and exhibited a superior discriminative ability (p = 0.02). The models that used extreme gradient boosting and a multilayer perceptron yielded a higher predictive performance than the conventional logistic regression-based models for analyses that used both datasets. Each machine learning algorithm yielded different classification lists of the 10 most important features. Therefore, prediction models that use nationwide prehospital data and are developed with appropriate structures can improve the identification of patients who require timely AMI management.

Impact of paramedic education on door-to-balloon times and appropriate use of the primary PCI pathway in ST-elevation myocardial infarction

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.

CVIT expert consensus document on primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) update 2022

Primary Percutaneous Coronary Intervention (PCI) has significantly contributed to reducing the mortality of patients with ST-segment elevation myocardial infarction (STEMI) even in cardiogenic shock and is now the standard of care in most of Japanese institutions. The Task Force on Primary PCI of the Japanese Association of Cardiovascular Interventional and Therapeutics (CVIT) society proposed an expert consensus document for the management of acute myocardial infarction (AMI) focusing on procedural aspects of primary PCI in 2018. Updated guidelines for the management of AMI were published by the European Society of Cardiology (ESC) in 2017 and 2020. Major changes in the guidelines for STEMI patients included: (1) radial access and drug-eluting stents (DES) over bare-metal stents (BMS) were recommended as a Class I indication, (2) complete revascularization before hospital discharge (either immediate or staged) is now considered as Class IIa recommendation. In 2020, updated guidelines for Non-ST-Elevation Myocardial Infarction (NSTEMI) patients, the followings were changed: (1) an early invasive strategy within 24 h is recommended in patients with NSTEMI as a Class I indication, (2) complete revascularization in NSTEMI patients without cardiogenic shock is considered as Class IIa recommendation, and (3) in patients with atrial fibrillation following a short period of triple antithrombotic therapy, dual antithrombotic therapy (e.g., DOAC and single oral antiplatelet agent preferably clopidogrel) is recommended, with discontinuation of the antiplatelet agent after 6 to 12 months. Furthermore, an aspirin-free strategy after PCI has been investigated in several trials those have started to show the safety and efficacy. The Task Force on Primary PCI of the CVIT group has now proposed the updated expert consensus document for the management of AMI focusing on procedural aspects of primary PCI in 2022 version.

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.

Analysis of ST-elevation myocardial infarction occurring in soldiers during strenous military training

BACKGROUND

At our tertiary care cardiology center, we are receiving soldiers who sustained acute ST-Elevation Myocardial Infarction (STEMI) during the strenuous Battle Field Efficiency Test (BPET) and other such activities.

METHODS

This was a single-center observational study to assimilate and analyze the precipitating causes, risk factors, symptoms, and the efficacy of the management protocols in soldiers sustaining STEMI during the BPET or other forms of strenuous military training.

RESULTS

All 25 soldiers with documented STEMI following strenuous military training presented with chest pain as the primary symptom. 88% had symptoms either during or within 1st hour of the strenuous activity. 76% underwent thrombolysis with an angiographic success rate of 95%. Primary PCI was possible in only 3/25 (12%) of the cases, of which 2 (66%) did not require stenting after thrombus aspiration; 88% of soldiers reported "training for the event" for less than four times/week.

CONCLUSION

STEMI precipitated by strenuous unaccustomed military training have exclusively single vessel affection with an excellent response to thrombolysis and thrombus aspiration. Thus, the timely institution of pharmacological or mechanical revascularization therapy has dramatic results in the preservation of ventricular function. The lack of training for the strenuous event provides strong evidence for comprehensive, graded, physical training prior to strenuous military activities to prevent acute coronary syndromes.

Evaluation of the emergency medical system in an area following lifting of the mandatory evacuation order after the Fukushima Daiichi Nuclear Power Plant accident: A retrospective cross-sectional observational study

Following the lifting of the evacuation order due to the Fukushima Daiichi Nuclear Power Plant accident, the medical demand and emergency medical system (EMS) in the area where the evacuation orders were lifted have not been well-investigated. This study aimed to evaluate the emergency transportation in such areas and compare the differences with areas that had minimal impact.Using the local EMS transport records, the characteristics of patients who were transferred by an EMS vehicle in Minamisoma City were collected between July 12, 2016 and July 31, 2018, and were compared between former evacuation zones and outside the evacuation zones in the city.The number of emergency transports in the study period in Minamisoma City were 325 cases in the area where the evacuation orders were lifted and 4307 cases in the other areas. The total EMS time was significantly longer in the area where the evacuation order was lifted (48 ± 16 minutes) than in the other areas (40 ± 15 minutes) (P < .001). In the analysis of each component of EMS times, the transport time, which is the time from departure from the patient's location to arrival at a hospital, was significantly longer in the former evacuation zone than in the other areas (16 ± 9 vs 9 ± 9 minutes, P < .001), suggesting that transport time contributed to the longer EMS response times.In areas where the evacuation orders were lifted, the EMS transport time was significantly longer than that in the area outside the former evacuation zone; correspondingly, the total EMS time significantly increased in the former evacuation zone. A plausible reason for this may be the closure of local medical facilities following the evacuation order after the nuclear accident.

Management of ST Elevation Myocardial Infarction (STEMI) in Different Settings

ST-segment elevation myocardial infarction (STEMI) is a life-threatening condition that requires emergent, complex, well-coordinated treatment. Although the primary goal of treatment is simple to describe-reperfusion as quickly as possible-the management process is complicated and is affected by multiple factors including location, patient, and practitioner characteristics. Hence, this narrative review will discuss the recommended management and treatment strategies of STEMI in the circumstances.

Impact of creating a haemodynamics room, a coronary unit and a primary angioplasty programme on the prognosis of acute coronary syndrome in a district hospital

OBJECTIVE

This work aims to analyze the prognosis and mortality of patients hospitalized for acute coronary syndrome before and after the implementation of a coronary care unit, hemodynamics room, and the Código Corazón [Infarction Code] primary angioplasty program METHODS: We conducted an observational, retrospective study that analyzed the epidemiological characteristics, reperfusion strategies, adverse cardiovascular events, and mortality over a follow-up period of five years. The results from the post-code period (March 1 - December 31, 2012; n=471) were compared with those from the pre-code period (March 1 - December 31, 2009; n=432).

RESULTS

There were no differences in the baseline characteristics of the two groups. However, an increase in ST-elevation acute coronary syndrome (STE-ACS) from 17.6% to 34.8% (p<.001) was observed during the postcode phase. The use of percutaneous coronary intervention was made widespread at the hospital and was used in 64.8% of non-ST-elevation acute coronary syndrome (NSTE-ACS) cases and in 95.5% of STE-ACS cases. A reduction was observed in readmissions (from 38.2% to 25.1% for NSTE-ACS (p=.001) and from 23.7% to 11.0% for STE-ACS (p=.018)), the composite prognostic variable of adverse cardiovascular events and 5-year mortality (from 58.7% to 45% (p=.001) for NSTE-ACS and from 40.8% to 23.8% (p=.009) for STE-ACS), and a decrease in 30-day mortality in STE-ACS (from 11.8% to 3.7%; p=.021).

CONCLUSIONS

With the structural changes in the hospital, the use of percutaneous coronary intervention was made widespread and improved the prognosis of patients with acute coronary syndrome, decreasing admissions, adverse cardiovascular events and mortality.

Impact of creating a hemodynamics room, a coronary care unit, and a primary angioplasty program on the prognosis of acute coronary syndrome in a district hospital

OBJECTIVE

This work aims to analyze the prognosis and mortality of patients hospitalized for acute coronary syndrome before and after the implementation of a coronary care unit, hemodynamics room, and the Código Corazón [Infarction Code] primary angioplasty program.

METHODS

We conducted an observational, retrospective study that analyzed the epidemiological characteristics, reperfusion strategies, adverse cardiovascular events, and mortality over a follow-up period of five years. The results from the post-code period (March 1 - December 31, 2012; n=471) were compared with those from the pre-code period (March 1 - December 31, 2009; n=432).

RESULTS

There were no differences in the baseline characteristics of the two groups. However, an increase in ST-elevation acute coronary syndrome (STE-ACS) from 17.6% to 34.8% (p<.001) was observed during the postcode phase. The use of percutaneous coronary intervention was made widespread at the hospital and was used in 64.8% of non-ST-elevation acute coronary syndrome (NSTE-ACS) cases and in 95.5% of STE-ACS cases. A reduction was observed in readmissions (from 38.2% to 25.1% for NSTE-ACS (p=.001) and from 23.7% to 11.0% for STE-ACS (p=.018)), the composite prognostic variable of adverse cardiovascular events and 5-year mortality (from 58.7% to 45% (p=.001) for NSTE-ACS and from 40.8% to 23.8% (p=.009) for STE-ACS), and a decrease in 30-day mortality in STE-ACS (from 11.8% to 3.7%; p=.021).

CONCLUSIONS

With the structural changes in the hospital, the use of percutaneous coronary intervention was made widespread and improved the prognosis of patients with acute coronary syndrome, decreasing admissions, adverse cardiovascular events, and mortality.

Resource and Infrastructure-Appropriate Management of ST-Segment Elevation Myocardial Infarction in Low- and Middle-Income Countries

The 143 low- and middle-income countries (LMICs) of the world constitute 80% of the world's population or roughly 5.86 billion people with much variation in geography, culture, literacy, financial resources, access to health care, insurance penetration, and healthcare regulation. Unfortunately, their burden of cardiovascular disease in general and acute ST-segment-elevation myocardial infarction (STEMI) in particular is increasing at an unprecedented rate. Compounding the problem, outcomes remain suboptimal because of a lack of awareness and a severe paucity of resources. Guideline-based treatment has dramatically improved the outcomes of STEMI in high-income countries. However, no such focused recommendations exist for LMICs, and the unique challenges in LMICs make directly implementing Western guidelines unfeasible. Thus, structured solutions tailored to their individual, local needs, and resources are a vital need. With this in mind, a multicountry collaboration of investigators interested in LMIC STEMI care have tried to create a consensus document that extracts transferable elements from Western guidelines and couples them with local realities gathered from expert experience. It outlines general operating principles for LMICs focused best practices and is intended to create the broad outlines of implementable, resource-appropriate paradigms for management of STEMI in LMICs. Although this document is focused primarily on governments and organizations involved with improvement in STEMI care in LMICs, it also provides some specific targeted information for the frontline clinicians to allow standardized care pathways and improved outcomes.

Pharmacoinvasive Strategy Versus Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction in Patients ≥70 Years of Age

The benefit-risk ratio of a pharmacoinvasive strategy (PI) in patients ≥70 years of age with ST-segment elevation myocardial infarction (STEMI) remains uncertain resulting in its limited use in this population. This study compared efficacy and safety of PI with primary percutaneous coronary intervention (pPCI). Data from 2,841 patients (mean age: 78.1 ± 5.6 years, female: 36.1%) included in a prospective multicenter registry, and who underwent either PI (n = 269) or pPCI (n = 2,572), were analyzed. The primary end point was in-hospital major adverse cardiovascular events (MACE) defined as the composite of all-cause mortality, nonfatal MI, stroke, and definite stent thrombosis. Secondary end points included all-cause death, major bleeding, net adverse clinical events, and the development of in-hospital Killip class III or IV heart failure. Propensity-score matching and conditional logistic regression were used to adjust for confounders. Within the matched cohort, rates of MACE was not statistically different between the PI (n = 247) and pPCI (n = 958) groups, (11.3% vs 9.0%, respectively, odds ratio 1.25, 95% confidence interval 0.81 to 1.94; p = 0.31). Secondary end points were comparable between groups at the exception of a lower rate of development of Killip class III or IV heart failure after PI. The rate of intracranial hemorrhage was significantly higher in the PI group (2.3% vs 0.0%, p = 0.03). In conclusion, the present study demonstrated no difference regarding in-hospital MACE following PI or pPCI in STEMI patients ≥70 years of age. An adequately-powered randomized trial is needed to precisely define the role of PI in this high-risk subgroup.

Bhutan's First Emergency Air Medical Retrieval Service: The First Year of Operations

OBJECTIVE

The Bhutan Emergency Aeromedical Retrieval (BEAR) Team is the only helicopter emergency medical service in Bhutan. This study was performed to review the clinical cases cared for by the BEAR Team, ascertain the types of interventions that were performed, and determine the outcomes of patients evacuated in its first year of operations.

METHODS

This is a retrospective observational study in which medical evacuations performed in the first year of operations were analyzed. The number of airlifts activated during the study period determined the sample size (171). Data were obtained from case logs and trip sheets.

RESULTS

The BEAR Team provided services to all regions of the country in its first year. The overall survival rate was 73.1%. The most common intervention required was securing a definitive airway (n = 24). The top 3 conditions requiring air medical retrieval were sepsis, acute mountain sickness, and trauma.

CONCLUSION

Helicopter emergency medical services are known to decrease the time to definitive treatment. This is particularly pertinent in Bhutan, given the scattered population distribution, long transport times, and distribution of medical resources and specialty care. This study is the first of its kind in Bhutan, and this can pave way to conduct more studies involving patients transported by air ambulance.

2019 Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology Guidelines on the Acute Management of ST-Elevation Myocardial Infarction: Focused Update on Regionalization and Reperfusion

Rapid reperfusion of the infarct-related artery is the cornerstone of therapy for the management of acute ST-elevation myocardial infarction (STEMI). Canada's geography presents unique challenges for timely delivery of reperfusion therapy for STEMI patients. The Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology STEMI guideline was developed to provide advice regarding the optimal acute management of STEMI patients irrespective of where they are initially identified: in the field, at a non-percutaneous coronary intervention-capable centre or at a percutaneous coronary intervention-capable centre. We had also planned to evaluate and incorporate sex and gender considerations in the development of our recommendations. Unfortunately, inadequate enrollment of women in randomized trials, lack of publication of main outcomes stratified according to sex, and lack of inclusion of gender as a study variable in the available literature limited the feasibility of such an approach. The Grading Recommendations, Assessment, Development, and Evaluation system was used to develop specific evidence-based recommendations for the early identification of STEMI patients, practical aspects of patient transport, regional reperfusion decision-making, adjunctive prehospital interventions (oxygen, opioids, antiplatelet therapy), and procedural aspects of mechanical reperfusion (access site, thrombectomy, antithrombotic therapy, extent of revascularization). Emphasis is placed on integrating these recommendations as part of an organized regional network of STEMI care and the development of appropriate reperfusion and transportation pathways for any given region. It is anticipated that these guidelines will serve as a practical template to develop systems of care capable of providing optimal treatment for a wide range of STEMI patients.

Near-simultaneous intensive care unit (ICU) admissions and all-cause mortality: a cohort study

PURPOSE

Prior studies have reported the adverse effects of strain on patient outcomes. There is a paucity of literature about a type of strain that may be caused by near-simultaneous intensive care unit (ICU) admissions. We hypothesized that when multiple admissions arrive nearly at the same time, the ICU teams are excessively strained, and this leads to unfavorable patient outcomes.

METHODS

This is a retrospective cohort study of consecutive adult patients admitted to an academic medical ICU of a tertiary referral center over five consecutive years. Primary outcomes were the all-cause hospital and ICU mortality.

RESULTS

We enrolled 13,234 consecutive ICU admissions during the study period. One-fourth of the admissions had an elapsed time since the last admission (ETLA) of < 55 min. Near-simultaneous admissions (NSA) had on average, a higher unadjusted odds ratio (OR) of ICU death of 1.16 (95% CI 1-1.35, P = 0.05), adjusted 1.23 (95% CI 1.04-1.44, P = 0.01), unadjusted hospital death of 1.11 (95% CI 0.99-1.24, P = 0.06), adjusted 1.20 (95% 1.05-1.35, P = 0.004), and a lower adjusted OR of home discharge of 0.91 (95% CI 0.84-0.99, P = 0.04). NSA was associated with 0.16 (95% CI 0.04-0.29, P = 0.01) added days in the ICU. For each incremental unit increase of the logarithmic transformation of ETLA [log (ETLA in minutes)], the average adjusted hospital mortality OR incrementally decreased by an added average OR of 0.93 (95% CI 0.89‒0.97, P = 0.001).

CONCLUSION

Our results suggest that near-simultaneous ICU admissions (NSA) are frequent and are associated with a dose-dependent effect on mortality, length of stay, and odds of home versus nursing facility discharge.

Paramedic-initiated helivac to tertiary hospital for primary percutaneous coronary intervention: a strategy for improving treatment delivery times

Background

In regions of New Zealand without coronary catheterisation laboratory (CCL) facilities, patients presenting with ST-elevation myocardial infarction (STEMI) are often subjected to prolonged delays before receiving primary percutaneous coronary intervention (PPCI) if it is the chosen reperfusion strategy. Therefore, we aimed to trial a new process of paramedic-initiated helivac of STEMI patients from the field directly to the CCL.

Methods

Utilising a prospective observational approach, over a 48-month period, paramedics identified patients with a clinical presentation and electrocardiogram features consistent with STEMI and transported them directly to the regional air ambulance base for helivac to the CCL (flight time 30-35 minutes). These patients were compared to two historic STEMI cohorts either transported by paramedics to the region's local hospital or self-presenting, prior to helivac. The primary outcome measures were: first medical contact-to-balloon (FMCTB) time and accuracy of paramedic diagnosis. Secondary outcome measures were mortality at 30 days and six months, and hospital length of stay (LOS).

Results

A total of 92 patients underwent helivac for PPCI (mean age of 64 years, SD ±10.3). Median FMCTB time was 155 minutes (IQR 27) for the historic cohorts (n=57), versus 102 minutes (IQR 16) for the experimental cohort (n=35, P<0.001). Paramedic diagnosis showed a sensitivity of 97% (95% CI: 85 to 99) and a specificity of 100% (95% CI: 84 to 100) with no inappropriate CCL activations. No significant difference was observed between groups in terms of 30 day and 6-month mortality. Hospital LOS was significantly shorter among the experimental cohort (P=0.01).

Conclusions

Paramedic-initiated helivac of STEMI patients from the field directly to the CCL for PPCI is safe and feasible and can significantly improve time-to-treatment to within benchmark timeframes, resulting in reduced hospital LOS.

Clinical Practice Guideline of Integrative Chinese and Western Medicine for Acute Myocardial Infarction

With increasing morbidity and mortality, acute myocardial infarction (AMI) has become one of the major causes of human death, leading to heavy burdens to individuals, families and society. Previous researches have found that though large amount of resources and great effort were devoted, no significant improvements were achieved in reducing the in-hospital mortality of AMI patients. Meanwhile, extensive studies about Chinese medicine (CM) have found that CM has special advantages in treating AMI patients. However, there is no standardized and unified clinical practice guideline (CPG) of CM for AMI. Therefore, a CPG with strict standard and generally acknowledgement is urgent to be established. This guideline was developed following the methodological process established by the World Health Organization Handbook for Guideline Development. Extensive search on clinical evidences including systematic review (SR), randomized controlled trial (RCT), observational study and case reports was launched, covering evidence of CM for AMI on several aspects, such as diagnosis, CM patterns, CM interventions on AMI and complications, cardiac rehabilitation and clinical pathway management. Besides, the application of Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach enabled the evaluation of evidence and formulation of grade of recommendation (GOR) and level of evidence (LOE). With the help of GOR and LOE, this CPG recommends the integrative CM and WM treatment method in AMI patients and provides useful information on medical decision for clinical physicians.

Preintensive care: Thrombolytic (streptokinase or tenecteplase) in ST elevated acute myocardial infarction at peripheral hospital

Background:

Coronary artery disease is a major cause of death in India. Sudden death preceded by chest pain is due to acute myocardial infarction. Villagers are aware and afraid of chest pain. Majority of chest pain victims attend the primary physician in golden hours. Hence, primary doctors can play important role for early thrombolysis and salvage the myocardium from irreversible injury. This study determined year mortality in a patient who received the rapid thrombolysis at primary care hospital (streptokinase or tenecteplase) at rural setting.

Setting:

Peripheral General Hospital Mahad on Mumbai–Goa highway.

Patients and Methods:

Patients with typical chest pain with electrocardiogram showed ST segment elevated myocardial infarction (STEMI) with or without risk factors admitted from 2005 to march 2016 were studied. Details clinically studied: time interval between chest pain to hospital, hospital to needle time, reperfusion and arrhythmias. Time required for regression of elevated ST segment, a response to thrombolytic (streptokinase or tenecteplase) therapy, is studied.

Results:

Total 244 patient reported with chest pain of these 35 cases brought dead with history of chest pain and convulsive moment before they died. Of these, 209 patients had acute STEMI. Of these, 162 received streptokinase (STK) and 47 received tenecteplase (TNP)]. Analysis of STK Vs TNP patients 18 (11.11%) versus 3 (6.38%) (P = 0.361) died during the treatment. Around 17 (18.49%) vs 5 (10.63%) (P = 0.941) did not show signs of reperfusion, respectively. Re infarction occurred during hospitalization 3 (2.5%) versus 3 (6.38%) (P = 0.094) cases. Around 12 (7.40%) versus 0% (P = 0.072) died at the end of 12 months of thrombolytic therapy.

Conclusion:

Thrombolysis of STEMI within golden hours improved the reperfusion. However, 1-year fatality is significance with streptokinase as compared with tenecteplase.

Sensitivity, specificity, and predictive value of cardiac symptoms assessed by emergency medical services providers in the diagnosis of acute myocardial infarction: a multi-center observational study

Objective

For patients with acute myocardial infarction (AMI), symptoms assessed by emergency medical services (EMS) providers have a critical role in prehospital treatment decisions. The purpose of this study was to evaluate the diagnostic accuracy of EMS provider-assessed cardiac symptoms of AMI.

Methods

Patients transported by EMS to 4 study hospitals from 2008 to 2012 were included. Using EMS and administrative emergency department databases, patients were stratified according to the presence of EMS-assessed cardiac symptoms and emergency department diagnosis of AMI. Cardiac symptoms were defined as chest pain, dyspnea, palpitations, and syncope. Disproportionate stratified sampling was used, and medical records of sampled patients were reviewed to identify an actual diagnosis of AMI. Using inverse probability weighting, verification bias-corrected diagnostic performance was estimated.

Results

Overall, 92,353 patients were enrolled in the study. Of these, 13,971 (15.1%) complained of cardiac symptoms to EMS providers. A total of 775 patients were sampled for hospital record review. The sensitivity, specificity, positive predictive value, and negative predictive value of EMS provider-assessed cardiac symptoms for the final diagnosis of AMI was 73.3% (95% confidence interval [CI], 70.8 to 75.7), 85.3% (95% CI, 85.3 to 85.4), 3.9% (95% CI, 3.6 to 4.2), and 99.7% (95% CI, 99.7 to 99.8), respectively.

Conclusion

We found that EMS provider-assessed cardiac symptoms had moderate sensitivity and high specificity for diagnosis of AMI. EMS policymakers can use these data to evaluate the pertinence of specific prehospital treatment of AMI.

Predictors of Outcomes in Myocardial Infarction and Cardiogenic Shock

Myocardial infarction (MI) complicated by cardiogenic shock (MI-CS) is a major cause of cardiovascular morbidity and mortality. Predictors of outcomes in MI-CS include clinical, laboratory, radiologic variables, and management strategies. This article reviews the existing literature on short- and long-term predictors and risk stratification in MI complicated by CS.

Impact of time of admission on short- and long-term mortality in the Vienna STEMI registry

BACKGROUND

Several studies have shown contradictive findings regarding mortality and hospital admission time in patients presenting with ST-elevation myocardial infarction (STEMI). The aim of this study was to assess the impact of "on-" or "off-hour" admission on short- and long-term all-cause mortality of patients in the advanced Vienna STEMI network between 2003 and 2009.

METHODS AND RESULTS

In total, 2829 patients were included into this analysis. Patients were stratified according to admission time into "on-hour" admission (07:30 until 15:00h on weekdays) and "off-hour" admission (15:00-7:30h on weekdays and 24h on weekends). As endpoint of interest, all-cause mortality was investigated after 30days and 3years of follow-up, the latter for all patients and as Landmark analysis for survivors of the index event. Mean age was 60.5±13.3years, 2048 (72.4%) patients were male and 1260 (44.5%) patients presented with anterior wall infarction. 683 (24.1%) patients were admitted "on-hours", 2146 (75.9%) patients were admitted "off-hours". All-cause death occurred in 176 (6.2%) patients after a follow-up of 30days and in 337 (11.9%) patients after 3years. For short- and long-term all-cause mortality no significant differences could be detected between "on-" and "off-hour" admission in univariate and multivariate Cox proportional hazard analyses as well as for propensity score adjusted outcome analysis.

CONCLUSION

In the Vienna STEMI network, "on-" or "off-hour" admission had no impact on short- and long-term mortality for all-comers presenting with acute STEMI. Our findings confirm the imperative need for well-structured STEMI networks of care, as previous data repeatedly demonstrated increased adverse cardiovascular outcome for "off-hour" admission.

Expert Consensus Document on Management of ST-Elevation Myocardial Infarction: Adaptation of 2012 ESC Guidelines

In 2012, the European Society of Cardiology (ESC) guidelines provided recommendations on the management of ST-elevation myocardial infarction (STEMI). The recommendation from these guidelines is restricted to the European subcontinent. To adapt the updated recommendations for Indian subset of STEMI patients, a panel of experts in the management of STEMI provided their expert opinions. This document provides expert consensus on adapting 2012 ESC STEMI guidelines recommendations in Indian setting. Document also discussed "India-specific" relevant literature to support the consensus opinions provided in the management of STEMI.

CVIT expert consensus document on primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) in 2018

While primary percutaneous coronary intervention (PCI) has significantly contributed to improve the mortality in patients with ST segment elevation myocardial infarction even in cardiogenic shock, primary PCI is a standard of care in most of Japanese institutions. Whereas there are high numbers of available facilities providing primary PCI in Japan, there are no clear guidelines focusing on procedural aspect of the standardized care. Whilst updated guidelines for the management of acute myocardial infarction were recently published by European Society of Cardiology, the following major changes are indicated; (1) radial access and drug-eluting stent over bare metal stent were recommended as Class I indication, and (2) complete revascularization before hospital discharge (either immediate or staged) is now considered as Class IIa recommendation. Although the primary PCI is consistently recommended in recent and previous guidelines, the device lag from Europe, the frequent usage of coronary imaging modalities in Japan, and the difference in available medical therapy or mechanical support may prevent direct application of European guidelines to Japanese population. The Task Force on Primary Percutaneous Coronary Intervention of the Japanese Association of Cardiovascular Intervention and Therapeutics (CVIT) has now proposed the expert consensus document for the management of acute myocardial infarction focusing on procedural aspect of primary PCI.

Influence of gender on delays and early mortality in ST-segment elevation myocardial infarction: Insight from the first French Metaregistry, 2005-2012 patient-level pooled analysis

BACKGROUND

Women show greater mortality after acute myocardial infarction. We decided to investigate whether gender affects delays and impacts in-hospital mortality in a large population.

METHODS AND RESULTS

We performed a patient-level analysis of 7 French MI registries from different regions from January 2005 to December 2012. All patients with acute STEMI were included within 12 h from symptom onset and a first medical contact with a mobile intensive care unit an emergency department of a hospital with percutaneous coronary intervention facility. Primary study outcomes were STEMI, patient and system, delays. Secondary outcome was in-hospital mortality. 16,733 patients were included with 4021 females (24%). Women were significantly older (mean age 70.6 vs 60.6), with higher diabetes (19.6% vs 15.4%) and hypertension rates (58.7% vs 38.8%). Patient delay was longer in women with adjusted mean difference of 14.4 min (p < 0.001); system delay did not differ. In-hospital death occurred 3 times more in women. This disadvantage persisted strongly adjusting for age, therapeutic strategy and delay with a 1.85 (1.32-2.61) adjusted hazard ratio.

CONCLUSIONS

This overview of 16,733 real-life consecutive STEMI patients in prospective registries over an extensive period strongly indicates gender-related discrepancies, highlighting clinically relevant delays in seeking medical attention. However, higher in-hospital mortality was not totally explained by clinical characteristics or delays. Dedicated studies of specific mechanisms underlying this female disadvantage are mandatory to reduce this gender gap.

Fibrinolytic treatment of ST-elevation myocardial infarction

Primary percutaneous coronary intervention (PPCI) is the preferred reperfusion therapy in ST-elevation myocardial infarction (STEMI), as long as it can be delivered within 90-120 minutes from patient’s first medical contact, and is the leading reperfusion strategy in most European countries. However, as PPCI cannot be offered in a timely manner to all patients, fibrinolytic therapy (FT) is the recommended choice in patients with an anticipated delay to PPCI of >90-120 minutes, presenting early after symptom onset and without contra-indications. FT should preferably be started in the pre-hospital setting. Following FT, all patients should be transferred to a PCI-center for rescue PCI or routine coronary angiography with PCI as indicated. Such a pharmaco-invasive strategy, combining FT with invasive treatment, has recently been shown to be non-inferior to PPCI in patients living in areas with long transfer delays to PCI (>60 minutes).

In this overview, we will briefly present the evidence for the benefit of FT in STEMI, and discuss the role of FT in the current era of PPCI as well as the optimal treatment following pharmacologic reperfusion.

Trends in clinical outcomes and survival following prehospital thrombolytic therapy given by ambulance clinicians for ST-elevation myocardial infarction in rural sub-arctic Norway

BACKGROUND:

Prehospital thrombolytic therapy given by ambulance emergency medical services to patients with acute ST-segment elevation myocardial infarction (STEMI) may produce earlier reperfusion than percutaneous coronary intervention. Clinical results from prehospital thrombolytic therapy in rural areas are scarce.

METHODS:

We studied outcomes during 11 years of a prehospital thrombolytic therapy system in rural sub-arctic Norway. Ambulance personnel gave protocol basic treatment and transmitted electrocardiograms to hospital physicians who made the decision for prehospital thrombolytic therapy. The study was divided into three time periods; 2000-2003, 2004-2007 and 2008-2011.

RESULTS:

A total of 385 STEMI patients received prehospital thrombolytic therapy, median patient age was 61.2 years, and 77% were men. Time saved by prehospital reperfusion therapy was 131 minutes. The proportion who got prehospital thrombolytic therapy within 2 hours of symptom onset increased from 21% in 2000-2003 to 39% in 2008-2011 ( P=0.003). The proportion who underwent coronary angiography or percutaneous coronary intervention within 24 hours of first medical contact increased from 56.4% to 95.4% ( P<0.001). Post-STEMI systolic heart failure decreased from 19.4% to 8.1% ( P=0.02), while 1-year mortality fell, non-significantly, by 50% over time to reach 5.6%. Thirteen patients suffered acute out-of-hospital cardiac arrest; all were successfully defibrillated. Ten patients had major bleeding events (2.6%).

CONCLUSION:

A decentralised prehospital thrombolytic therapy system based on ambulance personnel, telemetry and centralised 7/24 invasive diagnosis and treatment service, combined with system maturation over time, was associated with earlier reperfusion, improved clinical outcomes and better survival. Prehospital thrombolytic therapy is a feasible and safe intervention used in rural settings with long evacuation lines to percutaneous coronary intervention facilities.

National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Australian clinical guidelines for the management of acute coronary syndromes 2016

INTRODUCTION

The modern care of suspected and confirmed acute coronary syndrome (ACS) is informed by an extensive and evolving evidence base. This clinical practice guideline focuses on key components of management associated with improved clinical outcomes for patients with chest pain or ACS. These are presented as recommendations that have been graded on both the strength of evidence and the likely absolute benefit versus harm. Additional considerations influencing the delivery of specific therapies and management strategies are presented as practice points.

MAIN RECOMMENDATIONS

This guideline provides advice on the standardised assessment and management of patients with suspected ACS, including the implementation of clinical assessment pathways and subsequent functional and anatomical testing. It provides guidance on the: diagnosis and risk stratification of ACS; provision of acute reperfusion therapy and immediate post-fibrinolysis care for patients with ST segment elevation myocardial infarction; risk stratification informing the use of routine versus selective invasive management for patients with non-ST segment elevation ACS; administration of antithrombotic therapies in the acute setting and considerations affecting their long term use; and implementation of an individualised secondary prevention plan that includes both pharmacotherapies and cardiac rehabilitation. Changes in management as a result of the guideline: This guideline has been designed to facilitate the systematic integration of the recommendations into a standardised approach to ACS care, while also allowing for contextual adaptation of the recommendations in response to the individual's needs and preferences. The provision of ACS care should be subject to continuous monitoring, feedback and improvement of quality and patient outcomes.

Relationship between community hospital versus pre-hospital location of randomisation and clinical outcomes in ST-elevation myocardial infarction patients: insights from the Stream study

AIMS

The STREAM study randomly assigned ST-elevation myocardial infarction (STEMI) patients to receive a pharmacoinvasive versus primary percutaneous coronary intervention reperfusion strategy. We assessed whether there was an association between outcomes based on randomisation at a community hospital versus a prehospital location.

METHODS/RESULTS

Community hospital patients (358/1866 (19.2%)) were compared to prehospital patients and their outcomes categorised into pharmacoinvasive according to their treatment assignment. Compared to prehospital patients, community hospital patients had more diabetes (17.8% vs. 11.5%, P=0.001), higher Killip Class >1 (9.4% vs. 5.0%, P=0.002) and thrombolysis in myocardial infarction risk scores ⩾5 (18.2% vs. 12.4%, P=0.005). The 30-day primary endpoint (death, shock, congestive heart failure and re-infarction) for community hospital patients was 14.9% versus 13.2% for prehospital patients ( P=0.403). Community hospital pharmacoinvasive patients tended to receive less rescue (35.1% vs. 42.8%, P=0.062); when deployed their rescue was delayed 43 minutes. Community hospital patients undergoing primary percutaneous coronary intervention experienced a delay of 31 minutes versus prehospital patients. Pharmacoinvasive patients receiving scheduled angiography from a community hospital and prehospital patients had comparable times to angiography (17.7 vs. 18.7 hours) and low event rates (6.2% vs. 8.0%). Although the interaction between randomisation location and treatment received on the primary endpoint was not significant ( P_interaction=0.065) those pharmacoinvasive patients requiring rescue from community hospitals had worse outcomes than prehospital rescue patients (odds ratio 2.28, 95% confidence interval 1.16-4.49).

CONCLUSION

Within STREAM, STEMI patients randomly assigned at community hospitals had a higher baseline risk but similar outcomes compared to those studied prehospital patients irrespective of successful pharmacoinvasive therapy or primary percutaneous coronary intervention. However, worse outcomes in the pharmacoinvasive patients requiring rescue in community hospitals emphasises their need for immediate transfer to a percutaneous coronary intervention-capable hospital.

Clinical outcomes in myocardial infarction and multivessel disease after a cardiac rehabilitation programme: Partial versus complete revascularization

BACKGROUND

Current guideline recommendations encourage culprit vessel only percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease. However, recent studies have shown a better clinical outcome in patients who receive multivessel PCI.

AIM

To measure and compare clinical outcomes between partial revascularization (PR) versus complete revascularization (CR) in patients with STEMI and multivessel disease who underwent a cardiac rehabilitation programme.

METHODS

We retrospectively reviewed the medical records of 282 patients with STEMI and multivessel disease who received PR or CR and were subsequently enrolled in a cardiac rehabilitation programme between July 2006 and November 2013 at La Paz University Hospital. The incidences of cardiovascular events, new PCI, hospital admissions for cardiovascular reasons and mortality were compared between the PR and CR groups.

RESULTS

Overall, 143 patients received PR and 139 received CR. Baseline characteristics were similar in both groups, except for mean age (59.3 vs. 56.7 years; P=0.02), diabetes mellitus prevalence (34.3% vs. 20.1%; P=0.01) and number of arteries with stenosis (2.6 vs. 2.3; P=0.001). During the mean follow-up of 48.0±25.9 months, a cardiovascular event occurred in 23 (16.1%) PR patients and 20 (14.4%) CR patients, with no statistically significant differences in the early (hazard ratio: 0.61, 95% confidence interval: 0.19-1.89) or late (hazard ratio: 1.40, 95% confidence interval: 0.62-3.14) follow-up periods. Cox regression, adjusted for age, sex, presence of diabetes mellitus and number of affected coronary vessels, showed no difference in new cardiovascular event risk.

CONCLUSIONS

There were no statistical differences in clinical outcomes between PR and CR among patients who received cardiac rehabilitation.

The Comparison of the Outcomes between Primary PCI, Fibrinolysis, and No Reperfusion in Patients ≥ 75 Years Old with ST-Segment Elevation Myocardial Infarction: Results from the Chinese Acute Myocardial Infarction (CAMI) Registry

Background

Only a few randomized trials have analyzed the clinical outcomes of elderly ST-segment elevation myocardial infarction (STEMI) patients (≥ 75 years old). Therefore, the best reperfusion strategy has not been well established. An observational study focused on clinical outcomes was performed in this population.

Methods

Based on the national registry on STEMI patients, the in-hospital outcomes of elderly patients with different reperfusion strategies were compared. The primary endpoint was defined as death. Secondary endpoints included recurrent myocardial infarction, ischemia driven revascularization, myocardial infarction related complications, and major bleeding. Multivariable regression analysis was performed to adjust for the baseline disparities between the groups.

Results

Patients who had primary percutaneous coronary intervention (PCI) or fibrinolysis were relatively younger. They came to hospital earlier, and had lower risk of death compared with patients who had no reperfusion. The guideline recommended medications were more frequently used in patients with primary PCI during the hospitalization and at discharge. The rates of death were 7.7%, 15.0%, and 19.9% respectively, with primary PCI, fibrinolysis, and no reperfusion (P < 0.001). Patients having primary PCI also had lower rates of heart failure, mechanical complications, and cardiac arrest compared with fibrinolysis and no reperfusion (P < 0.05). The rates of hemorrhage stroke (0.3%, 0.6%, and 0.1%) and other major bleeding (3.0%, 5.0%, and 3.1%) were similar in the primary PCI, fibrinolysis, and no reperfusion group (P > 0.05). In the multivariable regression analysis, primary PCI outweighs no reperfusion in predicting the in-hospital death in patients ≥ 75 years old. However, fibrinolysis does not.

Conclusions

Early reperfusion, especially primary PCI was safe and effective with absolute reduction of mortality compared with no reperfusion. However, certain randomized trials were encouraged to support the conclusion.

Impacts of the 2011 Fukushima nuclear accident on emergency medical service times in Soma District, Japan: a retrospective observational study

OBJECTIVE

To assess the influence of the 3.11 triple disaster (earthquake, tsunami and nuclear accident) on the emergency medical service (EMS) system in Fukushima.

METHODS

Total EMS time (from EMS call to arrival at a hospital) was assessed in the EMS system of Soma district, located 10-40 km north of the nuclear plant, from 11 March to 31 December 2011. We defined the affected period as when total EMS time was significantly extended after the disasters compared with the historical control data from 1 January 2009 to 10 March 2011. To identify risk factors associated with the extension of total EMS time after the disasters, we investigated trends in 3 time segments of total EMS time; response time, defined as time from an EMS call to arrival at the location, on-scene time, defined as time from arrival at the location to departure, and transport time, defined as time from departure from the location to arrival at a hospital.

RESULTS

For the affected period from week 0 to week 11, the median total EMS time was 36 (IQR 27-52) minutes, while that in the predisaster control period was 31 (IQR 24-40) min. The percentage of transports exceeding 60 min in total EMS time increased from 8.2% (584/7087) in the control period to 22.2% (151/679) in the affected period. Among the 3 time segments, there was the most change in transport time (standardised mean difference: 0.41 vs 0.13-0.17).

CONCLUSIONS

EMS transport was significantly delayed for ∼3 months, from week 1 to 11 after the 3.11 triple disaster. This delay may be attributed to malfunctioning emergency hospitals after the triple disaster.

Antithrombotic therapy before, during and after emergency angioplasty for ST elevation myocardial infarction

The first three hours after symptom onset hold the maximum potential for myocardial reperfusion and salvage in ST-elevation myocardial infarction (STEMI) patients. During this period timely primary percutaneous coronary intervention (PPCI) or, when PPCI is not promptly feasible, pre-hospital administration of fibrinolyis or a glycoprotein IIb/IIIa-inhibitor (GPI) have been shown to restore coronary patency and reperfusion and even result in myocardial infarction (MI) abortion. On the other hand, oral antiplatelet therapy may not yet guarantee sufficient platelet inhibition. Patients presenting after this golden time have less, if any, benefit from an aggressive antithrombotic treatment prior to PPCI. Antithrombotic treatment during primary angioplasty should be tailored on the basis of the coronary thrombotic burden, vascular approach and the patient's risk of bleeding complications. A GPI-based approach may be favourable in patients presenting early with large MI and high thrombus burden, whereas a bivalirudin-based approach without GPI may be preferred in patients with higher bleeding risk. There are no data to support the use of GPI in bailout conditions. The powerful oral P2Y₁₂ inhibitors, prasugrel and ticagrelor, have been clearly shown to prevent stent thrombosis and recurrent ischaemic events after emergency percutaneous coronary intervention in STEMI patients. Open issues remaining are the treatment of patients with high bleeding risk, such as the elderly and those requiring anticoagulation, as well as the duration of dual antiplatelet therapy after STEMI.

Regional systems-of-care for primary percutaneous coronary intervention in ST-elevation myocardial infarction

ST-elevation myocardial infarction (STEMI) is a critical, time-dependent condition requiring immediate reperfusion of the coronary arteries to minimize mortality and morbidity. The preferred method of revascularization is a primary percutaneous coronary intervention (PCI) if this can be performed in a timely manner. This requires an effective and well-organized setup from symptom onset to revascularization. Such regional networks for the diagnosis and treatment of STEMI patients have been proven to be very effective in achieving the treatment goals stipulated by the international guidelines. Several trials have provided evidence that prehospital ECG recording and early diagnosis combined with direct referral to a primary PCI center reduces treatment delay considerably. In-hospital awareness with early notification of the PCI operator and technicians and admission directly to the catheterization laboratory also reduces time to treatment. There is solid evidence that the reduction in treatment delay achieved by dedicated STEMI networks is associated with a lower mortality and morbidity. Regional STEMI networks are now implemented in many countries with highly varying geographical challenges and healthcare systems, allowing patients everywhere to receive optimal treatment with primary PCI.

[Preclinical fibrinolysis in patients with ST-segment elevation myocardial infarction in a rural region]

BACKGROUND

In the current guidelines for the treatment of patients with ST-segment elevation myocardial infarction (STEMI), the European Society of Cardiology (ESC) recommends preclinical fibrinolysis as a reperfusion therapy if, due to long transportation times, no cardiac catheterisation is available within 90-120 min. However, there is little remaining in-depth expertise in this method because fibrinolysis is presently only rarely indicated.

METHODS

In a rural area in southwestern Germany, where an emergency primary percutaneous coronary intervention was not routinely available within 90-120 min, 156 STEMI patients underwent fibrinolysis with the plasminogen activator reteplase, performed by trained emergency physicians. The practicality of the treatment, as well as complications and the mortality of the patients in the preclinical phase until arrival at the hospital, were retrospectively studied.

RESULTS

The mean time from onset of the symptoms to first medical contact was 114 ± 116 min. The mean interval to the start of fibrinolysis of 13.5 ± 6.4 min was within the 30 min mandated by the ESC. Patients with inferior STEMI represented the largest subgroup. Occurring in 39 cases (25 %), complications due to infarction were relatively common during the prehospital phase, including 15 cases (9.6 %) of cardiogenic shock, but in all cases the complications were manageable. No patient died before arrival at the hospital. As lysis-associated adverse effects, merely two uncomplicated mucosal haemorrhages and one case of mild allergic skin reactions were seen.

CONCLUSION

In emergency situations with long transportation times to the nearest suitable cardiac catheterisation laboratory, preclinical fibrinolysis in STEMI still represents a workable method. Success of this strategy requires particularly strong training of the emergency physicians in ECG and lysis therapy, and co-operation with nearby cardiac centres.

Pharmacoinvasive and Primary Percutaneous Coronary Intervention Strategies in ST-Elevation Myocardial Infarction (from the Mayo Clinic STEMI Network)

The effectiveness of a pharmacoinvasive strategy consisting of fibrinolysis and transfer for percutaneous coronary intervention (PCI) compared to primary PCI (PPCI) in patients presenting to non-PCI-capable hospitals with ST-elevation myocardial infarction (STEMI) is not well defined. We analyzed data from the Mayo Clinic STEMI database of patients treated with a pharmacoinvasive strategy (favored in those presenting early after symptom onset) or PPCI in a regional STEMI network from 2004 to 2012. A total of 364 and 1,337 patients were included in the pharmacoinvasive and PPCI groups, respectively. Patients in the PPCI group were older and more frequently had cardiogenic shock at the time of presentation (12.1% vs 7.7%, p = 0.018). Death from any cause occurred in 58 (16%) and 314 (23%) patients in the pharmacoinvasive and PPCI groups, respectively (median follow-up 3.9 and 4.4 years, respectively). In multivariate analyses adjusting for age, gender, and other variables for which the 2 groups differed at baseline, there was no significant difference between the 2 strategies for 30-day (hazard ratio 0.66, 95% confidence interval 0.36 to 1.21) or overall mortality (hazard ratio 0.84, 95% confidence interval 0.63 to 1.12). Shorter door-to-balloon time was associated with increased effectiveness of PPCI (p for trend = 0.015), but there was no difference between the 2 strategies even when considering only the patients with door-to-balloon time in the lowest quartile. In conclusion, fibrinolysis followed by transfer for PCI represents a reasonable alternative when PPCI is not readily available especially in patients presenting early after symptom onset.