Pre-hospital delay in patients with first time myocardial infarction: an observational study in a northern Swedish population

Time to presentation and mortality outcomes among patients with diabetes and acute myocardial infarction

BACKGROUND/AIMS

Due to limited real-world evidence on the association between time to presentation (T2P) and outcomes following acute myocardial infarction and diabetes (AMI-DM), we investigated the characteristics of patients with AMI-DM and their outcomes based on their T2P.

METHODS

4,455 patients with AMI-DM from a Korean nationwide observational cohort (2011-2015) were divided into early and late presenters according to symptom-to-door time. The effects of T2P on three-year all-cause mortality were estimated using inverse probability of treatment weighting (IPTW) and survival analysis.

RESULTS

The incidence of all-cause mortality was consistently higher in late presenters than in early presenters (11.4 vs. 17.2%; p < 0.001). In the IPTW-adjusted dataset, the incidence of all-cause mortality was numerically higher in late presenters than in early presenters (9.1 vs. 12.4%; p = 0.072). In the survival analysis, the cumulative incidence of all-cause mortality was significantly higher in late presenters than in early presenters before and after IPTW. In the subgroup with ST-elevation myocardial infarction, late presenters had a higher incidence of cardiac death than early presenters before (4.8 vs. 10.5%; p < 0.001) and after IPTW (4.2 vs. 9.7%; p = 0.034). In the initial glycated hemoglobin (HbA1c)-stratified analysis, these effects were attenuated in patients with HbA1c ≥ 9.0% before (adjusted hazard ratio [HR]: 1.45, 95% confidence interval [CI]: 0.80-2.64) and after IPTW (adjusted HR: 0.82, 95% CI: 0.40-1.67).

CONCLUSION

Late presentation was associated with higher mortality in patients with AMI-DM; therefore, multifaceted and systematic interventions are needed to decrease pre-hospital delays.

Driving Time to the Nearest Percutaneous Coronary Intervention-Capable Hospital and the Risk of Case Fatality in Patients with Acute Myocardial Infarction in Beijing

Timely arrival at a hospital capable of percutaneous coronary intervention (PCI) is critical in treating acute myocardial infarction (AMI). We examined the association between driving time to the nearest PCI-capable hospital and case fatality among AMI patients. A total of 142,474 AMI events during 2013-2019 from the Beijing Cardiovascular Disease Surveillance System were included in this cross-sectional study. The driving time from the residential address to the nearest PCI-capable hospital was calculated. Logistic regression was used to estimate the risk of AMI death associated with driving time. In 2019, 54.5% of patients lived within a 15-min drive to a PCI-capable hospital, with a higher proportion in urban than peri-urban areas (71.2% vs. 31.8%, p < 0.001). Compared with patients who had driving times ≤15 min, the adjusted odds ratios (95% CI, p value) for AMI fatality risk associated with driving times 16-30, 31-45, and >45 min were 1.068 (95% CI 1.033-1.104, p < 0.001), 1.189 (95% CI 1.127-1.255, p < 0.001), and 1.436 (95% CI 1.334-1.544, p < 0.001), respectively. Despite the high accessibility to PCI-capable hospitals for AMI patients in Beijing, inequality between urban and peri-urban areas exists. A longer driving time is associated with an elevated AMI fatality risk. These findings may help guide the allocation of health resources.

Reducing patient delay in acute coronary syndrome: Randomized controlled trial testing effect of behaviour change intervention on intentions to seek help

OBJECTIVES

The aim of this study was to evaluate the efficacy of a behaviour change intervention to reduce patient delay with symptoms of acute coronary syndrome.

DESIGN

A 3-arm web-based, parallel randomized controlled trial.

METHODS

The intervention comprised 12 behaviour change techniques (BCTs) embedded in a text-only or text+visual narrative (the techniques were systematically identified through systematic review and a consensus exercise). Between February and November 2017, n = 145 people who had recently experienced acute coronary syndrome were randomly allocated to intervention ('text+visual' or 'text-only') or control. Intentions to phone an ambulance immediately for acute coronary syndrome symptoms were assessed before and after the intervention using symptom scenarios, and the change in intention was compared across the three groups.

RESULTS

Significant increases in intention to phone an ambulance immediately for ACS symptoms were seen following the 'text+visual' intervention but not following 'text-only' or control. However, the study was underpowered to detect any significant changes in intention between the 3 groups. There were no unintended effects on intentions for non-urgent symptoms.

CONCLUSIONS

A 'text+visual' BCT-based intervention may significantly increase intention to phone an ambulance with symptoms of ACS. Further testing of the effect of the intervention on actual behaviour is required.

Treatment Seeking Behaviors and Associated Factors among Patients Experiencing Acute Coronary Syndrome Using Health Belief Model in Addis Ababa, Ethiopia

Background

Acute coronary syndrome (ACS) is a life-threatening condition. The mortality rate will be reduced if immediate treatment is provided. Patients' awareness of ACS is limited, so they do not seek help as quite often as they should. The level of treatment seeking behavior and associated factors among ACS patients admitted to three hospitals in Addis Ababa, Ethiopia, were assessed using a health belief model.

Methods

A cross-sectional study was conducted among 330 ACS patients from November 2019 to December 2020. Sociodemographic and clinical variables data were extracted using pre-tested checklist. The outcome and other variables data were collected using the checklist and structured questionnaire. The data were entered into Epi-data 3.1 and exported to STATA 17.1 for analysis. Descriptive statistics relevant to the variable was performed. A multivariable logistic regression was used to identify factors associated with treatment seeking behavior.

Results

This study revealed that the mean time from symptom onset to arrival at the emergency unit (EU) was 24 ± 19.5 hours, slightly < half of the participants (n=149, 45.1 %) had adequate treatment seeking behavior. Perceived threat (AOR=1.03,95% CI:1.01–1.06, p=0.002), perceived benefits (AOR=1.09, 95%CI: 1.02–1.0, p≤0.001), self-efficacy (AOR=1.16, 95% CI :1.01- 1.22, p≤0.001), education (AOR=2.2,95%CI:1.31–3.9, p≤0.01) self-autonomy (AOR=3.1,95%CI:1.82–5.4, p<.001) and no depression (AOR=1.9,95%CI:1.1–3.3, p≤0.05) were found to have significantly association with adequate treatment seeking behavior.

Conclusion

This study indicates, less than half of ACS patients had adequate treatment seeking behavior. Thus, context-specific behavioral interventions, along with public awareness campaigns about ACS, should be implemented.

Transition from Syringe to Autoinjector Based on Bridging Pharmacokinetics and Pharmacodynamics of the P2Y12 Receptor Antagonist Selatogrel in Healthy Subjects

BACKGROUND AND OBJECTIVES

Selatogrel is a potent, reversible, and selective antagonist of the platelet P2Y₁₂ receptor currently developed for the treatment of acute myocardial infarction (AMI). In the completed Phase I/II studies, selatogrel was subcutaneously (s.c.) administered as a lyophilizate-based formulation by syringe by a healthcare professional. In the Phase III study, selatogrel will be self-administered s.c. as a liquid formulation with an autoinjector at the onset of AMI symptoms to shorten treatment delay. This clinical bridging study compared the pharmacokinetics (PK) of selatogrel between the different formulations.

METHODS

This was a single-center, randomized, open-label, three-period, cross-over Phase I study in 24 healthy subjects. In each period, a single subcutaneous dose of 16 mg selatogrel was administered as (1) a Phase III liquid formulation by autoinjector (Treatment A), (2) a Phase III liquid formulation by prefilled syringe (Treatment B), or (3) a Phase I/II reconstituted lyophilizate-based formulation by syringe (Treatment C). PK parameters including area under the plasma concentration-time curve from zero to infinity (AUC_0-∞), maximum plasma concentration (C_max), time to reach C_max(t_max), and terminal half-life (t_1/2) were determined using noncompartmental analysis. Pharmacodynamic (PD) parameters were estimated using PK/PD modeling, including the time of first occurrence of inhibition of platelet aggregation (IPA) ≥ 80% (t_onset), duration of IPA above 80% (t_duration), and responder rate defined as the percentage of subjects with t_onset ≤ 30 min and t_duration ≥ 3 h. Safety and tolerability were also assessed.

RESULTS

Comparing Treatment A to Treatment C, the exposure (AUC_0-∞) was bioequivalent with a geometric mean ratio (GMR) (90% confidence interval) of 0.95 (0.92-0.97) within the bioequivalence range (0.80-1.25). Absorption following Treatment A was slightly slower with a t_max occurring approximately 30 min later and a 20% lower C_max. The autoinjector itself had no impact on the PK of selatogrel, as similar values of C_max and AUC_0-∞ were determined after administration as a Phase III liquid formulation by autoinjector or by prefilled syringe (i.e., GMR [90% confidence interval] of 1.06 [0.97-1.15] and 0.99 [0.96-1.03] for C_max and AUC_0-∞, respectively). PK/PD modeling predicted that the median t_onset will occur slightly later for Treatment A (7.2 min) compared to Treatment C (4.2  min), while no relevant differences in t_duration and responder rate were estimated between the two treatments. Selatogrel was safe and well tolerated following all three treatments.

CONCLUSIONS

PK and simulated PD effects of selatogrel were similar across treatments.

CLINICAL TRIAL REGISTRATION

NCT04557280.

Pre hospital delay and its associated factors in acute myocardial infarction in a developing country

Background

Early revascularization and treatment is key to improving clinical outcomes and reducing mortality in acute myocardial infarction (AMI). In low- and middle-income countries such as Bangladesh, timely management of AMI is challenging, with pre-hospital delays playing a significant role. This study was designed to investigate pre-hospital delay and its associated factors among patients presenting with AMI in the capital city of Dhaka.

Methods

This retrospective cohort study was conducted on 333 patients presenting with AMI over a 3-month period at two of the largest primary reperfusion-capable tertiary cardiac care centres in Dhaka. Of the total patients, 239(71.8%) were admitted in the National Institute of Cardiovascular Diseases, Dhaka and 94(28.2%) at Ibrahim Cardiac Hospital & Research Institute, Dhaka Data were collected from patients by semi-structured interview and hospital medical records. Pre-hospital delay (median and inter-quartile range) was calculated. Statistical significance was determined by Chi-square test. Multivariate logistic regression analysis was done to determine the independent predictors of pre-hospital delay.

Results

The mean age of the respondents was 53.8±11.2 years. Two-thirds (67.6%) of the respondents were males. Median total pre-hospital delay was 11.5 (IQR-18.3) hours with median decision time from symptom onset to seeking medical care being 3.0 (IQR: 11.0) hours. Nearly half (48.9%) of patients presented to the hospital more than 12 hours after symptom onset. On multivariate logistic regression analysis, AMI patients with absence of typical chest pain [OR 5.21; (95% CI: 2.5–9.9)], diabetes [OR: 1.7 (95% CI: 1.0–2.9)], residing/staying > 30 km away from nearest hospital at the time of onset [OR: 4.3(95% CI = 2.3–7.2)] and belonged to lower and middle class [OR: 1.9(95% CI = 1.0–3.5)] were significantly associated with pre-hospital delays.

Conclusion

Acute myocardial infarction (AMI) patients with atypical chest pain, diabetes, staying far away from nearest hospital and belonged to lower and middle socioeconomic strata were significantly associated with pre-hospital delays. The findings could have immense implications for improvements about timely reaching of AMI patients to the hospital within the context of their sociodemographic status and geographic barriers of the city.

Patients' reflections on prehospital symptom recognition and timely treatment of myocardial infarction

AIMS

Early treatment is crucial to successful therapy in patients with acute myocardial infarction (MI). Prehospital delay is associated with increased morbidity and mortality. There is little empirical evidence of patients' reflections on prehospital symptoms of MI and timely treatment at the time of discharge from hospital. To explore patients' reflections on prehospital symptoms of MI and their experiences of interaction with local hospitals, general practitioners, and laypersons.

METHODS AND RESULTS

An inductive explorative design with a qualitative method approach was used to conduct in-depth interviews of patients after confirmed MI. Twenty patients were purposefully selected based on age and gender. Face-to-face, semi-structured interviews were conducted prior to hospital discharge. The interviews were organized around a set of predetermined, open-ended questions, transcribed verbatim and analysed using qualitative content analysis. There were patients who acted upon severe symptoms of MI by seeking medical assistance. Patients commonly experienced that the time from the onset of symptoms to treatment posed a transitional challenge. They did not take subtle signs of MI seriously; they underestimated symptoms of MI and delayed seeking medical assistance. Patients frequently experienced that healthcare professionals did not take them seriously, as they struggled to gain access to healthcare services.

CONCLUSION

This study highlights patients' unique experiences of the pathway from symptom onset to confirmed MI. Severe chest pain is associated with MI and triggers an immediate need for care. However, patients often underestimated moderate chest pain or subtle signs and symptoms of MI. Existing knowledge gaps concerning the misinterpretation of symptoms in primary care need to be addressed in order to reduce this clinical challenge.

Time to Seek Care and Hospital Length of Stay Among Older Adults With Acute Coronary Syndrome During the COVID-19 Pandemic

The prevalence of prehospital delay is high among older adults with acute coronary syndrome (ACS). The current study aimed to examine the associated factors of prehospital delay among patients with ACS during the COVID-19 pandemic. This cross-sectional study was conducted on a convenience sample of 300 older adults with ACS admitted to the emergency department in Jordan. Data were collected from June 1 to September 1, 2020. Bivariate and multivariate analyses were used to explore the predictors of prehospital delay. Being widowed, educational level, pain intensity, the gradual onset of ACS symptoms, symptoms lasting for more than 30 minutes, patients' feeling anxious about their ACS symptoms, patients' perceiving their symptoms to be particularly dangerous, history of myocardial infarction (MI), and mode of transportation were associated with the time taken before seeking emergency care. Significant predictors of time to seek help were chief complaint of chest pain or palpitations, abrupt onset of symptoms, the associated symptom of vertigo, and a higher number of chronic illnesses; they explained about 17.9% of the variance in the time to seek care. The average time to seek care among patients with ACS during the COVID-19 pandemic was found to be longer than the average time reported by studies conducted prior the pandemic. Improved understanding of the associations between prehospital delay is crucial for optimal ACS patient outcomes under the impacts of the COVID-19 pandemic.

In- and Out-of-Hospital Deaths by Acute Myocardial Infarction in Brazilian State Capitals

BACKGROUND

Acute myocardial infarction (AMI) is the main cause of death in Brazil and the world. Approximately half of these deaths occur outside the hospital.

OBJECTIVES

To analyze the distribution, temporal evolution, and sociodemographic characteristics (SDC) of in- and out-of-hospital deaths by AMI in Brazilian state capitals and their relationship with municipal development indicators (MDI).

METHODS

This is an ecological study of the number of deaths due to AMI reported annually by the 27 Brazilian state capitals from 2007 to 2016; these were divided into 2 groups: in-hospital (H) and out-of-hospital (OH). We evaluated the temporal evolution of mortality rates in each group and differences in SDC. Negative binomial regression models were used to compare the temporal evolution of the number of deaths in each group with the following variables: residing in the South/Southeast regions (S/SE), municipal human development index (MHDI), Gini coefficient, and expected years of schooling (EYS). We considered p-values<0.05 as statisticallysignificant.

RESULTS

The OH mortality rate increased with time for all state capitals. All studied SDC were different between groups (p<0.001). In the OH group, most deaths were of men and patients aged 80 years or older and not married. S/SE increased the incidence of OH deaths (incidence rate ratio [IRR]=2.84; 95% confidence interval [CI]=1.67-4.85), while higher EYS reduced it (IRR=0.86; 95% CI=0.77-0.97). In the H group, higher MHDI reduced the incidence of deaths (IRR=0.44; 95% CI=0.33-0.58), while higher EYS increased it (IRR=1.09; 95% CI=1.03-1.15).

CONCLUSIONS

In- and out-of-hospital deaths due to AMI in Brazilian state capitals were influenced by MDI, presented sociodemographic differences and a progressive increase in out-of-hospital occurrences.

Impact of myocardial infarction symptom presentation on emergency response and survival

AIMS

We examined associations between symptom presentation and chance of receiving an emergency dispatch and 30-day mortality among patients with acute myocardial infarction (MI).

METHODS AND RESULTS

Copenhagen, Denmark has a 24-h non-emergency medical helpline and an emergency number 1-1-2 (equivalent to 9-1-1). Both services register symptoms/purpose of calls. Among patients with MI as either hospital diagnosis or cause of death within 72 h after a call, the primary symptom was categorized as chest pain, atypical symptoms (breathing problems, unclear problem, central nervous system symptoms, abdominal/back/urinary, other cardiac symptoms, and other atypical symptoms), unconsciousness, non-informative symptoms, and no recorded symptoms. We identified 4880 emergency and 3456 non-emergency calls from patients with MI. The most common symptom was chest pain (N = 5219) followed by breathing problems (N = 556). Among patients with chest pain, 95% (3337/3508) of emergency calls and 76% (1306/1711) of non-emergency calls received emergency dispatch. Mortality was 5% (163/3508) and 3% (49/1711) for emergency/non-emergency calls, respectively. For atypical symptoms 62% (554/900) and 17% (137/813) of emergency/non-emergency calls received emergency dispatch and mortality was 23% (206/900) and 15% (125/813). Among unconscious, patients 99%/100% received emergency dispatch and mortality was 71%/75% for emergency/non-emergency calls. Standardized 30-day mortality was 4.3% for chest pain and 15.6% for atypical symptoms, and associations between symptoms and emergency dispatch remained in subgroups of age and sex.

CONCLUSION

Myocardial infarction patients presenting with atypical symptoms when calling for help have a reduced chance of receiving an emergency dispatch and increased 30-day mortality compared to MI patients with chest pain.

Pre-hospital delay among patients with acute myocardial infarction in Saudi Arabia. A cross-sectional study

OBJECTIVES

To estimate the pre-hospital delay time among patients diagnosed with acute myocardial infarction and to determine factors associated with pre-hospital delay.

METHODS

A cross-sectional study was conducted among 200 patients with myocardial infarction at Madinah Cardiac Center, Al Madinah Al Munawarah, Saudi Arabia between November 2019 and March 2020. Data were collected by direct physician-subject interviews. We used the validated version of the modified response to symptoms questionnaire. Chi-square test, t test, and multivariate analysis were used to examine factors associated with pre-hospital delay.

RESULTS

The median pre-hospital delay time was 3.7 hours. Among all the patients, 126 patients (63%) arrived at the hospital later than 2 hours from the onset of symptoms. Factors that were significantly associated with pre-hospital delay included a previous information on acute coronary syndrome (adjusted odds ratio [adj OR]=0.35, 95% confidence interval [CI] 0.1-0.6), history of hypercholesteremia (adj OR=2.3, 95% CI 1.1-4.7), arrived by ambulance (adj OR=0.3, 95% CI 0.1-0.8), and increased pain intensity (adj OR=0.7, 95% CI 0.6-0.9).

CONCLUSION

Approximately two-thirds of the patients arrived later than 2 hours from the onset of symptoms. A previous information about acute coronary syndrome, history of hypercholesteremia, arrived by ambulance, and increased pain intensity were associated with pre-hospital delay. The study recognizes the need for educational programs about acute myocardial infarction symptoms and the bene ts of availing an ambulance service.

The impact of Community intervention on the time from Symptom onset to first medical contact with acute coronary syndrome

OBJECTIVE

Patient delay in the recognition of and response to the symptoms of acute coronary syndrome (ACS) is a worldwide problem. A community education program about chest pain was implemented in China, and was aimed at providing better community intervention. In this study, the impact of this program on the time of symptom onset to the first medical contact (SO-to-FMC) in ACS patients was investigated, as was the incidence of major adverse cardiac and cerebrovascular events (MACCE) in these patients.

METHODS

A total of 10 local communities were included in this study. A 9-month intensive community education program about chest pain was conducted in these communities. The data on the demographics, mode of transportation, procedures, clinical outcomes, and discharge diagnoses of all ACS patients in these communities were collected.

RESULTS

The study communities had a combined population of 361,609, and all community population sizes ranged from 12,823 to 66,127. The average SO-to-FMC time of the control period was 510 min, whereas, following community intervention, the average SO-to-FMC time was 256 min (P <  0.001). Furthermore, comparative analyses revealed that, following discharge from the hospital, the 1.5-year MACCE-free survival rate was higher in the community intervention group than in the control group (95.0 % vs. 90.5 %, P =  0.025), and the 1.5-year mortality rate was lower in the community intervention group than in the control group (3.3 % vs. 6.3 %, P =  0.03).

CONCLUSIONS AND PRACTICAL IMPLICATIONS

The Hangzhou Chest Pain Science Education Project(HCPSEP) was found to reduce the SO-to-FMC time and improve the outcome of ACS patients. This indicates that a scientific, educational program on chest pain can be effective in improving the knowledge and alertness of the local residents about chest pain. This type of program may be recognized and carried out in other regions.

Time-to-Treatment and Its Association With Complications and Mortality Rate in Patients With Acute Myocardial Infarction: A Prospective Cohort Study

INTRODUCTION

Time-to-treatment is one of the most important factors affecting the complications and mortality rate in patients with acute myocardial infarction. The purpose of this study was to determine time-to-treatment and its association with complications and mortality rates in patients with acute myocardial infarction in selected hospitals in Zanjan, Iran.

METHODS

This prospective cohort study was performed with 200 patients suffering from acute myocardial infarction in selected educational hospitals of Zanjan from June 2016 to March 2017. Parameters including the interval between pain onset and treatment, myocardial infarction complications, in-hospital mortality, and 30-day mortality after the occurrence of myocardial infarction were collected through a special questionnaire and phone calls. The data were analyzed using descriptive statistics and logistic regression models.

RESULTS

The longest time-to-treatment delay is related to prehospital time (mean, 330.68 [SD=411.55] minutes). Based on the results, the increase in the interval time between onset of pain and treatment (odds ratio: 1.001; 95% confidence interval, 1.000-1.002; P = 0.01), hypertension (odds ratio: 2.96; 95% confidence interval, 1.14-7.68; P = 0.02), and left coronary artery complete occlusion (odds ratio: 2.78; 95% confidence interval, 1.57-4.94; P < 0.001) were mortality predictor factors. Furthermore, the increase in the interval time between onset of pain and treatment (odds ratio: 1.001; 95% confidence interval, 1.000-1.002; P = 0.03), current smoking (odds ratio: 5.53; 95% confidence interval, 1.75-17.43; P = 0.004), and right coronary artery complete occlusion (odds ratio: 5.87; 95% confidence interval, 1.34-25.82; P = 0.02) were highly associated with the occurrence of heart failure.

DISCUSSION

Hypertension, smoking history, and delay in treatment time were highly associated with the occurrence of heart failure and mortality. Therefore, in Iranian society, education on primary and secondary prevention of myocardial infarction is recommended to reduce patient mortality.

Pre-hospital delay in patients with myocardial infarction: an observational study in a tertiary care hospital of northern Bangladesh

Background

Delayed hospital presentation is a hindrance to the optimum clinical outcome of modern therapies of Myocardial infarction (MI). This study aimed to investigate the significant factors associated with prolonged pre-hospital delay and the impact of this delay on in-hospital mortality among patients with MI in Northern Bangladesh.

Methods

This cross sectional study was conducted in December 2019 in cardiology ward of a 1000-bed tertiary care hospital of Bangladesh. Patients admitted in the ward with the diagnosis of myocardial infarction were included in the study. Socio demographic data, clinical features and patients’ health seeking behavior was collected in a structured questionnaire from the patients. Median with interquartile range (IQR) of pre hospital delay were calculated and compared between different groups. Chi-square (χ²) test and binary logistic regression were used to estimate the determinants of pre-hospital delay and effect of pre-hospital delay on in-hospital mortality.

Results

Three hundred thirty-seven patients was enrolled in the study and their median (IQR) pre-hospital delay was 9.0 (13.0) hours. 39.5% patients admitted in the specialized hospital within 6 h. In logistic regression, determinants of pre-hospital delay were patients age (for < 40 years aOR 2.43, 95% CI 0.73–8.12; for 40 to 60 years aOR 0.44, 95% CI 0.21–0.93), family income (for lower income aOR 5.74, 95% CI 0.89–37.06; for middle income aOR 14.22, 95% CI 2.15–94.17), distance from primary care center ≤5 km (aOR 0.42, 95% CI 0.12–0.90), predominant chest pain (aOR 0.15, 95% CI 0.05–0.48), considering symptoms as non-significant (aOR 17.81, 95% CI 5.92–53.48), referral from primary care center (for government hospital aOR 4.45, 95% CI 2.03–9.74; for private hospital OR 98.67, 95% CI 11.87–820.34); and not having family history of MI (aOR 2.65, 95% CI 1.24–5.71) (R2 = 0.528). Risk of in-hospital mortality was almost four times higher who admitted after 6 h compared to their counterpart (aOR 0.28, 95% CI 0.12–0.66); (R² = 0.303).

Conclusion

Some modifiable factors contribute to higher pre-hospital delay of MI patients, resulting in increased in-hospital mortality. Patients’ awareness about cardiovascular diseases and improved referral pathway of the existing health care system may reduce this unexpected delay.

Pre-Hospital Delay and Its Contributing Factors in Patients with ST-Elevation Myocardial Infarction; a Cross sectional Study

INTRODUCTION

The outcome of ST-elevation myocardial infarction (STEMI) is significantly influenced by the total tissue ischemic time. In spite of efforts for reducing the in-hospital delay by full-time provision of primary percutaneous coronary intervention (P-PCI) in the 24/7 program, pre-hospital delay still persists. As a first report in Iran, we aimed to assess the duration of pre-hospital delay and its contributing factors in STEMI patients in the P-PCI era.

METHODS

The present cross-sectional study evaluated 2103 STEMI patients who underwent primary PCI from 2016 to 2018. Demographic, personal and socioeconomic factors, index event characteristics, past medical history, pain onset and door times of patients were recorded and independent factors of pre-hospital delay were calculated.

RESULTS

Median (IQR) of pain to door (P2D) time was 279 (120-630) minutes. In multivariate analysis, female gender [Beta=0.064 (95%CI: 0.003-0.125); p=0.038], being uneducated [Beta=0.213 (95%CI: 0.115-0.311); p<0.001], the onset of chest pain between 00:00 to 6:00 [Beta=0.130 (95%CI: 0.058-0.202); p<0.001] or 7:00 to 12:00 [Beta=0.119 (95%CI: 0.049-0.190); p=0.001], self-transportation [Beta=0.098 (95%CI: 0.015-0.181); p=0.020] or referral from another hospital [Beta=0.253 (95%CI: 0.117-0.389); p<0.001], atypical chest pain [Beta=0.170 (95%CI: 0.048-0.293); p=0.006], history of hypertension [Beta=0.052 (95%CI: 0.002-0.102); p=0.041], and opium abuse [Beta=0.076 (95%CI: 0.007-0.146); p=0.031] were associated with a significantly higher log(P2D), while history of CABG was associated with shorter P2D.

CONCLUSION

Our study showed that P2D is still very high in Iran and revealed the high-risk groups associated with longer P2D. Effective actions should be implemented to increase the public awareness about the symptoms of STEMI, and the importance of immediate appropriate help-seeking.

Abdominal Compartment Syndrome in Critically Ill Patients

BACKGROUND

Abdominal compartment syndrome patients suffer severe obstacles such as kidney failure and shock. To evade further complications, identifying the abdominal compartment syndrome (ACS) and Intra-abdominal hypertension (IAH), in critically ill individuals and hospitalised in the intensive care unit (ICU) is obligated.

AIM

The current study intended to study the abdominal compartment syndrome and the concomitant risk factors among hospitalised patients in ICU, by using the Intra-abdominal pressure test.

MATERIAL AND METHODS

One hundred and twenty-five hospitalised patients at ICU entered the current survey. Abdominal pressure was measured by standard intravesical technique. The SPSS 21 analysed the preoperative and intraoperative factors such as demographic records and comorbidities.

RESULTS

Seventy-three (58.4%) participants were males and 52 (41.6%) were women in the mean age of 55.1 ± 18.3 years. Eighty-nine patients (71.2%) showed normal intra-abdominal pressure since 31 patients (24.8%), and 5 patients (4%) developed IAH and ACS. The intra-abdominal pressure (IAP) applied to Glasgow Coma Scale (GCS), Acute Physiology, shock, Systemic Inflammatory Response Syndrome (SIRS), central venous oxygen saturation and Chronic Health Evaluation (APACHE II) score (P < 0.05). Patients with high IAP have shown a higher mortality frequency, compared to others (P < 0.05).

CONCLUSION

Current findings showed a correlation between IAP hospitalised patients in ICU and shock, SIRS, APACHE II, central venous oxygen saturation and GCS. Intra-abdominal pressure test, as a valuable prognosis test for the abdominal compartment syndrome (ACS) and Intra-abdominal hypertension (IAH), may offer better results when added to the routine medical checkup of ICU patients.

Pre-Hospital Factors Influencing Time of Arrival at Emergency Departments for Patients with Acute ST-Elevation Myocardial Infarction

Background

Pre-hospital delay is currently a major factor limiting early reperfusion among ST-elevation myocardial infarction (STEMI) patients worldwide. This study aims to determine pre-hospital factors affecting symptom-to-door time among STEMI patients in Malaysia.

Methods

This cross-sectional study included 222 STEMI patients admitted to two tertiary hospitals in Malaysia. By determining symptom-to-door time, the study population was categorised into two definitive treatment seeking groups: early (≤ 3 h) and delayed (> 3 h). Data was collected focusing on socio-demographical data, risk factors and comorbidities, clinical presentation, situational factors and action taken by patients.

Results

The mean age of our patients was 58.0 (SD = 11.9) years old, and the population consisted of 186 (83.8%) males and 36 (16.2%) females. Our study found that the median symptom-to-door time was 130.5 (IQR 240) min, with 64% of subjects arriving early and 36% arriving late. Pre-hospital delays were found to be significant among females (adj OR = 2.42; 95% CI: 1.02, 5.76; P = 0.046), patients with recurrence of similar clinical presentations (adj OR = 2.74; 95% CI: 1.37, 5.46; P = 0.004), patients experiencing atypical symptoms (adj OR = 2.64; 95% CI: 1.11, 6.31; P = 0.029) and patients who chose to have their first medical contact (FMC) for their symptoms with a general practitioner (adj OR = 2.80; 95% CI: 1.20, 6.56; P = 0.018). However, patients with hyperlipidaemia (adj OR = 0.46; 95% CI: 0.23, 0.93; P = 0.030), self-perceived cardiac symptoms (adj OR = 0.36; 95% CI: 0.17, 0.73; P = 0.005) and symptoms that began in public places (adj OR = 0.21; 95% CI: 0.06, 0.69; P = 0.010) tended to seek treatment earlier.

Conclusion

The symptom-to-door time among the Malaysian population is shorter in comparison to other developing countries. Nevertheless, identified, modifiable pre-hospital factors can be addressed to further shorten symptom-to-door time among STEMI patients.

Characteristics of patients with acute myocardial infarction contacting primary healthcare before hospitalisation: a cross-sectional study

Background

The characteristics of patients with on-going myocardial infarction (MI) contacting the primary healthcare (PHC) centre before hospitalisation are not well known. Prompt diagnosis is crucial in patients with MI, but many patients delay seeking medical care. The aims of this study was to 1) describe background characteristics, symptoms, actions and delay times in patients contacting the PHC before hospitalisation when falling ill with an acute MI, 2) compare those patients with acute MI patients not contacting the PHC, and 3) explore factors associated with a PHC contact in acute MI patients.

Methods

This was a cross-sectional multicentre study, enrolling consecutive patients with MI within 24 hours of admission to hospital from Nov 2012 until Feb 2014.

Results

A total of 688 patients with MI, 519 men and 169 women, were included; the mean age was 66±11 years. One in five people contacted PHC instead of the recommended emergency medical services (EMS), and 94% of these patients experienced cardinal symptoms of an acute MI; i.e., chest pain, and/or radiating pain in the arms, and/or cold sweat. Median delay time from symptom-onset-to-decision-to-seek-care was 2:15 hours in PHC patients and 0:40 hours in non-PHC patients (p<0.01). The probability of utilising the PHC before hospitalisation was associated with fluctuating symptoms (OR 1.74), pain intensity (OR 0.90) symptoms during off-hours (OR 0.42), study hospital (OR 3.49 and 2.52, respectively, for two of the county hospitals) and a final STEMI diagnosis (OR 0.58).

Conclusions

Ambulance services are still underutilized in acute MI patients. A substantial part of the patients contacts their primary healthcare centre before they are diagnosed with MI, although experiencing cardinal symptoms such as chest pain. There is need for better knowledge in the population about symptoms of MI and adequate pathways to qualified care. Knowledge and awareness amongst primary healthcare professionals on the occurrence of MI patients is imperative.

Analysis of prehospital care of patients with acute myocardial infarction in Bulgaria

Introduction:

Acute myocardial infarction is one of the most devastating cardiovascular diseases and about 50% of all deaths due to it occur prior to hospitalization. Our study aimed to evaluate the prehospital delay in patients with acute myocardial infarction.

Methods:

We enrolled 682 consecutive patients with acute myocardial infarction from May 2008 to December 2014, with a mean age of 66.6 ± 12.9 years. Detailed information was collected about the symptoms, first medical contact, concomitant clinical conditions, and the socioeconomic data. We analyzed the following prehospital times: (1) onset of symptoms to emergency call, (2) onset of symptoms to first medical contact, (3) first medical contact to hospital admission, and (4) onset of symptoms to hospital admission.

Results:

The first medical contact was with the National Emergency Medical Service in 266 (39.0%) patients, another emergency unit 106 (15.6%), cardiologist 41 (6%), general practitioner 36 (5.3%), and others 233 (34.1%). The median time from the onset of symptoms till emergency call was 190 min, from the first contact with a team of the National Emergency Medical Service till hospital admission 60 min, and from the onset of symptoms till hospital admission 4.8 h.

Conclusion:

The total prehospital delay in our study was unacceptably prolonged, with patient’s decision time as the major contributor. The delay could be substantially shortened by (1) increased awareness of the general population, particularly of individuals at high cardiovascular risk and (2) continuous medical education and regular practical training of the primary care providers about coping with medical emergencies.

Factors Affecting the Location of Road Emergency Bases in Iran Using Analytical Hierarchy Process (AHP)

Objective

To identify and prioritize factors affecting the location of road emergency bases in Iran using Analytical Hierarchy Process (AHP).

Methods

This was a mixed method (quantitative-qualitative) study conducted in 2016. The participants in this study included the professionals and experts in the field of pre-hospital and road emergency services issues working in the Health Deputy of Iran Ministry of Health and Medical Education, which were selected using purposive sampling method. In this study at first, the factors affecting the location of road emergency bases in Iran were identified using literature review and conducting interviews with the experts. Then, the identified factors were scored and prioritized using the studied professionals and experts' viewpoints through using the analytic hierarchy process (AHP) technique and its related pair-wise questionnaire. The collected data were analyzed using MAXQDA 10.0 software to analyze the answers given to the open question and Expert Choice 10.0 software to determine the weights and priorities of the identified factors.

Results

The results showed that eight factors were effective in locating the road emergency bases in Iran from the viewpoints of the studied professionals and experts in the field of pre-hospital and road emergency services issues, including respectively distance from the next base, region population, topography and geographical situation of the region, the volume of road traffic, the existence of amenities such as water, electricity, gas, etc. and proximity to the village, accident-prone sites, University ownership of the base site, and proximity to toll-house.

Conclusion

Among the eight factors which were effective in locating the road emergency bases from the studied professionals and experts' perspectives, "distance from the next base" and "region population" were respectively the most important ones which had great differences with other factors.

Differences in symptoms, first medical contact and pre-hospital delay times between patients with ST- and non-ST-elevation myocardial infarction

Aim:

In ST-elevation myocardial infarction, time to reperfusion is crucial for the prognosis. Symptom presentation in myocardial infarction influences pre-hospital delay times but studies about differences in symptoms between patients with ST-elevation myocardial infarction and non-ST-elevation myocardial infarction are sparse and inconclusive. The aim was to compare symptoms, first medical contact and pre-hospital delay times in patients with ST-elevation myocardial infarction and non-ST-elevation myocardial infarction.

Methods and results:

This multicentre, observational study included 694 myocardial infarction patients from five hospitals. The patients filled in a questionnaire about their pre-hospital experiences within 24 h of hospital admittance. Chest pain was the most common symptom in ST-elevation myocardial infarction and non-ST-elevation myocardial infarction (88.7 vs 87.0%, p=0.56). Patients with cold sweat (odds ratio 3.61, 95% confidence interval 2.29–5.70), jaw pain (odds ratio 2.41, 95% confidence interval 1.04–5.58), and nausea (odds ratio 1.70, 95% confidence interval 1.01–2.87) were more likely to present with ST-elevation myocardial infarction, whereas the opposite was true for symptoms that come and go (odds ratio 0.58, 95% confidence interval 0.38-0.90) or anxiety (odds ratio 0.52, 95% confidence interval 0.29–0.92). Use of emergency medical services was higher among patients admitted with ST-elevation myocardial infarction. The pre-hospital delay time from symptom onset to first medical contact was significantly longer in non-ST-elevation myocardial infarction (2:05 h vs 1:10 h, p=0.001).

Conclusion:

Patients with ST-elevation myocardial infarction differed from those with non-ST-elevation myocardial infarction regarding symptom presentation, ambulance utilisation and pre-hospital delay times. This knowledge is important to be aware of for all healthcare personnel and the general public especially in order to recognise symptoms suggestive of ST-elevation myocardial infarction and when to decide if there is a need for an ambulance.

Tempos de acesso a serviços de saúde face ao infarto do miocárdio

Resumo Objetivo Analisar os tempos relacionados ao acesso de homens e mulheres com infarto do miocárdio a hospitais referência em cardiologia e a correlação entre eles. Métodos Pesquisa transversal, com 100 pessoas com infarto entrevistadas em hospitais referência em cardiologia. Dados analisados por estatística descritiva e inferencial, adotando-se significância estatística. Resultados Os tempos foram elevados (decisão para atendimento, chegada ao primeiro serviço de saúde, permanência na rede de atenção e admissão em hospitais referência em cardiologia), exceto o de transporte, sobretudo para mulheres. Houve maior contribuição do tempo de decisão na composição do tempo de chegada ao primeiro serviço de saúde e do tempo de permanência na rede na composição do tempo de chegada aos hospitais referência em cardiologia. Conclusão A longa espera por atenção especializada reflete a falta de estrutura dos serviços de saúde, e o tempo de decisão elevado reflete a falta do não reconhecimento do infarto pelos participantes.