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Gerecht RB, Nable JV. Out-of-Hospital Cardiac Arrest. Cardiol Clin 2024; 42:317-331. [PMID: 38631798 DOI: 10.1016/j.ccl.2024.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
Survival from out-of-hospital cardiac arrest (OHCA) is predicated on a community and system-wide approach that includes rapid recognition of cardiac arrest, capable bystander CPR, effective basic and advanced life support (BLS and ALS) by EMS providers, and coordinated postresuscitation care. Management of these critically ill patients continues to evolve. This article focuses on the management of OHCA by EMS providers.
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Affiliation(s)
- Ryan B Gerecht
- District of Columbia Fire and EMS Department, MedStar Washington Hospital Center, 110 Irving Street Northwest, Washington, DC 20010, USA
| | - Jose V Nable
- Georgetown University School of Medicine, Georgetown EMS, MedStar Georgetown University Hospital, 3800 Reservoir Road Northwest, Washington, DC 20007, USA.
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Gerecht RB, Nable JV. Out-of-Hospital Cardiac Arrest. Emerg Med Clin North Am 2023; 41:433-453. [PMID: 37391243 DOI: 10.1016/j.emc.2023.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2023]
Abstract
Survival from out-of-hospital cardiac arrest (OHCA) is predicated on a community and system-wide approach that includes rapid recognition of cardiac arrest, capable bystander CPR, effective basic and advanced life support (BLS and ALS) by EMS providers, and coordinated postresuscitation care. Management of these critically ill patients continues to evolve. This article focuses on the management of OHCA by EMS providers.
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Affiliation(s)
- Ryan B Gerecht
- District of Columbia Fire and EMS Department, MedStar Washington Hospital Center, 110 Irving Street Northwest, Washington, DC 20010, USA
| | - Jose V Nable
- Georgetown University School of Medicine, Georgetown EMS, MedStar Georgetown University Hospital, 3800 Reservoir Road Northwest, Washington, DC 20007, USA.
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Hillerson D, Li S, Misumida N, Wegermann ZK, Abdel-Latif A, Ogunbayo GO, Wang TY, Ziada KM. Characteristics, Process Metrics, and Outcomes Among Patients With ST-Elevation Myocardial Infarction in Rural vs Urban Areas in the US: A Report From the US National Cardiovascular Data Registry. JAMA Cardiol 2022; 7:1016-1024. [PMID: 36044196 PMCID: PMC9434481 DOI: 10.1001/jamacardio.2022.2774] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 07/06/2022] [Indexed: 11/14/2022]
Abstract
Importance Patients with ST-segment elevation myocardial infarction (STEMI) living in rural settings often have worse clinical outcomes compared with their urban counterparts. Whether this discrepancy is due to clinical characteristics or delays in timely reperfusion with primary percutaneous coronary intervention (PPCI) or fibrinolysis is unclear. Objective To assess process metrics and outcomes among patients with STEMI in rural and urban settings across the US. Design, Setting, and Participants This cross-sectional multicenter study analyzed data for 70 424 adult patients with STEMI from the National Cardiovascular Data Registry Chest Pain-MI Registry in 686 participating US hospitals between January 1, 2019, and June 30, 2020. Patients without a valid zip code were excluded, and those transferred to a different hospital during the course of the study were excluded from outcome analysis. Main Outcomes and Measures In-hospital mortality and time-to-reperfusion metrics. Results This study included 70 424 patients with STEMI (median [IQR] age, 63 [54-73] years; 49 850 [70.8%] male and 20 574 [29.2%] female; patient self-reported race: 6753 [9.6%] Black, 60 114 [85.4%] White, and 2096 [3.0%] of another race [including American Indian, Alaskan Native, Native Hawaiian, and Pacific Islander]; 5281 [7.5%] individuals of Hispanic or Latino ethnicity) in 686 hospitals (50 702 [72.0%] living in urban zip codes and 19 722 [28.0%] in rural zip codes). Patients from rural settings were less likely to undergo PPCI compared with patients from urban settings (14 443 [73.2%] vs 43 142 [85.1%], respectively; P < .001) and more often received fibrinolytics (2848 [19.7%] vs 937 [2.7%]; P < .001). Compared with patients from urban settings, those in rural settings undergoing PPCI had longer median (IQR) time from first medical contact to catheterization laboratory activation (30 [12-42] minutes vs 22 [15-59] minutes; P < .001) and longer median (IQR) time from first medical contact to device (99 minutes [75-131] vs 81 [66-103] minutes; P < .001), including those who arrived directly at PPCI centers (83 [66-107] minutes vs 78 [64-97] minutes; P < .001) and those who transferred to PPCI centers from another treatment center (125 [102-163] minutes vs 103 [85-135] minutes; P < .001). Among those who transferred in, median (IQR) door-in-door-out time was longer in patients from rural settings (63 [41-100] minutes vs 50 [35-80] minutes; P < .001). Out-of-hospital cardiac arrest was more common in patients from urban vs rural settings (3099 [6.1%] vs 958 [4.9%]; P < .001), and patients from urban settings were more likely to present with heart failure (4112 [8.1%] vs 1314 [6.7%]; P < .001). After multivariable adjustment, there was no significant difference in in-hospital mortality between rural and urban groups (adjusted odds ratio, 0.97; 95% CI, 0.89-1.06). Conclusions and Relevance In this large cohort of patients with STEMI from US hospitals participating in the National Cardiovascular Data Registry Chest Pain-MI Registry, patients living in rural settings had longer times to reperfusion, were less likely to receive PPCI or meet guideline-recommended time to reperfusion, and more frequently received fibrinolytics than patients living in urban settings. However, there was no difference in adjusted in-hospital mortality between patients with STEMI from urban and rural settings.
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Affiliation(s)
- Dustin Hillerson
- Department of Medicine, Division of Cardiovascular Medicine, University of Wisconsin School of Medicine and Public Health, Madison
| | - Shuang Li
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Naoki Misumida
- Gill Heart and Vascular Institute, University of Kentucky, Lexington
| | - Zachary K. Wegermann
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Ahmed Abdel-Latif
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor
- Ann Arbor Veterans Affairs Health System, Ann Arbor, Michigan
| | | | - Tracy Y. Wang
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Khaled M. Ziada
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
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Gödde D, Bruckschen F, Burisch C, Weichert V, Nation KJ, Thal SC, Marsch S, Sellmann T. Manual and Mechanical Induced Peri-Resuscitation Injuries-Post-Mortem and Clinical Findings. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:10434. [PMID: 36012068 PMCID: PMC9408363 DOI: 10.3390/ijerph191610434] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 08/10/2022] [Accepted: 08/17/2022] [Indexed: 06/15/2023]
Abstract
(1) Background: Injuries related to resuscitation are not usually systematically recorded and documented. By evaluating this data, conclusions could be drawn about the quality of the resuscitation, with the aim of improving patient care and safety. (2) Methods: We are planning to conduct a multicentric, retrospective 3-phased study consisting of (1) a worldwide literature review (scoping review), (2) an analysis of anatomical pathological findings from local institutions in North Rhine-Westphalia, Germany to assess the transferability of the review data to the German healthcare system, and (3) depending on the results, possibly establishing potential prospective indicators for resuscitation-related injuries as part of quality assurance measures. (3) Conclusions: From the comparison of literature and local data, the picture of resuscitation-related injuries will be focused on and quality indicators will be derived.
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Affiliation(s)
- Daniel Gödde
- Department of Pathology and Molecularpathology, Helios University Hospital Wuppertal, University Witten/Herdecke, 58455 Witten, Germany
| | - Florian Bruckschen
- Department of Anaesthesiology and Intensive Care Medicine, Evangelisches Krankenhaus BETHESDA zu Duisburg, 47053 Duisburg, Germany
| | - Christian Burisch
- State of North Rhine-Westphalia/Regional Government, 44145 Düsseldorf, Germany
| | - Veronika Weichert
- Department of Trauma Surgery, Berufsgenossenschaftliche Unfallklinik Duisburg, 47249 Duisburg, Germany
| | - Kevin J. Nation
- NZRN, New Zealand Resuscitation Council, Wellington 6011, New Zealand
| | - Serge C. Thal
- Department of Anaesthesiology I, University Witten/Herdecke, 58455 Witten, Germany
- Department of Anesthesiology, HELIOS University Hospital, 42283 Wuppertal, Germany
| | - Stephan Marsch
- Department of Intensive Care, University Hospital, Petersgraben 4, 4031 Basel, Switzerland
| | - Timur Sellmann
- Department of Anaesthesiology and Intensive Care Medicine, Evangelisches Krankenhaus BETHESDA zu Duisburg, 47053 Duisburg, Germany
- Department of Anaesthesiology I, University Witten/Herdecke, 58455 Witten, Germany
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Analysis on the Effect of the Rehabilitation Intervention-Centered Targeted Nursing Model on the Cardiac Function Recovery and Negative Emotions in Patients with Acute Myocardial Infarction. JOURNAL OF HEALTHCARE ENGINEERING 2022; 2022:1246092. [PMID: 35251558 PMCID: PMC8894043 DOI: 10.1155/2022/1246092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 12/27/2021] [Indexed: 11/26/2022]
Abstract
Rehabilitation intervention which refers to the functional training by caregivers with the aid of specialized nursing techniques and the progressive promotion of patients' training initiative, with the purpose of improving mobility and quality of life, is of great significance. The purpose of the study was to investigate the effect of the rehabilitation intervention-centered targeted nursing model on the cardiac function recovery and negative emotions in patients with acute myocardial infarction (AMI). A total of 120 AMI patients admitted to our hospital between January 2019 and January 2020 were selected as the study subjects and randomly divided into group A (n = 60) and group B (n = 60), in which the group B patients received routine nursing combined with rehabilitation intervention, while based on the treatment in group B, the patients in group A underwent rehabilitation intervention-centered targeted nursing model. Then, the cardiac function indexes, negative emotion score, levels of risk factors for heart failure, complication rate (CR), and the quality of life (QOL) of the patients were compared between the two groups. The cardiac function indexes of the patients after nursing in group A were significantly better than those in group B (P < 0.001); the negative emotion scores of the patients after nursing in group A were significantly lower than those in group B (P < 0.001); the levels of risk factors for heart failure of the patients after nursing in group A were significantly lower than those in group B (P < 0.001); the CR of the patients in group A at 15 d and 30 d after admission was significantly lower than that in group B (P < 0.05); the QOL scores of the patients after nursing in group A were significantly higher than those in group B (P < 0.001). Rehabilitation intervention-centered targeted nursing model can optimize cardiac function, weaken the levels of risk factors for heart failure, reduce the incidence of complications, improve psychological conditions, and enhance the quality of life in AMI patients, which is worthy of application and promotion in clinical practice.
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Hsia RY, Zagorov S. Structural Discrimination in Emergency Care: How a Sick System Affects Us All. MED (NEW YORK, N.Y.) 2022; 3:98-103. [PMID: 35224522 PMCID: PMC8880827 DOI: 10.1016/j.medj.2022.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Drawing on evidence of socioeconomic disparities in emergency care, we show how structural discrimination is the most pervasive driver of these disparities, largely because of an inequitable distribution of healthcare services and unequal benefits derived from scientific advancement. We analyze how the market-based healthcare system in the U.S. has created a scenario in which the allocation of emergency care resources does not match community demand for emergency care, resulting in disproportionately poor access, treatment, and outcomes among historically underserved populations. Without fundamental reform, there is little hope for decreasing the health outcome gaps between the "haves" and "have-nots" in the United States.
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Affiliation(s)
- Renee Y. Hsia
- Department of Emergency Medicine, University of California, San Francisco,Philip R. Lee Institute of Health Policy Studies, University of California, San Francisco,San Francisco General Hospital and Trauma Center,Correspondence:
| | - Stefany Zagorov
- Department of Emergency Medicine, University of California, San Francisco
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Handran CB, Kunz M, Larson DM, Garberich RF, Baran K, Henry JT, Sharkey SW, Henry TD. The impact of regional STEMI systems on protocol use and quality improvement initiatives in community hospitals without cardiac catheterization laboratories. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2022; 13:100077. [PMID: 38560053 PMCID: PMC10978212 DOI: 10.1016/j.ahjo.2021.100077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 11/16/2021] [Accepted: 11/19/2021] [Indexed: 04/04/2024]
Abstract
Study objective Since the 1990s, national guidelines have recommended hospitals develop STEMI treatment protocols and monitor quality. A 2003 survey of Minnesota hospitals without cardiac catheterization laboratories (CCL) found <2/3 had STEMI protocols, <50% had a quality assessment (QA) process, and protocols in existence were incomplete. We evaluated temporal changes in STEMI processes in relationship to changes in mortality. Design setting and participants Follow-up surveys were mailed to emergency departments at 108 Minnesota hospitals without CCL. Results Among 87% of responding hospitals, 89% had formal protocols or guidelines for STEMI management compared to 63% in 2003 (p < 0.001). In 2010, 67% of hospitals had triage/transfer criteria and 15% of hospitals used protocols for transfer decisions, compared to only 8% (p < 0.001) and 1% (p = 0.098), respectively, in 2003. The percentage of hospitals transferring patients with STEMI from the emergency department increased from 23% in 2003 to 56% in 2010 (p < 0.001). During this time, age-adjusted acute MI mortality rate in Minnesota decreased 33% and was more pronounced in areas with regional STEMI systems. Conclusions Since 2003, utilization of STEMI guidelines, protocols, and standing orders in Minnesota hospitals without CCL has markedly improved with <10% of hospitals lacking specific STEMI management protocols. The majority of hospitals routinely transfer patients with STEMI for primary PCI and have comprehensive QA processes. This improvement was stimulated by regional STEMI systems, further supporting the current class I recommendation for STEMI systems of care in current guidelines. The decline in Minnesota STEMI mortality paralleled the growth of regional STEMI systems.
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Affiliation(s)
| | - Miranda Kunz
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN, United States of America
| | - David M. Larson
- Ridgeview Medical Center, Waconia, MN, United States of America
| | - Ross F. Garberich
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN, United States of America
| | - Kelsey Baran
- Berkshire Medical Center, Pittsfield, MA, United States of America
| | - Jason T. Henry
- Sarah Cannon Research Institute at HealthONE, Denver, CO, United States of America
| | - Scott W. Sharkey
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN, United States of America
| | - Timothy D. Henry
- The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital, Cincinnati, OH, United States of America
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Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Cardiovasc Comput Tomogr 2022; 16:54-122. [PMID: 34955448 DOI: 10.1016/j.jcct.2021.11.009] [Citation(s) in RCA: 54] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. STRUCTURE Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.
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Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2021; 78:e187-e285. [PMID: 34756653 DOI: 10.1016/j.jacc.2021.07.053] [Citation(s) in RCA: 310] [Impact Index Per Article: 103.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
AIM This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. STRUCTURE Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.
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2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2021; 78:2218-2261. [PMID: 34756652 DOI: 10.1016/j.jacc.2021.07.052] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM This executive summary of the clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. STRUCTURE Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. These guidelines present an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated and shared decision-making with patients is recommended.
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Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2021; 144:e368-e454. [PMID: 34709879 DOI: 10.1161/cir.0000000000001029] [Citation(s) in RCA: 136] [Impact Index Per Article: 45.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
AIM This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. Structure: Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.
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12
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Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2021; 144:e368-e454. [PMID: 34709928 DOI: 10.1161/cir.0000000000001030] [Citation(s) in RCA: 71] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
AIM This executive summary of the clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. Structure: Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. These guidelines present an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated and shared decision-making with patients is recommended.
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13
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Zhang Y, Tian Y, Dong P, Xu Y, Yu B, Li H, Li J, Ge J, Sun Y, Wang J, Wang L, Chen J, Yan H, Chen Y, Han Y, Huo Y. Treatment delay and reperfusion management of acute ST-segment elevation myocardial infarction: analysis of the China STEMI Care Project Phase 1. QJM 2021; 114:299-305. [PMID: 32569364 DOI: 10.1093/qjmed/hcaa186] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Revised: 04/11/2020] [Accepted: 04/21/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The China ST-segment elevation myocardial infarction (STEMI) Care Project (CSCAP) was launched in 2011 to address the problems of insufficient reperfusion and long treatment delay in STEMI care in China. AIM To describe the baseline status of STEMI emergency care in Tertiary PCI Hospitals using Phase 1 (CSCAP-1) data. DESIGN CSCAP-1 is a prospective multi-center STEMI registry. METHODS AND RESULTS A total of 4191 patients with symptom onset within 12 or 12-36 h requiring primary percutaneous coronary intervention (PCI), were enrolled from 53 tertiary PCI hospitals in 14 provinces, municipalities, and autonomous regions of China in CSCAP-1. Among them, 49.0% were self-transported to the hospital, 26.5% were transferred to the hospital by calling the emergency medical services directly, and 24.5% were transferred from other hospitals. In patients with symptom onset within 12 h, 83.2% received primary PCI, 5.9% received thrombolysis and 10.9% received conservative medications. The median door-to-balloon time was 115 (85-170) min and the median door-to-needle time for in-hospital thrombolysis was 80 (50-135) min. The overall in-hospital all-cause mortality was 2.4%, while it was 5.3% in the non-reperfusion group and 2.1% in the reperfusion group (P < 0.001). CONCLUSION Although a long treatment delay and a high proportion of patients transporting themselves to the hospital were observed, trends were positive with greater adoption of primary PCI and lower in-hospital mortality in tertiary hospitals in China. Our results provided important information for further integrated STEMI network construction in China.
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Affiliation(s)
- Y Zhang
- Department of Cardiology, Peking University First Hospital, 8 Xishiku Street, Xicheng District, Beijing 100034, China
| | - Y Tian
- Department of Cardiology, The First Affiliated Hospital of Harbin Medical University, 199 Dazhi Street, Nangang District, Harbin 150001, Heilongjiang Province, China
| | - P Dong
- Department of Cardiology, The First Affiliated Hospital of Henan University of Science and Technology, 24 Jinghua Road, Jianxi District, Luoyang 471003, Henan Province, China
| | - Y Xu
- Department of Cardiology, Tenth People's Hospital of Tongji University, 301 Yanchang Middle Road, Jingan District, Shanghai 200072, China
| | - B Yu
- Department of Cardiology, The Second Affiliated Hospital of Harbin Medical University, 246 Xuefu Road, Nangang District, Harbin 150086, Heilongjiang Province, China
| | - H Li
- Department of Cardiology, Daqing Oilfield General Hospital, 9 Zhongkang Street, Sartu District, Daqing 163001, Heilongjiang Province, China
| | - J Li
- Department of Cardiology, Qilu Hospital of Shandong University, 107 Wenhua West Road, Lixia District, Jinan 250012, Shandong Province, China
| | - J Ge
- Department of Cardiology, Zhongshan Hospital Fudan University, 180 Fenglin Road, Xuhui District, Shanghai 200032, China
| | - Y Sun
- Department of Cardiology, Shanxi Datong Coal Group General Hospital, 5999 Herui Street, Hengan New District, Datong 037003, Shanxi Province, China
| | - J Wang
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University, 88 Jiefang Road, Shangcheng District, Hangzhou 310009, Zhejiang Province, China
| | - L Wang
- Department of Cardiology, Beijing Chao-yang Hospital, 8 Gongti South Road, Chaoyang District, Beijing 100020, China
| | - J Chen
- Department of Cardiology, Guangdong General Hospital, 106 Zhongshan 2nd Road, Yuexiu District, Guangzhou 510080, Guangdong Province, China
| | - H Yan
- Department of Cardiology, Fuwai Hospital, Chinese Academy of Medical Sciences, 167 Beilishi Road, Xicheng District, Beijing 100037, China
| | - Y Chen
- Department of Cardiology, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing 100036, China
| | - Y Han
- Department of Cardiology, General Hospital of Northern Theater Command of People's Liberation Army, 83 Wenhua Road, Shenhe District, Shenyang 110016, Liaoning Province, China
| | - Y Huo
- Department of Cardiology, Peking University First Hospital, 8 Xishiku Street, Xicheng District, Beijing 100034, China
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14
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Palladino N, Shah A, McGovern J, Burns K, Coughlin R, Joseph D, Cone DC. STEMI Equivalents and Their Incidence during EMS Transport. PREHOSP EMERG CARE 2021:1-7. [PMID: 33320732 DOI: 10.1080/10903127.2020.1863533] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 12/09/2020] [Accepted: 12/09/2020] [Indexed: 10/24/2022]
Abstract
Objective: The management of patients with ST-elevation myocardial infarction (STEMI) is time-critical, with a focus on early reperfusion to decrease morbidity and mortality. It is imperative that prehospital clinicians recognize STEMI early and initiate transport to hospitals capable of percutaneous coronary intervention (PCI) with a door-to-balloon time of ≤90 minutes. Three patterns have been identified as STEMI equivalents that also likely warrant prompt attention and potentially PCI: Wellens syndrome, De Winter T waves, and aVR ST elevation. The goal of our study was to assess the incidence of these findings in prehospital patients presenting with chest pain. Methods: We conducted a retrospective chart review from a large urban tertiary care emergency department. We reviewed the prehospital ECG, or ECG upon arrival, of 861 patients who were hospitalized and required cardiac catheterization between 4/10/18 and 5/7/19. Patients who had field catheterization lab activation by EMS for STEMI were excluded. If a prehospital ECG was not available for review, the first ECG obtained in the hospital was used as a proxy. Each ECG was screened for aVR elevation, De Winter T waves, and Wellens syndrome. Results: Of 278 charts with prehospital ECGs available, 12 met our criteria for STEMI equivalency (4.4%): 6 Wellens syndrome and 6 aVR STEMI. There were no cases of De Winters T waves. Of 573 charts with no prehospital ECG available, 27 had initial hospital ECGs that met our STEMI equivalent criteria (4.7%): 7 Wellens syndrome and 20 aVR STEMI. Again, there were no cases of De Winters T waves. Conclusions: These preliminary data suggest that there are significant numbers of patients whose prehospital ECG findings do not currently meet criteria for field activation of the cardiac catheterization lab, but who may require prompt catheterization. Further studies are needed to look at outcomes, but these results could support the need for further education of prehospital clinicians regarding recognition of these STEMI equivalents, as well as quality initiatives aimed at decreasing door-to-balloon time for patients with STEMI equivalents.
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Affiliation(s)
- Nicholas Palladino
- Yale New Haven Medical Center Emergency Medicine Residency Program, New Haven, Connecticut (NP); Department of Emergency Medicine, Cooper University Health Care, New Haven, Connecticut (AS); Center for Emergency Medical Services, Yale New Haven Hospital, New Haven, Connecticut (JM, KB, DJ, DCC); Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut (KB, RC, DJ, DCC)
| | - Aman Shah
- Yale New Haven Medical Center Emergency Medicine Residency Program, New Haven, Connecticut (NP); Department of Emergency Medicine, Cooper University Health Care, New Haven, Connecticut (AS); Center for Emergency Medical Services, Yale New Haven Hospital, New Haven, Connecticut (JM, KB, DJ, DCC); Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut (KB, RC, DJ, DCC)
| | - Jeffrey McGovern
- Yale New Haven Medical Center Emergency Medicine Residency Program, New Haven, Connecticut (NP); Department of Emergency Medicine, Cooper University Health Care, New Haven, Connecticut (AS); Center for Emergency Medical Services, Yale New Haven Hospital, New Haven, Connecticut (JM, KB, DJ, DCC); Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut (KB, RC, DJ, DCC)
| | - Kevin Burns
- Yale New Haven Medical Center Emergency Medicine Residency Program, New Haven, Connecticut (NP); Department of Emergency Medicine, Cooper University Health Care, New Haven, Connecticut (AS); Center for Emergency Medical Services, Yale New Haven Hospital, New Haven, Connecticut (JM, KB, DJ, DCC); Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut (KB, RC, DJ, DCC)
| | - Ryan Coughlin
- Yale New Haven Medical Center Emergency Medicine Residency Program, New Haven, Connecticut (NP); Department of Emergency Medicine, Cooper University Health Care, New Haven, Connecticut (AS); Center for Emergency Medical Services, Yale New Haven Hospital, New Haven, Connecticut (JM, KB, DJ, DCC); Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut (KB, RC, DJ, DCC)
| | - Daniel Joseph
- Yale New Haven Medical Center Emergency Medicine Residency Program, New Haven, Connecticut (NP); Department of Emergency Medicine, Cooper University Health Care, New Haven, Connecticut (AS); Center for Emergency Medical Services, Yale New Haven Hospital, New Haven, Connecticut (JM, KB, DJ, DCC); Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut (KB, RC, DJ, DCC)
| | - David C Cone
- Yale New Haven Medical Center Emergency Medicine Residency Program, New Haven, Connecticut (NP); Department of Emergency Medicine, Cooper University Health Care, New Haven, Connecticut (AS); Center for Emergency Medical Services, Yale New Haven Hospital, New Haven, Connecticut (JM, KB, DJ, DCC); Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut (KB, RC, DJ, DCC)
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15
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Samsky MD, Krucoff MW, Morrow DA, Abraham WT, Aguel F, Althouse AD, Chen E, Cigarroa JE, DeVore AD, Farb A, Gilchrist IC, Henry TD, Hochman JS, Kapur NK, Morrow V, Ohman EM, O'Neill WW, Piña IL, Proudfoot AG, Sapirstein JS, Seltzer JH, Senatore F, Shinnar M, Simonton CA, Tehrani BN, Thiele H, Truesdell AG, Waksman R, Rao SV. Cardiac safety research consortium "shock II" think tank report: Advancing practical approaches to generating evidence for the treatment of cardiogenic shock. Am Heart J 2020; 230:93-97. [PMID: 33011148 DOI: 10.1016/j.ahj.2020.09.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 09/23/2020] [Indexed: 12/29/2022]
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16
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Boivin-Proulx LA, Matteau A, Pacheco C, Bastiany A, Mansour S, Kokis A, Quan É, Gobeil F, Potter BJ. Effect of Real-Time Physician Oversight of Prehospital STEMI Diagnosis on ECG-Inappropriate and False Positive Catheterization Laboratory Activation. CJC Open 2020; 3:419-426. [PMID: 34027344 PMCID: PMC8129458 DOI: 10.1016/j.cjco.2020.11.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 11/18/2020] [Indexed: 11/26/2022] Open
Abstract
Background ST-elevation myocardial infarction diagnosis at first medical contact (FMC) and prehospital cardiac catheterization laboratory (CCL) activation are associated with reduced total ischemic time and therefore have become the dominant ST-elevation myocardial infarction referral method in primary percutaneous coronary intervention systems. We sought to determine whether physician oversight was associated with improved diagnostic performance in a prehospital CCL activation system and what effect the additional interpretation has on treatment delay. Methods Between 2012 and 2015, all patients in 2 greater Montreal catchment areas with a chief symptom of chest paint or dyspnea had an in-the-field electrocardiogram (ECG). A machine diagnosis of "acute myocardial infarction" resulted either in automatic CCL (automated cohort without oversight) or transmission of the ECG to the receiving centre emergency physician for reinterpretation before CCL activation. System performance was assessed in terms of the proportion of false positive and inappropriate activations (IA), as well as the proportion of patients with FMC-to-device times ≤ 90 minutes. Results Four hundred twenty-eight (428) activations were analyzed (311 automated; 117 with physician oversight). Physician oversight tended to decrease IAs (7% vs 3%; P = 0.062), but was also associated with a smaller proportion of patients achieving target FMC-to-device (76% vs 60%; P < 0.001). There was no significant effect on the proportion of false positive activation. Conclusions Real-time physician oversight might be associated with fewer IAs, but also appears to have a deleterious effect on FMC-to-device performance. Identifying predictors of IA could improve overall performance by selecting ECGs that merit physician oversight and streamlining others. Larger clinical studies are warranted.
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Affiliation(s)
- Laurie-Anne Boivin-Proulx
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montréal, Québec, Canada.,Centre Cardiovasculaire du Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Alexis Matteau
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montréal, Québec, Canada.,Centre Cardiovasculaire du Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | | | | | - Samer Mansour
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montréal, Québec, Canada.,Centre Cardiovasculaire du Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - André Kokis
- Centre Cardiovasculaire du Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Éric Quan
- Hôpital Charles-Lemoyne, Greenfield Park, Québec, Canada
| | - François Gobeil
- Centre Cardiovasculaire du Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Brian J Potter
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montréal, Québec, Canada.,Centre Cardiovasculaire du Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
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17
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Dharma S. Comparison of Real-Life Systems of Care for ST-Segment Elevation Myocardial Infarction. Glob Heart 2020; 15:66. [PMID: 33150131 PMCID: PMC7528675 DOI: 10.5334/gh.343] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 09/14/2020] [Indexed: 01/30/2023] Open
Abstract
The success of ST-segment elevation myocardial infarction (STEMI) networks application in Europe and the United States in delivering rapid reperfusion therapy in the community have become an inspiration to other developing countries to develop regional STEMI network in order to improve the STEMI care. Although barriers are found in the beginning phase of constructing the network, recent analysis from national or regional registries worldwide have shown improvement of the STEMI care in many countries over the years. To improve the overall care of patients with STEMI particularly in developing countries, improvements should be focusing on how to minimize the total ischemia time, and this includes care improvement at each step of care after the patient shows signs and symptoms of chest pain. Innovation in health technology to develop the electrocardiogram transmission and communication system, along with routine performance measures of the STEMI network may help bridging the disparities of STEMI system of care between guideline recommended therapy and the real world clinical practice.
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Affiliation(s)
- Surya Dharma
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, University of Indonesia, Indonesian Cardiovascular Research Center, National Cardiovascular Center Harapan Kita, Jakarta, ID
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18
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Abstract
Cardiovascular disease (CVD) is the most common class of chronic and life-threatening diseases and, therefore, considered to be one of the main causes of mortality. The proposed new neural architecture based on the recent popularity of convolutional neural networks (CNN) was a solution for the development of automatic heart disease diagnosis systems using electrocardiogram (ECG) signals. More specifically, ECG signals were passed directly to a properly trained CNN network. The database consisted of more than 4000 ECG signal instances extracted from outpatient ECG examinations obtained from 47 subjects: 25 males and 22 females. The confusion matrix derived from the testing dataset indicated 99% accuracy for the “normal” class. For the “atrial premature beat” class, ECG segments were correctly classified 100% of the time. Finally, for the “premature ventricular contraction” class, ECG segments were correctly classified 96% of the time. In total, there was an average classification accuracy of 98.33%. The sensitivity (SNS) and the specificity (SPC) were, respectively, 98.33% and 98.35%. The new approach based on deep learning and, in particular, on a CNN network guaranteed excellent performance in automatic recognition and, therefore, prevention of cardiovascular diseases.
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19
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Ehrlich ME, Kolls BJ, Roettig M, Monk L, Shah S, Xian Y, Jollis JG, Granger CB, Graffagnino C. Implementation of Best Practices-Developing and Optimizing Regional Systems of Stroke Care: Design and Methodology. Am Heart J 2020; 222:105-111. [PMID: 32028136 DOI: 10.1016/j.ahj.2020.01.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 01/13/2020] [Indexed: 11/18/2022]
Abstract
The AHA Guidelines recommend developing multi-tiered systems for the care of patients with acute stroke.1 An ideal stroke system of care should ensure that all patients receive the most efficient and timely care, regardless of how they first enter or access the medical care system. Coordination among the components of a stroke system is the most challenging but most essential aspect of any system of care. The Implementation of Best Practices For Acute Stroke Care-Developing and Optimizing Regional Systems of Stroke Care (IMPROVE Stroke Care) project, is designed to implement existing guidelines and systematically improve the acute stroke system of care in the Southeastern United States. Project participation includes 9 hub hospitals, approximately 80 spoke hospitals, numerous pre-hospital agencies (911, fire, and emergency medical services) and communities within the region. The goal of the IMPROVE Stroke program is to develop a regional integrated stroke care system that identifies, classifies, and treats acute ischemic stroke patients more rapidly and effectively with reperfusion therapy. The project will identify gaps and barriers to implementation of stroke systems of care, leverage existing resources within the regions, aid in designing strategies to improve care processes, bring regional representatives together to agree on and implement best practices, protocols, and plans based on guidelines, and establish methods to monitor quality of care. The impact of implementation of stroke systems of care on mortality and long-term functional outcomes will be measured.
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Affiliation(s)
- Matthew E Ehrlich
- Department of Neurology, Duke University School of Medicine, Durham, NC.
| | - Brad J Kolls
- Department of Neurology, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Durham, NC
| | | | - Lisa Monk
- Duke Clinical Research Institute, Durham, NC
| | - Shreyansh Shah
- Department of Neurology, Duke University School of Medicine, Durham, NC
| | - Ying Xian
- Department of Neurology, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Durham, NC
| | - James G Jollis
- Duke Clinical Research Institute, Durham, NC; Division of Cardiology, Duke University School of Medicine, Durham, NC
| | - Christopher B Granger
- Duke Clinical Research Institute, Durham, NC; Division of Cardiology, Duke University School of Medicine, Durham, NC
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20
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Kontos MC, Gunderson MR, Zegre-Hemsey JK, Lange DC, French WJ, Henry TD, McCarthy JJ, Corbett C, Jacobs AK, Jollis JG, Manoukian SV, Suter RE, Travis DT, Garvey JL. Prehospital Activation of Hospital Resources (PreAct) ST-Segment-Elevation Myocardial Infarction (STEMI): A Standardized Approach to Prehospital Activation and Direct to the Catheterization Laboratory for STEMI Recommendations From the American Heart Association's Mission: Lifeline Program. J Am Heart Assoc 2020; 9:e011963. [PMID: 31957530 PMCID: PMC7033830 DOI: 10.1161/jaha.119.011963] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Michael C Kontos
- Pauley Heart Center Virginia Commonwealth University Richmond VA
| | | | | | - David C Lange
- The Permanente Medical Group Kaiser Permanente Santa Clara Santa Clara CA
| | - William J French
- Harbor-UCLA Medical Center and Los Angeles Biomedical Institute Torrance CA.,David Geffen School of Medicine at UCLA Los Angeles CA
| | - Timothy D Henry
- The Lindner Center for Research and Education at The Christ Hospital Cincinnati OH
| | - James J McCarthy
- Department of Emergency Medicine McGovern Medical School University of Texas Health Science Center at Houston TX
| | | | - Alice K Jacobs
- Section of Cardiology Department of Medicine Boston University Medical Center Boston MA
| | | | | | - Robert E Suter
- Department of Emergency Medicine UT Southwestern and Augusta University Dallas Texas.,Department of Military and Emergency Medicine Uniformed Services University Dallas TX
| | | | - J Lee Garvey
- Department of Emergency MedicineCarolinas Medical Center Charlotte NC
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21
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Granger CB, Bates ER, Jollis JG, Antman EM, Nichol G, O'Connor RE, Gregory T, Roettig ML, Peng SA, Ellrodt G, Henry TD, French WJ, Jacobs AK. Improving Care of STEMI in the United States 2008 to 2012. J Am Heart Assoc 2020; 8:e008096. [PMID: 30596310 PMCID: PMC6405711 DOI: 10.1161/jaha.118.008096] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background We aimed to determine the change in treatment strategies and times to treatment over the first 5 years of the Mission: Lifeline program. Methods and Results We assessed pre‐ and in‐hospital care and outcomes from 2008 to 2012 for patients with ST‐segment–elevation myocardial infarction at US hospitals, using data from the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry—Get With The Guidelines Registry. In‐hospital adjusted mortality was calculated including and excluding cardiac arrest as a reason for primary percutaneous coronary intervention delay. A total of 147 466 patients from 485 hospitals were analyzed. There was a decrease in the proportion of eligible patients not treated with reperfusion (6.2% versus 3.3%) and treated with fibrinolytic therapy (13.4% versus 7.0%). Median time from symptom onset to first medical contact was unchanged (≈50 minutes). Use of prehospital ECGs increased (45% versus 71%). All major reperfusion times improved: median first medical contact‐to‐device for emergency medical systems transport to percutaneous coronary intervention–capable hospitals (93 to 84 minutes), first door‐to‐device for transfers for primary percutaneous coronary intervention (130 to 112 minutes), and door‐in–door‐out at non–percutaneous coronary intervention–capable hospitals (76 to 62 minutes) (all P<0.001 over 5 years). Rates of cardiogenic shock and cardiac arrest, and overall in‐hospital mortality increased (5.7% to 6.3%). Adjusted mortality excluding patients with known cardiac arrest decreased by 14% at 3 years and 25% at 5 years (P<0.001). Conclusions Quality of care for patients with ST‐segment–elevation myocardial infarction improved over time in Mission: Lifeline, including increased use of reperfusion therapy and faster times‐to‐treatment. In‐hospital mortality improved for patients without cardiac arrest but did not appear to improve overall as the number of these high‐risk patients increased.
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Affiliation(s)
| | - Eric R Bates
- 2 Department of Internal Medicine University of Michigan Ann Arbor MI
| | - James G Jollis
- 1 Division of Cardiology Duke Clinical Research Institute Durham NC
| | | | - Graham Nichol
- 4 University of Washington-Harborview Center for Prehospital Emergency Care University of Washington Seattle WA
| | - Robert E O'Connor
- 5 Department of Emergency Medicine University of Virginia School of Medicine Charlottesville VA
| | | | - Mayme L Roettig
- 1 Division of Cardiology Duke Clinical Research Institute Durham NC
| | | | - Gray Ellrodt
- 8 Department of Medicine Berkshire Medical Center Pittsfield MA
| | | | - William J French
- 10 Department of Medicine Harbor-University of California at Los Angeles Medical Center Torrance CA
| | - Alice K Jacobs
- 11 Department of Medicine Boston University School of Medicine Boston MA
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22
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Samsky M, Krucoff M, Althouse AD, Abraham WT, Adamson P, Aguel F, Bilazarian S, Dangas GD, Gilchrist IC, Henry TD, Hochman JS, Kapur NK, Laschinger J, Masters RG, Michelson E, Morrow DA, Morrow V, Ohman EM, Pina I, Proudfoot AG, Rogers J, Sapirstein J, Senatore F, Stockbridge N, Thiele H, Truesdell AG, Waksman R, Rao S. Clinical and regulatory landscape for cardiogenic shock: A report from the Cardiac Safety Research Consortium ThinkTank on cardiogenic shock. Am Heart J 2020; 219:1-8. [PMID: 31707323 DOI: 10.1016/j.ahj.2019.10.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 10/17/2019] [Indexed: 02/04/2023]
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23
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Zègre-Hemsey JK, Patel MD, Fernandez AR, Pelter MM, Brice J, Rosamond W. A Statewide Assessment of Prehospital Electrocardiography Approaches of Acquisition and Interpretation for ST-Elevation Myocardial Infarction Based on Emergency Medical Services Characteristics. PREHOSP EMERG CARE 2019; 24:550-556. [PMID: 31593496 DOI: 10.1080/10903127.2019.1677831] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Background: The American Heart Association recommends acquiring and interpreting prehospital electrocardiograms (ECG) for patients transported by Emergency Medical Services (EMS) to the emergency department with symptoms highly suspicious of acute coronary syndrome. If interpreted correctly, prehospital ECGs have the potential to improve early detection of ST-elevation myocardial infarction (STEMI) and inform prehospital activation of the cardiac catheterization laboratory, thus reducing total ischemic time and improving patient outcomes. Standardized protocols for prehospital ECG interpretation methods are lacking due to variations in EMS system design, training, and procedures. Objectives: We aimed to describe approaches for prehospital ECG interpretation in EMS systems across North Carolina (NC), and examine potential differences among systems. Methods: A 35-item internet survey was sent to all NC EMS systems (n = 99). Questions pertaining to prehospital ECG interpretation methods included: paramedic, computerized algorithm (i.e., software interpretation), combined approaches, and/or transmission for physician interpretation, transmission capability, cardiac catheterization laboratory activation, and EMS system characteristics (e.g. rural versus urban). Data were summarized and compared. Results: A total of 96 EMS systems across NC responded to the survey (97% response rate); of these, 69% were rural. EMS medical directors (53%) or EMS administrative directors (42%) completed the majority of surveys. While 91% of EMS systems had a prehospital ECG interpretation protocol in place, only 61% had a written cardiac catheterization laboratory activation policy. More than half (55%) of systems reported paramedic interpretation of prehospital ECGs, followed by a combined paramedic and software interpretation approach (39%), physician interpretation (4%), or software interpretation only approach (2%). Nearly 80% of EMS systems transmitted prehospital ECGs to receiving hospitals (always or sometimes), regardless of interpretation method. All EMS systems had some paid versus non-paid EMS personnel and the majority (86%) had both basic and advanced life support capabilities. Conclusions: Most NC EMS systems had a paramedic only ECG interpretation or paramedic in combination with a computerized algorithm approach. Very few used a physician read approach following transmission, even in rural service areas.
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24
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Green JL, Jacobs AK, Holmes D, Chiswell K, Blanco R, Bates ER, French W, Kupas DF, Mears G, Roe M, Nallamothu BK. Taking the Reins on Systems of Care for ST-Segment-Elevation Myocardial Infarction Patients: A Report From the American Heart Association Mission: Lifeline Program. Circ Cardiovasc Interv 2019; 11:e005706. [PMID: 29716933 DOI: 10.1161/circinterventions.117.005706] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 03/12/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Early success with regionalization of ST-segment-elevation myocardial infarction (STEMI) care has led many states to adopt statewide prehospital STEMI hospital destination policies, allowing emergency medical services to bypass non-percutaneous coronary intervention-capable hospitals. The association between adoption of these policies and patterns of care among STEMI patients is unknown. METHODS AND RESULTS Using data from January 1, 2013, to December 31, 2014, from the National Cardiovascular Data Registry and Acute Coronary Treatment and Intervention Outcomes Network Registry, 6 states with bypass policies (cases included Delaware, Iowa, Maryland, North Carolina, Pennsylvania, and Massachusetts) were matched to 6 states without bypass policies (controls included South Carolina, Minnesota, Virginia, Texas, New York, and Connecticut) a priori on region, hospital density, and percent state participation in the registry. Using the matched sample, logistic regression models were adjusted for patient- and state-level characteristics. Outcomes were receipt of reperfusion and receipt of timely percutaneous coronary intervention. Our study cohort included 19 287 patients at 379 sites across 12 states. Patients from states with hospital destination policies were similar in age, sex, and comorbidities to patients from states without such policies. After adjustment for patient- and state-level characteristics, 57.9% (95% confidence intervals, 53.2%-62.5%) of patients living in states with hospital destination policies when compared with 47.5% (95% confidence intervals, 43.4%-51.7%) living in states without hospital destination policies received primary percutaneous coronary intervention within their relevant guideline-recommended time from first medical contact. CONCLUSIONS Statewide adoption of STEMI hospital destination policies allowing emergency medical services to bypass non-percutaneous coronary intervention-capable facilities is associated with significantly faster treatment times for patients with STEMI.
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Affiliation(s)
- Jacqueline L Green
- From the Department of Internal Medicine, University of Michigan, Ann Arbor (J.L.G., E.R.B., B.K.N.)
| | - Alice K Jacobs
- Department of Internal Medicine, Boston University School of Medicine, Boston University, MA (A.K.J.)
| | - DaJuanicia Holmes
- Department of Internal Medicine, Duke University, Durham, NC (D.H., K.C., R.B., M.R.)
| | - Karen Chiswell
- Department of Internal Medicine, Duke University, Durham, NC (D.H., K.C., R.B., M.R.)
| | - Rosalia Blanco
- Department of Internal Medicine, Duke University, Durham, NC (D.H., K.C., R.B., M.R.)
| | - Eric R Bates
- From the Department of Internal Medicine, University of Michigan, Ann Arbor (J.L.G., E.R.B., B.K.N.)
| | - William French
- Department of Internal Medicine, UCLA Medical Center, Los Angeles, CA (W.F.)
| | - Douglas F Kupas
- Department of Emergency Medicine, Geisinger Medical Center, Mechanicsville, PA (D.F.K.)
| | | | - Matthew Roe
- Department of Internal Medicine, Duke University, Durham, NC (D.H., K.C., R.B., M.R.)
| | - Brahmajee K Nallamothu
- From the Department of Internal Medicine, University of Michigan, Ann Arbor (J.L.G., E.R.B., B.K.N.)
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25
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Zhang Y, Yu B, Han Y, Wang J, Yang L, Wan Z, Zhang Z, Chen Y, Fu X, Gao C, Li B, Chen J, Wu M, Ma Y, Zhao X, Chen Y, Yan H, Xiang D, Fang W, Mehta S, Naber CK, Ge J, Huo Y. Protocol of the China ST-segment elevation myocardial infarction (STEMI) Care Project (CSCAP): a 10-year project to improve quality of care by building up a regional STEMI care network. BMJ Open 2019; 9:e026362. [PMID: 31320346 PMCID: PMC6661651 DOI: 10.1136/bmjopen-2018-026362] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
INTRODUCTION Successful ST-segment elevation myocardial infarction (STEMI) management is time-sensitive and is based on prompt reperfusion mainly to reduce patient mortality. It has evolved from a single hospital care to an integrated regional network approach over the last decades. This prospective study, named the China STEMI Care Project (CSCAP), aims to show how implementation of different types of integrated regional STEMI care networks can improve the reperfusion treatment rate, shorten the total duration of myocardial ischaemia and lead to mortality reduction step by step. METHODS AND ANALYSIS The CSCAP is a prospective, multicentre registry study of three phases. A total of 18 provinces, 4 municipalities and 2 autonomous regions in China were included. Patients who meet the third universal definition of myocardial infarction and the Chinese STEMI diagnosis and treatment guidelines are enrolled. Phase 1 (CSCAP-1) focuses on the in-hospital process optimisation of primary percutaneous coronary intervention (PPCI) hospitals, phase 2 (CSCAP-2) focuses on the PPCI hospital-based regional STEMI care network construction together with emergency medical services and adjacent non-PPCI hospitals, while phase 3 (CSCAP-3) focuses on the whole-city STEMI care network construction by promoting chest pain centre accreditation. Systematic data collection, key performance index assessment and subsequent improvement are implemented throughout the project to continuously improve the quality of STEMI care. ETHICS AND DISSEMINATION The study has been reviewed and approved by the Ethics Committee of Peking University First Hospital. Ranking reports of quality of care will be generated available to all participant affiliations. Results will be disseminated via peer-reviewed scientific journals and presentations at congresses. TRIAL REGISTRATION NUMBER NCT03821012.
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Affiliation(s)
- Yan Zhang
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Bo Yu
- Cardiology, Key Laboratories of Education Ministry for Myocardial Ischemia Mechanism and Treatment, 2nd Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Yaling Han
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Jianan Wang
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Lixia Yang
- Department of Cardiology, The 920 Hospital of Joint Logistics Support Force of the Chinese People’s Liberation Army, Kunmin, China
| | - Zheng Wan
- Department of Cardiology, The General Hospital of Tianjin Medical University, Tianjin, China
| | - Zheng Zhang
- Department of Cardiology, The First Hospital of Lanzhou University, Lanzhou, China
| | - Yuguo Chen
- Department of Emergency, Qilu Hospital of Shandong University, Jinan, China
| | - Xianghua Fu
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Chuanyu Gao
- Cardiology, Henan Provincial People’s Hospital, Zhengzhou University People’s Hospital, Zhengzhou, China
| | - Bao Li
- Department of Cardiology, Shanxi Cardiovascular Hospital, Taiyuan, China
| | - Jiyan Chen
- Cardiology, Guangdong Cardiovascular Institute, Guangdong provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Ming Wu
- Department of Cardiology, Hainan General Hospital, Haikou, China
| | - Yitong Ma
- Department of Cardiology, The First Affiliated Hospital of Xinjiang Medical University, Urumchi, China
| | - Xingsheng Zhao
- Department of Cardiology, Inner Mongolia People’s Hospital, Hohhot, China
| | - Yundai Chen
- Department of Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Hongbing Yan
- Department of Cardiology, Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Dingcheng Xiang
- Department of Cardiology, General Hospital of Southern Theater Command of People’s Liberation Army, Guangzhou, China
| | - Weiyi Fang
- Department of Cardiology, Shanghai Chest Hospital, Shanghai, China
| | | | | | - Junbo Ge
- Department of Cardiology, Zhongshan Hospital Fudan University, Shanghai, China
| | - Yong Huo
- Department of Cardiology, Peking University First Hospital, Beijing, China
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Zègre-Hemsey JK, Asafu-Adjei J, Fernandez A, Brice J. Characteristics of Prehospital Electrocardiogram Use in North Carolina Using a Novel Linkage of Emergency Medical Services and Emergency Department Data. PREHOSP EMERG CARE 2019; 23:772-779. [PMID: 30885071 DOI: 10.1080/10903127.2019.1597230] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Objective: Prehospital electrocardiography (ECG) is recommended for patients with suspected acute coronary syndrome (ACS), yet only 20-80% of chest pain patients receive a prehospital ECG. Less is known about prehospital ECG use in patients with less common complaints (e.g., fatigue) suspicious for ACS who are transported by emergency medical services (EMS). The aims of this study were to determine: (1) the proportion of patients with chest pain and less typical complaints, and (2) patient characteristics associated with prehospital ECG use in patients transported by EMS to emergency departments across North Carolina. Methods: A novel linked database was created between prehospital and emergency department (ED) patient care data from the North Carolina Prehospital Medical Information System and the North Carolina Disease Event Tracking and Epidemiologic Collection Tool. Institutional review board approval and a data use agreement were received prior to the start of the study. Patients ≥21 transported during 2010-14 by EMS with select variables were included. We examined patients' complaints (symptoms), characteristics (e.g., race, ethnicity, final hospital diagnosis), and prehospital ECG use (yes/no). Analysis included descriptive statistics and mixed logistic regression. Results: During 2010-14, there were 1,967,542 patients with linked EMS-ED data (mean age: 56.9 [SD: 22.2], 43.2% male, 63.7% White). Of these, 643,174 (32.6%) received a prehospital ECG. Patients with prehospital ECG presented with the following complaints: 20% chest pain; 10% shortness of breath; 6% abdominal pain/problems; 6% altered level of consciousness; 5% syncope/dizziness; 4% palpitations; 12% other complaints; and 37% missing. Patients' presenting complaints were the strongest predictor of prehospital ECG use, adjusting for age, sex, race, ethnicity, urbanicity, and date and time of EMS dispatch. Conclusions: Patients with chest pain were significantly more likely to receive a prehospital ECG compared to those with less typical but suspicious complaints for ACS. Patients with less common presentations remain disadvantaged for early triage, risk stratification, and intervention prior to the hospital.
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Nascimento BR, Brant LCC, Marino BCA, Passaglia LG, Ribeiro ALP. Implementing myocardial infarction systems of care in low/middle-income countries. Heart 2018; 105:20-26. [DOI: 10.1136/heartjnl-2018-313398] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 09/01/2018] [Accepted: 09/05/2018] [Indexed: 01/09/2023] Open
Abstract
Ischaemic heart disease is the leading cause of death worldwide, with an increasing trend from 6.1 million deaths in 1990 to 9.5 million in 2016, markedly driven by rates observed in low/middle-income countries (LMIC). Improvements in myocardial infarction (MI) care are crucial for reducing premature mortality. We aimed to evaluate the main challenges for adequate MI care in LMIC, and possible strategies to overcome these existing barriers.Reperfusion is the cornerstone of MI treatment, but worldwide around 30% of patients are not reperfused, with even lower rates in LMIC. The main challenges are related to delays associated with patient education, late diagnosis and inadequate referral strategies, health infrastructure and insufficient funding. The implementation of regional MI systems of care in LMIC, systematising timely reperfusion strategies, access to intensive care, risk stratification and use of adjunctive medications have shown some successful strategies. Telemedicine support for remote ECG, diagnosis and organisation of referrals has proven to be useful, improving access to reperfusion even in prehospital settings. Organisation of transport and referral hubs based on anticipated delays and development of MI excellence centres have also resulted in better equality of care. Also, education of healthcare staff and task shifting may potentially widen access to optimal therapy.In conclusion, efforts have been made for the implementation of MI systems of care in LMIC, aiming to address particularities of the health systems. However, the increasing impact of MI in these countries urges the development of further strategies to improve reperfusion and reduce system delays.
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Developing a Rural, Community-Based Registry for Cardiovascular Quality Improvement. Qual Manag Health Care 2018; 27:209-214. [PMID: 30260928 DOI: 10.1097/qmh.0000000000000189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Cardiovascular disease is one of the leading causes of death, yet most evidence is collected from small clinical trials or individual hospital providers. Achieving scalable data to enable quality improvements (QIs) remains a challenge. We investigate whether a registry that is shared by multiple providers and integrates data longitudinally could help drive QIs across a large rural geographic region. METHODS We describe a case study involving the development of an informatics infrastructure across the entire state of Wyoming. This rural, regional, community-based cardiovascular system of care involved all interventional hospitals in the state as well as all surrounding states. Data exchange was initiated between 36 hospitals, and 56 ambulance agencies, to a centralized registry for clinical analytics and QI for patients with acute myocardial infarction. RESULTS After 3 years, the registry maintained all documented acute myocardial infarctions across Wyoming. Median total ischemic time (time from patient's symptom onset to definitive treatment) had a 36.7% improvement during the program. Changes in quality for the rural community included reduction in overall treatment times, as well as enhanced training, standardized protocols, and community awareness. We also share key lessons learned. CONCLUSIONS Collaborative data registries for emergency cardiovascular care can help providers and communities measure and improve the quality of the care across regions.
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Balamurugan A, Phillips M, Selig JP, Felix H, Ryan K. Association Between System Factors and Acute Myocardial Infarction Mortality. South Med J 2018; 111:556-564. [PMID: 30180254 DOI: 10.14423/smj.0000000000000853] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES We conducted a cross-sectional study to assess the association between healthcare system factors and death from acute myocardial infarction (AMI), in terms of access (distance to the hospital, mode of transportation), availability (emergency medical services, hospitals), and capability (emergency medical services' 12-lead electrocardiogram capability, continuous percutaneous coronary intervention [PCI] and cardiothoracic surgical services), after accounting for individual and environmental factors. METHODS Data on 14,663 deaths (in-hospital and out of hospital) and live hospital discharges as a result of AMI for 2012 and 2013 among Arkansas residents were obtained from the Arkansas Department of Health. A mixed-effects logistic regression model was used to account for nesting, in which an individual was nested within either a county or a hospital to evaluate the association of system factors with death from AMI. RESULTS Deaths from AMI were significantly associated with two system factors: a 9.2% increase in the odds of deaths from AMI for every 10-mi increase in distance to the nearest hospital (odds ratio 1.092, 95% confidence interval 1.009-1.181) and a 64% increase in the odds of death from AMI among hospitals without continuous PCI capability (odds ratio 1.64, 95% confidence interval 1.15-2.34), after adjusting for individual and environmental factors. CONCLUSIONS A higher risk of AMI deaths was associated with healthcare system factors, especially distance to nearest hospital, and hospitals' continuous PCI capability, even after adjusting for individual and environmental factors. A coordinated system of care approaches that mitigates gaps in these system factors may prevent death from AMI.
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Affiliation(s)
- Appathurai Balamurugan
- From the Arkansas Department of Health, Little Rock, and the Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Martha Phillips
- From the Arkansas Department of Health, Little Rock, and the Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - James P Selig
- From the Arkansas Department of Health, Little Rock, and the Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Holly Felix
- From the Arkansas Department of Health, Little Rock, and the Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Kevin Ryan
- From the Arkansas Department of Health, Little Rock, and the Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas
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Victor SM, Mullasari AS. Systems of care for STEMI in developing countries – the way forward. ASIAINTERVENTION 2018; 4:74-76. [PMID: 36484000 PMCID: PMC9706771 DOI: 10.4244/aijv4i1a15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
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Veronese JP, Wallis L, Allgaier R, Botha R. Cardiopulmonary resuscitation by Emergency Medical Services in South Africa: Barriers to achieving high quality performance. Afr J Emerg Med 2018; 8:6-11. [PMID: 30456138 PMCID: PMC6223582 DOI: 10.1016/j.afjem.2017.08.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2016] [Revised: 07/10/2017] [Accepted: 08/24/2017] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Survival rates from out-of-hospital cardiac arrest significantly improve when high-quality cardiopulmonary resuscitation (CPR) is performed. Despite sudden cardiac arrest being a leading cause of death in many parts of the world, no studies have determined the quality of CPR delivery by Emergency Medical Services (EMS) personnel in South Africa. The aim of this study was to determine the quality of CPR provision by EMS staff in a simulated setting. METHODS A descriptive study design was used to determine competency of CPR among intermediate-qualified EMS personnel. Theoretical knowledge was determined using a multiple-choice questionnaire, and psychomotor skills were video-recorded then assessed by independent reviewers. Correlational and regression analysis were used to determine the effect of demographic information on knowledge and skills. RESULTS Overall competency of CPR among participants (n = 114) was poor: median knowledge was 50%; median skill 33%. Only 25% of the items tested showed that participants applied relevant knowledge to the equivalent skill, and the nature and strength of knowledge influencing skills was small. Demographic factors that significantly influenced both knowledge and skill were the sector of employment, the guidelines EMS personnel were trained to, age, experience, and the location of training. CONCLUSION Overall knowledge and skill performance was below standard. This study suggests that theoretical knowledge has a small but notable role to play on some components of skill performance. Demographic variables that affected both knowledge and skill may be used to improve training and the overall quality of Basic Life Support CPR delivery by EMS personnel.
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Affiliation(s)
| | - Lee Wallis
- Division of Emergency Medicine, University of Cape Town, South Africa
| | - Rachel Allgaier
- Division of Emergency Medicine, Stellenbosch University, South Africa
| | - Ryan Botha
- Faculty of Science, University of Fort Hare, South Africa
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Chang BL, Mercer MP, Bosson N, Sporer KA. Variations in Cardiac Arrest Regionalization in California. West J Emerg Med 2018; 19:259-265. [PMID: 29560052 PMCID: PMC5851497 DOI: 10.5811/westjem.2017.10.34869] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 10/14/2017] [Accepted: 10/11/2017] [Indexed: 11/11/2022] Open
Abstract
Introduction The development of cardiac arrest centers and regionalization of systems of care may improve survival of patients with out-of-hospital cardiac arrest (OHCA). This survey of the local EMS agencies (LEMSA) in California was intended to determine current practices regarding the treatment and routing of OHCA patients and the extent to which EMS systems have regionalized OHCA care across California. Methods We surveyed all of the 33 LEMSA in California regarding the treatment and routing of OHCA patients according to the current recommendations for OHCA management. Results Two counties, representing 29% of the California population, have formally regionalized cardiac arrest care. Twenty of the remaining LEMSA have specific regionalization protocols to direct all OHCA patients with return of spontaneous circulation to designated percutaneous coronary intervention (PCI)-capable hospitals, representing another 36% of the population. There is large variation in LEMSA ability to influence inhospital care. Only 14 agencies (36%), representing 44% of the population, have access to hospital outcome data, including survival to hospital discharge and cerebral performance category scores. Conclusion Regionalized care of OHCA is established in two of 33 California LEMSA, providing access to approximately one-third of California residents. Many other LEMSA direct OHCA patients to PCI-capable hospitals for primary PCI and targeted temperature management, but there is limited regional coordination and system quality improvement. Only one-third of LEMSA have access to hospital data for patient outcomes.
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Affiliation(s)
- Brian L Chang
- University of California San Francisco School of Medicine, Department of Emergency Medicine, San Francisco, California
| | - Mary P Mercer
- University of California San Francisco School of Medicine, Department of Emergency Medicine, San Francisco, California
| | - Nichole Bosson
- Los Angeles County Emergency Medical Service Agency, Los Angeles, California.,Harbor-UCLA Medical Center and the Los Angeles Biomedical Research Institute, Carson, California
| | - Karl A Sporer
- University of California San Francisco School of Medicine, Department of Emergency Medicine, San Francisco, California.,Alameda County Emergency Medical Service Agency, Alameda, California
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Langabeer JR, Henry TD, Fowler R, Champagne-Langabeer T, Kim J, Jacobs AK. Sex-Based Differences in Discharge Disposition and Outcomes for ST-Segment Elevation Myocardial Infarction Patients Within a Regional Network. J Womens Health (Larchmt) 2018; 27:1001-1006. [PMID: 29319393 DOI: 10.1089/jwh.2017.6553] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND It is known that women with ST-segment elevation myocardial infarction (STEMI) have higher mortality in comparison to men. While the reasons for this sex-based difference are not completely understood, biologic differences and disparities in care have been implicated. Whether these differences persist within an urban, regional STEMI system of care with defined protocols is unclear. Our objective was to explore sex-related effects in outcomes in a large regional system of care. MATERIALS AND METHODS Data were drawn from a regional subset of the National Cardiovascular Data Registry for 33 hospitals in and around Dallas County, Texas from 2010 to 2015. We explored adjusted differences between women and men for discharge disposition, door to balloon (D2B), total ischemic time (TIS), length of stay, and in-hospital mortality rates. RESULTS Multivariate regressions to control for confounding factors, including age, D2B, and TIS, were significantly prolonged in women compared to men (D2B 58 vs. 54 minutes; TIS 206 vs. 178 minutes; both p < 0.001). Length of stay was 0.45 median days longer. Women were also much less likely to survive at discharge than men [odds ratio (OR): 0.63; 95% confidence interval (CI): 0.52-0.76]. Most notably, they were much less likely to be discharged to home than men (88% vs. 92%, p < 0.001). CONCLUSIONS In this study, we found that sex-based disparities persist for both cardiovascular outcomes and discharge disposition, even in a modern regionalized system of care.
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Affiliation(s)
- James R Langabeer
- 1 School of Biomedical Informatics, University of Texas Health Science Center , Houston, Texas
| | | | - Raymond Fowler
- 3 Department of Emergency Medicine, University of Texas Southwestern Medical Center , Dallas, Texas
| | | | - Junghyun Kim
- 1 School of Biomedical Informatics, University of Texas Health Science Center , Houston, Texas
| | - Alice K Jacobs
- 4 Department of Cardiology, Boston Medical Center, Boston University School of Medicine , Boston, Massachusetts
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Huber K, Halvorsen S. Fibrinolytic treatment of ST-elevation myocardial infarction. Hamostaseologie 2017; 34:47-53. [DOI: 10.5482/hamo-13-07-0040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Accepted: 09/18/2013] [Indexed: 11/05/2022] Open
Abstract
SummaryPrimary 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.
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van Diepen S, Katz JN, Albert NM, Henry TD, Jacobs AK, Kapur NK, Kilic A, Menon V, Ohman EM, Sweitzer NK, Thiele H, Washam JB, Cohen MG. Contemporary Management of Cardiogenic Shock: A Scientific Statement From the American Heart Association. Circulation 2017; 136:e232-e268. [PMID: 28923988 DOI: 10.1161/cir.0000000000000525] [Citation(s) in RCA: 933] [Impact Index Per Article: 133.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Cardiogenic shock is a high-acuity, potentially complex, and hemodynamically diverse state of end-organ hypoperfusion that is frequently associated with multisystem organ failure. Despite improving survival in recent years, patient morbidity and mortality remain high, and there are few evidence-based therapeutic interventions known to clearly improve patient outcomes. This scientific statement on cardiogenic shock summarizes the epidemiology, pathophysiology, causes, and outcomes of cardiogenic shock; reviews contemporary best medical, surgical, mechanical circulatory support, and palliative care practices; advocates for the development of regionalized systems of care; and outlines future research priorities.
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Tra J, de Blok C, van der Wulp I, de Bruijne MC, Wagner C. Multicentre analysis of current ST-elevation myocardial infarction acute care pathways. Open Heart 2017; 4:e000458. [PMID: 28890792 PMCID: PMC5566983 DOI: 10.1136/openhrt-2016-000458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Revised: 11/23/2016] [Accepted: 12/20/2016] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Rapid reperfusion with percutaneous coronary intervention (PCI) is vital for patients with ST segment elevation myocardial infarction (STEMI). However, the guideline-recommended time targets are regularly exceeded. The goal of this study was to gain insight into how Dutch PCI centres try to achieve these time targets by comparing their care processes with one another and with the European guideline-recommended process. In addition, accelerating factors perceived by care providers were identified. METHODS In this multiple case study, interviews with STEMI care providers were conducted, transcribed and used to create process descriptions per centre. Analyses consisted of within-case and between-case analyses of the processes. Accelerating factors were identified by means of open and axial coding. RESULTS In total, 28 interviews were conducted in six PCI centres. The centres differed from the guideline-recommended process on, for example, additional, unavoidable patient routings and monitoring delays, and from one another on the communication of diagnostic information (eg, transmitting all, only ambiguous or no ECGs) and catheterisation room preparation. These differences indicated diverging choices to maintain a balance between speed and diagnostic accuracy. Factors perceived by care providers as accelerating the process included trust in the tentative diagnosis, and avoiding unnecessary intercaregiver consultations. The combination of processes and accelerating factors were summarised in a model. CONCLUSIONS Numerous differences in processes between PCI centres were identified. Several time-saving strategies were applied by PCI centres, however, in different configurations. To further improve the care for patients with STEMI, best practices can be shared between centres and countries.
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Affiliation(s)
- Joppe Tra
- Department of Occupational and Public Health, EMGO+/VU University Medical Center, Amsterdam, The Netherlands
| | - Carolien de Blok
- Faculty of Economics and Business, Department of Operations, University of Groningen, Groningen, The Netherlands
| | - Ineke van der Wulp
- Department of Occupational and Public Health, EMGO+/VU University Medical Center, Amsterdam, The Netherlands
| | - Martine C de Bruijne
- Department of Occupational and Public Health, EMGO+/VU University Medical Center, Amsterdam, The Netherlands
| | - Cordula Wagner
- Department of Occupational and Public Health, EMGO+/VU University Medical Center, Amsterdam, The Netherlands.,The Netherlands Institute of Health Services Research (NIVEL), Utrecht, The Netherlands
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Hsia RY, Sabbagh S, Sarkar N, Sporer K, Rokos IC, Brown JF, Brindis RG, Guo J, Shen YC. Trends in Regionalization of Care for ST-Segment Elevation Myocardial Infarction. West J Emerg Med 2017; 18:1010-1017. [PMID: 29085531 PMCID: PMC5654868 DOI: 10.5811/westjem.2017.8.34592] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Revised: 07/12/2017] [Accepted: 08/08/2017] [Indexed: 11/17/2022] Open
Abstract
Introduction California has led successful regionalized efforts for several time-critical medical conditions, including ST-segment elevation myocardial infarction (STEMI), but no specific mandated protocols exist to define regionalization of care. We aimed to study the trends in regionalization of care for STEMI patients in the state of California and to examine the differences in patient demographic, hospital, and county trends. Methods Using survey responses collected from all California emergency medical services (EMS) agencies, we developed four categories – no, partial, substantial, and complete regionalization – to capture prehospital and inter-hospital components of regionalization in each EMS agency’s jurisdiction between 2005–2014. We linked the survey responses to 2006 California non-public hospital discharge data to study the patient distribution at baseline. Results STEMI regionalization-of-care networks steadily developed across California. Only 14% of counties were regionalized in 2006, accounting for 42% of California’s STEMI patient population, but over half of these counties, representing 86% of California’s STEMI patient population, reached complete regionalization in 2014. We did not find any dramatic differences in underlying patient characteristics based on regionalization status; however, differences in hospital characteristics were relatively substantial. Conclusion Potential barriers to achieving regionalization included competition, hospital ownership, population density, and financial challenges. Minimal differences in patient characteristics can establish that patient differences unlikely played any role in influencing earlier or later regionalization and can provide a framework for future analyses evaluating the impact of regionalization on patient outcomes.
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Affiliation(s)
- Renee Y Hsia
- University of California, San Francisco, Department of Emergency Medicine, San Francisco, California.,University of California, San Francisco, Philip R. Lee Institute for Health Policy Studies, San Francisco, California
| | - Sarah Sabbagh
- University of California, San Francisco, Department of Emergency Medicine, San Francisco, California
| | - Nandita Sarkar
- National Bureau of Economic Research, Cambridge, Massachusetts
| | - Karl Sporer
- University of California, San Francisco, Department of Emergency Medicine, San Francisco, California.,Alameda County Emergency Medical Services Agency, Oakland, California
| | - Ivan C Rokos
- University of California, Los Angeles-Olive View Medical Center; Geffen School of Medicine, Los Angeles, California
| | - John F Brown
- University of California, San Francisco, Department of Emergency Medicine, San Francisco, California.,San Francisco Emergency Medical Services Agency, San Francisco, California
| | - Ralph G Brindis
- University of California, San Francisco, Philip R. Lee Institute for Health Policy Studies, San Francisco, California.,University of California, San Francisco, Department of Medicine, San Francisco, California
| | - Joanna Guo
- University of California, San Francisco, Department of Emergency Medicine, San Francisco, California
| | - Yu-Chu Shen
- National Bureau of Economic Research, Cambridge, Massachusetts.,Naval Postgraduate School, Graduate School of Business and Public Policy, Monterey, California
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Confronting system barriers for ST- elevation MI in low and middle income countries with a focus on India. Indian Heart J 2017; 70:185-190. [PMID: 29455776 PMCID: PMC5903067 DOI: 10.1016/j.ihj.2017.06.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 06/19/2017] [Accepted: 06/29/2017] [Indexed: 01/05/2023] Open
Abstract
Our previous research found seven specific factors that cause system delays in ST-elevation Myocardial infarction management in developing countries. These delays, in conjunction with a lack of organized STEMI systems of care, result in inefficient processes to treat AMI in developing countries. In our present opinion paper, we have specifically explored the three most pertinent causes that afflict the seven specific factors responsible for system delays. In doing so, we incorporated a unique strategy of global STEMI expertise. With this methodology, the recommendations were provided by expert Indian cardiologist and final guidelines were drafted after comprehensive discussions by the entire group of submitting authors. We expect these recommendations to be utilitarian in improving STEMI care in developing countries.
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Tiulim J, Mak K, Shavelle DM. ST segment elevation myocardial infarction in patients hospitalized for non-cardiac conditions. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2017; 19:17-20. [PMID: 28600021 DOI: 10.1016/j.carrev.2017.05.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 05/18/2017] [Accepted: 05/26/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Timely use of primary percutaneous coronary intervention (PCI) is the standard of care for patients with ST segment elevation myocardial infarction (STEMI). Most patients with STEMI present via emergency medical services or self-transport to the emergency department (ED) and relatively little is known about the minority of patients that develop STEMI while hospitalized for non-cardiac conditions. The objective of this study was to analyze treatment times and clinical outcome for in-hospital STEMI patients. METHODS Two-hundred fifty-five patients with STEMI treated at Keck Medical Center of USC and Los Angeles County USC Medical Center from January, 2009 to December, 2013 were retrospectively analyzed. Demographics, treatment time intervals and clinical outcome were collected. Patients arriving via the ED (ED STEMI Group, n=228; 89%) were compared to patients that developed in-hospital STEMI (In-hospital STEMI Group, n=27; 11%). RESULTS Patients with in-hospital STEMI were similar in age, gender and associated medical conditions to ED STEMI patients. In-hospital STEMI patients were less likely to present with chest pain compared to ED STEMI patients, 5% vs. 79%, respectively, p<0.0001. Time from first abnormal electrocardiogram to device was 195±202min for in-hospital STEMI Group compared to door to device time of 88±64min for ED STEMI Group, p<0.001. Length of hospital stay was significantly longer for in-hospital STEMI Group compared to ED STEMI Group, 13±10 vs. 6.8±7.8days, respectively, p<0.001. In-hospital mortality was significantly higher for the in-hospital STEMI Group compared to the ED STEMI Group, 37% vs. 7%, respectively, p<0.001. CONCLUSIONS In-hospital STEMI patients have significant treatment delays and worse clinical outcome compared to STEMI patients that present via the emergency department. Additional efforts are required to promptly identify in-hospital patients that develop STEMI.
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Affiliation(s)
- Justin Tiulim
- Division of Cardiovascular Medicine, University of Southern California, Los Angeles, CA
| | - Kevin Mak
- Division of Cardiovascular Medicine, University of Southern California, Los Angeles, CA
| | - David M Shavelle
- Division of Cardiovascular Medicine, University of Southern California, Los Angeles, CA.
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Fordyce CB, Henry TD, Granger CB. Implementation of Regional ST-Segment Elevation Myocardial Infarction Systems of Care: Successes and Challenges. Interv Cardiol Clin 2017; 5:415-425. [PMID: 28581992 DOI: 10.1016/j.iccl.2016.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Current guidelines recommend that communities create and maintain a regional system of ST-segment elevation myocardial infarction (STEMI) care that includes assessment and continuous quality improvement of emergency medical services and hospital-based activities. Availability and timely access is a challenge in many areas of the United States. This article reviews clinical trial data supporting the use of primary percutaneous coronary intervention as the optimal reperfusion strategy, and fibrinolysis as an option when this is not possible. It then describes the outcomes and benefits of implementing regional systems of STEMI care, and discusses ongoing challenges for STEMI system implementation, including inadequate data collection and feedback, and hospital and physician competition.
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Affiliation(s)
| | - Timothy D Henry
- Cedars-Sinai Heart Institute, 127 South San Vicente Boulevard, Suite A3100, Los Angeles, CA 90048, USA
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Miller AL, Simon D, Roe MT, Kontos MC, Diercks D, Amsterdam E, Bhatt DL. Comparison of Delay Times from Symptom Onset to Medical Contact in Blacks Versus Whites With Acute Myocardial Infarction. Am J Cardiol 2017; 119:1127-1134. [PMID: 28237284 DOI: 10.1016/j.amjcard.2016.12.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Revised: 12/22/2016] [Accepted: 12/22/2016] [Indexed: 12/13/2022]
Abstract
Clinical outcomes in acute myocardial infarction (AMI) worsen with increasing delay between symptom onset and clinical presentation. Previous studies have shown that black patients with AMI have longer presentation delays. The objective of this analysis is to explore the potential contribution of community factors to presentation delays in black patients with AMI. We linked clinical data for 346,499 consecutive patients with AMI from Acute Coronary Treatment Intervention Outcomes Network Registry-Get With the Guidelines™ (2007-2014) to socioeconomic and community information from the American Community Survey. Black patients with AMI had longer symptom onset to first medical contact times than white patients (114 vs 101 minutes, p <0.0001) regardless of ambulance versus self-transport. Compared with white patients, black patients were younger and more likely to have clinical co-morbidities such as hypertension, diabetes, previous heart failure, and stroke. They were also more likely to live in urban communities with lower socioeconomic status, lower rates of long-term residence, and higher proportion of single-person households than white patients. In sequential linear regression models adjusting for patient demographic and clinical characteristics, logistic barriers to prompt presentation, and community socioeconomic and composition factors, black patients had a persistent 9% greater time from symptom onset to presentation compared with white patients (95% CI 8% to 11%, p <0.0001). In conclusion, the longer delay in time to presentation in black patients with AMI compared with white patients persists after accounting for a number of both patient and community factors.
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Reducing system delays in treatment of ST elevation myocardial infarction and confronting the challenges of late presentation in low and middle-income countries. Indian Heart J 2017; 69 Suppl 1:S1-S5. [PMID: 28400032 PMCID: PMC5388017 DOI: 10.1016/j.ihj.2016.12.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Potter BJ, Matteau A, Mansour S, Naim C, Riahi M, Essiambre R, Montigny M, Sareault I, Gobeil F. Sustained Performance of a "Physicianless" System of Automated Prehospital STEMI Diagnosis and Catheterization Laboratory Activation. Can J Cardiol 2016; 33:148-154. [PMID: 28024553 DOI: 10.1016/j.cjca.2016.10.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 10/01/2016] [Accepted: 10/09/2016] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Treatment times for primary percutaneous coronary intervention frequently exceed the recommended maximum delay. Automated "physicianless" systems of prehospital cardiac catheterization laboratory (CCL) activation show promise, but have been met with resistance over concerns regarding the potential for false positive and inappropriate activations (IAs). METHODS From 2010 to 2015, first responders performed electrocardiograms (ECGs) in the field for all patients with a complaint of chest pain or dyspnea. An automated machine diagnosis of "acute myocardial infarction" resulted in immediate CCL activation and direct transfer without transmission or human reinterpretation of the ECG prior to patient arrival. Any activation resulting from a nondiagnostic ECG (no ST-elevation) was deemed an IA, whereas activations resulting from ECG's compatible with ST-elevation myocardial infarction but without angiographic evidence of a coronary event were deemed false positive. In 2012, the referral algorithm was modified to exclude supraventricular tachycardia and left bundle branch block. RESULTS There were 155 activations in the early cohort (2010-2012; prior to algorithm modification) and 313 in the late cohort (2012-2015). Algorithm modification resulted in a 42% relative decrease in the rate of IAs (12% vs 7%; P < 0.01) without a significant effect on treatment delay. CONCLUSIONS A combination of prehospital automated ST-elevation myocardial infarction diagnosis and "physicianless" CCL activation is safe and effective in improving treatment delay and these results are sustainable over time. The performance of the referral algorithm in terms of IA and false positive is at least on par with systems that ensure real-time human oversight.
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Affiliation(s)
- Brian J Potter
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montréal, Québec, Canada; Centre Cardiovasculaire du Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada.
| | - Alexis Matteau
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montréal, Québec, Canada; Centre Cardiovasculaire du Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Samer Mansour
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montréal, Québec, Canada; Centre Cardiovasculaire du Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada; Hôpital de la Cité de la Santé, Laval, Québec, Canada
| | - Charbel Naim
- Centre Cardiovasculaire du Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Mounir Riahi
- Centre Cardiovasculaire du Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | | | | | | | - François Gobeil
- Centre Cardiovasculaire du Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada; Hôpital de la Cité de la Santé, Laval, Québec, Canada
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Affiliation(s)
- Harlan M Krumholz
- From the Section of Cardiovascular Medicine and the Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, CT; Department of Health Policy and Management, Yale School of Public Health, New Haven, CT; and Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, CT.
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Rumsfeld JS, Brooks SC, Aufderheide TP, Leary M, Bradley SM, Nkonde-Price C, Schwamm LH, Jessup M, Ferrer JME, Merchant RM. Use of Mobile Devices, Social Media, and Crowdsourcing as Digital Strategies to Improve Emergency Cardiovascular Care. Circulation 2016; 134:e87-e108. [DOI: 10.1161/cir.0000000000000428] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Jollis JG, Al-Khalidi HR, Roettig ML, Berger PB, Corbett CC, Dauerman HL, Fordyce CB, Fox K, Garvey JL, Gregory T, Henry TD, Rokos IC, Sherwood MW, Suter RE, Wilson BH, Granger CB. Regional Systems of Care Demonstration Project: American Heart Association Mission: Lifeline STEMI Systems Accelerator. Circulation 2016; 134:365-74. [PMID: 27482000 PMCID: PMC4975540 DOI: 10.1161/circulationaha.115.019474] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 06/01/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Up to 50% of patients fail to meet ST-segment-elevation myocardial infarction (STEMI) guideline goals recommending a first medical contact-to-device time of <90 minutes for patients directly presenting to percutaneous coronary intervention-capable hospitals and <120 minutes for transferred patients. We sought to increase the proportion of patients treated within guideline goals by organizing coordinated regional reperfusion plans. METHODS We established leadership teams, coordinated protocols, and provided regular feedback for 484 hospitals and 1253 emergency medical services (EMS) agencies in 16 regions across the United States. RESULTS Between July 2012 and December 2013, 23 809 patients presented with acute STEMI (direct to percutaneous coronary intervention hospital: 11 765 EMS transported and 6502 self-transported; 5542 transferred). EMS-transported patients differed from self-transported patients in symptom onset to first medical contact time (median, 47 versus 114 minutes), incidence of cardiac arrest (10% versus 3%), shock on admission (11% versus 3%), and in-hospital mortality (8% versus 3%; P<0.001 for all comparisons). There was a significant increase in the proportion of patients meeting guideline goals of first medical contact-to-device time, including those directly presenting via EMS (50% to 55%; P<0.001) and transferred patients (44%-48%; P=0.002). Despite regional variability, the greatest gains occurred among patients in the 5 most improved regions, increasing from 45% to 57% (direct EMS; P<0.001) and 38% to 50% (transfers; P<0.001). CONCLUSIONS This Mission: Lifeline STEMI Systems Accelerator demonstration project represents the largest national effort to organize regional STEMI care. By focusing on first medical contact-to-device time, coordinated treatment protocols, and regional data collection and reporting, we were able to increase significantly the proportion of patients treated within guideline goals.
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Affiliation(s)
- James G Jollis
- From University of North Carolina, Chapel Hill (J.G.J.); Duke Clinical Research Institute, Duke University, Durham, NC (H.R.A.-K., M.L.R., C.B.F., K.F., M.W.S., C.B.G.); Northwell Health, New Hyde Park, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); American Heart Association, Dallas, TX (T.G., R.E.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.)
| | - Hussein R Al-Khalidi
- From University of North Carolina, Chapel Hill (J.G.J.); Duke Clinical Research Institute, Duke University, Durham, NC (H.R.A.-K., M.L.R., C.B.F., K.F., M.W.S., C.B.G.); Northwell Health, New Hyde Park, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); American Heart Association, Dallas, TX (T.G., R.E.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.)
| | - Mayme L Roettig
- From University of North Carolina, Chapel Hill (J.G.J.); Duke Clinical Research Institute, Duke University, Durham, NC (H.R.A.-K., M.L.R., C.B.F., K.F., M.W.S., C.B.G.); Northwell Health, New Hyde Park, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); American Heart Association, Dallas, TX (T.G., R.E.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.)
| | - Peter B Berger
- From University of North Carolina, Chapel Hill (J.G.J.); Duke Clinical Research Institute, Duke University, Durham, NC (H.R.A.-K., M.L.R., C.B.F., K.F., M.W.S., C.B.G.); Northwell Health, New Hyde Park, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); American Heart Association, Dallas, TX (T.G., R.E.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.)
| | - Claire C Corbett
- From University of North Carolina, Chapel Hill (J.G.J.); Duke Clinical Research Institute, Duke University, Durham, NC (H.R.A.-K., M.L.R., C.B.F., K.F., M.W.S., C.B.G.); Northwell Health, New Hyde Park, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); American Heart Association, Dallas, TX (T.G., R.E.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.)
| | - Harold L Dauerman
- From University of North Carolina, Chapel Hill (J.G.J.); Duke Clinical Research Institute, Duke University, Durham, NC (H.R.A.-K., M.L.R., C.B.F., K.F., M.W.S., C.B.G.); Northwell Health, New Hyde Park, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); American Heart Association, Dallas, TX (T.G., R.E.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.)
| | - Christopher B Fordyce
- From University of North Carolina, Chapel Hill (J.G.J.); Duke Clinical Research Institute, Duke University, Durham, NC (H.R.A.-K., M.L.R., C.B.F., K.F., M.W.S., C.B.G.); Northwell Health, New Hyde Park, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); American Heart Association, Dallas, TX (T.G., R.E.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.)
| | - Kathleen Fox
- From University of North Carolina, Chapel Hill (J.G.J.); Duke Clinical Research Institute, Duke University, Durham, NC (H.R.A.-K., M.L.R., C.B.F., K.F., M.W.S., C.B.G.); Northwell Health, New Hyde Park, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); American Heart Association, Dallas, TX (T.G., R.E.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.)
| | - J Lee Garvey
- From University of North Carolina, Chapel Hill (J.G.J.); Duke Clinical Research Institute, Duke University, Durham, NC (H.R.A.-K., M.L.R., C.B.F., K.F., M.W.S., C.B.G.); Northwell Health, New Hyde Park, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); American Heart Association, Dallas, TX (T.G., R.E.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.)
| | - Tammy Gregory
- From University of North Carolina, Chapel Hill (J.G.J.); Duke Clinical Research Institute, Duke University, Durham, NC (H.R.A.-K., M.L.R., C.B.F., K.F., M.W.S., C.B.G.); Northwell Health, New Hyde Park, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); American Heart Association, Dallas, TX (T.G., R.E.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.)
| | - Timothy D Henry
- From University of North Carolina, Chapel Hill (J.G.J.); Duke Clinical Research Institute, Duke University, Durham, NC (H.R.A.-K., M.L.R., C.B.F., K.F., M.W.S., C.B.G.); Northwell Health, New Hyde Park, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); American Heart Association, Dallas, TX (T.G., R.E.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.)
| | - Ivan C Rokos
- From University of North Carolina, Chapel Hill (J.G.J.); Duke Clinical Research Institute, Duke University, Durham, NC (H.R.A.-K., M.L.R., C.B.F., K.F., M.W.S., C.B.G.); Northwell Health, New Hyde Park, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); American Heart Association, Dallas, TX (T.G., R.E.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.)
| | - Matthew W Sherwood
- From University of North Carolina, Chapel Hill (J.G.J.); Duke Clinical Research Institute, Duke University, Durham, NC (H.R.A.-K., M.L.R., C.B.F., K.F., M.W.S., C.B.G.); Northwell Health, New Hyde Park, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); American Heart Association, Dallas, TX (T.G., R.E.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.)
| | - Robert E Suter
- From University of North Carolina, Chapel Hill (J.G.J.); Duke Clinical Research Institute, Duke University, Durham, NC (H.R.A.-K., M.L.R., C.B.F., K.F., M.W.S., C.B.G.); Northwell Health, New Hyde Park, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); American Heart Association, Dallas, TX (T.G., R.E.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.)
| | - B Hadley Wilson
- From University of North Carolina, Chapel Hill (J.G.J.); Duke Clinical Research Institute, Duke University, Durham, NC (H.R.A.-K., M.L.R., C.B.F., K.F., M.W.S., C.B.G.); Northwell Health, New Hyde Park, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); American Heart Association, Dallas, TX (T.G., R.E.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.)
| | - Christopher B Granger
- From University of North Carolina, Chapel Hill (J.G.J.); Duke Clinical Research Institute, Duke University, Durham, NC (H.R.A.-K., M.L.R., C.B.F., K.F., M.W.S., C.B.G.); Northwell Health, New Hyde Park, NY (P.B.B.); New Hanover Regional Medical Center, Wilmington, NC (C.C.C.); University of Vermont College of Medicine, Burlington (H.L.D.); Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC (J.L.G.); American Heart Association, Dallas, TX (T.G., R.E.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); UCLA-Olive View Medical Center, Los Angeles, CA (I.C.R.); and Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (B.H.W.).
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Merlo AE, Chauhan D, Pettit C, Hong KN, Saunders CR, Chen C, Russo MJ. Outcomes following emergent open repair for thoracic aortic dissection are improved at higher volume centers in direct admissions and transfers. J Cardiothorac Surg 2016; 11:118. [PMID: 27484472 PMCID: PMC4969670 DOI: 10.1186/s13019-016-0529-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Accepted: 07/28/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The purpose of this study is (1) to define the proportion of patients undergoing emergent open repair of thoracic aortic dissection admitted directly through the emergency room versus those transferred from outside hospitals and (2) to determine if a volume-outcomes relationship exists for those patients across admission types. METHODS De-identified patient-level data was obtained from the Nationwide Inpatient Sample (2004-2008). Patients undergoing emergent aortic surgery for thoracic aortic dissection (n = 1,507) were identified by ICD-9 codes and stratified by annual center volume into low volume (≤5 cases/year) (n = 963; 63.9 %), intermediate volume (6-10 cases/year) (n = 370; 24.5 %), and high volume (≥11 cases/year) (n = 174; 11.6 %) groups. The analysis was further stratified by admission type: direct admission (DA), transfer admission (TA), and other. The primary outcome was in-hospital mortality. Multivariate logistic regression analysis was performed comparing outcomes between high vs low and high vs intermediate volume centers. RESULTS Overall in-hospital mortality was 21.8 % (n = 328/1,507). Absolute percent mortality at high volume centers was significantly lower (12.6 %) than at medium (20.6 %) and low volume (23.9 %) centers. For DA patients, mortality was 10.6, 21.4, and 24.0 % for high, medium, and low volume centers respectively. For TA patients, mortality was 10.2, 12.7, and 23.5 % for high, medium, and low volume centers, respectively. Multivariate analysis suggested that patients in low volume center were more likely to die compared to high volume center (Odds Ratio 2.06, 95 % CI 1.25 - 3.38, p = 0.004). Admission source was not associated with increased mortality. CONCLUSIONS Direct admissions comprise the largest proportion of dissections regardless of volume strata, and they comprise the largest proportion in the low and intermediate volume cohorts. Admission to low volume center is an independent risk factor for increased mortality. Patients transferred to high volume centers from low volume centers have similar outcome as direct admits in terms of mortality.
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Affiliation(s)
- Aurelie E Merlo
- Cardiovascular Clinical Research Unit, Barnabas Heart Hospitals, Newark, NJ, USA.,Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Dhaval Chauhan
- Cardiovascular Clinical Research Unit, Barnabas Heart Hospitals, Newark, NJ, USA. .,Department of Surgery, Rutgers - New Jersey Medical School, Newark, NJ, USA. .,Newark Beth Israel Medical Center, Barnabas Health Heart Centers, 201 Lyons Ave, Suite G5, Newark, NJ, 07112, USA.
| | - Chris Pettit
- Cardiovascular Clinical Research Unit, Barnabas Heart Hospitals, Newark, NJ, USA
| | - Kimberly N Hong
- Department of Health Evidence and Policy, Mount Sinai School of Medicine, New York, NY, USA
| | - Craig R Saunders
- Newark Beth Israel Medical Center, Barnabas Heart Hospitals, Newark, NJ, USA
| | - Chunguang Chen
- Newark Beth Israel Medical Center, Barnabas Heart Hospitals, Newark, NJ, USA
| | - Mark J Russo
- Cardiovascular Clinical Research Unit, Barnabas Heart Hospitals, Newark, NJ, USA.,Department of Surgery, Rutgers - New Jersey Medical School, Newark, NJ, USA.,Newark Beth Israel Medical Center, Barnabas Heart Hospitals, Newark, NJ, USA
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Patel A, Mohanan PP, Prabhakaran D, Huffman MD. Pre-hospital acute coronary syndrome care in Kerala, India: A qualitative analysis. Indian Heart J 2016; 69:93-100. [PMID: 28228314 PMCID: PMC5319123 DOI: 10.1016/j.ihj.2016.07.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 06/26/2016] [Accepted: 07/16/2016] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE Ischemic heart disease is the leading cause of death in India. Many of these deaths are due to acute coronary syndromes (ACS), which require prompt symptom recognition, care-seeking behavior, and transport to a treatment facility in the critical pre-hospital period. In India, little is known about pre-hospital management of individuals with ACS. We aim to understand the facilitators, barriers, and context of optimal pre-hospital ACS care to provide opportunities to reduce pre-hospital delays and improve acute cardiovascular care. METHODS AND RESULTS We conducted a qualitative study using in-depth interviews and focus group discussions with 27 ACS providers in Kerala, India to understand facilitators, barriers, and context to pre-hospital ACS care. Six themes emerged from these interviews and discussions: (1) individuals with ACS misperceive their symptoms as non-cardiac in origin; (2) emergency medical services are infrequently used; (3) insufficient pre-hospital healthcare infrastructure contributes to pre-hospital delay; (4) multiple stops are made before arriving at a facility that can provide definitive diagnosis and treatment; (5) relatively high costs of treatment and lack of widespread health insurance coverage limits care delivery; and (6) novel mobile technologies may allow for faster diagnosis and initiation of treatment in the pre-hospital setting. CONCLUSIONS Individualized patient-based factors (general knowledge of ACS symptoms, socioeconomic position) and broader systems-based factors (ambulance networks, coordination of transport) affect pre-hospital ACS care in Kerala. Improving public awareness of ACS symptoms, increasing appropriate use of emergency medical services, and building a infrastructure for rapid and coordinated transport may improve pre-hospital ACS care.
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Affiliation(s)
- Amisha Patel
- Departments of Preventive Medicine and Medicine-Cardiology, Northwestern University Feinberg School of Medicine, Chicago, USA.
| | | | - Dorairaj Prabhakaran
- Centre for Chronic Disease Control and Public Health Foundation of India, Gurgaon, NCR, India
| | - Mark D Huffman
- Departments of Preventive Medicine and Medicine-Cardiology, Northwestern University Feinberg School of Medicine, Chicago, USA
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Ting R, Tejpal A, Finken L, Fisher M, Lefkowitz C, Parthasarathy H, Fallis B, Fosbol EL, Al-Shehri M, Kutryk M, Buller CE, Fam N, Graham JJ, Cheema AN, Bagai A. Repatriation to referral hospital after reperfusion of STEMI patients transferred for primary percutaneous coronary intervention: Insights of a Canadian regional STEMI care system. Am Heart J 2016; 177:145-52. [PMID: 27297860 DOI: 10.1016/j.ahj.2016.04.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 04/26/2016] [Indexed: 11/24/2022]
Abstract
BACKGROUND In regional systems of ST-segment elevation myocardial infarction (STEMI) care, patients presenting to hospitals without percutaneous coronary intervention (PCI) are transferred to PCI-capable hospitals for primary PCI. Repatriation, a practice whereby such patients are transferred back to non-PCI referral hospitals after reperfusion is prevalent in many jurisdictions, yet little is known of this practice and its safety. METHODS We studied 979 consecutive STEMI patients transported from the emergency department and catchment area of two non-PCI hospitals in Ontario, Canada to a regional PCI-hospital for primary PCI between January 2008 and June 2014. Logistic regression modeling was performed to determine factors associated with delayed repatriation beyond 24 hours and to evaluate the association between repatriation and index-admission mortality. RESULTS Eight hundred and fifteen (83.2%) patients were repatriated with 524 (65.2%) patients repatriated within 24 hours. Factors independently associated with delayed repatriation included systolic blood pressure (OR 1.03 per 5 mmHg decrease, 95% CI 1.01-1.06, P= .04), requirement for mechanical ventilation (OR 24.9, 95% CI 5.4-115.3, P< .0001), ventricular arrhythmia (OR 3.0, 95% CI 1.3-6.6, P= .01), infarct-related artery (P= .03), final TIMI flow grade (P= .01) and access-site complications (OR 2.36, 95% CI 1.04-5.4, P= .04). After repatriation, 9 (1.3%) patients returned to the PCI-hospital for urgent care, and 16 (2.0%) died during index-admission. After adjustment, repatriation was not associated with increase in index-admission mortality (adjusted OR 0.46, 95% CI 0.16-1.32, P= .15). CONCLUSIONS In a regional STEMI care system in Ontario, Canada, patients are routinely repatriated to non-PCI hospitals after primary PCI. This practice was associated with very low and acceptable rate of return to the PCI-hospital during index-admission without an adverse impact on short-term outcomes.
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50
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Meloni L, Floris R, Montisci R, De Candia G, Cadeddu M, Lai G, Sori P, Ruscazio M, Pinna G, Iasiello G, Pirisi R. Care quality monitoring of a ST-segment elevation myocardial infarction programme over a 5-year period. J Cardiovasc Med (Hagerstown) 2016; 17:494-500. [DOI: 10.2459/jcm.0000000000000285] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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