Association of Rapid Care Process Implementation on Reperfusion Times Across Multiple ST-Segment-Elevation Myocardial Infarction Networks

Evaluation of the ODISEA APP for improving a STEMI regional network

BACKGROUND

The use of technological innovations in ST elevation myocardial infarction (STEMI) care networks has been shown to be effective in improving information flow and coordination, and thus reducing the time to reperfusion. We developed a smartphone application called ODISEA to improve our STEMI care network and evaluated the results of its use.

METHOD

Quasi-experimental study that compared the outcomes of STEMI suspected patients with an alert and indication for transfer to a cath lab during a previous period and a period in which the ODISEA APP was used. The main objective was to examine differences in reperfusion time and the proportion of patients with a final diagnosis other than acute coronary syndrome.

RESULTS

A total of 699 patients were included (415 before and 284 during the ODISEA-APP period). No differences were observed in patient characteristics, infarct type, or acute complications. We observed a reduction in the time from diagnostic ECG to wire crossing with the use of the ODISEA APP (117 vs 102 min, p < 0.001) and a reduction in the percentage of patients with a final diagnosis other than acute coronary syndrome (17.1% vs 9.5%, p = 0.004).

CONCLUSIONS

The use of the ODISEA APP in the management of patients with suspected STEMI may be useful for reducing the time from diagnostic ECG to wire crossing and the percentage of patients with a final diagnosis other than acute coronary syndrome.

Ventricular Arrhythmias After Primary Percutaneous Coronary Intervention for STEMI

Importance

Currently, mortality risk for patients with ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI) with an uncomplicated postprocedure course is low. Less is known regarding the risk of in-hospital ventricular tachycardia (VT) and ventricular fibrillation (VF).

Objective

To evaluate the risk of late VT and VF after primary PCI for STEMI.

Design, Setting, and Participants

This cohort study included adults aged 18 years or older with STEMI treated with primary PCI between January 1, 2015, and December 31, 2018, identified in the US National Cardiovascular Data Registry Chest Pain-MI Registry. Data were analyzed from April to December 2020.

Main Outcomes and Measures

Multivariable logistic regression was used to evaluate the risk of late VT (≥7 beat run of VT during STEMI hospitalization ≥1 day after PCI) or VF (any episode of VF≥1 day after PCI) associated with cardiac arrest and associations between late VT or VF and in-hospital mortality in the overall cohort and a cohort with uncomplicated STEMI without prior myocardial infarction or heart failure, systolic blood pressure less than 90 mm Hg, cardiogenic shock, cardiac arrest, reinfarction, or left ventricular ejection fraction (LVEF) less than 40%.

Results

A total of 174 126 eligible patients with STEMI were treated with primary PCI at 814 sites in the study; 15 460 (8.9%) had VT or VF after primary PCI, and 4156 (2.4%) had late VT or VF. Among the eligible patients, 99 905 (57.4%) at 807 sites had uncomplicated STEMI. The median age for patients with late VT or VF overall was 63 years (IQR, 55-73 years), and 75.5% were men; the median age for patients with late VT or VF with uncomplicated STEMI was 60 years (IQR, 53-69 years), and 77.7% were men. The median length of stay was 3 days (IQR, 2-7 days) for the overall cohort with late VT or VF and 3 days (IQR, 2-4 days) for the cohort with uncomplicated STEMI with late VT or VF. The risk of late VT or VF was 2.4% (overall) and 1.7% (uncomplicated STEMI). Late VT or VF with cardiac arrest occurred in 674 patients overall (0.4%) and in 117 with uncomplicated STEMI (0.1%). LVEF was the most significant factor associated with late VT or VF with cardiac arrest (adjusted odds ratio [AOR] for every 5-unit decrease ≤40%: 1.67; 95% CI, 1.54-1.85). Late VT or VF events were associated with increased odds of in-hospital mortality in the overall cohort (AOR, 6.40; 95% CI, 5.63-7.29) and the cohort with uncomplicated STEMI (AOR, 8.74; 95% CI, 6.53-11.70).

Conclusions and Relevance

In this study, a small proportion of patients with STEMI treated with primary PCI had late VT or VF. However, late VT or VF with cardiac arrest was rare, particularly in the cohort with uncomplicated STEMI. This information may be useful when determining the optimal timing for hospital discharge after STEMI.

Culprit Lesion Coronary Intervention Before Complete Angiography in ST-Elevation Myocardial Infarction: A Randomized Clinical Trial

Importance

Rapid reperfusion during primary percutaneous coronary intervention (PCI) is associated with improved outcomes among patients with ST-elevation myocardial infarction (STEMI). Although attempts at reducing the time from STEMI diagnosis to arrival at the catheterization laboratory have been widely investigated, intraprocedural strategies aimed at reducing the time to reperfusion are lacking.

Objective

To evaluate the effect of culprit lesion PCI before complete diagnostic coronary angiography (CAG) vs complete CAG followed by culprit lesion PCI on reperfusion times among patients with STEMI.

Design, Setting, and Participants

This open-label, prospective, randomized clinical trial was conducted between April 1, 2021, and August 31, 2022, among patients admitted to a tertiary center in Jerusalem, Israel, with a diagnosis of STEMI undergoing primary PCI. All patients were followed up for 1 year. Analysis was on an intention-to-treat basis.

Intervention

Patients were randomized in a 1:1 ratio to undergo either culprit lesion PCI before complete CAG or complete CAG followed by culprit lesion PCI.

Main Outcomes and Measures

A needle-to-balloon time of 10 minutes or less.

Results

A total of 216 patients were randomized, with 184 patients (mean [SD] age, 62.9 [12.2] years; 155 men [84.2%]) included in the final intention-to-treat analysis; 90 patients (48.9%) were randomized to undergo culprit lesion PCI before CAG, and 94 (51.1%) were randomized to undergo to CAG followed by PCI. Patients who underwent culprit lesion PCI before complete CAG had a shorter mean (SD) needle-to-balloon time (11.4 [5.9] vs 17.3 [13.3] minutes; P < .001). The primary outcome of a needle-to-balloon time of 10 minutes or less was achieved for 51.1% of patients (46 of 90) who underwent culprit lesion PCI before CAG and for 19.1% of patients (18 of 94) who underwent complete CAG followed by culprit lesion PCI (odds ratio, 4.4 [95% CI, 2.2-9.1]; P < .001). Rates of adverse events were similar between groups. In a subgroup analysis, the effect of culprit lesion PCI before complete CAG on the primary outcome was consistent. There were no differences in rates of in-hospital, 30-day, and 1-year all-cause mortality.

Conclusions and Relevance

In this randomized clinical trial of patients with STEMI, culprit lesion PCI before complete CAG resulted in shorter reperfusion times. Larger trials are needed to validate these results and to evaluate the effect on clinical outcomes.

Trial Registration

ClinicalTrials.gov Identifier: NCT05415085.

Regionalization of stroke systems of care in the stroke belt states: The IMPROVE stroke care quality improvement program

BACKGROUND

Despite guidelines and strong evidence supporting intravenous thrombolysis and endovascular thrombectomy for acute stroke, access to these interventions remains a challenge. The objective of the IMPROVE stroke care program was to accelerate acute stroke care delivery by implementing best practices and improving the regional systems of care within comprehensive stroke networks.

METHODS

The IMPROVE Stroke Care program was a prospective quality improvement program based on established models used in acute coronary care. Nine hub hospitals (comprehensive stroke centers), 52 regional/community referral hospitals (spokes), and over 100 emergency medical service agencies participated. Through 6 regional meetings, 49 best practices were chosen for improvement by the participating sites. Over 2 years, progress was tracked and discussed weekly and performance reviews were disseminated quarterly.

RESULTS

Data were collected on 21,647 stroke code activations of which 8,502 (39.3%) activations had a final diagnosis of stroke. There were 7,226 (85.0%) ischemic strokes, and thrombolytic therapy was administered 2,814 times (38.9%). There was significant overall improvement in the proportion that received lytic therapy within 45 minutes (baseline of 44.6%-60.4%). The hubs were more frequently achieving this at baseline, but both site types improved. A total of 1,455 (17.1%) thrombectomies were included in the data of which 401 (27.6%) were transferred from a spoke. There was no clinically significant change in door-to-groin times for hub-presenting thrombectomy patients, however, significant improvement occurred for transferred cases, 46 minutes (interquartile range [IQR] 36, 115.5) at baseline to 27 minutes (IQR 10, 59).

CONCLUSIONS

The IMPROVE program approach was successful at improving the delivery of thrombolytic intervention across the consortium at both spoke and hub sites through collaborative efforts to operationalize guideline-based care through iterative sharing of performance and best practices for implementation. Our approach allowed identification of both opportunities for improvement and operational best practices providing guidance on how best to create a regional stroke care network and operationalize the published acute stroke care guidelines.

Rural EMS STEMI Patients - Why the Delay to PCI?

BACKGROUND

The objective of this study is to identify patient and EMS agency factors associated with timely reperfusion of patients with ST-elevation myocardial infarction (STEMI).

METHODS

We conducted a cohort study of adult patients (≥18 years old) with STEMI activations from 2016 to 2020. Data was obtained from a regional STEMI registry, which included eight rural county EMS agencies and three North Carolina percutaneous coronary intervention (PCI) centers. On each patient, prehospital and in-hospital time intervals were abstracted. The primary outcome was the ability to achieve the 90-minute EMS FMC to PCI time goal (yes vs. no). We used generalized estimating equations accounting for within-agency clustering to evaluate the association between patient and agency factors and meeting first medical contact (FMC) to PCI time goal while accounting for clustering within the agency.

RESULTS

Among 365 rural STEMI patients 30.1% were female (110/365) with a mean age of 62.5 ± 12.7 years. PCI was performed within the time goal in 60.5% (221/365) of encounters. The FMC to PCI time goal was met in 45.5% (50/110) of women vs 69.8% (178/255) of men (p < 0.001). The median PCI center activation time was 12 min (IQR 7-19) in the group that received PCI within the time goal compared to 21 min (IQR 10-37) in the cohort that did not. After adjusting for loaded mileage and other clinical variables (e.g., pulse rate, hypertension etc.), the male sex was associated with an improved chance of meeting the goal of FMC to PCI (aOR: 2.94; 95% CI 2.11-4.10) compared to the female sex.

CONCLUSION

Nearly 40% of rural STEMI patients transported by EMS failed to receive FMC to PCI within 90 min. Women were less likely than men to receive reperfusion within the time goal, which represents an important health care disparity.

Delayed first medical contact to reperfusion time increases mortality in rural emergency medical services patients with ST-elevation myocardial infarction

BACKGROUND

ST-elevation myocardial infarction (STEMI) guidelines recommend an emergency medical services (EMS) first medical contact (FMC) to percutaneous coronary intervention (PCI) time of ≤90 min. The primary objective of this study was to evaluate the association between FMC to PCI time and mortality in rural STEMI patients.

METHODS

We conducted a cohort study of patients ≥18 years old with STEMI activations from January 2016 to March 2020. Data were obtained from a rural North Carolina Regional STEMI Data Registry, which included eight rural EMS agencies and three PCI centers, the National Cardiovascular Data Registry, and the EMS electronic health record. Prehospital and in-hospital time intervals were digitally abstracted. The outcome of index hospitalization mortality was compared between patients who did and did not meet FMC to PCI time goal using Fisher's exact tests. Negative predictive value (NPV) for index hospitalization death was calculated with 95% confidence intervals (CIs). A receiver operating characteristic curve was constructed and an optimal FMC to PCI time goal was identified by maximizing NPV to prevent index hospitalization death.

RESULTS

Among 365 rural EMS STEMI patients, 30.1% (110/365) were female with a mean ± SD age of 62.5 ± 12.7 years. PCI was performed within the 90-min time goal in 60.5% (221/365) of patients. Among these patients, 3% (11/365) died during initial STEMI hospitalization, with 1.4% (3/221) mortality in the group that met the 90-minute time goal compared to 5.6% (8/144) in patients exceeding the time goal (p = 0.03). Meeting the 90-min time goal yielded a 98.6% (95% CI 96.1%-99.7%) NPV for index death. A 78-min FMC to PCI time was the optimal cut point, yielding a NPV for index mortality of 99.3% (95% CI 96.1%-100%).

CONCLUSIONS

Death among rural patients with STEMI was four times more likely when they did not receive PCI within 90 min.

Detection of Ischemic ST-Segment Changes Using a Novel Handheld ECG Device in a Porcine Model

Background

Portable, smartphone-sized electrocardiography (ECG) has the potential to reduce time to treatment for patients suffering acute cardiac ischemia, thereby lowering the morbidity and mortality. In the UMC Utrecht, a portable, smartphone-sized, multi-lead precordial ECG recording device (miniECG 1.0, UMC Utrecht) was developed.

Objectives

The purpose of this study was to investigate the ability of the miniECG to capture ischemic ECG changes in a porcine coronary occlusion model.

Methods

In 8 animals, antero-septal myocardial infarction was induced by 75-minute occlusion of the left anterior descending artery, after the first or second diagonal. MiniECG and 12-lead ECG recordings were acquired simultaneously before, during and after coronary artery occlusion and ST-segment deviation was evaluated.

Results

During the complete occlusion and reperfusion period, miniECG showed large ST-segment deviation in comparison to 12-lead ECG. MiniECG ST-segment deviation was observed within 1 minute for most animals. The miniECG was positive for ischemia (ie, ST-segment deviation ≥1 mm) for 99.7% (Q1-Q3: 99.6%-99.9%) of the occlusion time, while the 12-lead was only positive for 79.8% (Q1-Q3: 81.1%-98.7%) of the time (P = 0.018). ST-segment deviation reached maxima of 10.5 mm [95% CI: 6.5-14.5 mm] vs 5.0 mm [95% CI: 2.0-8.0 mm] for the miniECG vs 12-lead ECG, respectively.

Conclusions

MiniECG ST-segment deviation was observed early and was of large magnitude during 75 minutes of porcine transmural antero-septal infarction. The miniECG was positive for ischemia for the complete occlusion period. These findings demonstrate the potential of the miniECG in the detection of cardiac ischemia. Although clinical research is required, data suggests that the miniECG is a promising tool for the detection of cardiac ischemia.

Temporal Trends in Reperfusion Delivery and Clinical Outcomes Following Implementation of a Regional STEMI Protocol – a 12 Year Perspective

Background

The Vancouver Coastal Health (VCH) ST-elevation myocardial infarction (STEMI) program aimed to increase access to primary percutaneous coronary intervention (PPCI) and reduce first-medical-contact-to-device times (FMC-DTs). We evaluated the long-term program impact on PPCI access and FMC-DT, and overall and reperfusion-specific in-hospital mortality.

Methods

We analyzed all VCH STEMI patients between June 2007 and November 2019. The primary outcome was the proportion of patients receiving PPCI over 4 program implementation phases over 12 years. We also evaluated overall changes in median FMC-DT and the proportion of patients achieving guideline-mandated FMC-DT, in addition to overall and reperfusion-specific in-hospital mortality.

Results

A total of 3138 of 4305 VCH STEMI patients were treated with PPCI. PPCI rates increased from 40.2% to 78.7% from 2007 to 2019 (P < 0.001). From phase 1 to 4, median FMC-DT improved from 118 to 93 minutes (percutaneous coronary intervention [PCI]-capable hospitals, P < 0.001) and from 174 to 118 minutes (non-PCI-capable hospitals, P < 0.001), with a concomitant increase in those achieving guideline-mandated FMC-DT (35.5% to 66.1%, P < 0.001). Overall in-hospital mortality was 9.0% (P = 0.20 across phases), with mortality differing significantly by reperfusion strategy (4.0% fibrinolysis, 5.7% PPCI, 30.6% no reperfusion therapy, P < 0.001). Mortality significantly decreased from phase 1 to phase 4 at non-PCI-capable centres (9.6% to 3.9%, P = 0.022) but not at PCI-capable centres (8.7% vs 9.9%, P = 0.27).

Conclusions

A regional STEMI program increased the proportion of patients who received PPCI and improved reperfusion times over 12 years. Although no statistically significant decrease occurred in overall regional mortality incidence, mortality incidence was decreased for patients presenting to non-PCI-capable centres.

Treatment Time and In-Hospital Mortality Among Patients With ST-Segment Elevation Myocardial Infarction, 2018-2021

IMPORTANCE

Recognizing the association between timely treatment and less myocardial injury for patients with ST-segment elevation myocardial infarction (STEMI), US national guidelines recommend specific treatment-time goals.

OBJECTIVE

To describe these process measures and outcomes for a recent cohort of patients.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional study of a diagnosis-based registry between the second quarter of 2018 and the third quarter of 2021 for 114 871 patients with STEMI treated at 648 hospitals in the Get With The Guidelines-Coronary Artery Disease registry.

EXPOSURES

STEMI or STEMI equivalent.

MAIN OUTCOMES AND MEASURES

Treatment times, in-hospital mortality, and adherence to system goals (75% treated ≤90 minutes of first medical contact if the first hospital is percutaneous coronary intervention [PCI]-capable and ≤120 minutes if patients require transfer to a PCI-capable hospital).

RESULTS

In the study population, median age was 63 (IQR, 54-72) years, 71% were men, and 29% were women. Median time from symptom onset to PCI was 148 minutes (IQR, 111-226) for patients presenting to PCI-capable hospitals by emergency medical service, 195 minutes (IQR, 127-349) for patients walking in, and 240 minutes (IQR, 166-402) for patients transferred from another hospital. Adjusted in-hospital mortality was lower for those treated within target times vs beyond time goals for patients transported via emergency medical services (first medical contact to laboratory activation ≤20 minutes [in-hospital mortality, 3.6 vs 9.2] adjusted OR, 0.54 [95% CI, 0.48-0.60], and first medical contact to device ≤90 minutes [in-hospital mortality, 3.3 vs 12.1] adjusted OR, 0.40 [95% CI, 0.36-0.44]), walk-in patients (hospital arrival to device ≤90 minutes [in-hospital mortality, 1.8 vs 4.7] adjusted OR, 0.47 [95% CI, 0.40-0.55]), and transferred patients (door-in to door-out time <30 minutes [in-hospital mortality, 2.9 vs 6.4] adjusted OR, 0.51 [95% CI, 0.32-0.78], and first hospital arrival to device ≤120 minutes [in-hospital mortality, 4.3 vs 14.2] adjusted OR, 0.44 [95% CI, 0.26-0.71]). Regardless of mode of presentation, system goals were not met in most quarters, with the most delayed system performance among patients requiring interhospital transfer (17% treated ≤120 minutes).

CONCLUSIONS AND RELEVANCE

This study of patients with STEMI included in a US national registry provides information on changes in process and outcomes between 2018 and 2021.

Gender Differences in the Outcomes of Cardiogenic Shock Requiring Percutaneous Mechanical Circulatory Support

There is evidence for the lower use of percutaneous mechanical circulatory support (pMCS) in women. We aimed to determine (1) whether gender differences exist regarding in-hospital mortality, hospital course, and procedures; (2) whether socio-demographic and treatment-related factors were associated with these differences. Using the National Inpatient Sample, we collected the International Classification of Diseases, Ninth Revision, Clinical Modification codes for cardiogenic shock (CS) because of acute myocardial infarction AMI or acutely decompensated advanced heart failure and included intra-aortic balloon pump, Impella or Tandem Heart percutaneous ventricular assist devices (pVADs), extracorporeal membrane oxygenation. Demographics, co-morbidities, in-hospital course and procedures were recorded, and the Charlson Co-morbidity Index was calculated. Multivariable hierarchical logistic regression analysis and additional sensitivity analyses were performed. We identified 376,116 cases of CS because of acute myocardial infarction or acutely decompensated advanced heart failure, of which 113,305 required pMCS. Women were more likely to be older, non-White, insured by Medicare, and have a higher burden of co-morbidities and higher Charlson Co-morbidity Index. pMCS devices were inserted in 35,516 women (24.9%) and 77,789 men (33.3%). Women were less likely to receive pVAD or pulmonary artery (PA) catheters. Blood transfusions and acute respiratory failure were more common in women than men. Women had 15% higher in-hospital mortality and in a multivariate analysis, women, older age, having no insurance, diabetes mellitus, chronic kidney disease, cerebrovascular disease, peripheral arterial disease, longer time to pMCS insertion, receiving PA catheter, pVAD or extracorporeal membrane oxygenation and having cardiac arrest were associated with higher in-hospital mortality. In conclusion, women requiring pMCS support had a higher co-morbidity load, in-hospital mortality, acute respiratory failure, blood transfusions, and lower PA catheter use. Studies addressing early gender-specific interventions in CS are needed to reduce these differences.

Barriers associated with emergency medical service activation in patients with ST-segment elevation acute coronary syndromes

Many ST-segment elevation acute coronary syndrome (STEACS) patients fail to activate the Emergency Medical System (EMS), with possible dramatic consequences. Prior studies focusing on barriers to EMS activation included patients with any acute coronary syndrome (ACS) without representation of southern European populations. We aimed to investigate the barriers to EMS call for patients diagnosed for STEACS in Italy. A prospective, single-center, survey administered to all patients treated with primary percutaneous coronary intervention for STEACS in a tertiary hospital in northern Italy from 01/06/2018 to 31/05/2020. The questionnaire was filled out by 293 patients. Of these, 191 (65.2%) activated the EMS after symptoms onset. The main reasons for failing to contact EMS were the perception that the symptoms were unrelated to an important health problem (45.5%) and that a private vehicle is faster than EMS to reach the hospital (34.7%). Patients who called a private doctor after symptoms onset did not call EMS more frequently than those who did not and 30% of the patients who did not call the EMS would still act in the same way if a new episode occurred. Previous history of cardiovascular disease was the only predictor of EMS call. Information campaigns are urgently needed to increase EMS activation in case of suspected STEACS and should be primary focused on patients without cardiovascular history, on the misperception that a private vehicle is faster than EMS activation, and on the fact that cardiac arrest occurs early and may be prevented by EMS activation.

Practical Aspects of the Use of Telematic Systems in the Diagnosis of Acute Coronary Syndrome in Poland

Background and Objectives: The guidelines of the European Society of Cardiology (ESC) recommend the use of telematic methods in the diagnosis of myocardial infarction, allowing for transtelephonic electrocardiography (TTECG) from the emergency scene to centers performing percutaneous coronary interventions (PCI center). It has been proven that such a procedure has a beneficial effect on the survival of patients with ST elevation myocardial infarction (STEMI). Fewer data can be found on the correct use of these methods in everyday clinical practice. The aim of this study was to indicate potential indications and contraindications for the use of the TTECG system, and provide recommendations for proper collaboration between emergency medical systems (EMS) teams and PCI centers. Materials and Methods: The article is a systematic review of cardiological emergencies, with an assessment of indications for the use of the TTECG system. The authors introduced their own grading of the validity of indications for transmission of the TTECG, similar to those used in the official ESC guidelines.: Results:: The authors described individual cardiological emergencies occurring in the practice of EMS, considering specific indications or contraindications for the transmission of the TTECG. The article also discusses individual practical recommendations for proper cooperation between EMS teams and PCI centers in detail. All of the recommendations are compiled in a handy table to facilitate its use in everyday clinical practice. Conclusions: The summary presents a comparison of the realities of the functioning of the telematic support system in Poland in the field of STEMI diagnostics, with the model’s recommendations. The necessity of further educating the members of individual teams included in the network dealing with STEMI treatment was indicated, as well as the necessity of introducing legal regulations sanctioning the functioning of telematic systems in modern medicine.

The relationship between symptom onset-to-needle time and ischemic outcomes in patients with acute myocardial infarction treated with primary PCI: Observations from Prague-18 Study

OBJECTIVES

Based on previous studies with clopidogrel, the time between acute myocardial infarction (AMI) symptoms onset and primary percutaneous coronary intervention (PCI) was proven as important prognostic factor. Our aim was to assess the relationship between symptoms onset to needle time (SNT) and procedural results and the occurrence of ischemic endpoints in primary angioplasty patients treated with potent P2Y12 inhibitors.

METHODS

A total of 1,131 out of 1,230 patients randomized to the Prague-18 study (prasugrel vs. ticagrelor in primary PCI) were divided into a high and a low-risk group. The effect of defined SNT on patients' ischemic endpoints and prognosis by their risk status at admission was tested.

RESULTS

The median SNT was 3.2 hours. Longer SNTs resulted in a more frequent incidence of TIMI flow <3 post PCI (p=0.015). There were significant differences in the occurrence of the combined ischemic endpoint among the compared SNT groups at 30 days (p=0.032), and 1 year (p=0.011), with the highest incidence in the ≤1 h SNT group of patients. "Latecomers" (SNT>4 hs) in the high-risk group experienced more reinfarction within 1 year [OR (95% CI) 3.23 (1.09-9.62) p=0.035]; no difference was found in the low-risk group.

CONCLUSIONS

In the era of intense antithrombotic medication, stratification of MI patients undergoing primary angioplasty, based on initial ischemic risk assessment affected prognosis more than symptom onset to needle time. Longer time delay was significantly related to increased incidence of ischemic events and all-cause mortality only in patients with high ischemic risk.

The Effect of Periprocedural Clinical Factors Related to the Course of STEMI in Men and Women Based on the National Registry of Invasive Cardiology Procedures (ORPKI) between 2014 and 2019

Background: There are several sex-related differences in the course, management, and outcomes of ST-elevation myocardial infarction (STEMI). This study aimed to identify the risk factors that may affect the odds of procedure-related death in patients with STEMI. Methods: The observational cohort study group consisted of 118,601 participants recruited from the National Registry of Invasive Cardiology Procedures (ORPKI). Results: Procedure-related death occurred in 802 (1.0%) men and in 663 (1.7%) women. The odds of procedure-related death among women were significantly higher than among men (OR, 1.76; 95% CI, 1.59–1.95; p < 0.001). The probability of procedure-related mortality was highest in both men and women with cardiac arrest in the cath lab, critical stenosis of the left main coronary artery, and direct transfer to the cath lab. The factors that reduced the probability of procedure-related mortality in both men and women were thrombolysis in myocardial infarction (TIMI) flow grade and the use of P2Y12 inhibitors in the peri-infarct period. Psoriasis was associated with increased odds of procedure-related death among men, whereas cigarette smoking reduced the odds among women. Conclusions: Procedure-related deaths occurred more frequently in women than men with STEMI. Additional scrutiny needs to be undertaken to identify factors influencing survival regarding gender differences.

Effect of regional cooperative rescue systems based on chest pain centers for patients with acute myocardial infarction in a first-tier city in China

Given the increasing burden of acute myocardial infarction (AMI) in China, regional cooperative rescue systems have been constructed based on chest pain centers (CPCs). This study evaluated the effects of these regional cooperative rescue systems on reperfusion time and prognosis of AMI patients. This study included 1937 AMI patients, divided into two groups according to the date of admission, group A (July 2017-June 2018) and group B (July 2018-June 2019). Reperfusion time, the fatality rate for any cause during hospitalization, and the incidence of major adverse cardiovascular and cerebrovascular events (MACCE) in the 6 months following discharge were compared between the two groups. The proportion of patients treated within the guideline goals for first medical contact to balloon (FMC-to-B) time showed improvement from 40.7% in group A to 50.4% in group B (P = 0.005). The fatality rate for any cause (5.5% vs. 8.0%, P = 0.026) during hospitalization was lower in the B group compared to the A group. Multivariate logistic regression analysis revealed that the fatality rate for any cause (OR 0.614, 95% CI 0.411-0.918, P = 0.017) was significantly lower in group B compared with group A. No significant differences were detected between the two groups for the incidence of MACCE and death for any cause at 6 months using the log-rank test and multivariate Cox regression analysis. The improvement of regional cooperative rescue systems shortened system delays and reduced in-hospital deaths. Although the system has resulted in some substantial improvements, additional improvement is needed.

Factors affecting STEMI performance in six hospitals within one healthcare system

BACKGROUND

How quickly percutaneous coronary intervention is performed in patients with ST-elevation myocardial infarction (STEMI) is a quality measure, reported as door-to-balloon (D2B) time.

OBJECTIVES

To explore factors affecting STEMI performance in six hospitals in one healthcare system.

METHODS

This was a retrospective chart review of clinical features and D2B times. Predictors for D2B times were identified using multivariate linear regression.

RESULTS

The median D2B time for all six hospitals was 63 minutes and all hospitals surpassed the minimal recommended percentage of patients achieving D2B time ≤90 minutes (87.8%vs75%,p<0.001). Patient confounders adversely affect D2B times (+21.5 minutes, p<0.001). Field ECG/activation with emergency department (ED) transport (-22.0 minutes) or direct cardiac catheterization laboratory (CCL) transport (-27.3 minutes) was superior to ED ECG/activation (p<0.001).

CONCLUSION

Field ECG/STEMI activation significantly shortened D2B time. To improve D2B time, hospital and Emergency Medical Service collaboration should be advocated to increase field activation and direct patient transportation to CCL.

Development of a machine learning model to predict the risk of late cardiogenic shock in patients with ST-segment elevation myocardial infarction

Background

The in-hospital mortality of patients with ST-segment elevation myocardial infarction (STEMI) increases to more than 50% following a cardiogenic shock (CS) event. This study highlights the need to consider the risk of delayed calculation in developing in-hospital CS risk models. This report compared the performances of multiple machine learning models and established a late-CS risk nomogram for STEMI patients.

Methods

This study used logistic regression (LR) models, least absolute shrinkage and selection operator (LASSO), support vector regression (SVM), and tree-based ensemble machine learning models [light gradient boosting machine (LightGBM) and extreme gradient boosting (XGBoost)] to predict CS risk in STEMI patients. The models were developed based on 1,598 and 684 STEMI patients in the training and test datasets, respectively. The models were compared based on accuracy, the area under the curve (AUC), recall, precision, and Gini score, and the optimal model was used to develop a late CS risk nomogram. Discrimination, calibration, and the clinical usefulness of the predictive model were assessed using C-index, calibration plotd, and decision curve analyses.

Results

A total of 2282 STEMI patients recruited between January 1, 2016 and May 31, 2020, were included in the complete dataset. The linear models built using LASSO and LR showed the highest overall predictive power, with an average accuracy over 0.93 and an AUC above 0.82. With a C-index of 0.811 [95% confidence interval (CI): 0.769-0.853], the LASSO nomogram showed good differentiation and proper calibration. In internal validation tests, a high C-index value of 0.821 was achieved. Decision curve analysis (DCA) and clinical impact curve (CIC) examination showed that compared with the previous score-based models, the LASSO model showed superior clinical relevance.

Conclusions

In this study, five machine learning methods were developed for in-hospital CS prediction. The LASSO model showed the best predictive performance. This nomogram could provide an accurate prognostic prediction for CS risk in patients with STEMI.

Off-hours admission does not impact outcomes in patients undergoing primary percutaneous coronary intervention and with a first medical contact-to-device time within 90 min

Background:

It remains unclear whether the outcomes of ST-elevation myocardial infarction (STEMI) patients treated with primary percutaneous coronary intervention (PPCI) during off-hours are as favorable as those treated during on-hours, especially those with a first medical contact-to-device (FMC-to-device) time within 90 min. We aimed to determine whether off-hours admission impacted late outcomes in patients undergoing PPCI and with an FMC-to-device time ≤90 min.

Methods:

This multicenter retrospective study included 670 STEMI patients who underwent successful PPCI and had an FMC-to-device time ≤90 min from 19 chest pain centers in Beijing from January 2018 to December 2018. Patients were divided into on-hours group and off-hours group based on their arrival time. Baseline characteristics, clinical data, and key time intervals during treatment were collected from the Quality Control & Improvement Center of Cardiovascular Intervention of Beijing by the “Heart and Brain Green Channel” app.

Results:

Overall, the median age of the patients was 58.8 years and 19.9% (133/670) were female. Of these, 296 (44.2%) patients underwent PPCI during on-hours and 374 (55.8%) patients underwent PPCI during off-hours. Compared with the on-hours group, the off-hours group had a longer FMC-to-device time and fewer patients with FMC-to-device time ≤60 min (P < 0.05). During the mean follow-up period of 24 months, a total of 64 (9.6%) participants experienced a major adverse cardiovascular event (MACE), with 28 (9.1%) in the on-hours group and 36 (9.6%) in the off-hours group (P > 0.05). According to the Cox regression analyses, off-hours admission was not a predictor of 2-year MACEs (P = 0.788). Similarly, the Kaplan-Meier curves showed that the risks of a MACE, all-cause death, reinfarction, and target vessel revascularization were not significantly different between the two groups (P > 0.05).

Conclusions:

This real-world, multicenter retrospective study demonstrated that for STEMI patients who underwent PPCI within 90 min, off-hours admission was safe, with no difference in the risk of 2-year MACEs compared with those with on-hours admission.

Impact of admission hours on each stage of care and total reperfusion delays in patients with ST elevation myocardial infarction

BACKGROUND

ST segment elevation myocardial infarction (STEMI) is preferably treated by prompt primary percutaneous coronary intervention (pPCI). Delays in initial stages of care of STEMI patients admitted off versus routine hours are controversial. The aim of this study was to evaluate time periods in each stage of care of STEMI patients submitted to pPCI in a private tertiary hospital during on- vs. off-hours, and the adherence to current guidelines recommended times.

METHODS

consecutive STEMI patients admitted 2013-2019 who underwent pPCI were enrolled in this cohort study. Time periods were prospectively registered and other variables retrieved from electronic medical records. Primary outcomes were the time periods of each stage of care, since patient arrival in the emergency room (ER) until reperfusion of the culprit artery, performed during on-hours (weekdays, from 08:00 AM to 07:59 PM) or off-hours (all other days and time periods, or holidays).

RESULTS

218 patients were included, 131 (60%) presented off-hours, with longer time periods between calling the catheterization laboratory staff until reperfusion, [55 min × 72 min; P < 0.001] and ER door-to-reperfusion [73 min × 98 min; P < 0.001]. Exploratory analysis by year suggested a decreasing reperfusion delay during on-hours admissions. In most years, total time for reperfusion exceeded the sixty minutes frame recommended in current North American guidelines, for both on- and off-hours admissions. Considering the ninety minutes recommendation of the European guideline, only on-hour admissions were in accordance during most years.

CONCLUSIONS

STEMI patients, particularly when admitted off-hours, have lags in some stages of care, culminating in delayed myocardial reperfusion greater than recommended in current guidelines.

Mobile application to optimize care for ST-segment elevation myocardial infarction patients in a large healthcare system, STEMIcathAID: rationale and design

Aims

Technological advancements have transformed healthcare. System delays in transferring patients with ST-segment elevation myocardial infarction (STEMI) to a primary percutaneous coronary intervention (PCI) centre are associated with worse clinical outcomes. Our aim was to design and develop a secure mobile application, STEMIcathAID, streamlining communication, and coordination between the STEMI care teams to reduce ischaemia time and improve patient outcomes.

Methods and results

The app was designed for transfer of patients with STEMI to a cardiac catheterization laboratory (CCL) from an emergency department (ED) of either a PCI capable or a non-PCI capable hospital. When a suspected STEMI arrives to a non-PCI hospital ED, the ED physician uploads the electrocardiogram and relevant patient information. An instant notification is simultaneously sent to the on-call CCL attending and transfer centre. The attending reviews the information, makes a video call and decides to either accept or reject the transfer. If accepted, on-call CCL team members receive an immediate push notification and begin communicating with the ED team via a HIPAA compliant chat. The app provides live GPS tracking of the ambulance and frequent clinical status updates of the patient. In addition, it allows for screening of STEMI patients in cardiogenic shock. Prior to discharge, important data elements have to be entered to close the case.

Conclusion

We developed a novel mobile app to optimize care for STEMI patients and facilitate electronic extraction of relevant performance metrics to improve allocation of resources and reduction of costs.

Catheterization Laboratory Activation Time in Patients Transferred With ST-Segment–Elevation Myocardial Infarction: Insights From the Mission: Lifeline STEMI Accelerator-2 Project

Background:

Catheterization laboratory (cath lab) activation time is a newly available process measure for patients with ST-segment–elevation myocardial infarction requiring inter-hospital transfers for primary percutaneous coronary intervention that reflects inter-facility communication and urgent mobilization of interventional laboratory resources. Our aim was to determine whether faster activation is associated with improved reperfusion time and outcomes in the American Heart Association Mission: Lifeline Accelerator-2 Project.

Methods and Results:

From April 2015 to March 2017, treatment times of 2063 patients with ST-segment–elevation myocardial infarction requiring inter-hospital transfer for primary percutaneous coronary intervention from 12 regions around the United States were stratified by cath lab activation time (first hospital arrival to cath lab activation within [timely] or beyond 20 minutes [delayed]). Median cath lab activation time was 26 minutes, with a delayed activation observed in 1241 (60.2%) patients. Prior cardiovascular or cerebrovascular disease, arterial hypotension at admission, and black or Latino ethnicity were independent factors of delayed cath lab activation. Timely cath lab activation patients had shorter door-in door-out times (40 versus 68 minutes) and reperfusion times (98 versus 135 minutes) with 80.1% treated within the national goal of ≤120 minutes versus 39.0% in the delayed group.

Conclusions:

Cath lab activation within 20 minutes across a geographically diverse group of hospitals was associated with performing primary percutaneous coronary intervention within the national goal of ≤120 minutes in >75% of patients. While several confounding factors were associated with delayed activation, this work suggests that this process measure has the potential to direct resources and practices to more timely treatment of patients requiring inter-hospital transfer for primary percutaneous coronary intervention.

Effect of percutaneous coronary intervention team prenotification based on real time electrocardiogram transmission in interhospital transfer of ST elevation myocardial infarction patients: pilot trial of Preparing Revascularization Effort before Patients' Arrival via Regionalization Engagement protocol

Objective

Prompt reperfusion is important for patients with ST elevation myocardial infarction (STEMI). However, patients often require interhospital transfer for percutaneous coronary intervention (PCI) because not all hospitals can provide. The purpose of this study is to reduce the PCI delay using a regionalization protocol in patients with STEMI following transfer from another hospital lacking PCI facility.

Methods

We established a revascularization protocol designated as Preparing Revascularization Effort before Patients’ Arrival via Regionalization Engagement (PREPARE) for the STEMI patients transferred from an outside regional hospital. The protocol included immediate referral acceptance by an emergency physician, real-time electrocardiogram sharing via mobile phone and early activation of the PCI team. We analyzed the differences between the PREPARE and the non-PREPARE groups.

Results

In the PREPARE group, the median time from the first hospital visit to the ballooning procedure via PCI at the receiving facility (D1-to-B time) was 111.0 (interquartile range 97.0– 130.0) minutes, which was significantly shorter than in the non-PREPARE group 134.0 (interquartile range 115.0–182.0) minutes. The proportion of D1-to-B time within 120 minutes was 30.4% in the group and 60.0% in the PREPARE group, which represents a significant difference (P=0.004). Multivariate logistic regression analysis revealed that patient transfer via PREPARE protocol (odds ratio, 3.399; 95% confidence interval, 1.150–10.050, P=0.027) was related to adequate D1-to-B time. No statistically significant differences were found in the hospital length of stay or major adverse cardiac events within 4 weeks.

Conclusion

The PREPARE protocol is an effective strategy to reduce the time to revascularization of the transferred STEMI patients.

Door-in to door-out times in acute ST-segment elevation myocardial infarction in emergency departments of non-interventional hospitals: A cohort study

In France, one in eight patients with acute ST-segment elevation myocardial infarction (STEMI) is admitted direct to an emergency department (ED) in a hospital without percutaneous coronary intervention (PCI) facilities. Guidelines recommend transfer to a PCI center, with a door-in to door-out (DI-DO) time of ≤30 min. We report DI-DO times and identify the main factors affecting them.RESURCOR is a French Northern Alps registry of patients with STEMI of <12 h duration. We focused on patients admitted direct, without prehospital medical care, to EDs in 19 non-PCI centers from 2012 to 2014. We divided DI-DO time into diagnostic time (ED admission to call for transfer) and logistical time (call for transfer to ED discharge).Among 2007 patients, 240 were admitted direct to EDs in non-PCI centers; 57.9% were treated with primary angioplasty and 32.9% received thrombolysis. Median (interquartile range) DI-DO time was 92.5 (67-143) min, with a diagnostic time of 41 (23-74) min and a logistical time of 47.5 (32-69) min. Five patients (2.1%) had a DI-DO time ≤30 min. Five variables were independently associated with a shorter DI-DO time: local transfer (mobile intensive care unit [MICU] team available at referring ED) (P = .017) or transfer by air ambulance (P = .004); shorter distance from referring ED to PCI center (P < .001); shorter time from symptom onset to ED admission (P = .002); thrombolysis (P = .006); and extended myocardial infarction (P = .007).In view of longer-than-recommended DI-DO times, efforts are required to promote urgent local transfer and use of thrombolysis.

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.

Variation in Hospital Door-to-Intervention Time for Ruptured AAAs and Its Association with Outcomes

BACKGROUND

A ruptured abdominal aortic aneurysm (rAAA) is a life-threatening condition that carries a high mortality rate. Recent guidelines have recommended a goal "door-to-intervention" time of ≤90 minutes despite a paucity of evidence to support this goal. The aim of this study was to analyze recent trends in door-to-intervention time for rAAAs and determine the effect of the 90-minute door-to-intervention benchmark on postoperative complications.

METHODS

A retrospective analysis of all patients who underwent open aortic repair (OAR) or endovascular aneurysm repair (EVAR) of a rAAA in the Vascular Quality Initiative database (2003-2018) was performed. Variation in door-to-intervention time was analyzed at the patient and hospital level. Patients were dichotomized into ≤90 or >90 minute door-to-intervention time cohorts. Hierarchical modeling controlling for the hospital random effect and multivariate logistic models was used to analyze the association on 30-day mortality and major in-hospital complications.

RESULTS

A total of 3,630 operative cases for rAAA were identified (1696 OAR and 1934 EVAR). For the OAR cohort, 1035 patients (61%) had a door-to-intervention time of ≤90 minutes. However, at the hospital level, a minority of hospitals (49%) reliably achieved the OAR goal door-to-intervention time. For OARs, there was no difference in 30-day risk-adjusted major complications or mortality between the ≤90- and > 90-minute cohorts. For EVAR, 1014 patients (53.8%) had a door-to-intervention time of ≤90 minutes and a minority of hospitals (40%) upheld the recommended ≤90 minute door-to-intervention threshold. In the EVAR group, patients with a ≤90 minute door-to-intervention time had higher rates of postoperative myocardial infarction (12.0% vs. 8.5%; P < 0.05) but no difference in 30-day risk-adjusted mortality.

CONCLUSIONS

A low percentage of rAAAs are being treated within the recommended door-to-intervention time. Despite this deficiency, the ≤90-minute benchmark has minimal impact on postoperative morbidity and mortality. Based on these findings, alternative quality metrics should be identified to improve the clinical care of patients with rAAA.

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.

Delayed Diagnosis of Non-ST Segment Elevation Myocardial Infarction in a Young Patient with Multivessel Disease and Familial Hypercholesterolemia Complicated by Cardiogenic Shock Finally Treated with Intra-Aortic Balloon Pump as a Bridge to Extra Corporeal Membrane Oxygenation

Delayed diagnosis of coronary artery disease in young patients after cardiac arrest of unknown origin could increase the risk of death in further diagnostic and therapeutic process. Familial history of premature coronary atherosclerosis and hypercholesterolemia could help in proper diagnosis and treatment. We present a case of a 29-year-old female admitted to the catheterization laboratory with cardiogenic shock and multivessel coronary artery disease treated successfully with multivessel percutaneous coronary intervention and intra-aortic balloon counterpulsation as a bridge to extracorporeal membrane oxygenation.

Impact of the Regional Network for AMI in the Management of STEMI on Care Processes, Outcomes and Health Inequities in the Veneto Region, Italy

Cardiovascular diseases are a leading cause of death in Europe. Outcomes in terms of mortality and health equity in the management of patients with ST-Elevation Myocardial Infarction (STEMI) are influenced by health care service organization. The main aim of the present study was to examine the impact of the new organizational model of the Veneto Region’s network for Acute Myocardial Infarction (AMI) to facilitate primary percutaneous coronary intervention (PCI) on STEMI, and its efficacy in reducing health inequities. A retrospective cohort study was conducted on HDRs in the Veneto Region for the period 2007–2016, analyzing 65,261 hospitalizations for AMI. The proportion of patients with STEMI treated with PCI within 24 h increased significantly for men and women, and was statistically much higher for patients over 75 years of age (APC, 75–84: 9.8; >85: 12.5) than for younger patients (APC, <45: 3.3; 45–64: 4.9), with no difference relating to citizenship. The reduction in in-hospital, STEMI-related mortality was only statistically significant for patients aged 75–84 (APC: −3.0 [−4.5;−1.6]), and for Italians (APC: −1.9 [−3.2;−0.6]). Multivariate analyses confirmed a reduction in the disparities between socio-demographic categories. Although the new network improved the care process and reduced health care disparities in all subgroups, these efforts did not result in the expected survival benefit in all patient subgroups.

Impact of Regionalization of ST-Segment–Elevation Myocardial Infarction Care on Treatment Times and Outcomes for Emergency Medical Services–Transported Patients Presenting to Hospitals With Percutaneous Coronary Intervention

Background:

Regional variations in reperfusion times and mortality in patients with ST-segment–elevation myocardial infarction are influenced by differences in coordinating care between emergency medical services (EMS) and hospitals. Building on the Accelerator-1 Project, we hypothesized that time to reperfusion could be further reduced with enhanced regional efforts.

Methods:

Between April 2015 and March 2017, we worked with 12 metropolitan regions across the United States with 132 percutaneous coronary intervention–capable hospitals and 946 EMS agencies. Data were collected in the ACTION (Acute Coronary Treatment and Intervention Outcomes Network)-Get With The Guidelines Registry for quarterly Mission: Lifeline reports. The primary end point was the change in the proportion of EMS-transported patients with first medical contact to device time ≤90 minutes from baseline to final quarter. We also compared treatment times and mortality with patients treated in hospitals not participating in the project during the corresponding time period.

Results:

During the study period, 10 730 patients were transported to percutaneous coronary intervention–capable hospitals, including 974 in the baseline quarter and 972 in the final quarter who met inclusion criteria. Median age was 61 years; 27% were women, 6% had cardiac arrest, and 6% had shock on admission; 10% were black, 12% were Latino, and 10% were uninsured. By the end of the intervention, all process measures reflecting coordination between EMS and hospitals had improved, including the proportion of patients with a first medical contact to device time of ≤90 minutes (67%–74%; P <0.002), a first medical contact to device time to catheterization laboratory activation of ≤20 minutes (38%–56%; P <0.0001), and emergency department dwell time of ≤20 minutes (33%–43%; P <0.0001). Of the 12 regions, 9 regions reduced first medical contact to device time, and 8 met or exceeded the national goal of 75% of patients treated in ≤90 minutes. Improvements in treatment times corresponded with a significant reduction in mortality (in-hospital death, 4.4%–2.3%; P =0.001) that was not apparent in hospitals not participating in the project during the same time period.

Conclusions:

Organization of care among EMS and hospitals in 12 regions was associated with significant reductions in time to reperfusion in patients with ST-segment–elevation myocardial infarction as well as in in-hospital mortality. These findings support a more intensive regional approach to emergency care for patients with ST-segment–elevation myocardial infarction.

Impact of Regional Systems of Care on Disparities in Care Among Female and Black Patients Presenting With ST-Segment-Elevation Myocardial Infarction

BACKGROUND

The American Heart Association Mission: Lifeline STEMI (ST-segment-elevation myocardial infarction) Systems Accelerator program, conducted in 16 regions across the United States to improve key care processes, resulted in more patients being treated within national guideline goals (time from first medical contact to device: <90 minutes for direct presenters to hospitals capable of performing percutaneous coronary intervention; <120 minutes for transfers). We examined whether the effort reduced reperfusion disparities in the proportions of female versus male and black versus white patients.

METHODS AND RESULTS

In total, 23 809 patients (29.3% female, 82.3% white, and 10.7% black) presented with acute STEMI between July 2012 and March 2014. Change in the proportion of patients treated within guideline goals was compared between sex and race subgroups for patients presenting directly to hospitals capable of performing percutaneous coronary intervention (n=18 267) and patients requiring transfer (n=5542). The intervention was associated with an increase in the proportion of men treated within guideline goals that presented directly (58.7-62.1%, P=0.01) or were transferred (43.3-50.7%, P<0.01). An increase was also seen among white patients who presented directly (57.7-59.9%, P=0.02) or were transferred (43.9-48.8%, P<0.01). There was no change in the proportion of female or black patients treated within guideline goals, including both those presenting directly and transferred.

CONCLUSION

The STEMI Systems Accelerator project was associated with an increase in the proportion of patients meeting guideline reperfusion targets for male and white patients but not for female or black patients. Efforts to organize systems of STEMI care should implement additional processes targeting barriers to timely reperfusion among female and black patients.