The effects of prehospital system delays on the treatment efficacy of STEMI patients

Patients With AMI and Severely Reduced LVEF, a Well-Defined, Still Extremely Vulnerable Population (Insights from AMIS Plus Registry)

Left ventricular ejection fraction (LVEF) represents one of the strongest predictors of both in-hospital and long-term prognosis in acute myocardial infarction (AMI). Temporal trends data coming from real-world experiences focused on patients with AMI with severely reduced LVEF (i.e., <30%) are lacking. In a total of 48,543 screened patients with AMI included in the Acute Myocardial Infarction in Switzerland Plus Registry between 2005 and 2020, data on LVEF were available for 23,510 patients. Study patients were classified according to LVEF as patients with AMI with or without severely reduced LVEF (i.e., patients with LVEF <30% and ≥30%, respectively). Overall, 1,657 patients with AMI (7%) displayed severely reduced LVEF. The prevalence of severe LVEF reduction constantly decreased over the study period (from 11% to 4%, p <0.001). In the subgroup of patients with severely reduced LVEF, a significant increase in revascularization rate was observed (from 61% to 84%, p <0.001); however, in-hospital mortality did not significantly decrease and remained well above 20% over the study period (from 23% to 26%, p = 0.65). At discharge, prescription of optimal cardioprotective therapy (defined as an association of renin-angiotensin-aldosterone-system inhibitors, β-blocker, and mineral corticoid receptor antagonist) remained low across the study period (from 17% in 2011 to 20%, p = 0.96). In conclusion, patients with AMI with severely reduced LVEF remain a fragile subgroup of patients with an in-hospital mortality that did not significantly decrease and remained well above 20% over the study period. Moreover, access at discharge to optimal cardioprotective therapy remains suboptimal. Efforts are, therefore, needed to improve prognosis and access to guidelines-directed therapies in this fragile population.

Multi-criteria assignment problems for optimising the emergency medical services (EMS), considering non-homogeneous speciality of the emergency departments and EMS crews

Dispatching of the EMS crews (ambulances) to awaiting patients and then directing the patients, that are already onboard, to appropriate Emergency Departments (ED), is a nontrivial decision problem. In many emergency medical systems it is handled by the Medical Dispatcher using various strategies-sometimes preferring the closest unit. However, applying a wrong strategy may result in transferring acute-state patients, who require very specialised medical aid, to low-speciality EDs with insufficient treatment capabilities. Then, they would need to be re-transferred to referential units, prolonging substantially the time to receive treatment. In some cases such a delay might make the treatment less effective or even impossible. In this work we propose two multi-criteria mathematical optimisation problems-the first one allows us to calculate the ambulance-to-patient assignment, the second one-to establish the patient-to-hospital assignment. These problems not only take the time-to-support criterion into consideration but also optimise for the speciality of care received by each patient. The ED dispatching problem proposed allows both for direct transfers of patients to referential units and for re-transferring them from non-referential EDs. The performance of the proposed approach is tested in simulations with real-life emergency cases from the NEMSIS data set and compared with classic assignment strategies. The tests showed the proposed approach is able to produce better and more fit-for-purpose dispatching results than other strategies tested. Additionally, we propose a framework for embedding the proposed optimisation problems in the current EMS/ED dispatching process.

Prediction of inappropriate pre-hospital transfer of patients with suspected cardiovascular emergency diseases using machine learning: a retrospective observational study

BACKGROUND

This study aimed to develop a prediction model for transferring patients to an inappropriate hospital for suspected cardiovascular emergency diseases at the pre-hospital stage, using variables obtained from an integrated nationwide dataset, and to assess the performance of this model.

METHODS

We integrated three nationwide datasets and developed a two-step prediction model utilizing a machine learning algorithm. Ninety-eight clinical characteristics of patients identified at the pre-hospital stage and 13 hospital components were used as input data for the model. The primary endpoint of the model was the prediction of transfer to an inappropriate hospital.

RESULTS

A total of 94,256 transferred patients in the public pre-hospital care system matched the National Emergency Department Information System data of patients with a pre-hospital cardiovascular registry created in South Korea between July 2017 and December 2018. Of these, 1,770 (6.26%) patients failed to be transferred to a capable hospital. The area under the receiver operating characteristic curve of the final predictive model was 0.813 (0.800-0.825), and the area under the receiver precision-recall curve was 0.286 (0.265-0.308).

CONCLUSIONS

Our prediction model used machine learning to show favorable performance in transferring patients with suspected cardiovascular disease to a capable hospital. For our results to lead to changes in the pre-hospital care system, a digital platform for sharing real-time information should be developed.

Comparison of the outcomes of EMS vs. Non-EMS transport of patients with ST-segment elevation myocardial infarction (STEMI) in Southern Iran: a population-based study

BACKGROUND

In the medical management of acute myocardial infarction, the transport of patients and primary care provided by emergency medical technicians (EMTs) and paramedics are effective in reducing the mortality and disabilities. Therefore, the present study aimed to compare the outcomes of emergency medical services (EMS) vs. non-EMS transport of patients with ST-segment elevation myocardial infarction (STEMI) in southern Iran.

METHODS

This is an analytical, cross-sectional study. The study population consisted of the individuals registered in Fasa Registry on Acute Myocardial Infarction (FaRMI) in the south of Iran. 2244 patients with STEMI were included in the study. Statistical analyses were performed using Chi-Square test and independent t-test at a significance level of P < 0.05 in SPSS 22.

RESULTS

Out of the 2244 patients with STEMI, 1552 (69.16%) were male and 672 patients (29.94%) were female. 934(41.62%) patients used EMS transport to the hospital, while 1310 (58.37%) patients used non-EMS transport to the hospital. A total of 169 patients with STEMI (7.26%) expired (out-of-hospital cardiac arrest); of them, 113 (66.86%) patients did not use EMS transport to the hospital. Successful cardiopulmonary resuscitation (CPR) was performed on 52 patients who used EMS transport. 27 patients also received an effective DC shock due to ventricular fibrillation (VF). Of the total number of patients, 49 had a stroke; among them, 37(75.51%) patients did not use EMS transport.

CONCLUSION

In the present study, the death rate in patients with acute myocardial infarction who used EMS transport was lower than those who used non-EMS transport. The health system managers and policymakers in the healthcare systems are recommended to take the necessary measures to increase public health awareness and knowledge about the use of EMS and consequently reduce the death rate and complications of acute myocardial infarction.

Telecardiology interventions for patients with cardiovascular Disease: A systematic review on characteristics and effects

INTRODUCTION

The prevalence and mortality of cardiovascular diseases are high worldwide. Telecardiology can be used to diagnose and treat these diseases. This paper aimed to review the effectiveness (positive and negative) of implemented telecardiology services in terms of clinical, economic, and patient-reported aspects.

METHODS

A comprehensive search was conducted in Medline (through PubMed), Scopus, ISI web of science, and IEEE Xplore databases from inception to April 7, 2021. the studies that examined the effectiveness of telecardiology interventions were included.

RESULTS

Fifty studies were included in this systematic review. Most investigations (22%) were conducted in the US. In 22% of studies, telecardiology intervention was used for patients with heart failure. Telecardiology has been used in most studies for tele-monitoring (n = 21, 42%) and tele-consultation (n = 17, 34%) and in 29 studies (58%), was applied for ECG transmission. The highest rate of effects reported by studies was clinical. Thirty-five studies (70%) reported the clinical effects; twenty-one studies reported the positive effects for the economic category, and fifteen studies reported the positive effect for patient-reported class. The most positive clinical effects of telecardiology were early diagnosis, early treatment, and mortality reduction. The most positive effect of the economic class was the reduction of health care costs. The most effects of the patient-reported category were improving the patient's quality of life and patient satisfaction.

CONCLUSION

Telecardiology can help early diagnosis and treatment of cardiovascular diseases. It also has great potential in reducing health care costs and increasing quality of life and patient satisfaction.

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.

Factors associated with time delay to angiography in acute ST-elevation myocardial infarction - A retrospective cohort study in Northern Finland

BACKGROUND

The delay of percutaneous coronary intervention increases the risk of heart failure and mortality in STEMI. The aim of this study was to examine the time intervals of EMS and the factors associated with the time delay to angiography in patients with STEMI.

METHODS

The present study was conducted in Northern Ostrobothnia, Finland in 2014-2016. All patients transported to the hospital by EMS who were diagnosed with STEMI and underwent a primary angiography within 24 h of arrival were included. Angiography was defined as delayed if it was performed over 120 min of the first medical contact (FMC).

RESULTS

310 patients met the inclusion criteria during the study period. Time from the FMC to angiography was less than 120 min in 231 patients (74.5%). In multivariate analysis, the factors associated with delayed angiography were the absence of chest pain (OR 2.46 (1.18-5.13),p = 0.016), dyspnea (OR 3.11 (1.54-6.28),p = 0.002), the treatment protocol violations by EMS (OR 2.41 (0.99-5.80),p = 0.050), treatment initiation at a primary health care center (OR 3.64 (1.39-9.48),p = 0.008), and the distance to hospital of over 100 km (OR 11.87 (6.14-22.93),p < 0.001).

CONCLUSION

In our study, treatment protocol violations, non-specific symptoms, and the distance to hospital of over 100 km were associated with primary angiography in patients with STEMI transported to the hospital by EMS.

Size of Acute Myocardial Infarction Correlates with Earlier Time of Initiation of Reperfusion Therapy with Cardiac Perfusion Scintigraphy: A National Single-Center Study

BACKGROUND The aim of this study was to determine the correlation between the size of acute myocardial infarction (AMI) and the time of initiation of reperfusion therapy with cardiac perfusion scintigraphy. MATERIAL AND METHODS Overall, 80 patients with acute ST elevation myocardial infarction (STEMI) were examined. All patients were treated with primary percutaneous coronary intervention (pPCI). Data on patient and system delay expressed in minutes were recorded and compared with recommended timelines. Cardiac scintigraphy was performed with 99m Tc-sestamibi single-photon emission computed tomography (SPECT). The median time of cardiac scintigraphy was 20 days. The correlation between the size of infarction and the time of initiation of reperfusion therapy was evaluated. RESULTS The mean age of patients was 60.5±11.5 years, and 72.5% were male. The average system delay was 348 min, and the average patient delay was 173 min. The mean total ischemic time was 800 min. There was a correlation between time delays of reperfusion therapy and infarct size. Patients with a shorter time delay to patent artery after FMC showed smaller infarct size when compared to the patients with longer delay times. Multiple linear regression analysis showed that FMC, being male, and smokers had statistical significance when predicting infarct size. CONCLUSIONS There is a correlation between the size of myocardial infarction and the time of initiation of reperfusion therapy determined by perfusion myocardial scintigraphy. The study showed that there are time delays in starting the treatment of AMI with pPCI when compared to the recommended time, which requires an action plan in the near future to ensure earlier treatment for our patients.

Disparities in Emergency Medical Services Time Intervals for Patients with Suspected Acute Coronary Syndrome: Findings from the North Carolina Prehospital Medical Information System

Background

Timely emergency medical services (EMS) response, management, and transport of patients with suspected acute coronary syndrome (ACS) significantly reduce delays to emergency treatment and improve outcomes. We evaluated EMS response, scene, and transport times and adherence to proposed time benchmarks for patients with suspected ACS in North Carolina from 2011 to 2017.

Methods and Results

We conducted a population‐based, retrospective study with the North Carolina Prehospital Medical Information System, a statewide electronic database of all EMS patient care reports. We analyzed 2011 to 2017 data on patient demographics, incident characteristics, EMS care, and county population density for EMS‐suspected patients with ACS, defined as a complaint of chest pain or suspected cardiac event and documentation of myocardial ischemia on prehospital ECG or prehospital activation of the cardiac care team. Descriptive statistics for each EMS time interval were computed. Multivariable logistic regression was used to quantify relationships between meeting response and scene time benchmarks (11 and 15 minutes, respectively) and prespecified covariates. Among 4667 patients meeting eligibility criteria, median response time (8 minutes) was shorter than median scene (16 minutes) and transport (17 minutes) time. While scene times were comparable by population density, patients in rural (versus urban) counties experienced longer response and transport times. Overall, 62% of EMS encounters met the 11‐minute response time benchmark and 49% met the 15‐minute scene time benchmark. In adjusted regression analyses, EMS encounters of older and female patients and obtaining a 12‐lead ECG and venous access were independently associated with lower adherence to the scene time benchmark.

Conclusions

Our statewide study identified urban–rural differences in response and transport times for suspected ACS as well as patient demographic and EMS care characteristics related to lower adherence to scene time benchmark. Strategies to reduce EMS scene times among patients with ACS need to be developed and evaluated.

Prehospital Adenosine Diphosphate Receptor Blocker Use, Culprit Artery Flow, and Mortality in STEMI: The MADDEC Study

BACKGROUND AND OBJECTIVE

The newer adenosine diphosphate (ADP) receptor blockers ticagrelor and prasugrel are superior to clopidogrel in the long-term management of acute coronary syndrome (ACS). We evaluated the acute performance (prehospital loading) of these ADP receptor blockers in a primary percutaneous coronary intervention (PCI) for an ST-elevation myocardial infarction (STEMI).

METHODS

In a retrospective, single-center registry study, data on all STEMI patients admitted for their first primary PCI between January 2007 and April 2020 were analyzed (n = 3218). The three ADP receptor blockers were mainly used during consecutive periods (clopidogrel 2007-2010, prasugrel 2011-2014, and ticagrelor 2014-2020), and were compared with risk factor-adjusted multivariate logistic regression for acute 3- and 7-day mortality and culprit artery flow before and after PCI.

RESULTS

Of the 3218 total patients, 47.6% (n = 1532) were treated with ticagrelor, 22.1% (n = 711) were treated with prasugrel, and 30.3% (n = 975) were treated with clopidogrel. The use of ticagrelor or prasugrel as opposed to clopidogrel was associated with better culprit artery flow before PCI (odds ratio [OR] 1.21 for moderate or good flow, 95% confidence interval [CI] 1.03-1.42, p = 0.022), as well as lower acute mortality (OR 0.66 for 3-day mortality, 95% CI 0.46-0.95, p = 0.025; and OR 0.71 for 7-day mortality, 95% CI 0.52-0.98, p = 0.039). The results in regard to acute mortality were highlighted among patients with short treatment delays (disappearing with longer treatment delays; p < 0.05 for interaction).

CONCLUSIONS

The newer ADP receptor blockers are associated with lower mortality and better culprit artery flow at presentation when compared with clopidogrel. There are no significant differences between the two newer drugs. As the drugs were mainly used during three consecutive periods, unmeasured confounding related to the development of cardiac care and changes in the population may contribute to the results.

The accuracy of preliminary diagnoses made by paramedics - a cross-sectional comparative study

Background

Clinical decision-making skills of paramedics have been emphasized because of the growing complexity of emergency medicine nursing. A preliminary diagnosis made by a paramedic has an essential role in directing the subsequent care. An accurate preliminary diagnosis improves the patient’s outcome. The research in this area is relatively scarce and there are no previous studies in Finland describing the accuracy of preliminary diagnoses made by paramedics. The aim of this study was to evaluate whether paramedics are making accurate preliminary diagnoses for the patients they are transporting to hospital. In addition, the aim was to describe the variables related to an accurate preliminary diagnosis.

Methods

A cross-sectional comparative approach was used and conducted through a questionnaire to gather data from the paramedics. A total of 71 paramedics participated in the study and 378 patient cases were included. The paramedics were asked to describe the basic information of a case, to state their preliminary diagnosis, and give their own educational background. The accuracy of the paramedic’s preliminary diagnosis was compared with the discharge diagnosis of the ED physicians retrieved from hospital’s patient records. Logistic regression analysis and a binomial test were used to test the statistical significance.

Results

The agreement between the paramedics’ preliminary diagnosis vs. hospital diagnosis was 70% (n = 261). Diagnostic accuracy varied according to the medical condition from mental diseases and intoxication (86%, p = 0,000), cerebral strokes (81%, p = 0,007) to infections (31% p = 0,029). The educational background of a bachelor-degree-level paramedic (p = 0,016, 95% Cl 1,7-139,6) and a good self-assessment value (p = 0,003, 95% Cl 1,2-2,7) were related to making a correct diagnosis.

Conclusions

Paramedics are able to determine preliminary diagnoses at satisfactory level. The relationship between educational background and diagnostic accuracy suggests that there is a definitive need for a specific pre-hospital nursing education.

ECG pre-hospital teletransmission by emergency teams staffed with an emergency physician and paramedics and its impact on transportation and hospital admission

Electrocardiography (ECG) is essential to detect and diagnose life threatening cardiac conditions and to determine further treatment. Correct interpretation of an ECG can be challenging, especially in the out-of-hospital setting and by less experienced emergency team members.The aim of this study was to compare the rate of ECG transmission from an out-of-hospital emergency scene to an in-hospital cardiologist on call in EMS-B and EMS-S providers and its impact on direct transportation to a cardiac catheterization laboratory and hospital admission.The study was designed as an observational study. Data from 3 separate emergency medical service teams were collected. Two teams are staffed by paramedics only (EMT-B), while another specialized team is staffed with an emergency physician (EMT-S). 5864 out-of-hospital emergencies were performed during a 12-month period and were analyzed for this study.In 124 out of 5864 (2.1%) out-of-hospital emergencies, an ECG transmission from the out-of-hospital scene to an in-hospital cardiologist on call was performed. Rate of transmission was similar between both teams (EMT-B n = 70, 2.2% vs EMT-S n = 54, 2.0%, P = .054). After coordinating with the cardiologist on call, 11 patients (15.7%) of the EMT-B (15.7%) and 24 patients (44.4%) of the EMT-S were directly transported from the scene of emergency to a cardiac catheterization laboratory (P < .001). Overall, 80% of patients treated by EMT-S, compared to 52.5% treated by the EMT-B required subsequent hospital admission (P < .05).Transmission of ECG from the out-of-hospital emergency scene to the in-hospital cardiologist is infrequently performed. The rate of STEMI in transmitted ECG's by emergency teams staffed with an emergency physician was higher compared to emergency teams staffed with paramedics only.