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Yang J, Zhao Y, Wang J, Ma L, Xu H, Leng W, Wang Y, Wang Y, Wang Z, Gao X, Yang Y. Current status of emergency medical service use in ST-segment elevation myocardial infarction in China: Findings from China Acute Myocardial Infarction (CAMI) Registry. Int J Cardiol 2024; 406:132040. [PMID: 38614365 DOI: 10.1016/j.ijcard.2024.132040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 04/01/2024] [Accepted: 04/10/2024] [Indexed: 04/15/2024]
Abstract
BACKGROUND The mortality rate of myocardial infarction in China has increased dramatically in the past three decades. Although emergency medical service (EMS) played a pivotal role for the management of patients with ST-segment elevation myocardial infarction (STEMI), the corresponding data in China are limited. METHODS An observational analysis was performed in 26,305 STEMI patients, who were documented in China acute myocardial infarction (CAMI) Registry and treated in 162 hospitals from January 1st, 2013 to January 31th, 2016. We compared the differences such as demographic factors, social factors, medical history, risk factors, socioeconomic distribution and treatment strategies between EMS transport group and self-transport group. RESULTS Only 4336 patients (16.5%) were transported by EMS. Patients with symptom onset outside, out-of-hospital cardiac arrest and presented to province-level hospital were more likely to use EMS. Besides those factors, low systolic blood pressure, severe dyspnea or syncope, and high Killip class were also positively related to EMS activation. Notably, compared to self-transport, use of EMS was associated with a shorter prehospital delay (median, 180 vs. 245 min, P < 0.0001) but similar door-to-needle time (median, 45 min vs. 52 min, P = 0.1400) and door-to-balloon time (median, 105 min vs. 103 min, P = 0.1834). CONCLUSIONS EMS care for STEMI is greatly underused in China. EMS transport is associated with shorter onset-to-door time and higher rate of reperfusion, but not substantial reduction in treatment delays or mortality rate. Targeted efforts are needed to promote EMS use when chest pain occurs and to set up a unique regionalized STEMI network focusing on integration of prehospital care procedures in China. TRIAL REGISTRATION ClinicalTrials.gov (NCT01874691), retrospectively registered June 11, 2013.
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Affiliation(s)
- Jingang Yang
- Coronary Heart Disease Center, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yanyan Zhao
- Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Jianyi Wang
- Coronary Heart Disease Center, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Liyuan Ma
- Coronary Heart Disease Center, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Haiyan Xu
- Coronary Heart Disease Center, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Wenxiu Leng
- Coronary Heart Disease Center, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yang Wang
- Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yan Wang
- Department of Cardiology, Xiamen Cardiovascular Hospital Xiamen University, Xia Men, Fujian Province, China
| | - Zhifang Wang
- Department of Cardiology, Xinxiang Central Hospital, Xinxiang, He Nan Province, China
| | - Xiaojin Gao
- Coronary Heart Disease Center, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China.
| | - Yuejin Yang
- Coronary Heart Disease Center, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China.
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Baradi A, Dinh DT, Brennan A, Stub D, Somaratne J, Palmer S, Nehme Z, Andrew E, Smith K, Liew D, Reid CM, Lefkovits J, Wilson A. Prevalence and Predictors of Emergency Medical Service Use in Patients Undergoing Primary Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction. Heart Lung Circ 2024; 33:990-997. [PMID: 38570261 DOI: 10.1016/j.hlc.2024.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 02/08/2024] [Accepted: 02/15/2024] [Indexed: 04/05/2024]
Abstract
AIM We aim to describe prevalence of Emergency Medical Service (EMS) use, investigate factors predictive of EMS use, and determine if EMS use predicts treatment delay and mortality in our ST-elevation myocardial infarction (STEMI) cohort. METHOD We prospectively collected data on 5,602 patients presenting with STEMI for primary percutaneous coronary intervention (PCI) transported to PCI-capable hospitals in Victoria, Australia, from 2013-2018 who were entered into the Victorian Cardiac Outcomes Registry (VCOR). We linked this dataset to the Ambulance Victoria and National Death Index (NDI) datasets. We excluded late presentation, thrombolysed, and in-hospital STEMI, as well as patients presenting with cardiogenic shock and out-of-hospital cardiac arrest. RESULTS In total, 74% of patients undergoing primary PCI for STEMI used EMS. Older age, female gender, higher socioeconomic status, and a history of prior ischaemic heart disease were independent predictors of using EMS. EMS use was associated with shorter adjusted door-to-balloon (53 vs 72 minutes, p<0.001) and symptom-to-balloon (183 vs 212 minutes, p<0.001) times. Mode of transport was not predictive of 30-day or 12-month mortality. CONCLUSIONS EMS use in Victoria is relatively high compared with internationally reported data. EMS use reduces treatment delay. Predictors of EMS use in our cohort are consistent with those prevalent in prior literature. Understanding the patients who are less likely to use EMS might inform more targeted education campaigns in the future.
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Affiliation(s)
- Arul Baradi
- Cambridge Cardiovascular Epidemiology Unit, Cambridge University, Cambridgeshire, United Kingdom; Department of Medicine, University of Melbourne, St Vincent's Hospital, Melbourne, Vic, Australia.
| | - Diem T Dinh
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia
| | - Angela Brennan
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia
| | - Dion Stub
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Department of Cardiology, Alfred Hospital, Melbourne, Vic, Australia; Centre for Research and Evaluation, Ambulance Victoria, Melbourne, Vic, Australia
| | - Jithendra Somaratne
- Department of Cardiology, Auckland City Hospital, Auckland, New Zealand; Faculty of Medicine, University of Auckland, Auckland, New Zealand
| | - Sonny Palmer
- Department of Medicine, University of Melbourne, St Vincent's Hospital, Melbourne, Vic, Australia; Department of Cardiology, Alfred Hospital, Melbourne, Vic, Australia
| | - Ziad Nehme
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Centre for Research and Evaluation, Ambulance Victoria, Melbourne, Vic, Australia
| | - Emily Andrew
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Centre for Research and Evaluation, Ambulance Victoria, Melbourne, Vic, Australia
| | - Karen Smith
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Centre for Research and Evaluation, Ambulance Victoria, Melbourne, Vic, Australia
| | - Danny Liew
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Department of General Medicine, Alfred Hospital, Melbourne, Vic, Australia
| | - Christopher M Reid
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia; School of Public Health, Curtin University, Perth, WA, Australia
| | - Jeffrey Lefkovits
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Department of Cardiology, Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - Andrew Wilson
- Department of Medicine, University of Melbourne, St Vincent's Hospital, Melbourne, Vic, Australia; Department of Cardiology, St Vincent's Hospital, Melbourne, Vic, Australia
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3
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Saito Y, Inohara T, Kohsaka S, Wada H, Kumamaru H, Yamaji K, Ishii H, Amano T, Miyata H, Kobayashi Y, Kozuma K. Benchmarking System Monitoring on Quality Improvement in Percutaneous Coronary Intervention: A Nationwide Registry in Japan. JACC. ASIA 2024; 4:323-331. [PMID: 38660107 PMCID: PMC11035937 DOI: 10.1016/j.jacasi.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 12/11/2023] [Accepted: 12/11/2023] [Indexed: 04/26/2024]
Abstract
Background Quality indicators (QIs) have been developed to improve and standardize care quality in percutaneous coronary intervention (PCI). In Japan, consecutive PCI procedures are registered in a nationwide database (the Japanese Percutaneous Coronary Intervention registry), which introduces a benchmarking system for comparing individual institutional performance against the national average. Objectives The aim of this study was to assess the impact of the benchmarking system implementation on QI improvement at the hospital level. Methods A total of 734,264 PCIs were conducted at 1,194 institutions between January 2019 and December 2021. In January 2018, a web-based benchmarking system encompassing 7 QIs for PCI at the institutional level, including door-to-balloon time and rate of transradial intervention, was introduced. The process by which institutions tracked their QIs was centrally monitored. Results During the 3-year study period, the benchmarking system was reviewed at least once at 742 institutions (62.1%) (median 4 times; Q1-Q3: 2-7 times). The institutions that reviewed their records had higher PCI volumes. Among these institutions, although door-to-balloon time was not directly associated, the proportion of transradial intervention increased by 2.3% in the system review group during the initial year compared with 0.7% in their counterparts. However, in the subsequent year, the association between system reviews and QI improvement was attenuated. Conclusions The implementation of a benchmarking system, reviewed by participating institutions in Japan, was partially associated with improved QIs during the first year; however, this improvement was attenuated in the subsequent year, highlighting the need for further efforts to develop effective and sustainable interventions to enhance care quality in PCI.
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Affiliation(s)
- Yuichi Saito
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Taku Inohara
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Hideki Wada
- Department of Cardiovascular Medicine, Juntendo University Shizuoka Hospital, Izunokuni, Japan
| | - Hiraku Kumamaru
- Department of Healthcare Quality Assessment, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Kyohei Yamaji
- Department of Cardiology, Kyoto University, Kyoto, Japan
| | - Hideki Ishii
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Tetsuya Amano
- Department of Cardiology, Aichi Medical University, Nagakute, Japan
| | - Hiroaki Miyata
- Department of Healthcare Quality Assessment, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Ken Kozuma
- Department of Cardiology, Teikyo University Hospital, Tokyo, Japan
| | - J-PCI Registry Investigators
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
- Department of Cardiovascular Medicine, Juntendo University Shizuoka Hospital, Izunokuni, Japan
- Department of Healthcare Quality Assessment, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
- Department of Cardiology, Kyoto University, Kyoto, Japan
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Gunma, Japan
- Department of Cardiology, Aichi Medical University, Nagakute, Japan
- Department of Cardiology, Teikyo University Hospital, Tokyo, Japan
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Stevenson MJ, Kenigsberg BB, Singam NSV, Papolos AI. Shock Teams: A Contemporary Review. Curr Cardiol Rep 2023; 25:1657-1663. [PMID: 37861851 DOI: 10.1007/s11886-023-01983-7] [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] [Accepted: 10/11/2023] [Indexed: 10/21/2023]
Abstract
PURPOSE OF REVIEW Cardiogenic shock (CS) is a time-sensitive and often fatal condition. To address this issue, many centers have developed multidisciplinary shock teams with a common goal of expediting the recognition and treatment of CS. In this review, we examine the mission, structure, implementation, and outcomes reported by these early shock teams. RECENT FINDINGS To date, there have been four observational shock team analyses, each providing unique insight into the utility of the shock team. The limited available data supports that shock teams are associated with improved CS mortality. However, there is considerable operational heterogeneity among shock teams, and randomized data assessing their value and best practices in both local and regional care models are needed.
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Affiliation(s)
- Margaret J Stevenson
- Department of Critical Care and Division of Cardiology, MedStar Washington Hospital Center, 110 Irving St NW, Suite 1A-27, Washington, DC, 20010, USA
| | - Benjamin B Kenigsberg
- Department of Critical Care and Division of Cardiology, MedStar Washington Hospital Center, 110 Irving St NW, Suite 1A-27, Washington, DC, 20010, USA
| | - Narayana Sarma V Singam
- Department of Critical Care and Division of Cardiology, MedStar Washington Hospital Center, 110 Irving St NW, Suite 1A-27, Washington, DC, 20010, USA
| | - Alexander I Papolos
- Department of Critical Care and Division of Cardiology, MedStar Washington Hospital Center, 110 Irving St NW, Suite 1A-27, Washington, DC, 20010, USA.
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5
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Kochan A, Lee T, Moghaddam N, Milley G, Singer J, Cairns JA, Wong GC, Jentzer JC, van Diepen S, Alviar C, Fordyce CB. Reperfusion Delays and Outcomes Among Patients With ST-Segment-Elevation Myocardial Infarction With and Without Cardiogenic Shock. Circ Cardiovasc Interv 2023; 16:e012810. [PMID: 37339233 DOI: 10.1161/circinterventions.122.012810] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 04/18/2023] [Indexed: 06/22/2023]
Abstract
BACKGROUND Mortality remains high in patients with ST-segment-elevation myocardial infarction (STEMI) complicated by cardiogenic shock (CS), and early reperfusion has been shown to improve outcomes. We analyzed the association between first medical contact (FMC)-to-percutaneous coronary angiography time with mortality and major adverse cardiovascular events among patients with STEMI with and without CS. METHODS We performed a retrospective analysis of the Vancouver Coastal Health Authority STEMI registry, including all patients with STEMI who received primary percutaneous coronary angiography between January 1, 2010, and December 31, 2020, and stratified them by presence or absence of CS at hospital arrival. The primary outcome was in-hospital mortality, the secondary outcome was in-hospital major adverse cardiovascular events, defined as a composite of the first occurrence of mortality, cardiac arrest, heart failure, intracerebral hemorrhage, cerebrovascular accident, or reinfarction. Mixed effects logistic regression with restricted cubic splines was used to estimate the relationships between FMC-to-device time and the outcomes in the CS and non-CS groups. RESULTS 2929 patients were included, 9.4% (n=275) had CS. Median FMC-to-device time was 113.5 (interquartile range, 93.0-145.0) and 103.0 (interquartile range, 85.0-130.0) minutes for patients with CS and without CS, respectively. More patients with CS had FMC-to-device times above guideline recommendations (76.6% versus 54.1%, P<0.001). Between 60 and 90 minutes, for each 10-minute increase in FMC-to-device time, absolute mortality for patients with CS increased by 4% to 7%, whereas for patients without CS, it increased by <0.5%. CONCLUSIONS Among patients with STEMI undergoing primary percutaneous coronary angiography, reperfusion delays among patients with CS are associated with significantly worse outcomes. Strategies to reduce FMC-to-device times for patients with STEMI presenting with CS are required.
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Affiliation(s)
- Andrew Kochan
- Division of Cardiology, Department of Medicine (A.K., J.A.C., G.C.W., C.B.F.), University of British Columbia, Vancouver, Canada
| | - Terry Lee
- Centre for Health Evaluation and Outcome Sciences, Providence Health Care Research Institute (T.L., J.S.), University of British Columbia, Vancouver, Canada
| | - Nima Moghaddam
- Division of Cardiology, Department of Medicine, Duke University, Durham, NC (N.M.)
| | - Grace Milley
- Division of Cardiology, Department of Medicine, Duke University, Durham, NC (N.M.)
| | - Joel Singer
- Centre for Health Evaluation and Outcome Sciences, Providence Health Care Research Institute (T.L., J.S.), University of British Columbia, Vancouver, Canada
| | - John A Cairns
- Division of Cardiology, Department of Medicine (A.K., J.A.C., G.C.W., C.B.F.), University of British Columbia, Vancouver, Canada
| | - Graham C Wong
- Division of Cardiology, Department of Medicine (A.K., J.A.C., G.C.W., C.B.F.), University of British Columbia, Vancouver, Canada
| | - Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (J.C.J.)
| | - Sean van Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Canada (S.v.D.)
| | - Carlos Alviar
- The Leon H. Charney Division of Cardiovascular Medicine, New York University Grossman School of Medicine, NY (C.A.)
| | - Christopher B Fordyce
- Division of Cardiology, Department of Medicine (A.K., J.A.C., G.C.W., C.B.F.), University of British Columbia, Vancouver, Canada
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Inflammatory cell response following ST-elevation myocardial infarction treated with primary percutaneous coronary intervention and its impact on cardiovascular outcomes: A systematic review and meta-analysis. Int J Cardiol 2023; 376:1-10. [PMID: 36758862 DOI: 10.1016/j.ijcard.2023.01.082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 01/21/2023] [Accepted: 01/30/2023] [Indexed: 02/10/2023]
Abstract
BACKGROUND Inflammatory responses post STEMI may mediate major adverse cardiovascular events (MACE). This is the first systematic review to map leukocyte response following a STEMI and its association with outcomes. METHODS We systematically searched EMBASE and Medline for studies of STEMIs undergoing primary PCI. Eligible studies reported leukocytes or its subtype plus either 30-day and/or 1-year MACE. Random effects model for pooled proportions was used to estimate 30-day and 1-year mortality and MACE. Meta-regression was used to estimate the effect of leukocyte counts on cardiovascular outcomes. Publication bias was assessed using Egger's regression-based test. The review was registered with PROSPERO (CRD42019124991). RESULTS Of the 3,813 studies meeting the preliminary search criteria, 24 cohort studies were eligible for inclusion, representing 19,074 persons [76.4% male (n = 14,539); mean age 61.6 years]. Leukocytes had a mean of 10.5x109 (SD 4.7) on admission and 11.1x109 (SD 3.3) at day one post STEMI. Neutrophils increased day one post STEMI, while lymphocytes decreased. There was limited data on other leukocyte subtypes and beyond day one. Estimated 30-day and 1-year all-cause mortality were 6.5% (95% CI 4.8-8.2, p <0.001) and 9.7% (95% CI 5.6-13.8, p <0.001), while the estimated 30-day and 1-year MACE were 14.9% (95% CI 5.3-24.4, p < 0.001) and 15.2% (95% CI 7.2-23.2, p < 0.001). The meta-analysis was limited by a high degree of heterogeneity between studies. CONCLUSIONS This review highlights the urgent need to better characterise inflammation post STEMI to identify mediators for the persistently high mortality and morbidity associated with STEMI.
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Oristrell G, Ribera A. [Evolution of the prognosis of acute myocardial infarction]. Med Clin (Barc) 2023; 160:118-120. [PMID: 36049971 DOI: 10.1016/j.medcli.2022.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 07/14/2022] [Accepted: 07/15/2022] [Indexed: 02/06/2023]
Affiliation(s)
- Gerard Oristrell
- Servicio de Cardiología, Hospital Universitario Vall d'Hebron, Barcelona, España; Centro de Investigación Biomédica en Red - Enfermedades Cardiovasculares (CIBER CV), Madrid, España.
| | - Aida Ribera
- Grupo de Investigación en Envejecimiento, Fragilidad y Transiciones (REFiT), Parc Sanitari Pere Virgili e Instituto de Investigación Vall d'Hebron (VHIR), Barcelona, España; Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), España
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8
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Patlolla SH, Truesdell AG, Basir MB, Rab ST, Singh M, Belford PM, Zhao DX, Vallabhajosyula S. No "July Effect" in the management and outcomes of acute myocardial infarction: An 18-year United States national study. Catheter Cardiovasc Interv 2023; 101:264-273. [PMID: 36617382 DOI: 10.1002/ccd.30553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 12/08/2022] [Accepted: 12/31/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND There has been conflicting reports on the effect of new trainees on clinical outcomes at teaching hospitals in the first training month (July in the United States of America). We sought to assess this "July effect" in a contemporary acute myocardial infarction (AMI) population. METHODS Adult (>18 years) AMI hospitalizations in May and July in urban teaching and urban nonteaching hospitals in the United States were identified from the HCUP-NIS database (2000-2017). In-hospital mortality was compared between May and July admissions. A difference-in-difference analysis comparing a change in outcome from May to July in teaching hospitals to a change in outcome from May to July in nonteaching hospitals was also performed. RESULTS A total of 1,312,006 AMI hospitalizations from urban teaching (n = 710,593; 54.2%) or nonteaching (n = 601,413; 45.8%) hospitals in the months of May and July were evaluated. May admissions in teaching hospitals, had greater comorbidity, higher rates of acute multiorgan failure (10.6% vs. 10.2%, p < 0.001) and lower rates of cardiac arrest when compared to July admissions. July AMI admissions had lower in-hospital mortality compared to May (5.6% vs. 5.8%; adjusted odds ratio 0.94 [95% confidence interval 0.92-0.97]; p < 0.001) in teaching hospitals. Using the difference-in-difference model, there was no evidence of a July effect for in-hospital mortality (p = 0.19). CONCLUSIONS There was no July effect for in-hospital mortality in this contemporary AMI population.
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Affiliation(s)
- Sri Harsha Patlolla
- Staten Island University Hospital, Northwell Health, Staten Island, New York, USA
| | | | - Mir B Basir
- Division of Cardiovascular Medicine, Henry Ford Hospital and Health System, Detroit, Michigan, USA
| | - Syed T Rab
- Division of Cardiovascular Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Mandeep Singh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Peter Matthew Belford
- Department of Medicine, Section of Cardiovascular Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - David X Zhao
- Department of Medicine, Section of Cardiovascular Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Saraschandra Vallabhajosyula
- Department of Medicine, Section of Cardiovascular Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
- Department of Implementation Science, Section of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
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9
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Ma J, Zhou S, Li N, Dong X, Maimaitiming M, Yue D, Jin Y, Zheng ZJ. Quality of healthcare and admission rates for acute cardiac events during COVID-19 pandemic: a retrospective cohort study on ST-segment-elevation myocardial infarction in China. BMJ Open 2022; 12:e059720. [PMID: 36357000 PMCID: PMC9659714 DOI: 10.1136/bmjopen-2021-059720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To evaluate changes in admission rates for and quality of healthcare of ST-segment-elevation myocardial infarction (STEMI) during the period of the COVID-19 outbreak and postoutbreak. METHODS We conducted a retrospective study among patients with STEMI in the outbreak time and the postoutbreak time. DESIGN To examine the changes in the admission rates and in quality of healthcare, by comparison between periods of the postoutbreak and the outbreak, and between the postoutbreak and the corresponding periods. SETTING Data for this analysis were included from patients discharge diagnosed with STEMI from all the hospitals of Suzhou in each month of the year until the end of July 2020. PARTICIPANTS 1965 STEMI admissions. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome was the number of moecondary outcomnthly STEMI admissions, and the secondary outcomes were the quality metrics of STEMI healthcare. RESULTS There were a 53% and 38% fall in daily admissions at the phase of outbreak and postoutbreak, compared with the 2019 corresponding. There remained a gap in actual number of postoutbreak admissions at 306 and the predicted number at 497, an estimated 26 deaths due to STEMI would have been caused by not seeking healthcare. Postoutbreak period of 2020 compared with corresponding period of 2019, the percentage of cases transferred by ambulance decreased from 9.3% to 4.2% (p=0.013), the door-to-balloon median time increased from 17.5 to 34.0 min (p=0.001) and the rate of percutaneous coronary intervention (PCI) therapy declined from 71.3% to 60.1% (p=0.002). CONCLUSIONS The impact of public health restrictions may lead to unexpected out-of-hospital deaths and compromised quality of healthcare for acute cardiac events. Delay or absence in patients should be continuously considered avoiding the secondary disaster of the pandemic. System delay should be modifiable for reversing the worst clinical outcomes from the COVID-19 outbreak, by coordination measures with focus on the balance between timely PCI procedure and minimising contamination of cardiac catheterisation rooms.
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Affiliation(s)
- Junxiong Ma
- Department of Global Health, School of Public Health, Peking University, Beijing, China
- Institute for Global Health and Development, Peking University, Beijing, China
| | - Shuduo Zhou
- Department of Global Health, School of Public Health, Peking University, Beijing, China
- Institute for Global Health and Development, Peking University, Beijing, China
| | - Na Li
- Department of Global Health, School of Public Health, Peking University, Beijing, China
- Institute for Global Health and Development, Peking University, Beijing, China
| | - Xuejie Dong
- Department of Global Health, School of Public Health, Peking University, Beijing, China
- Institute for Global Health and Development, Peking University, Beijing, China
| | - Mailikezhati Maimaitiming
- Department of Global Health, School of Public Health, Peking University, Beijing, China
- Institute for Global Health and Development, Peking University, Beijing, China
| | - Dahai Yue
- Department of Health Policy and Management, University of Maryland at College Park, College Park, Maryland, USA
| | - Yinzi Jin
- Department of Global Health, School of Public Health, Peking University, Beijing, China
- Institute for Global Health and Development, Peking University, Beijing, China
| | - Zhi-Jie Zheng
- Department of Global Health, School of Public Health, Peking University, Beijing, China
- Institute for Global Health and Development, Peking University, Beijing, China
- Bill & Melinda Gates Foundation China Office, Beijing, China
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Primary Percutaneous Coronary Intervention and Application of the Pharmacoinvasive Approach Within ST-Elevation Myocardial Infarction Care Networks. Can J Cardiol 2022; 38:S5-S16. [PMID: 33838227 DOI: 10.1016/j.cjca.2021.02.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 02/12/2021] [Accepted: 02/13/2021] [Indexed: 12/30/2022] Open
Abstract
The management of acute ST-elevation myocardial infarction (STEMI) has transitioned from observation and reactive treatment of hemodynamic and arrhythmic complications to accelerated reperfusion and application of evidence-based treatment to minimize morbidity and mortality. International research established the importance of timely reperfusion therapy and the application of fibrinolysis, primary percutaneous coronary intervention (PCI), and subsequent development of the pharmacoinvasive approach. Clinician thought leaders developed and investigated comprehensive systems of care to optimize the outcomes of patients with STEMI, with a key focus in Canada being the integration of prehospital paramedics in diagnosis, triage, and treatment. This article will review highlights of these interventions and identify future challenges and opportunities in STEMI patient care.
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Ashburn NP, Snavely AC, Angi RM, Scheidler JF, Crowe RP, McGinnis HD, Hiestand BC, Miller CD, Mahler SA, Stopyra JP. Prehospital time for patients with acute cardiac complaints: A rural health disparity. Am J Emerg Med 2022; 52:64-68. [PMID: 34871845 PMCID: PMC9029257 DOI: 10.1016/j.ajem.2021.11.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 10/29/2021] [Accepted: 11/24/2021] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVE Delays in care for patients with acute cardiac complaints are associated with increased morbidity and mortality. The objective of this study was to quantify rural and urban differences in prehospital time intervals for patients with cardiac complaints. METHODS The ESO Data Collaborative dataset consisting of records from 1332 EMS agencies was queried for 9-1-1 encounters with acute cardiac problems among adults (age ≥ 18) from 1/1/2013-6/1/2018. Location was classified as rural or urban using the 2010 United States Census. The primary outcome was total prehospital time. Generalized estimating equations evaluated differences in the average times between rural and urban encounters while controlling for age, sex, race, transport mode, loaded mileage, and patient stability. RESULTS Among 428,054 encounters, the median age was 62 (IQR 50-75) years with 50.7% female, 75.3% white, and 10.3% rural. The median total prehospital, response, scene, and transport times were 37.0 (IQR 29.0-48.0), 6.0 (IQR 4.0-9.0), 16.0 (IQR 12.0-21.0), and 13.0 (IQR 8.0-21.0) minutes. Rural patients had an average total prehospital time that was 16.76 min (95%CI 15.15-18.38) longer than urban patients. After adjusting for covariates, average total time was 5.08 (95%CI 4.37-5.78) minutes longer for rural patients. Average response and transport time were 4.36 (95%CI 3.83-4.89) and 0.62 (95%CI 0.33-0.90) minutes longer for rural patients. Scene time was similar in rural and urban patients (0.09 min, 95%CI -0.15-0.33). CONCLUSION Rural patients with acute cardiac complaints experienced longer prehospital time than urban patients, even after accounting for other key variables, such as loaded mileage.
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Affiliation(s)
- Nicklaus P Ashburn
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC, United States of America.
| | - Anna C Snavely
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC, United States of America; Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, NC, United States of America
| | - Ryan M Angi
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC, United States of America
| | - James F Scheidler
- Department of Emergency Medicine, West Virginia University, Morgantown, WV, United States of America
| | | | - Henderson D McGinnis
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC, United States of America
| | - Brian C Hiestand
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC, United States of America
| | - Chadwick D Miller
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC, United States of America
| | - Simon A Mahler
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC, United States of America
| | - Jason P Stopyra
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC, United States of America
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12
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Walton NT, Mohr NM. Concept review of regionalized systems of acute care: Is regionalization the next frontier in sepsis care? J Am Coll Emerg Physicians Open 2022; 3:e12631. [PMID: 35024689 PMCID: PMC8733842 DOI: 10.1002/emp2.12631] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 11/21/2021] [Accepted: 11/23/2021] [Indexed: 11/10/2022] Open
Abstract
Regionalization has become a buzzword in US health care policy. Regionalization, however, has varied meanings, and definitions have lacked contextual information important to understanding its role in improving care. This concept review is a comprehensive primer and summation of 8 common core components of the national models of regionalization informed by text-based analysis of the writing of involved organizations (professional, regulatory, and research) guided by semistructured interviews with organizational leaders. Further, this generalized model of regionalized care is applied to sepsis care, a novel discussion, drawing on existing small-scale applications. This discussion highlights the fit of regionalization principles to the sepsis care model and the actualized and perceived potential benefits. The principal aim of this concept review is to outline regionalization in the United States and provide a roadmap and novel discussion of regionalized care integration for sepsis care.
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Affiliation(s)
| | - Nicholas M. Mohr
- Departments of Emergency Medicine, Anesthesia‐Critical Care Medicine, and EpidemiologyUniversity of Iowa–Carver College of MedicineIowa CityIowaUSA
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13
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Loccoh EC, Maddox KEJ, Wang Y, Kazi DS, Yeh RW, Wadhera RK. Rural-Urban Disparities in Outcomes of Myocardial Infarction, Heart Failure, and Stroke in the United States. J Am Coll Cardiol 2022; 79:267-279. [PMID: 35057913 PMCID: PMC8958031 DOI: 10.1016/j.jacc.2021.10.045] [Citation(s) in RCA: 68] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 10/22/2021] [Indexed: 01/27/2023]
Abstract
BACKGROUND U.S. policy efforts have focused on reducing rural-urban health inequities. However, it is unclear whether gaps in care and outcomes remain among older adults with acute cardiovascular conditions. OBJECTIVES This study aims to evaluate rural-urban differences in procedural care and mortality for acute myocardial infarction (AMI), heart failure (HF), and ischemic stroke. METHODS This is a retrospective cross-sectional study of Medicare fee-for-service beneficiaries aged ≥65 years with acute cardiovascular conditions from 2016 to 2018. Cox proportional hazards models with random hospital intercepts were fit to examine the association of presenting to a rural (vs urban) hospital and 30- and 90-day patient-level mortality. RESULTS There were 2,182,903 Medicare patients hospitalized with AMI, HF, or ischemic stroke from 2016 to 2018. Patients with AMI were less likely to undergo cardiac catherization (49.7% vs 63.6%, P < 0.001), percutaneous coronary intervention (42.1% vs 45.7%, P < 0.001) or coronary artery bypass graft (9.0% vs 10.2%, P < 0.001) within 30 days at rural versus urban hospitals. Thrombolysis rates (3.1% vs 10.1%, P < 0.001) and endovascular therapy (1.8% vs 3.6%, P < 0.001) for ischemic stroke were lower at rural hospitals. After adjustment for demographics and clinical comorbidities, the 30-day mortality HR was significantly higher among patients presenting to rural hospitals for AMI (HR: 1.10, 95% CI: 1.08 to 1.12), HF (HR: 1.15; 95% CI: 1.13 to 1.16), and ischemic stroke (HR: 1.20; 95% CI: 1.18 to 1.22), with similar patterns at 90 days. These differences were most pronounced for the subset of critical access hospitals that serve remote, rural areas. CONCLUSIONS Clinical, public health, and policy efforts are needed to improve rural-urban gaps in care and outcomes for acute cardiovascular conditions.
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Affiliation(s)
- Eméfah C. Loccoh
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical and Harvard Medical School, Boston, MA,Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | | | - Yun Wang
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical and Harvard Medical School, Boston, MA
| | - Dhruv S. Kazi
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical and Harvard Medical School, Boston, MA
| | - Robert W. Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical and Harvard Medical School, Boston, MA
| | - Rishi K. Wadhera
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical and Harvard Medical School, Boston, MA
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14
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Jacobs AK, Ali MJ, Best PJ, Bieniarz MC, Bufalino VJ, French WJ, Henry TD, Hollowell L, Jauch EC, Kurz MC, Levy M, Patel P, Spier T, Stone RH, Tataris KL, Thomas RJ, Zègre-Hemsey JK. Systems of Care for ST-Segment-Elevation Myocardial Infarction: A Policy Statement From the American Heart Association. Circulation 2021; 144:e310-e327. [PMID: 34641735 DOI: 10.1161/cir.0000000000001025] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The introduction of Mission: Lifeline significantly increased timely access to percutaneous coronary intervention for patients with ST-segment-elevation myocardial infarction (STEMI). In the years since, morbidity and mortality rates have declined, and research has led to significant developments that have broadened our concept of the STEMI system of care. However, significant barriers and opportunities remain. From community education to 9-1-1 activation and emergency medical services triage and from emergency department and interfacility transfer protocols to postacute care, each critical juncture presents unique challenges for the optimal care of patients with STEMI. This policy statement sets forth recommendations for how the ideal STEMI system of care should be designed and implemented to ensure that patients with STEMI receive the best evidence-based care at each stage in their illness.
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15
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Zhang YM, Cheng LC, Zhou MG, Chen YZ, Zhu F, Cui CY, Li SY, Cai L. Effect of regional cooperative rescue systems based on chest pain centers for patients with acute myocardial infarction in a first-tier city in China. Intern Emerg Med 2021; 16:2069-2076. [PMID: 34304351 DOI: 10.1007/s11739-021-02681-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 02/17/2021] [Indexed: 10/20/2022]
Abstract
Given the increasing burden of acute myocardial infarction (AMI) in China, regional cooperative rescue systems have been constructed based on chest pain centers (CPCs). This study evaluated the effects of these regional cooperative rescue systems on reperfusion time and prognosis of AMI patients. This study included 1937 AMI patients, divided into two groups according to the date of admission, group A (July 2017-June 2018) and group B (July 2018-June 2019). Reperfusion time, the fatality rate for any cause during hospitalization, and the incidence of major adverse cardiovascular and cerebrovascular events (MACCE) in the 6 months following discharge were compared between the two groups. The proportion of patients treated within the guideline goals for first medical contact to balloon (FMC-to-B) time showed improvement from 40.7% in group A to 50.4% in group B (P = 0.005). The fatality rate for any cause (5.5% vs. 8.0%, P = 0.026) during hospitalization was lower in the B group compared to the A group. Multivariate logistic regression analysis revealed that the fatality rate for any cause (OR 0.614, 95% CI 0.411-0.918, P = 0.017) was significantly lower in group B compared with group A. No significant differences were detected between the two groups for the incidence of MACCE and death for any cause at 6 months using the log-rank test and multivariate Cox regression analysis. The improvement of regional cooperative rescue systems shortened system delays and reduced in-hospital deaths. Although the system has resulted in some substantial improvements, additional improvement is needed.
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Affiliation(s)
- Yu-Mei Zhang
- Department of Cardiology, Affiliated Hospital of Southwest Jiaotong University, The Third People's Hospital of Chengdu, 82 Qinglong St. Chengdu, Sichuan, China
| | - Lian-Chao Cheng
- Department of Cardiology, Affiliated Hospital of Southwest Jiaotong University, The Third People's Hospital of Chengdu, 82 Qinglong St. Chengdu, Sichuan, China
| | - Ming-Gang Zhou
- Department of Cardiology, Affiliated Hospital of Southwest Jiaotong University, The Third People's Hospital of Chengdu, 82 Qinglong St. Chengdu, Sichuan, China
| | - Ying-Zhong Chen
- Department of Cardiology, Affiliated Hospital of Southwest Jiaotong University, The Third People's Hospital of Chengdu, 82 Qinglong St. Chengdu, Sichuan, China
| | - Feng Zhu
- Department of Cardiology, Affiliated Hospital of Southwest Jiaotong University, The Third People's Hospital of Chengdu, 82 Qinglong St. Chengdu, Sichuan, China
| | - Cai-Yan Cui
- Department of Cardiology, Affiliated Hospital of Southwest Jiaotong University, The Third People's Hospital of Chengdu, 82 Qinglong St. Chengdu, Sichuan, China
| | - Si-Yi Li
- Department of Cardiology, Affiliated Hospital of Southwest Jiaotong University, The Third People's Hospital of Chengdu, 82 Qinglong St. Chengdu, Sichuan, China
| | - Lin Cai
- Department of Cardiology, Affiliated Hospital of Southwest Jiaotong University, The Third People's Hospital of Chengdu, 82 Qinglong St. Chengdu, Sichuan, China.
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16
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Yildiz M, Wade SR, Henry TD. STEMI care 2021: Addressing the knowledge gaps. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2021; 11:100044. [PMID: 34664037 PMCID: PMC8515361 DOI: 10.1016/j.ahjo.2021.100044] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 07/26/2021] [Accepted: 07/27/2021] [Indexed: 12/27/2022]
Abstract
Tremendous progress has been made in the treatment of ST-segment elevation myocardial infarction (STEMI), the most severe and time-sensitive acute coronary syndrome. Primary percutaneous coronary intervention (PCI) is the preferred method of reperfusion, which has stimulated the development of regional STEMI systems of care with standardized protocols designed to optimize care. However, challenges remain for patients with cardiogenic shock, out-of-hospital cardiac arrest, an expected delay to reperfusion (>120 min), in-hospital STEMI, and more recently, those with Covid-19 infection. Ultimately, the goal is to provide timely reperfusion with primary PCI coupled with the optimal antiplatelet and anticoagulant therapies. We review the challenges and provide insights into the remaining knowledge gaps for contemporary STEMI care.
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Key Words
- CCL, cardiac catheterization laboratory
- CS, cardiogenic shock
- Cangrelor
- Cardiogenic shock
- Covid-19
- Covid-19, coronavirus disease 2019
- DAPT, dual antiplatelet therapy
- EMS, emergency medical service
- MCS, mechanical circulatory support
- OHCA, out-of-hospital cardiac arrest
- Out-of-hospital cardiac arrest
- PCI, percutaneous coronary intervention
- Regional systems
- SARS-CoV-2, severe acute respiratory syndrome coronavirus-2
- ST-segment elevation myocardial infarction
- STEMI, ST-segment elevation myocardial infarction
- TH, therapeutic hypothermia
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Affiliation(s)
- Mehmet Yildiz
- The Carl and Edyth Lindner Center for Research and Education at The Christ Hospital, Cincinnati, OH, United States of America
| | - Spencer R. Wade
- Department of Internal Medicine at The Christ Hospital, Cincinnati, OH, United States of America
| | - Timothy D. Henry
- The Carl and Edyth Lindner Center for Research and Education at The Christ Hospital, Cincinnati, OH, United States of America,Corresponding author at: The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital Health Network, 2123 Auburn Avenue Suite 424, Cincinnati, OH 45219, United States of America
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17
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Li N, Ma J, Zhou S, Dong X, Maimaitiming M, Jin Y, Zheng Z. Can a Healthcare Quality Improvement Initiative Reduce Disparity in the Treatment Delay among ST-Segment Elevation Myocardial Infarction Patients with Different Arrival Modes? Evidence from 33 General Hospitals and Their Anticipated Impact on Healthcare during Disasters and Public Health Emergencies. Healthcare (Basel) 2021; 9:1462. [PMID: 34828508 PMCID: PMC8621169 DOI: 10.3390/healthcare9111462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 10/25/2021] [Accepted: 10/26/2021] [Indexed: 11/18/2022] Open
Abstract
(1) Background: Chest pain center accreditation has been associated with improved timelines of primary percutaneous coronary intervention (PCI) for ST-segment elevated myocardial infarction (STEMI). However, evidence from low- and middle-income regions was insufficient, and whether the sensitivity to improvements differs between walk-in and emergency medical service (EMS)-transported patients remained unclear. In this study, we aimed to examine the association of chest pain center accreditation status with door-to-balloon (D2B) time and the potential modification effect of arrival mode. (2) Methods: The associations were examined using generalized linear mixed models, and the effect modification of arrival mode was examined by incorporating an interaction term in the models. (3) Results: In 4186 STEMI patients, during and after accreditation were respectively associated with 65% (95% CI: 54%, 73%) and 71% (95% CI: 61%, 79%) reduced risk of D2B time being more than 90 min (using before accreditation as the reference). Decreases of 27.88 (95% CI: 19.57, 36.22) minutes and 26.55 (95% CI: 17.45, 35.70) minutes in D2B were also observed for the during and after accreditation groups, respectively. The impact of accreditation on timeline improvement was greater for EMS-transported patients than for walk-in patients. (4) Conclusions: EMS-transported patients were more sensitive to the shortened in-hospital delay associated with the initiative, which could exacerbate the existing disparity among patients with different arrival modes.
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Affiliation(s)
- Na Li
- Department of Global Health, School of Public Health, Peking University, Beijing 100871, China; (N.L.); (J.M.); (S.Z.); (X.D.); (Z.Z.)
- Institute for Global Health and Development, Peking University, Beijing 100871, China
| | - Junxiong Ma
- Department of Global Health, School of Public Health, Peking University, Beijing 100871, China; (N.L.); (J.M.); (S.Z.); (X.D.); (Z.Z.)
- Institute for Global Health and Development, Peking University, Beijing 100871, China
| | - Shuduo Zhou
- Department of Global Health, School of Public Health, Peking University, Beijing 100871, China; (N.L.); (J.M.); (S.Z.); (X.D.); (Z.Z.)
- Institute for Global Health and Development, Peking University, Beijing 100871, China
| | - Xuejie Dong
- Department of Global Health, School of Public Health, Peking University, Beijing 100871, China; (N.L.); (J.M.); (S.Z.); (X.D.); (Z.Z.)
- Institute for Global Health and Development, Peking University, Beijing 100871, China
| | | | - Yinzi Jin
- Department of Global Health, School of Public Health, Peking University, Beijing 100871, China; (N.L.); (J.M.); (S.Z.); (X.D.); (Z.Z.)
- Institute for Global Health and Development, Peking University, Beijing 100871, China
| | - Zhijie Zheng
- Department of Global Health, School of Public Health, Peking University, Beijing 100871, China; (N.L.); (J.M.); (S.Z.); (X.D.); (Z.Z.)
- Institute for Global Health and Development, Peking University, Beijing 100871, China
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18
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Temporal Trends in Post Myocardial Infarction Heart Failure and Outcomes Among Older Adults. J Card Fail 2021; 28:531-539. [PMID: 34624511 DOI: 10.1016/j.cardfail.2021.09.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Revised: 09/01/2021] [Accepted: 09/01/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND We sought to determine national trends and long term outcomes of post myocardial infarction (MI) heart failure. An MI can be complicated by heart failure; there are limited data describing the contemporary patterns and clinical implications of post-MI heart failure. METHODS AND RESULTS We studied patients with an MI aged 65 years or older from 2000 to 2013 in a Medicare database. New-onset heart failure after an MI was defined as either heart failure during the index MI admission or a hospitalization for heart failure within 1 year of the index MI event. A trend analysis of the incidence of heart failure was performed, and differences were examined by Gray tests. The 5-year mortality rates were evaluated and differences among heart failure cohorts were ascertained by Gray tests. There were a total of 1,531,638 patients with an MI and 565,291 patients had heart failure (36.0%). The rate of heart failure during index admission was 32.3% and the frequency of heart failure hospitalization within 1 year was 10.4%. Patients with heart failure were older (81 years vs 77 years). The temporal trend from 2001 to 2012 suggested a decrease in the incidence of heart failure during index admission (2001: 34.7%, 2012: 31.2%, Ptrend < .01), as well as heart failure hospitalization within 1 year (2001: 11.3%, 2012: 8.7%, Ptrend < .01). The 5-year mortality rate among patients without heart failure was 38.4% and for patients with any heart failure it was 68.7%. CONCLUSIONS Post-MI heart failure in older adults occurs in 1 in 3 patients within 1 year; heart failure portends significantly higher long-term mortality.
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19
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Elijovich L, Dornbos Iii D, Nickele C, Alexandrov A, Inoa-Acosta V, Arthur AS, Hoit D. Automated emergent large vessel occlusion detection by artificial intelligence improves stroke workflow in a hub and spoke stroke system of care. J Neurointerv Surg 2021; 14:704-708. [PMID: 34417344 DOI: 10.1136/neurintsurg-2021-017714] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 07/17/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND Emergent large vessel occlusion (ELVO) acute ischemic stroke is a time-sensitive disease. OBJECTIVE To describe our experience with artificial intelligence (AI) for automated ELVO detection and its impact on stroke workflow. METHODS We conducted a retrospective chart review of code stroke cases in which VizAI was used for automated ELVO detection. Patients with ELVO identified by VizAI were compared with patients with ELVO identified by usual care. Details of treatment, CT angiography (CTA) interpretation by blinded neuroradiologists, and stroke workflow metrics were collected. Univariate statistical comparisons and linear regression analysis were performed to quantify time savings for stroke metrics. RESULTS Six hundred and eighty consecutive code strokes were evaluated by AI; 104 patients were diagnosed with ELVO during the study period. Forty-five patients with ELVO were identified by AI and 59 by usual care. Sixty-nine mechanical thrombectomies were performed.Median time from CTA to team notification was shorter for AI ELVOs (7 vs 26 min; p<0.001). Door to arterial puncture was faster for transfer patients with ELVO detected by AI versus usual care transfer patients (141 vs 185 min; p=0.027). AI yielded a time savings of 22 min for team notification and a 23 min reduction in door to arterial puncture for transfer patients. CONCLUSIONS AI automated alerts can be incorporated into a comprehensive stroke center hub and spoke system of care. The use of AI to detect ELVO improves clinically meaningful stroke workflow metrics, resulting in faster treatment times for mechanical thrombectomy.
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Affiliation(s)
- Lucas Elijovich
- Department of Neurology, University of Tennessee Health Sciences Center, Memphis, TN, USA .,Department of Neurosurgery, Semmes-Murphey Clinic, University of Tennessee Health Sciences Center, Memphis, TN, USA
| | - David Dornbos Iii
- Department of Neurosurgery, Semmes-Murphey Clinic, University of Tennessee Health Sciences Center, Memphis, TN, USA
| | - Christopher Nickele
- Department of Neurosurgery, Semmes-Murphey Clinic, University of Tennessee Health Sciences Center, Memphis, TN, USA
| | - Andrei Alexandrov
- Department of Neurology, University of Tennessee Health Sciences Center, Memphis, TN, USA
| | - Violiza Inoa-Acosta
- Department of Neurology, University of Tennessee Health Sciences Center, Memphis, TN, USA.,Department of Neurosurgery, Semmes-Murphey Clinic, University of Tennessee Health Sciences Center, Memphis, TN, USA
| | - Adam S Arthur
- Department of Neurosurgery, Semmes-Murphey Clinic, University of Tennessee Health Sciences Center, Memphis, TN, USA
| | - Daniel Hoit
- Department of Neurosurgery, Semmes-Murphey Clinic, University of Tennessee Health Sciences Center, Memphis, TN, USA
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20
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Sturm RC, Jones TL, Youngquist ST, Shah RU. Regional Systems of Care in ST Elevation Myocardial Infarction. Interv Cardiol Clin 2021; 10:281-291. [PMID: 34053615 DOI: 10.1016/j.iccl.2021.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
ST-segment elevation myocardial infarction is a medical emergency with significant health care delivery challenges to ensure rapid triage and treatment. Several developments over the past decades have led to improved care delivery, decreased time to reperfusion, and decreased mortality. Still, significant challenges remain to further optimize the delivery of care for this patient population.
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Affiliation(s)
- Robert C Sturm
- Division of Cardiovascular Medicine, University of Utah, 30 N. 1900 E, Room 4A100, Salt Lake City, UT, 84132, USA.
| | - Tara L Jones
- Division of Cardiovascular Medicine, University of Utah, 30 N. 1900 E, Room 4A100, Salt Lake City, UT, 84132, USA
| | - Scott T Youngquist
- Division of Emergency Medicine, University of Utah, 30 N 1900 E 1C026, Salt Lake City, UT 84132, USA
| | - Rashmee U Shah
- Division of Cardiovascular Medicine, University of Utah, 30 N. 1900 E, Room 4A100, Salt Lake City, UT, 84132, USA
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21
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Salwan R, Seth A. Development of ST-elevation Myocardial Infarction Programs in Developing Countries: Global Challenges and Solutions. Interv Cardiol Clin 2021; 10:401-411. [PMID: 34053626 DOI: 10.1016/j.iccl.2021.03.010] [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: 11/30/2022]
Abstract
Cardiovascular disease (CVD) is the leading cause of death worldwide; approximately 80% of CVD deaths occur in low-income and middle-income countries (LMICs). The epidemiologic transition to a high burden of ischemic heart disease (IHD) has happened with greater rapidity in LMICs than in high-income countries. The absolute number of individuals with premature IHD has increased substantially. Higher event rates are observed compared with high-income countries. The technological capability to do extraordinary things for patients has increased, as has patient demand, in a setting of constrained resources and expensive health care of variable quality.
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Affiliation(s)
- Roopa Salwan
- Max Super Speciality Hospital, Saket, New Delhi 110017, India
| | - Ashok Seth
- Fortis Escorts Heart Institute, Okhla Road, New Delhi 110025, India.
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22
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Yang Y, Wang Q, Cai X, Wei Z, Hou J, Fei Y, Li W, Li Y. Activin receptor-like kinase 4 haplodeficiency alleviates the cardiac inflammation and pacing-induced ventricular arrhythmias after myocardial infarction. Aging (Albany NY) 2021; 13:17473-17488. [PMID: 34214050 PMCID: PMC8312420 DOI: 10.18632/aging.203236] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 03/26/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Inflammation process is an important determinant for subsequent changes in cardiac function and remodeling after acute myocardial infarction (MI). Recent studies have implicated that ALK4 haplodeficiency improves cardiac function after MI. However, it remains unknown if the beneficial effects are partly attributed to ALK4 haplodeficiency-induced modulation on inflammatory response in the inflammatory phase of MI. In this research, we aimed to explore the mechanism of ALK4 haplodeficiency in the inflammatory stage of MI. METHODS ALK4, CD16, and CD14 were detected in peripheral blood mononuclear cells (PBMCs) isolated from MI patients and healthy volunteers. ALK4 haplodeficiency (ALK4+/-) mice and wild-type (WT) littermates were randomly divided into the sham group and the MI group. Inflammation cytokines and chemokines were measured. Echocardiography and intracardiac electrophysiological recordings were performed on the 3rd day and the 7th day after MI operation. ALK4 expression and inflammation cytokines were also detected in LPS- or IL-4-stimulated bone marrow-derived macrophages (BMDM) from the ALK4+/- mice and WT littermates. RESULTS ALK4 gene expression in circulating monocytes of MI patients was higher than that in those of healthy volunteers. Cardiac inflammation and vulnerability of ventricular arrhythmia after acute myocardial injury are significantly alleviated in ALK4+/- mice as compared to WT littermates. On the 3rd day post-MI, the level of M1 macrophages were decreased in ALK4+/- mice as compared to WT littermates, while the level of M2 macrophages were increased on the 7th day post-MI. BMDM isolated from ALK4+/- mice displayed reduced secretion of pro-inflammation cytokines after stimulation by LPS in hypoxic condition and increased secretion of anti-inflammation cytokines after stimulation by IL-4. As a result, the haplodeficiency of ALK4 might be responsible for reduced inflammation response in the post-MI stage. CONCLUSIONS ALK4 haplodeficiency reduces cardiac inflammation, improves cardiac function, and finally reduces the vulnerability of ventricular arrhythmia in the inflammatory stage after MI.
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Affiliation(s)
- Yuli Yang
- Department of Cardiology, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Qian Wang
- Department of Cardiology, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xingxing Cai
- Department of Cardiology, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Zhixing Wei
- Department of Cardiology, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jianwen Hou
- Department of Cardiology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Yudong Fei
- Department of Cardiology, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Wei Li
- Department of Cardiology, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yigang Li
- Department of Cardiology, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
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23
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Shen Y, Hsia RY. Differential benefits of cardiac care regionalization based on driving time to percutaneous coronary intervention. Acad Emerg Med 2021; 28:519-529. [PMID: 33319420 DOI: 10.1111/acem.14195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 11/25/2020] [Accepted: 12/09/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Patients with ST-elevation myocardial infarction (STEMI) require timely reperfusion, and percutaneous coronary intervention (PCI) decreases morbidity and mortality. Regionalization of STEMI care has increased timeliness and use of PCI, but it is unknown whether benefits to regionalization depend on a community's distance from its nearest PCI center. We sought to determine whether STEMI regionalization benefits, measured by access to PCI centers, timeliness of treatment (same-day or in-hospital PCI), and mortality, differ by baseline distance to nearest PCI center. METHODS Using a difference-in-difference-in-differences model, we examined access to PCI-capable hospitals, receipt of PCI either on the day of admission or during the care episode, and health outcomes for patients hospitalized from January 1, 2006, to September 30, 2015. RESULTS Of 139,408 patients (2006 to 2015), 51% could reach the nearest PCI center in <30 minutes, and 49% required ≥30 minutes driving time. For communities with baseline access ≥30 minutes, regionalization increased the probability of admission to a PCI-capable hospital by 9.4% and also increased the likelihood of receiving same-day PCI (by 11.2%) and PCI during the hospitalization (by 7.4%). Patients living within 30 minutes did not accrue significant benefits (measured by admission to a PCI-capable hospital or receipt of PCI) from regionalization initiatives. Regionalization more than halved access disparities and completely eliminated treatment disparities between communities ≥30 minutes and communities <30 minutes from the nearest PCI hospital. CONCLUSIONS Measured by likelihood of admission to a PCI-capable facility and receipt of PCI, benefits of STEMI regionalization in California accrued only to patients whose nearest PCI center was ≥30 minutes away. We found no mortality benefits of regionalization based on distance from PCI center. Our results suggest that policymakers focus STEMI regionalization efforts in communities that are not already well serviced by PCI-capable hospitals.
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Affiliation(s)
- Yu‐Chu Shen
- Graduate School of Defense Management Naval Postgraduate School Monterey California USA
- National Bureau of Economic Research Cambridge Massachusetts USA
| | - Renee Y. Hsia
- Department of Emergency Medicine University of California at San Francisco San Francisco California USA
- Philip R. Lee Institute for Health Policy StudiesUniversity of California at San Francisco San Francisco California USA
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24
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Zhou S, Dong X, Liu F, Zhang Y, Yue D, Zhou Q, Jin Y, Zheng ZJ. A stepped wedge cluster randomized control trial to evaluate the implementation and effectiveness of optimized initiatives in improving quality of care for ST segment elevation myocardial infarction in response to the COVID-19 outbreak. Implement Sci 2021; 16:38. [PMID: 33845863 PMCID: PMC8040354 DOI: 10.1186/s13012-021-01107-1] [Citation(s) in RCA: 4] [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: 02/16/2021] [Accepted: 03/29/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The National Chest Pain Center Accreditation Program (CHANGE) is the first hospital-based, multifaceted, nationwide quality improvement (QI) initiative, to monitor and improve the quality of the ST segment elevation myocardial infarction (STEMI) care in China. The QI initiatives, as implementation strategies, include a bundle of evidence-based interventions adapted for implementation in China. During the pandemic of coronavirus disease 2019 (COVID-19), fear of infection with severe acute respiratory syndrome coronavirus 2, national lockdowns, and altered health care priorities have highlighted the program's importance in improving STEMI care quality. This study aims to minimize the adverse impact of the COVID-19 pandemic on the quality of STEMI care, by developing interventions that optimize the QI initiatives, implementing and evaluating the optimized QI initiatives, and developing scale-up activities of the optimized QI initiatives in response to COVID-19 and other public health emergencies. METHODS A stepped wedge cluster randomized control trial will be conducted in three selected cities of China: Wuhan, Suzhou, and Shenzhen. Two districts have been randomly selected in each city, yielding a total of 24 registered hospitals. This study will conduct a rollout in these hospitals every 3 months. The 24 hospitals will be randomly assigned to four clusters, and each cluster will commence the intervention (optimized QI initiatives) at one of the four steps. We will conduct hospital-based assessments, questionnaire surveys among health care providers, community-based household surveys, and key informant interviews during the trial. All outcome measures will be organized using the RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework, including implementation outcomes, service outcomes (e.g., treatment time), and patient outcomes (e.g., in-hospital mortality and 1-year complication). The Consolidated Framework for Implementation Research framework will be used to identify factors that influence implementation of the optimized QI interventions. DISCUSSION The study findings could be translated into a systematic solution to implementing QI initiatives in response to COVID-19 and future potential major public health emergencies. Such actionable knowledge is critical for implementors of scale-up activities in low- and middle-income settings. TRIAL REGISTRATION ChiCTR 2100043319 . Registered on 10 February 2021.
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Affiliation(s)
- Shuduo Zhou
- Department of Global Health, School of Public Health, Peking University, 38 Xue Yuan Road, Haidian District, Beijing, 100191, China
- Institute for Global Health, Peking University, Beijing, China
| | - Xuejie Dong
- Department of Global Health, School of Public Health, Peking University, 38 Xue Yuan Road, Haidian District, Beijing, 100191, China
- Institute for Global Health, Peking University, Beijing, China
| | - Fangjing Liu
- Department of Global Health, School of Public Health, Peking University, 38 Xue Yuan Road, Haidian District, Beijing, 100191, China
- Institute for Global Health, Peking University, Beijing, China
| | - Yan Zhang
- Institute of Cardiovascular Disease, Peking University First Hospital, Beijing, China
| | - Dahai Yue
- University of Maryland, College Park, USA
| | - Qiang Zhou
- Shenzhen Center for Prehospital Care, Shenzhen, China
| | - Yinzi Jin
- Department of Global Health, School of Public Health, Peking University, 38 Xue Yuan Road, Haidian District, Beijing, 100191, China.
- Institute for Global Health, Peking University, Beijing, China.
| | - Zhi-Jie Zheng
- Department of Global Health, School of Public Health, Peking University, 38 Xue Yuan Road, Haidian District, Beijing, 100191, China
- Institute for Global Health, Peking University, Beijing, China
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25
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Cordero A, Cid-Alvarez B, Alegría E, Fernández-Cisnal A, Escribano D, Bautista J, Juskova M, Trillo R, Bertomeu-Gonzalez V, Ferreiro JL. Multicenter and all-comers validation of a score to select patients for manual thrombectomy, the DDTA score. Catheter Cardiovasc Interv 2021; 98:E342-E350. [PMID: 33829625 DOI: 10.1002/ccd.29689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 03/08/2021] [Accepted: 03/24/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND Routine manual thrombectomy (MT) is not recommended in primary percutaneous coronary intervention (P-PCI) but it is performed in many procedures. The objective of our study was validating the DDTA score, designed for selecting patients who benefit most from MT. METHODS Observational and multicenter study of all consecutive patients undergoing P-PCI in five institutions. Results were compared with the design cohort and the performance of the DDTA was analyzed in all patients. Primary end-point of the analyses was TIMI 3 after MT; secondary endpoints were final TIMI 3, no-reflow incidence, in-hospital mortality and in-hospital major cardiovascular events (MACE). In-hospital prognosis was assessed by the Zwolle risk score. RESULTS Three hundred forty patients were included in the validation cohort and no differences were observed as compared to the design cohort (618 patients) except for lower use of MT and higher IIb/IIIa inhibitors or drug-eluting stents. The probability of TIMI 3 after MT decreased as delay to P-PCI was higher. If DDTA score, MT was associated to TIMI 3 after MT (OR: 4.11) and final TIMI 3 (OR: 2.44). There was a linear and continuous relationship between DDTA score and all endpoints. DDTA score ≥ 4 was independently associated to lower no-reflow, in-hospital MACE or mortality. The lowest incidence of in-hospital mortality or MACE was in patients who had DDTA score ≥ 4 and Zwolle risk score 0-3. CONCLUSIONS MT is associated to higher rate of final TIMI3 in patients with the DDTA score ≥ 4. Patients with DDTA score ≥ 4 had lower no-reflow and in-hospital complications.
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Affiliation(s)
- Alberto Cordero
- Cardiology Department, Hospital Universitario de San Juan, Alicante, Spain.,Cardiology Department, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Belén Cid-Alvarez
- Cardiology Department, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.,Cardiology Department, Complejo Hospitalario de Santiago, Santiago de Compostela, Santiago, Spain
| | - Eduardo Alegría
- Hospital Universitario de Torrejón, Universidad Francisco de Vitoria, Madrid, Spain
| | | | - David Escribano
- Cardiology Department, Hospital Universitario de San Juan, Alicante, Spain
| | - Jenniffer Bautista
- Cardiology Department, Hospital Universitario Bellvitge, L'Hospitalet de Llobregat, Spain
| | - Maria Juskova
- Cardiology Department, Complejo Hospitalario de Santiago, Santiago de Compostela, Santiago, Spain
| | - Ramiro Trillo
- Cardiology Department, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.,Cardiology Department, Complejo Hospitalario de Santiago, Santiago de Compostela, Santiago, Spain
| | | | - José Luis Ferreiro
- Cardiology Department, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.,Cardiology Department, Hospital Universitario Bellvitge, L'Hospitalet de Llobregat, Spain
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26
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Shen YC, Krumholz H, Hsia RY. Association of Cardiac Care Regionalization With Access, Treatment, and Mortality Among Patients With ST-Segment Elevation Myocardial Infarction. Circ Cardiovasc Qual Outcomes 2021; 14:e007195. [PMID: 33641339 DOI: 10.1161/circoutcomes.120.007195] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Regionalization of ST-segment elevation myocardial infarction (STEMI) systems of care has been championed over the past decade. Although timely access to percutaneous coronary intervention (PCI) has been shown to improve outcomes, no studies have determined how regionalization has affected the care and outcomes of patients. We sought to determine if STEMI regionalization is associated with changes in access, treatment, and outcomes. METHODS Using a difference-in-differences approach, we analyzed a statewide, administrative database of 139 494 patients with STEMI in California from 2006 to 2015 using regionalization data based on a survey of all local Emergency Medical Services agencies in the state. RESULTS For patients with STEMI, the base rate of admission to a hospital with PCI capability was 72.7%, and regionalization was associated with an increase of 5.34 percentage points (95% CI, 1.58-9.10), representing a 7.1% increase. Regionalization was also associated with a statistically significant increase of 3.54 (95% CI, 0.61-6.48) percentage points in the probability of same-day PCI, representing an increase of 7.1% from the 49.7% base rate and a 4.6% relative increase (2.97 percentage points [95% CI, 0.1-5.85]) in the probability of receiving PCI at any time during the hospitalization. There was a 1.84 percentage point decrease (95% CI, -3.31 to -0.37) in the probability of receiving fibrinolytics. For 7-day mortality, regionalization was associated with a 0.53 (95% CI, -1 to -0.06) percentage point greater reduction (representing 5.8% off the base rate of 9.1%) and a 1.75 percentage point decrease in the likelihood of all-cause 30-day readmission (95% CI, -3.39 to -0.11; representing 6.4% off the base rate of 27.4%). No differences were found in longer-term mortality. CONCLUSIONS Among patients with STEMI in California from 2006 to 2015, STEMI regionalization was associated with increased access to a PCI-capable hospital, greater use of PCI, lower 7-day mortality, and lower 30-day readmissions.
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Affiliation(s)
- Yu-Chu Shen
- Graduate School of Defense Management, Naval Postgraduate School (Y.-C.S.).,National Bureau of Economic Research (Y.-C.S.)
| | - Harlan Krumholz
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine (H.K.).,Department of Health Policy and Management, Yale School of Public Health (H.K.).,Center for Outcomes Research and Evaluation, Yale-New Haven Hospital (H.K.)
| | - Renee Y Hsia
- Department of Emergency Medicine (R.Y.H.), University of California at San Francisco.,Philip R. Lee Institute for Health Policy Studies (R.Y.H.), University of California at San Francisco
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27
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Murugiah K, Gupta A, Krumholz HM. Time to Reperfusion in ST-Segment Elevation Acute Myocardial Infarction: When Does the Clock Start? Circ Cardiovasc Interv 2021; 14:e010459. [PMID: 33441005 DOI: 10.1161/circinterventions.121.010459] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Karthik Murugiah
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT (K.M., H.M.K.).,Department of Health Policy and Management, Yale School of Public Health, New Haven, CT (K.M., H.M.K.).,Center for Outcomes Research and Evaluation, Yale New Haven Hospital, CT (K.M., A.G., H.M.K.)
| | - Aakriti Gupta
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, CT (K.M., A.G., H.M.K.).,Division of Cardiovascular Medicine, Department of Internal Medicine, Columbia University Irving Medical Center, New York (A.G.)
| | - Harlan M Krumholz
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT (K.M., H.M.K.).,Department of Health Policy and Management, Yale School of Public Health, New Haven, CT (K.M., H.M.K.).,Center for Outcomes Research and Evaluation, Yale New Haven Hospital, CT (K.M., A.G., H.M.K.)
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28
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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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29
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Hsia RY, Krumholz H, Shen YC. Evaluation of STEMI Regionalization on Access, Treatment, and Outcomes Among Adults Living in Nonminority and Minority Communities. JAMA Netw Open 2020; 3:e2025874. [PMID: 33196809 PMCID: PMC7670311 DOI: 10.1001/jamanetworkopen.2020.25874] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
IMPORTANCE Cardiac care regionalization, specifically for patients with ST-segment elevation myocardial infarction (STEMI), has been touted as a potential mechanism to reduce systematic disparities by protocolizing the treatment of these conditions. However, it is unknown whether such regionalization arrangements have widened or narrowed disparities in access, treatment, and outcomes for minority communities. OBJECTIVE To determine the extent to which disparities in access, treatment, and outcomes have changed for patients with STEMI living in zip codes that are in the top tertile of the Black or Hispanic population compared with patients in nonminority zip codes in regionalized vs nonregionalized counties. DESIGN, SETTING, AND PARTICIPANTS This cohort study used a quasi-experimental approach exploiting the different timing of regionalization across California. Nonpublic inpatient data for all patients with STEMI from January 1, 2006, to October 31, 2015, were analyzed using a difference-in-difference-in-differences estimation approach. EXPOSURE Exposure to the intervention was defined as on and after the year a patient's county was exposed to regionalization. MAIN OUTCOMES AND MEASURES Access to percutaneous coronary intervention (PCI)-capable hospital, receipt of PCI on the same day and at any time during the hospitalization, and time-specific all-cause mortality. RESULTS This study included 139 494 patients with STEMI; 61.9% of patients were non-Hispanic White, 5.6% Black, 17.8% Hispanic, and 9.0% Asian; 32.8% were women. Access to PCI-capable hospitals improved by 6.3 percentage points (95% CI, 5.5 to 7.1 percentage points; P < .001) when patients in nonminority communities were exposed to regionalization. Patients in minority communities experienced a 1.8-percentage point smaller improvement in access (95% CI, -2.8 to -0.8 percentage points; P < .001), or 28.9% smaller, compared with those in nonminority communities when both were exposed to regionalization. Regionalization was associated with an improvement to same-day PCI and in-hospital PCI by 5.1 percentage points (95% CI, 4.2 to 6.1 percentage points; P < .001) and 5.0 percentage points (95% CI, 4.2 to 5.9 percentage points; P < .001), respectively, for patients in nonminority communities. Patients in minority communities experienced only 33.3% and 15.1% of that benefit. Only White patients in nonminority communities experienced mortality improvement from regionalization. CONCLUSIONS AND RELEVANCE Although regionalization was associated with improved access to PCI hospitals and receipt of PCI treatment, patients in minority communities derived significantly smaller improvement relative to those in nonminority communities.
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Affiliation(s)
- Renee Y. Hsia
- Department of Emergency Medicine, University of California, San Francisco
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
| | - Harlan Krumholz
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
- Center for Outcomes Research and Evaluation, Yale–New Haven Hospital, New Haven, Connecticut
| | - Yu-Chu Shen
- Graduate School of Defense Management, Naval Postgraduate School, Monterey, California
- National Bureau of Economic Research, Cambridge, Massachusetts
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30
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Mahmud E, Dauerman HL, Welt FGP, Messenger JC, Rao SV, Grines C, Mattu A, Kirtane AJ, Jauhar R, Meraj P, Rokos IC, Rumsfeld JS, Henry TD. Management of Acute Myocardial Infarction During the COVID-19 Pandemic: A Position Statement From the Society for Cardiovascular Angiography and Interventions (SCAI), the American College of Cardiology (ACC), and the American College of Emergency Physicians (ACEP). J Am Coll Cardiol 2020; 76:1375-1384. [PMID: 32330544 PMCID: PMC7173829 DOI: 10.1016/j.jacc.2020.04.039] [Citation(s) in RCA: 221] [Impact Index Per Article: 55.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The worldwide pandemic caused by the novel acute respiratory syndrome coronavirus 2 has resulted in a new and lethal disease termed coronavirus disease-2019 (COVID-19). Although there is an association between cardiovascular disease and COVID-19, the majority of patients who need cardiovascular care for the management of ischemic heart disease may not be infected with this novel coronavirus. The objective of this document is to provide recommendations for a systematic approach for the care of patients with an acute myocardial infarction (AMI) during the COVID-19 pandemic. There is a recognition of two major challenges in providing recommendations for AMI care in the COVID-19 era. Cardiovascular manifestations of COVID-19 are complex with patients presenting with AMI, myocarditis simulating an ST-elevation myocardial infarction (STEMI) presentation, stress cardiomyopathy, non-ischemic cardiomyopathy, coronary spasm, or nonspecific myocardial injury, and the prevalence of COVID-19 disease in the U.S. population remains unknown with risk of asymptomatic spread. This document addresses the care of these patients focusing on 1) the varied clinical presentations; 2) appropriate personal protection equipment (PPE) for health care workers; 3) role of the Emergency Department, Emergency Medical System and the Cardiac Catheterization Laboratory; and 4) Regional STEMI systems of care. During the COVID-19 pandemic, primary PCI remains the standard of care for STEMI patients at PCI capable hospitals when it can be provided in a timely fashion, with an expert team outfitted with PPE in a dedicated CCL room. A fibrinolysis-based strategy may be entertained at non-PCI capable referral hospitals or in specific situations where primary PCI cannot be executed or is not deemed the best option.
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Affiliation(s)
- Ehtisham Mahmud
- Sulpizio Cardiovascular Center, University of California-San Diego, La Jolla, California.
| | | | | | | | - Sunil V Rao
- Duke University Hospital, Durham, North Carolina
| | - Cindy Grines
- Northside Cardiovascular Institute, Atlanta, Georgia
| | - Amal Mattu
- University of Maryland School of Medicine, Baltimore, Maryland
| | - Ajay J Kirtane
- Columbia University Medical Center, Center for Interventional Vascular Therapy, New York, New York
| | | | - Perwaiz Meraj
- Hofstra North Shore-LIJ School of Medicine, Manhasset, New York
| | | | | | - Timothy D Henry
- The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital, Cincinnati, Ohio
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31
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Utilization of a multidisciplinary emergency department sepsis huddle to reduce time to antibiotics and improve SEP-1 compliance. Am J Emerg Med 2020; 38:2400-2404. [PMID: 33041123 DOI: 10.1016/j.ajem.2020.09.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/03/2020] [Accepted: 09/06/2020] [Indexed: 11/20/2022] Open
Abstract
Sepsis is a significant public health crisis in the United States, contributing to 50% of inpatient hospital deaths. Given its dramatic health effects and implications in the setting of new CMS care guidelines, ED leaders have renewed focus on appropriate and timely sepsis care, including timely administration of antibiotics in patients at risk for sepsis. Modeling the success of multidisciplinary bedside huddles in improving compliance with appropriate care in other healthcare settings, a Sepsis Huddle was implemented in a large, academic ED, with the goal of driving compliance with standardized sepsis care as described in the CMS SEP-1 measure. A retrospective cohort analysis was performed, with the primary finding that utilization of the Sepsis Huddle resulted in antibiotics being administered on average 41 min sooner than when the Sepsis Huddle was not performed. Given that literature suggests that early administration of appropriate antibiotic therapy is a major driver of mortality reduction in patients with sepsis, this study represents a proof of concept that utilization of a Sepsis Huddle may serve to improve outcomes among ED patients at risk for sepsis.
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32
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Nathan AS, Raman S, Yang N, Painter I, Khatana SAM, Dayoub EJ, Herrmann HC, Yeh RW, Groeneveld PW, Doll JA, McCabe JM, Hira RS, Giri J, Fanaroff AC. Association Between 90-Minute Door-to-Balloon Time, Selective Exclusion of Myocardial Infarction Cases, and Access Site Choice: Insights From the Cardiac Care Outcomes Assessment Program (COAP) in Washington State. Circ Cardiovasc Interv 2020; 13:e009179. [PMID: 32883103 DOI: 10.1161/circinterventions.120.009179] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND For patients presenting with ST-segment-elevation myocardial infarction, national quality initiatives monitor hospitals' proportion of cases with door-to-balloon (D2B) time under 90 minutes. Hospitals are allowed to exclude patients from reporting and may modify behavior to improve performance. We sought to identify whether there is a discontinuity in the number of cases included in the D2B time metric at 90 minutes and whether operators were increasingly likely to pursue femoral access in patients with less time to meet the 90-minute quality metric. METHODS Adult patients with ST-segment-elevation myocardial infarction undergoing primary percutaneous coronary intervention from 2011 to 2018 were identified from the Cardiac Care Outcomes Assessment Program, a quality improvement registry in Washington state. We used the regression discontinuity framework to test for discontinuity at 90 minutes among the included cases. We defined a novel variable, remaining D2B as 90 minutes minus the time between hospital arrival and catheterization laboratory arrival. We estimated multivariable logistic regression models to assess the relationship between remaining D2B time and access site. RESULTS A total of 19 348 patients underwent primary percutaneous coronary intervention and were included in the analysis. Overall, 7436 (38.4%) were excluded from the metric. There appeared to be a visual discontinuity in included cases around 90 minutes; however, local quadratic regression around the 90-minute cutoff did not reveal evidence of a significant discontinuity (P=0.66). Multivariable analysis showed no significant relationship between remaining D2B time and the odds of undergoing femoral access (P=0.73). CONCLUSIONS Among patients undergoing percutaneous coronary intervention for ST-segment-elevation myocardial infarction, we did not find evidence of a statistically significant discontinuity in the frequency of included cases around 90 minutes or an increased preference for femoral access correlated with decreasing time to meet the 90-minute D2B time quality metric. Together, these findings indicate no evidence of widespread inappropriate methods to improve performance on D2B time metrics.
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Affiliation(s)
- Ashwin S Nathan
- Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia (A.S.N., S.A.M.K., H.C.H., J.G., A.C.F.).,Leonard Davis Institute of Health Economics (A.S.N., S.A.M.K., E.J.D., P.W.G., J.G., A.C.F.), University of Pennsylvania, Philadelphia, PA.,Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center (A.S.N., S.A.M.K., E.J.D., P.W.G., J.G., A.C.F.), University of Pennsylvania, Philadelphia, PA
| | - Swathi Raman
- College of Arts and Sciences (S.R., N.Y.), University of Pennsylvania, Philadelphia, PA
| | - Nancy Yang
- College of Arts and Sciences (S.R., N.Y.), University of Pennsylvania, Philadelphia, PA
| | - Ian Painter
- Division of Cardiology, University of Washington, Seattle (I.P., J.A.D., J.M.M., R.S.H.)
| | - Sameed Ahmed M Khatana
- Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia (A.S.N., S.A.M.K., H.C.H., J.G., A.C.F.).,Leonard Davis Institute of Health Economics (A.S.N., S.A.M.K., E.J.D., P.W.G., J.G., A.C.F.), University of Pennsylvania, Philadelphia, PA.,Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center (A.S.N., S.A.M.K., E.J.D., P.W.G., J.G., A.C.F.), University of Pennsylvania, Philadelphia, PA
| | - Elias J Dayoub
- Leonard Davis Institute of Health Economics (A.S.N., S.A.M.K., E.J.D., P.W.G., J.G., A.C.F.), University of Pennsylvania, Philadelphia, PA.,Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center (A.S.N., S.A.M.K., E.J.D., P.W.G., J.G., A.C.F.), University of Pennsylvania, Philadelphia, PA.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA (E.J.D., P.W.G., J.G.)
| | - Howard C Herrmann
- Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia (A.S.N., S.A.M.K., H.C.H., J.G., A.C.F.)
| | - Robert W Yeh
- Richard and Susan Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA (R.W.Y.)
| | - Peter W Groeneveld
- Leonard Davis Institute of Health Economics (A.S.N., S.A.M.K., E.J.D., P.W.G., J.G., A.C.F.), University of Pennsylvania, Philadelphia, PA.,Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center (A.S.N., S.A.M.K., E.J.D., P.W.G., J.G., A.C.F.), University of Pennsylvania, Philadelphia, PA.,Division of General Internal Medicine, Perelman School of Medicine (P.W.G.), University of Pennsylvania, Philadelphia, PA.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA (E.J.D., P.W.G., J.G.)
| | - Jacob A Doll
- Division of Cardiology, University of Washington, Seattle (I.P., J.A.D., J.M.M., R.S.H.)
| | - James M McCabe
- Division of Cardiology, University of Washington, Seattle (I.P., J.A.D., J.M.M., R.S.H.).,Foundation for Health Care Quality, Seattle, WA (J.M.M., R.S.H.)
| | - Ravi S Hira
- Division of Cardiology, University of Washington, Seattle (I.P., J.A.D., J.M.M., R.S.H.).,Foundation for Health Care Quality, Seattle, WA (J.M.M., R.S.H.)
| | - Jay Giri
- Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia (A.S.N., S.A.M.K., H.C.H., J.G., A.C.F.).,Leonard Davis Institute of Health Economics (A.S.N., S.A.M.K., E.J.D., P.W.G., J.G., A.C.F.), University of Pennsylvania, Philadelphia, PA.,Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center (A.S.N., S.A.M.K., E.J.D., P.W.G., J.G., A.C.F.), University of Pennsylvania, Philadelphia, PA.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA (E.J.D., P.W.G., J.G.)
| | - Alexander C Fanaroff
- Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia (A.S.N., S.A.M.K., H.C.H., J.G., A.C.F.).,Leonard Davis Institute of Health Economics (A.S.N., S.A.M.K., E.J.D., P.W.G., J.G., A.C.F.), University of Pennsylvania, Philadelphia, PA.,Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center (A.S.N., S.A.M.K., E.J.D., P.W.G., J.G., A.C.F.), University of Pennsylvania, Philadelphia, PA
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Kereiakes DJ, Henry TD, DeMaria AN, Bentur O, Carlson M, Seng Yue C, Martin LH, Midkiff J, Mueller M, Meek T, Garza D, Gibson CM, Coller BS. First Human Use of RUC-4: A Nonactivating Second-Generation Small-Molecule Platelet Glycoprotein IIb/IIIa (Integrin αIIbβ3) Inhibitor Designed for Subcutaneous Point-of-Care Treatment of ST-Segment-Elevation Myocardial Infarction. J Am Heart Assoc 2020; 9:e016552. [PMID: 32844723 PMCID: PMC7660780 DOI: 10.1161/jaha.120.016552] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 06/08/2020] [Indexed: 01/14/2023]
Abstract
Background Despite reductions in door-to-balloon times for primary coronary intervention, mortality from ST-segment-elevation myocardial infarction has plateaued. Early pre-primary coronary intervention treatment of ST-segment-elevation myocardial infarction with glycoprotein IIb/IIIa inhibitors improves pre-primary coronary intervention coronary flow, limits infarct size, and improves survival. We report the first human use of a novel glycoprotein IIb/IIIa inhibitor designed for subcutaneous first point-of-care ST-segment-elevation myocardial infarction treatment. Methods and Results Healthy volunteers and patients with stable coronary artery disease receiving aspirin received escalating doses of RUC-4 or placebo in a sentinel-dose, randomized, blinded fashion. Inhibition of platelet aggregation (IPA) to ADP (20 μmol/L), RUC-4 blood levels, laboratory evaluations, and clinical assessments were made through 24 hours and at 7 days. Doses were increased until reaching the biologically effective dose (the dose producing ≥80% IPA within 15 minutes, with return toward baseline within 4 hours). In healthy volunteers, 15 minutes after subcutaneous injection, mean±SD IPA was 6.9%+7.1% after placebo and 71.8%±15.0% at 0.05 mg/kg (n=6) and 84.7%±16.7% at 0.075 mg/kg (n=6) after RUC-4. IPA diminished over 90 to 120 minutes. In patients with coronary artery disease, 15 minutes after subcutaneous injection of placebo or 0.04 mg/kg (n=2), 0.05 mg/kg (n=6), and 0.075 mg/kg (n=18) of RUC-4, IPA was 14.6%±11.7%, 53.6%±17.0%, 76.9%±10.6%, and 88.9%±12.7%, respectively. RUC-4 blood levels correlated with IPA. Aspirin did not affect IPA or RUC-4 blood levels. Platelet counts were stable and no serious adverse events, bleeding, or injection site reactions were observed. Conclusions RUC-4 provides rapid, high-grade, limited-duration platelet inhibition following subcutaneous administration that appears to be safe and well tolerated. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NTC03844191.
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Affiliation(s)
- Dean J. Kereiakes
- The Carl and Edyth Lindner Center for Research and Education at The Christ HospitalCincinnatiOH
| | - Tim D. Henry
- The Carl and Edyth Lindner Center for Research and Education at The Christ HospitalCincinnatiOH
| | | | - Ohad Bentur
- Allen and Frances Adler Laboratory of Blood and Vascular BiologyRockefeller UniversityNew YorkNY
| | | | | | - Linda H. Martin
- The Carl and Edyth Lindner Center for Research and Education at The Christ HospitalCincinnatiOH
| | - Jeff Midkiff
- The Carl and Edyth Lindner Center for Research and Education at The Christ HospitalCincinnatiOH
| | - Michele Mueller
- The Carl and Edyth Lindner Center for Research and Education at The Christ HospitalCincinnatiOH
| | - Terah Meek
- The Carl and Edyth Lindner Center for Research and Education at The Christ HospitalCincinnatiOH
| | - Deborah Garza
- The Carl and Edyth Lindner Center for Research and Education at The Christ HospitalCincinnatiOH
| | | | - Barry S. Coller
- Allen and Frances Adler Laboratory of Blood and Vascular BiologyRockefeller UniversityNew YorkNY
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Yildiz M, Sharkey S, Aguirre FV, Tannenbaum M, Garberich R, Smith TD, Shivapour D, Schmidt CW, Pacheco-Coronado R, Rohm HS, Chambers J, Coulson T, Garcia S, Henry TD. The Midwest ST-Elevation Myocardial Infarction Consortium: Design and Rationale. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2020; 23:86-90. [PMID: 32883587 PMCID: PMC7425714 DOI: 10.1016/j.carrev.2020.08.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 08/11/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND Over the past 20 years, the development of regional ST-elevation myocardial infarction (STEMI) care systems has led to remarkable progress in achieving timely coronary reperfusion with attendant improvement in clinical outcomes, including survival. Despite this progress, contemporary STEMI care does not consistently meet the national guideline-recommended goals, which offers an opportunity for further improvement in STEMI outcomes. The lack of single, comprehensive, national STEMI registry complicates our ability to improve STEMI outcomes in particular for high-risk STEMI subsets such as cardiac arrest (CA) and/or cardiogenic shock (CS). OBJECTIVES To address this need, the Midwest STEMI Consortium (MSC) was created as a collaboration of 4 large, regional STEMI care systems to provide a comprehensive, multicenter, and prospective STEMI registry without any exclusionary criteria. METHODS The MSC is a collaboration of 4 large, regional STEMI care systems: Iowa Heart Center in Des Moines, IA; Minneapolis Heart Institute Foundation in Minneapolis, MN; Prairie Heart Institute in Springfield, IL; and The Christ Hospital in Cincinnati, OH. Each has similar standardized STEMI protocol and together include 6 percutaneous coronary intervention (PCI)-capable hospitals and over 100 non-PCI-capable hospitals. Each center had a prospective database that was transferred to a data coordinating center to create the multicenter database. The comprehensive database includes traditional risk factors, cardiovascular history, medications, time to treatment data, detailed angiographic characteristics, and short- and long-term clinical outcomes up to 5-year for myocardial infarction, stroke, and cardiovascular and all-cause mortality. Ten-year mortality rates were assessed by using national death index. RESULTS Currently, the comprehensive database (03/2003-01/2020) includes 14,911 consecutive STEMI patients with mean age of 62.3 ± 13.6 years, female gender (29%), and left anterior descending artery as the culprit vessel (34%). High risk features included: Age >75 years (19%), left ventricular ejection fraction <35% (15%), CA (10%), and CS (8%). CONCLUSION This collaboration of 4 large, regional STEMI care systems with broad entry criteria including high-risk STEMI subsets such as CA and/or CS provides a unique platform to conduct clinical research studies to optimize STEMI care.
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Affiliation(s)
- Mehmet Yildiz
- The Carl and Edyth Lindner Center for Research and Education at The Christ Hospital, Cincinnati, OH, United States of America
| | - Scott Sharkey
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN, United States of America
| | - Frank V Aguirre
- Prairie Heart Institute at St John's Hospital, Springfield, IL, United States of America
| | | | - Ross Garberich
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN, United States of America
| | - Timothy D Smith
- The Carl and Edyth Lindner Center for Research and Education at The Christ Hospital, Cincinnati, OH, United States of America
| | | | - Christian W Schmidt
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN, United States of America
| | | | - Heather S Rohm
- The Carl and Edyth Lindner Center for Research and Education at The Christ Hospital, Cincinnati, OH, United States of America
| | - Jenny Chambers
- Prairie Heart Institute at St John's Hospital, Springfield, IL, United States of America
| | - Teresa Coulson
- Iowa Heart Center, Des Moines, IA, United States of America
| | - Santiago Garcia
- 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 at The Christ Hospital, Cincinnati, OH, United States of America.
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Breaking down walls: a qualitative evaluation of perceived emergency department delays for patients transferred with ST-elevation myocardial infarction. BMC Emerg Med 2020; 20:60. [PMID: 32762657 PMCID: PMC7409424 DOI: 10.1186/s12873-020-00355-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 07/27/2020] [Indexed: 11/10/2022] Open
Abstract
Background Despite regionalization efforts, delays at transferring hospitals for patients transferred with ST-elevation myocardial infarction (STEMI) for primary percutaneous coronary intervention (PCI) persist. These delays primarily occur in the emergency department (ED), and are associated with increased mortality. We sought to use qualitative methods to understand staff and clinician perceptions underlying these delays. Methods We conducted semi-structured interviews at 3 EDs that routinely transfer STEMI patients to identify staff perceptions of delays and potential interventions. Interviews were recorded, transcribed, coded, and analyzed using an iterative inductive-deductive approach to build and refine a list of themes and subthemes, and identify supporting quotes. Results We interviewed 43 ED staff (staff, nurses, and physicians) and identified 3 major themes influencing inter-facility transfers of STEMI patients: 1) Processes, 2) Communication; and 3) Resources. Standardized processes (i.e., protocols) reduce uncertainty and can mobilize resources. Use of performance benchmarks can motivate staff but are frequently focused on internal, not inter-organizational performance. Direct use ofcommunication between ORGANIZATIONS can process uncertainty and expedite care. Record sharing and regular post-transfer communication could provide opportunities to discuss and learn from delays and increase professional satisfaction. Finally, characteristics of resources that enhanced their capacity, clarity, experience, and reliability were identified as contributing to timely transfers. Conclusions Processes, communication, and resources were identified as modifying inter-facility transfer timeliness. Potential quality improvement strategies include ongoing updates of protocols within and between organizations to account for changes, enhanced post-transfer feedback between organizations, shared medical records, and designated roles for coordination.
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Zeitouni M, Al-Khalidi HR, Roettig ML, Bolles MM, Doerfler SM, Fordyce CB, Hellkamp AS, Henry TD, Magdon-Ismail Z, Monk L, Nelson RD, O’Brien PK, Wilson BH, Ziada KM, Granger CB, Jollis JG. Catheterization Laboratory Activation Time in Patients Transferred With ST-Segment–Elevation Myocardial Infarction: Insights From the Mission: Lifeline STEMI Accelerator-2 Project. Circ Cardiovasc Qual Outcomes 2020; 13:e006204. [DOI: 10.1161/circoutcomes.119.006204] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Catheterization laboratory (cath lab) activation time is a newly available process measure for patients with ST-segment–elevation myocardial infarction requiring inter-hospital transfers for primary percutaneous coronary intervention that reflects inter-facility communication and urgent mobilization of interventional laboratory resources. Our aim was to determine whether faster activation is associated with improved reperfusion time and outcomes in the American Heart Association Mission: Lifeline Accelerator-2 Project.
Methods and Results:
From April 2015 to March 2017, treatment times of 2063 patients with ST-segment–elevation myocardial infarction requiring inter-hospital transfer for primary percutaneous coronary intervention from 12 regions around the United States were stratified by cath lab activation time (first hospital arrival to cath lab activation within [timely] or beyond 20 minutes [delayed]). Median cath lab activation time was 26 minutes, with a delayed activation observed in 1241 (60.2%) patients. Prior cardiovascular or cerebrovascular disease, arterial hypotension at admission, and black or Latino ethnicity were independent factors of delayed cath lab activation. Timely cath lab activation patients had shorter door-in door-out times (40 versus 68 minutes) and reperfusion times (98 versus 135 minutes) with 80.1% treated within the national goal of ≤120 minutes versus 39.0% in the delayed group.
Conclusions:
Cath lab activation within 20 minutes across a geographically diverse group of hospitals was associated with performing primary percutaneous coronary intervention within the national goal of ≤120 minutes in >75% of patients. While several confounding factors were associated with delayed activation, this work suggests that this process measure has the potential to direct resources and practices to more timely treatment of patients requiring inter-hospital transfer for primary percutaneous coronary intervention.
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Affiliation(s)
- Michel Zeitouni
- Duke Clinical Research Institute, Durham, NC (M.Z., H.R.A.-K., M.L.R., S.M.D., A.S.H., L.M., C.B.G.)
| | - Hussein R. Al-Khalidi
- Duke Clinical Research Institute, Durham, NC (M.Z., H.R.A.-K., M.L.R., S.M.D., A.S.H., L.M., C.B.G.)
| | - Mayme L. Roettig
- Duke Clinical Research Institute, Durham, NC (M.Z., H.R.A.-K., M.L.R., S.M.D., A.S.H., L.M., C.B.G.)
| | | | - Shannon M. Doerfler
- Duke Clinical Research Institute, Durham, NC (M.Z., H.R.A.-K., M.L.R., S.M.D., A.S.H., L.M., C.B.G.)
| | | | - Anne S. Hellkamp
- Duke Clinical Research Institute, Durham, NC (M.Z., H.R.A.-K., M.L.R., S.M.D., A.S.H., L.M., C.B.G.)
| | - Timothy D. Henry
- The Carl and Edyth Lindner Center for Research and Education at The Christ Hospital, Cincinnati, OH (T.D.H.)
| | | | - Lisa Monk
- Duke Clinical Research Institute, Durham, NC (M.Z., H.R.A.-K., M.L.R., S.M.D., A.S.H., L.M., C.B.G.)
| | | | | | - B. Hadley Wilson
- Sanger Heart and Vascular Institute, Atrium Health, Charlotte, NC (B.H.W.)
| | - Khaled M. Ziada
- Gill Heart & Vascular Institute University of Kentucky, Lexington (K.M.Z.)
| | - Christopher B. Granger
- Duke Clinical Research Institute, Durham, NC (M.Z., H.R.A.-K., M.L.R., S.M.D., A.S.H., L.M., C.B.G.)
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Cordero A, Freites A, Escribano D, Bertomeu-Martínez V, Zuazola P, Badimon L. A simple score to select patients for manual thrombectomy in emergent percutaneous coronary interventions: the DDTA score. J Cardiovasc Med (Hagerstown) 2020; 21:595-602. [PMID: 32520860 DOI: 10.2459/jcm.0000000000000992] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The objective of manual thrombectomy is the removal of occlusive thrombus to improve the results of primary angioplasty. The better understanding of the factors associated with successful manual thrombectomy may provide relevant information regarding thrombus formation and resolution. METHODS Observational study of all consecutive patients remitted for emergent percutaneous coronary intervention (PCI) in a single centre. Successful manual thrombectomy was considered when TIMI 3 was achieved after using the device and a score to predict successful manual thrombectomy was designed. RESULTS We included 618 patients, 65.1% treated with manual thrombectomy. No relevant differences in clinical features or time delays were observed between patients treated with vs. without manual thrombectomy, but manual thrombectomy treated patients received more often dual antiplatelet treatment (DAPT) before PCI. Final TIMI flow 3 was achieved in most patients and more frequently in manual thrombectomy treated patients (94.8 vs. 86.6%; P < 0.01). The successful manual thrombectomy rate was 81.3% and it was higher in patients pretreated with DAPT (89.0 vs. 73.3%; P < 0.01). The time delay to first medical contact was not related to the final TIMI 3, but it was significantly and negatively related to successful manual thrombectomy. According to the multivariate analysis, we designed the DDTA score: DAPT pretreatment (2), delay less than 2 h (3) or 2-4 h (2), TIMI flow improvement after wiring the lesion (2) and age less than 55 years (3). Patients with DDTA score at least 4 had lower no-reflow, mortality and major cardiovascular complications incidence. CONCLUSION The DDTA score (DAPT pretreatment, time delays, TIMI flow improvement after wiring the lesion and age) identifies patients who benefit mostly from manual thrombectomy.
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Affiliation(s)
- Alberto Cordero
- Cardiology Department, Hospital Universitario de San Juan, San Juan de Alicante, Alicante.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid
| | - Alfonso Freites
- Cardiology Department, Hospital Universitario de San Juan, San Juan de Alicante, Alicante
| | - David Escribano
- Cardiology Department, Hospital Universitario de San Juan, San Juan de Alicante, Alicante
| | | | - Pilar Zuazola
- Cardiology Department, Hospital Universitario de San Juan, San Juan de Alicante, Alicante
| | - Lina Badimon
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid.,Institut Català de Ciències Cardiovasculars (ICCC), Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
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Care and outcomes of urban and non-urban out-of-hospital cardiac arrest patients during the HeartRescue Project in Washington state and North Carolina. Resuscitation 2020; 152:5-15. [PMID: 32430288 DOI: 10.1016/j.resuscitation.2020.04.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 04/14/2020] [Accepted: 04/23/2020] [Indexed: 11/20/2022]
Abstract
AIM We examined overall and temporal differences in out-of-hospital cardiac arrest (OHCA) care and outcomes by urban versus non-urban setting separately for North Carolina (NC) and Washington State (WA) during HeartRescue initiatives and associations of urban/non-urban settings with outcome by state. METHODS OHCAs of presumed cardiac etiology from counties with complete registry enrollment in NC during 2010-2014 (catchment population = 3,143,809) and WA during 2011-2014 (catchment population = 3,653,506) were identified. Geospatial arrest location data and US Census classification were used to categorize urban areas with ≥50,000 versus non-urban <50,000 people. RESULTS Included were 7731 NC cases (78.9% urban) and 4472 WA cases (85.8% urban). Bystander cardiopulmonary resuscitation (CPR) increased from 36.9% (2010) to 50.3% (2014) in NC non-urban areas versus 58.2% (2011) to 69.2% (2014) in WA; and from 39.3% to 51.1% in NC urban areas versus 52.4% to 61.8% in WA. Crude discharge survival odds ratio (OR) was 2.49 (95%CI 1.96-3.16) for urban versus non-urban NC cases not declared dead in field (N = 4241). Adjusted for age, sex, public location, bystander-witness status, time between emergency call and emergency medical service (EMS) arrival, calendar-year, bystander and first-responder CPR and defibrillation and direct PCI-center transport, OR was 1.30 (95%CI 0.98-1.73). In WA, corresponding crude and adjusted ORs were 1.38 (95%CI 0.99-1.93) and 1.46 (95%CI 1.00-2.13). In both states, bystander and first-responder CPR and defibrillation and direct PCI-hospital transport were associated with increased survival. CONCLUSIONS During HeartRescue initiatives, bystander CPR increased in urban and non-urban locations. Bystander and first-responder interventions and direct PCI-hospital transport were associated with improved outcomes, including in non-urban areas.
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Mahmud E, Dauerman HL, Welt FGP, Messenger JC, Rao SV, Grines C, Mattu A, Kirtane AJ, Jauhar R, Meraj P, Rokos IC, Rumsfeld JS, Henry TD. Management of acute myocardial infarction during the COVID-19 pandemic: A Consensus Statement from the Society for Cardiovascular Angiography and Interventions (SCAI), the American College of Cardiology (ACC), and the American College of Emergency Physicians (ACEP). Catheter Cardiovasc Interv 2020; 96:336-345. [PMID: 32311816 DOI: 10.1002/ccd.28946] [Citation(s) in RCA: 95] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 04/17/2020] [Indexed: 01/03/2023]
Abstract
The worldwide pandemic caused by the novel acute respiratory syndrome coronavirus 2 has resulted in a new and lethal disease termed coronavirus disease 2019 (COVID-19). Although there is an association between cardiovascular disease and COVID-19, the majority of patients who need cardiovascular care for the management of ischemic heart disease may not be infected with this novel coronavirus. The objective of this document is to provide recommendations for a systematic approach for the care of patients with an acute myocardial infarction (AMI) during the COVID-19 pandemic. There is a recognition of two major challenges in providing recommendations for AMI care in the COVID-19 era. Cardiovascular manifestations of COVID-19 are complex with patients presenting with AMI, myocarditis simulating an ST-elevation myocardial infarction (STEMI) presentation, stress cardiomyopathy, non-ischemic cardiomyopathy, coronary spasm, or nonspecific myocardial injury, and the prevalence of COVID-19 disease in the US population remains unknown with risk of asymptomatic spread. This document addresses the care of these patients focusing on (a) varied clinical presentations; (b) appropriate personal protection equipment (PPE) for health care workers; (c) the roles of the emergency department, emergency medical system, and the cardiac catheterization laboratory (CCL); and (4) regional STEMI systems of care. During the COVID-19 pandemic, primary percutaneous coronary intervention (PCI) remains the standard of care for STEMI patients at PCI-capable hospitals when it can be provided in a timely manner, with an expert team outfitted with PPE in a dedicated CCL room. A fibrinolysis-based strategy may be entertained at non-PCI-capable referral hospitals or in specific situations where primary PCI cannot be executed or is not deemed the best option.
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Affiliation(s)
- Ehtisham Mahmud
- Sulpizio Cardiovascular Center, University of California, San Diego, La Jolla, California
| | | | | | | | - Sunil V Rao
- Duke University Hospital, Durham, North Carolina
| | - Cindy Grines
- Northside Cardiovascular Institute, Atlanta, Georgia
| | - Amal Mattu
- University of Maryland School of Medicine, Baltimore, Maryland
| | - Ajay J Kirtane
- Columbia University Medical Center, Center for Interventional Vascular Therapy, New York, New York
| | | | - Perwaiz Meraj
- Hofstra North Shore-LIJ School of Medicine, Manhasset, New York
| | | | | | - Timothy D Henry
- The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital, Cincinnati, Ohio
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Patarroyo Aponte MM, Manrique C, Kar B. Systems of Care in Cardiogenic Shock. Methodist Debakey Cardiovasc J 2020; 16:50-56. [PMID: 32280418 DOI: 10.14797/mdcj-16-1-50] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Cardiogenic shock presents a significant challenge to the medical community, and there is much debate as to the best classification system and treatment mechanisms. As interventions and technologies improve, systems of care for patients with cardiogenic shock must evolve as well. This review describes the current treatment models for cardiogenic shock, including the "hub-and-spoke" model, and defines specific characteristics of the ideal system of care for this patient population.
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Affiliation(s)
| | - Carlos Manrique
- UNIVERSITY OF TEXAS HEALTH SCIENCE CENTER AT HOUSTON, HOUSTON, TEXAS
| | - Biswajit Kar
- UNIVERSITY OF TEXAS HEALTH SCIENCE CENTER AT HOUSTON, HOUSTON, TEXAS
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Darkness on the Edge of Thrombolysis. J Am Coll Cardiol 2020; 75:1422-1425. [PMID: 32216910 DOI: 10.1016/j.jacc.2020.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 01/31/2020] [Accepted: 02/03/2020] [Indexed: 11/22/2022]
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Wenner JB, Wong GC, Cairns JA, Perry-Arnesen M, Tocher W, Mackay M, Singer J, Lee T, Fordyce CB. Impact of Patient- and System-Level Delays on Reperfusion Among Patients With ST-Elevation Myocardial Infarction. CJC Open 2020; 2:94-103. [PMID: 32462122 PMCID: PMC7242498 DOI: 10.1016/j.cjco.2020.01.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 01/23/2020] [Indexed: 01/06/2023] Open
Abstract
Background Patients with ST-elevation myocardial infarction (STEMI) presenting to percutaneous coronary intervention (PCI)-capable hospitals often experience delays for primary PCI (pPCI). We sought to describe the effect of specific delay intervals and patient/system-level factors on STEMI reperfusion times. Methods We analyzed all consecutive patients with STEMI who presented to 2 PCI-capable hospital emergency departments (EDs) between June 2007 and March 2016 who received successful pPCI. We excluded patients with prehospital cardiac arrest. We compared specific system delay intervals, patient characteristics, and in-hospital outcomes among patients who received timely (first medical contact-device ≤90/≤120 minutes) vs delayed >90/>120 minutes) pPCI. Results Of 1936 patients with STEMI, 1127 (58%) presented directly to a PCI-capable hospital via emergency health services (EHS), 499 (26%) were transferred from the ED of a non-PCI hospital, and 310 (16%) self-presented to the ED of a pPCI-capable hospital. Guideline-recommended reperfusion times were met in 47% of direct-EHS, 42% of transfers, and 33% of self-presenters. Each time interval from first medical contact to device deployment was significantly prolonged in the delayed vs timely reperfusion cohorts across all 3 groups, excepting vascular access time. ED dwell time contributed the most to the difference in median reperfusion time within each group. Time of presentation, comorbidities, and sex were each significantly associated with delayed reperfusion. Within the EHS-direct group, prolonged reperfusion and ED dwell times were significantly associated with increased mortality, major bleeding, and cardiogenic shock. Conclusion Ongoing efforts to identify and reduce ED dwell time and other systemic pPCI delays may improve STEMI outcomes, including mortality.
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Affiliation(s)
- Joshua B. Wenner
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
- Fraser Health Authority, Surrey, British Columbia, Canada
| | - Graham C. Wong
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
- Vancouver Coastal Health Authority, Vancouver, British Columbia, Canada
| | - John A. Cairns
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
- Vancouver Coastal Health Authority, Vancouver, British Columbia, Canada
| | | | - Wendy Tocher
- Vancouver Coastal Health Authority, Vancouver, British Columbia, Canada
| | - Martha Mackay
- Centre for Health Evaluation and Outcome Sciences, Providence Health Care Research Institute, University of British Columbia, Vancouver, British Columbia, Canada
| | - Joel Singer
- Centre for Health Evaluation and Outcome Sciences, Providence Health Care Research Institute, University of British Columbia, Vancouver, British Columbia, Canada
| | - Terry Lee
- Centre for Health Evaluation and Outcome Sciences, Providence Health Care Research Institute, University of British Columbia, Vancouver, British Columbia, Canada
| | - Christopher B. Fordyce
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
- Vancouver Coastal Health Authority, Vancouver, British Columbia, Canada
- Corresponding author: Dr Christopher B. Fordyce, 9th Floor – 2775 Laurel St., Vancouver, British Columbia V5Z 1M9, Canada. Tel.: +1-604-875-5230; fax: +1-604-675-3007.
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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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2019 Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology Guidelines on the Acute Management of ST-Elevation Myocardial Infarction: Focused Update on Regionalization and Reperfusion. Can J Cardiol 2019; 35:107-132. [PMID: 30760415 DOI: 10.1016/j.cjca.2018.11.031] [Citation(s) in RCA: 106] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 11/29/2018] [Accepted: 11/29/2018] [Indexed: 12/15/2022] Open
Abstract
Rapid reperfusion of the infarct-related artery is the cornerstone of therapy for the management of acute ST-elevation myocardial infarction (STEMI). Canada's geography presents unique challenges for timely delivery of reperfusion therapy for STEMI patients. The Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology STEMI guideline was developed to provide advice regarding the optimal acute management of STEMI patients irrespective of where they are initially identified: in the field, at a non-percutaneous coronary intervention-capable centre or at a percutaneous coronary intervention-capable centre. We had also planned to evaluate and incorporate sex and gender considerations in the development of our recommendations. Unfortunately, inadequate enrollment of women in randomized trials, lack of publication of main outcomes stratified according to sex, and lack of inclusion of gender as a study variable in the available literature limited the feasibility of such an approach. The Grading Recommendations, Assessment, Development, and Evaluation system was used to develop specific evidence-based recommendations for the early identification of STEMI patients, practical aspects of patient transport, regional reperfusion decision-making, adjunctive prehospital interventions (oxygen, opioids, antiplatelet therapy), and procedural aspects of mechanical reperfusion (access site, thrombectomy, antithrombotic therapy, extent of revascularization). Emphasis is placed on integrating these recommendations as part of an organized regional network of STEMI care and the development of appropriate reperfusion and transportation pathways for any given region. It is anticipated that these guidelines will serve as a practical template to develop systems of care capable of providing optimal treatment for a wide range of STEMI patients.
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45
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Cordero A, Bertomeu-González V, Moreno-Arribas J, Marco A, Sánchez A, Pomares A, Torroba G, Martínez Rey-Rañal E, Moreno MJ, Quiles J, Valero R, Bertomeu-Martínez V. Ventajas de la guardia de cardiología en un hospital secundario en el tratamiento de los pacientes con síndrome coronario agudo. ACTA ACUST UNITED AC 2019. [DOI: 10.1016/j.rccl.2019.05.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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46
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Mechanical Complications in Acute Myocardial Infarction. JACC Cardiovasc Interv 2019; 12:1837-1839. [DOI: 10.1016/j.jcin.2019.06.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 06/04/2019] [Indexed: 11/23/2022]
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Fiorilli PN, Kolansky DM. Getting to the Right Place at the Right Time: Another Piece of the STEMI Puzzle. Circ Cardiovasc Interv 2019; 11:e006700. [PMID: 29716934 DOI: 10.1161/circinterventions.118.006700] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Paul N Fiorilli
- From the Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia
| | - Daniel M Kolansky
- From the Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia.
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48
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Alrawashdeh A, Nehme Z, Williams B, Stub D. Emergency medical service delays in ST-elevation myocardial infarction: a meta-analysis. Heart 2019; 106:365-373. [PMID: 31253694 DOI: 10.1136/heartjnl-2019-315034] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 05/02/2019] [Accepted: 05/26/2019] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVES To evaluate emergency medical services (EMS) delays and their impact on time to treatment and mortality in patients with ST-elevation myocardial infarction (STEMI). METHOD We collected data on EMS time intervals from published studies across five electronic databases. The primary EMS interval was the time in minutes between first medical contact and arrival at hospital door (FMC-to-door time). Secondary intervals were other components of EMS delay. Weighted means were measured using random-effects models. Meta-regression was used to identify factors associated with EMS delays and to assess the impact of EMS delay on the proportion of patients treated within90 min and mortality. RESULTS Two independent reviewers included 100 studies (125 343 patients) conducted in 20 countries. The weighted mean FMC-to-door time was 41 min (n=101 646; 95% CI 39 to 43, range 21-88). However, substantial heterogeneity was observed with each interval, which could be explained by region and urban classification, distance to hospital and method of ECG interpretation. In a meta-regression adjusted for door-to-balloon time, a 10 min increase in FMC-to-door time was associated with a 10.6% (95% CI 7.6% to 13.5%; p<0.001) reduction in the proportion of patients treated within 90 min. Shorter EMS delay was significantly associated with lower short-term mortality in patients receiving prehospital thrombolysis (p=0.018). CONCLUSION EMS delays account for half of the total system delay in STEMI. There is a fourfold global variation in EMS delays, which are not completely explained by differences in system characteristics. Reducing unexplained variation could yield improvements in the time to treatment and outcome of STEMI patients. PROSPERO REGISTRATION NUMBER CRD42017074118.
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Affiliation(s)
- Ahmad Alrawashdeh
- Department of Community Emergency Health and Paramedic Practice, Monash University, Frankston, Victoria, Australia.,Department of Allied Medical Sciences, Jordan University of Science and Technology, Irbid, Jordan
| | - Ziad Nehme
- Department of Epidemiology and PreventiveMedicine, Monash University, Prahran, Victoria, Australia.,Center for Research and Evaluation, Ambulance Victoria, Doncaster, Victoria, Australia
| | - Brett Williams
- Department of Community Emergency Health and Paramedic Practice, Monash University, Frankston, Victoria, Australia
| | - Dion Stub
- Department of Epidemiology and PreventiveMedicine, Monash University, Prahran, Victoria, Australia.,Heart Centre, Alfred Hospital, Melbourne, Victoria, Australia.,Baker IDI Heart and Diabetes Institute, Melbourne, Victoria, Australia
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Nishimura RA, O’Gara PT, Bavaria JE, Brindis RG, Carroll JD, Kavinsky CJ, Lindman BR, Linderbaum JA, Little SH, Mack MJ, Mauri L, Miranda WR, Shahian DM, Sundt TM. 2019 AATS/ACC/ASE/SCAI/STS Expert Consensus Systems of Care Document: A Proposal to Optimize Care for Patients With Valvular Heart Disease. Ann Thorac Surg 2019; 107:1884-1910. [DOI: 10.1016/j.athoracsur.2019.03.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 03/08/2019] [Indexed: 10/27/2022]
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50
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2019 AATS/ACC/ASE/SCAI/STS Expert Consensus Systems of Care Document: A Proposal to Optimize Care for Patients With Valvular Heart Disease. J Am Coll Cardiol 2019; 73:2609-2635. [DOI: 10.1016/j.jacc.2018.10.007] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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