Barriers Associated With Door-to-Balloon Delay in Contemporary Japanese Practice

Influence of Organisational-Level Factors on Delayed Door-to-Balloon Time among Patients with ST-Elevation Myocardial Infarction

Objectives

This study aimed to estimate the door-to-balloon (DTB) time and determine the organisational-level factors that influence delayed DTB times among patients with ST-elevation myocardial infarction in Oman.

Methods

A cross-sectional retrospective study was conducted on all patients who presented to the emergency department at Sultan Qaboos University Hospital and Royal Hospital, Muscat, Oman, and underwent primary percutaneous coronary interventions during 2018-2019.

Results

The sample included 426 patients and the median DTB time was 142 minutes. The result of the bivariate logistic regression showed that patients who presented to the emergency department with atypical symptoms were 3 times more likely to have a delayed DTB time, when compared to patients who presented with typical symptoms (odds ratio [OR] = 3.003, 95% confidence interval [CI]: 1.409-6.400; P = 0.004). In addition, patients who presented during off-hours were 2 times more likely to have a delayed DTB time, when compared to patients who presented during regular working hours (OR = 2.291, 95% CI: 1.284-4.087; P = 0.005).

Conclusion

To meet the DTB time recommendation, it is important to ensure adequate staffing during both regular and irregular working hours. Results from this study can be used as a baseline for future studies and inform strategies for improving the quality of care.

Health Inequalities of STEMI Care Before Implementation of a New Regional Network: A Prefecture-Level Analysis of Social Determinants of Healthcare in Yunnan, China

BACKGROUND

As one of the most serious types of coronary heart disease, ST-elevation myocardial infarction (STEMI) faces huge challenges in the equal management and care of patients due to its life-threatening and time-critical condition. Health inequalities such as sex and age differences in STEMI care have been reported from developed countries. However, limited outcomes have been investigated and the major drivers of inequality are still unclear, especially in under-developed areas. This study aimed to explore the major drivers of health inequalities in STEMI care before implementation of a new regional network in the south-west of China.

METHODS

Prefecture-level data of STEMI patients before the implementation of a regional network were analysed retrospectively. Drivers of inequality were identified from six social determinants of health, namely area of residence, ethnicity, sex, age, education and occupation. Outcomes of STEMI care included timely presentation, reperfusion therapy, timely reperfusion therapy, heart failure, inpatient mortality, length of hospital stay, hospital costs, and various intervals of ischaemic time.

RESULTS

A total of 376 STEMI patients in the research area before implementation of the STEMI network were included. Compared with urban residents, rural patients were significantly less likely to have timely presentation (odds ratio [OR]=0.47, 95% CI: 0.28-0.80, P=.004) and timely reperfusion therapy (OR=0.32, 95% CI: 0.14-0.70, P=.005). Rural residents were less likely to present to hospital promptly than urban residents (HR=0.65, 95% CI=0.52-0.82, P<.001). In the first 3 hours of percutaneous coronary intervention (PCI) reperfusion delay and first 6 hours of total ischaemic time, rural patients had a significantly lower probability to receive prompt PCI (hazard ratio [HR]=0.40, 95% CI: 0.29-0.54, P<.001) and reperfusion therapy (HR=0.37, 95% CI: 0.25-0.56, P<.001) compared to urban patients.

CONCLUSION

Rural residents were a major vulnerable group before implementation of the regional STEMI network. No obvious inequalities in ethnicity, sex, age, education or occupation existed in STEMI care in Chuxiong Prefecture of China.

Reducing the Wire Crossing Time in Primary Percutaneous Coronary Angioplasty: A Study From a Tier II City in India

Acute coronary syndrome is a major cause of morbidity and mortality all over the world. Timely intervention in ST-elevation myocardial infarction (STEMI) in the form of primary angioplasty is the gold standard of treatment to reduce mortality and morbidity. “Time is muscle” is the phrase to impress upon the importance of time in treating patients with STEMI. Traditional treatment target included “door to balloon time” of 90 min or less. This “door to balloon time” is now rephrased as the “wire crossing time” (WCT). The European Society of Cardiology (ESC) updated its guidelines further, reducing the target of wire crossing time to 60 min.

The present study is a brief report on the door to wire crossing time status in one of the tertiary care centers of a nonmetro city. Retrospective analysis of case records was done for 79 patients admitted with acute MI who underwent primary angioplasty between November 2018 and June 2019 (pre-corrective action group). Various reasons for the delay, right from the time of the patient reaching the emergency room (ER) to the time of wire crossing, were analysed and measures were taken to reduce the delay. The post-corrective action group comprised 77 patients. The major causes of a prolonged WCT in our setup were delayed diagnosis of STEMI in ER, delay in giving consent by the patient’s relatives, financial issues, and availability of cath lab technicians during the off-duty hour. The delay in WCT in our center was 121 min. Remedial actions were taken to mitigate the problems at each step, which resulted in a reduction of delay by 20 min, i.e., to 101 min leading to a significant difference in the outcome in view of morbidity and mortality.

Contemporary Implications of ECG to Activation Time on Long-term Outcomes in Patients With ST-Segment Elevation Myocardial Infarction Treated With Primary Percutaneous Coronary Intervention

PURPOSE

The prognosis of door to balloon time (DBT) after primary percutaneous coronary intervention (PPCI) in ST-segment elevation myocardial infarction (STEMI) has been extensively studied. However, the clinical implications of the ECG to activation time (EAT), as a component of DBT, on long-term outcomes are less well established. This study evaluates the association of EAT with major adverse cardiovascular events (MACEs) in more contemporary patients undergoing PPCI and investigates factors that influence EAT.

METHODS

A total of 1082 consecutive patients with STEMI who underwent PPCI from 2013 to 2019 were classified into 3 groups according to EAT: EAT ≤30 minutes, EAT of 30 to 60 minutes, and EAT >60 minutes. We analyzed the incidence of MACEs, including all-cause death, nonfatal recurrence of MI, or nonfatal stroke during a median follow-up of 37 months.

FINDINGS

The median EAT was 58 minutes (interquartile range, 44-80 minutes), which explained 90% of the variability in DBT and had the strongest correlation with DBT (r = 0.95, P < 0.001). Achieving an EAT of ≤30 minutes resulted in a 94.1% chance of achieving a DBT ≤90 minutes. The incidence of MACEs had a concurrent increase with increased EAT (10.2% for EAT ≤30 minutes, 14.3% for EAT of 30-60 minutes, and 17.3% for EAT >60 minutes; P = 0.027) that was driven by more mortality (4.2% for EAT ≤30 minutes, 6.9% for EAT of 30-60 minutes, and 9.8% for EAT >60 minutes; P = 0.020). An EAT >30 minutes was independently associated with risk-adjusted long-term MACEs (hazard ratio = 1.99; 95% CI, 1.07-3.69; P = 0.030). Critically ill status in emergency department (P = 0.001) and time required for consent of revascularization (P < 0.001) were significantly associated with delayed EAT.

IMPLICATIONS

Achieving an EAT ≤30 minutes was key to achieving the guideline-recommended target time of DBT in contemporary practice. As a strong driver of overall DBT, EAT >30 minutes was associated with worse clinical outcome in patients with STEMI undergoing PPCI. These data suggest that efforts to minimize EAT are needed to reduce long-term MACEs in contemporary population. (Clin Ther. 2021;XX:XXX-XXX) © 2021 Elsevier HS Journals, Inc.

Impact of Exercise-Based Cardiac Rehabilitation on the Mid-Term Outcomes of Patients After Acute Myocardial Infarction Treated With Current Acute-Phase Management and Optimal Medical Therapy

BACKGROUND

Early reported beneficial effects of cardiac rehabilitation (CR) have recently been disputed. The present study aimed to investigate the clinical impact of CR on the mid-term outcomes of patients following ST-segment elevation myocardial infarction (STEMI) treated with currently available management.

METHODS

This study reviewed 145 consecutive patients who underwent primary coronary intervention and were discharged without any disability after STEMI during 2013-2015.

RESULTS

Among the patients, 66 (45.5%) completed an outpatient CR program (CR group) and 79 were their non-CR counterparts or patients who dropped out of the program (N-D group). There were no between-group differences in patient demographics and clinical profiles, including door-to-balloon times and prescriptions. A total of 27 patients developed major adverse cardiac and cerebrovascular events (MACCE) during follow-up. The MACCE-free survival rates were 88% and 76% in the CR and N-D groups, respectively (log-rank, p=0.04). Cox proportional analysis demonstrated that inclusion in the N-D group was a significant predictor of MACCEs (HR, 2.36; 95% CI, 1.07-5.74; p=0.03). In the CR group, peak oxygen consumption and ventilatory efficiency determined by cardiopulmonary exercise testing significantly improved after the program (p<0.01).

CONCLUSIONS

The impact of CR on the mid-term prognosis of patients with STEMI, even in the current myocardial infarction management era, was beneficial.

Comparison of Door-to-Balloon Time and 30-Day Mortality According to Symptom Presentation in Patients With Acute Myocardial Infarction

Background: We hypothesized that symptom presentation in patients with acute myocardial infarction (AMI) may affect their management and subsequent outcome. Methods and Results: Using Rural AMI Registry data, 1,337 consecutive patients with AMI who underwent percutaneous coronary intervention were analyzed. Typical symptoms were defined as any symptoms of chest pain or pressure due to myocardial ischemia. We considered the specific symptoms of dyspnea, nausea, or vomiting as atypical symptoms. The primary outcome was 30-day mortality. There were 150 (11.2%) and 1,187 (88.8%) patients who presented with atypical and typical symptoms, respectively. Those who presented with atypical symptoms were significantly older (mean [±SD] age 74±12 vs. 68±13 years; P<0.001) and had a higher Killip class (46.7% vs. 21.8%; P<0.001) than patients presenting with typical symptoms. The prevalence of door-to-balloon time of ≤90 min was significantly lower in patients with atypical than typical symptoms (40.0% vs. 66.3%; P<0.001). At 30 days, there were 55 incidents of all-cause death. Multivariate Cox proportional hazards regression analysis revealed that symptom presentation was associated with 30-day mortality (hazard ratio 2.33; 95% confidence interval 1.20-4.38; P<0.05). Conclusions: Atypical symptoms in patients with AMI are less likely to lead to timely reperfusion and are associated with increased risk of 30-day mortality.

Stroke After Percutaneous Coronary Intervention in the Era of Transradial Intervention

BACKGROUND

Periprocedural stroke is a rare but life-threatening complication of percutaneous coronary intervention (PCI). Transradial intervention (TRI) is more beneficial than transfemoral intervention for periprocedural bleeding and acute kidney injuries, but its effect on periprocedural stroke has not been fully investigated. Our study aimed to assess risk predictors of periprocedural stroke according to PCI access site.

METHODS AND RESULTS

Between 2008 and 2016, 17 966 patients undergoing PCI were registered in a prospective multicenter database. Periprocedural stroke was defined as loss of neurological function caused by an ischemic or hemorrhagic event with residual symptoms lasting at least 24 hours after onset. Periprocedural stroke was observed in 42 patients (0.3%). Stroke patients were older and had a higher incidence of chronic kidney disease, peripheral artery disease, and acute coronary syndrome but were less likely to undergo TRI. Multivariable logistic regression analysis revealed TRI (odds ratio; 0.33; 95% CI, 0.16-0.71; P=0.004) was significantly associated with a lower occurrence of periprocedural stroke. Finally, propensity score-matching analysis showed that TRI was associated with a reduced risk of periprocedural stroke compared with transfemoral intervention (0.1% versus 0.4%; P=0.014). According to our sensitivity analysis, this finding was robust to the presence of an unmeasured confounder in almost all plausible scenarios.

CONCLUSIONS

TRI was associated with a reduced risk of periprocedural stroke compared with transfemoral intervention. Increased TRI use may reduce overall PCI complications and should be recommended as the optimal access site for both urgent/emergent and elective PCIs.

The impact of door-to-electrocardiogram time on door-to-balloon time after achieving the guideline-recommended target rate

Background

Little is known about the components and contributing factors of door-to-balloon time after implementation of Door-to-Balloon Alliance quality-improving (QI) strategies, including the impact of door-to-ECG time on door-to-balloon time.

Objective

We investigated whether modification of emergency department (ED) triage processes could improve door-to-ECG and door-to-balloon times after implementation of QI strategies.

Methods

This was a retrospective before-and-after study of a prospectively collected database. From June 2014 to October 2014, interventions were implemented in our ED, including a protocol-driven ECG initiation and moving an ECG station and technician to the triage area. The primary outcome was the percentage of patients with ST-elevation myocardial infarction (STEMI) who received ECG within 10 min of arrival; the secondary outcome was the percentage of patients with door-to-balloon times of <90 min from arrival. Patients from the year pre- and post-QI initiative were defined as the control and intervention groups, respectively.

Results

Enrollment comprised 214 patients with STEMI: 109 before the intervention and 105 after the intervention. We analyzed the components of the door-to-balloon process and found the door-to-ECG process was the most critical interval of delay (20.8%). Unrecognized symptoms were the most common cause of delay in the door-to-ECG process resulting in a significant impact on the door-to-balloon time. The intervention group had a higher percentage of patients with door-to-ECG times <10 min than did the control group (93.3% vs. 79.8%, p = 0.005), with a corresponding improvement in door-to-balloon times <90 min (91.1% vs. 76.2%, p = 0.007). In subgroup analysis, the intervention benefits occurred only in non-transferred or walk-in patients. After adjustment for possible co-variates, the QI interventions remained a significant contributing factor for achieving the door-to-ECG and door-to-balloon targets.

Conclusions

The modification of ED triage processes through implementation of QI strategies are effective in achieving better door-to-ECG times and thus, achieving door-to-balloon times <90 min. In patients presenting with ambiguous symptoms, improved door-to ECG target achievement rates, through a protocol-driven and multidisciplinary approach allows for earlier identification of STEMI.

Door-to-balloon time and factors associated with delayed door-to-balloon time in ST-segment elevation myocardial infarction at Thailand's largest tertiary referral centre

OBJECTIVE

To analyse door-to-balloon (DTB) time and to identify factors significantly associated with delayed DTB in patients with ST-segment elevation myocardial infarction (STEMI) at Thailand's largest tertiary referral centre.

BACKGROUND

DTB time is considered an important measure of performance quality.

METHODS

This observational study analysed DTB time in patients with STEMI who presented to our institute's emergency department and underwent primary percutaneous coronary intervention (PCI) during June 2008 to May 2011. DTB time greater than 90 minutes was considered delayed. Data were collected to determine which clinical variables were associated with delays.

RESULTS

One hundred thirty-three patients were included. The mean age of patients was 61.1 ± 13.2 years, and 71.4% were male. Delayed DTB was observed in 70.7% of patients. Median DTB time was 117 (interquartile range [IQR], 86-168), 66 (IQR, 58-84), and 135 (IQR, 112-194) minutes in all patients, in nondelayed patients, and in delayed patients, respectively. Univariate analysis revealed triage to urgent care (P = 0.001) and presentation during on-call hours (P < 0.001) to be significantly associated with delayed DTB. Patients who were triaged to urgent care had a DTB time of 184 vs 105 minutes for triage to the emergency room. Patients who presented during on-call hours had a DTB time of 128 vs 86 minutes for work hour presentation. Presentation during on-call hours was the only significant predictor of DTB time >90 minutes in multivariate analysis (odds ratio [OR], 7.86; 95% confidence interval [CI], 3.39-18.22; P < 0.001). All patients that were triaged to urgent care were delayed; thus, association between urgent care triage and on-call hour service could not be determined.

CONCLUSIONS

Delayed DTB time occurred in 70.7% of patients. Two key factors that significantly contributed to delayed DTB were patient mistriage to urgent care and presentation during on-call hours.

In-Hospital Outcomes After Percutaneous Coronary Intervention for Acute Coronary Syndrome With Cardiogenic Shock (from a Japanese Nationwide Registry [J-PCI Registry])

In-hospital complications and their predictors in acute coronary syndrome (ACS) patients with cardiogenic shock (CS) have not been fully investigated, particularly in those who underwent invasive revascularization procedures. This study investigated the in-hospital outcomes, along with the volume-outcome relationship of ACS patients with CS, using a contemporary large-scale nationwide percutaneous coronary intervention (PCI) registry in Japan. We analyzed PCI procedural data on ACS patients treated between 2014 and 2016 in a nationwide Japanese PCI registry. Predictors of in-hospital death and major bleeding complications requiring transfusion were identified via multivariable logistic regression analysis. The association of bleeding complications with in-hospital death was also analyzed. This study enrolled 253,355 patients who underwent PCI for ACS, of whom 17,549 (6.9%) were with CS. The rates of in-hospital mortality and access/nonaccess site bleeding complications in CS patients were 13.2%, 1.2%, and 1.3%, respectively. Age, gender, and baseline kidney condition, along with presentation status (e.g., cardiopulmonary arrest and/or acute heart failure) or the number and location of diseased vessels (e.g., left main lesion), were associated with in-hospital mortality and bleeding complications. Of note, the in-hospital mortalities decreased in parallel with the increasing institutional PCI volumes. In-hospital mortality also differed by the presence of concomitant bleeding complications (43.1% and 48.3% with access or nonaccess site bleeding, and 12.9% and 12.7% without, respectively). In conclusion, in-hospital mortality was 13.2% in ACS patients with CS who underwent contemporary PCI. Other than traditional predictors of PCI complications, lower institutional PCI volumes, and concurrent bleeding were associated with higher in-hospital mortality.

Effects of body habitus on contrast-induced acute kidney injury after percutaneous coronary intervention

Background

Limiting the contrast volume to creatinine clearance (V/CrCl) ratio is crucial for preventing contrast-induced acute kidney injury (CI-AKI) after percutaneous coronary intervention (PCI). However, the incidence of CI-AKI and the distribution of V/CrCl ratios may vary according to patient body habitus.

Objective

We aimed to identify the clinical factors predicting CI-AKI in patients with different body mass indexes (BMIs).

Methods

We evaluated 8782 consecutive patients undergoing PCI and who were registered in a large Japanese database. CI-AKI was defined as an absolute serum creatinine increase of 0.3 mg/dL or a relative increase of 50%. The effect of the V/CrCl ratio relative to CI-AKI incidence was evaluated within the low- (≤25 kg/m²) and high- (>25 kg/m²) BMI groups, with a V/CrCl ratio > 3 considered to be a risk factor for CI-AKI.

Results

A V/CrCl ratio > 3 was predictive of CI-AKI, regardless of BMI (low-BMI group: odds ratio [OR], 1.77 [1.42–2.21]; P < 0.001; high-BMI group: OR, 1.67 [1.22–2.29]; P = 0.001). The relationship between BMI and CI-AKI followed a reverse J-curve relationship, although baseline renal dysfunction (creatinine clearance <60 mL/min, 46.9% vs. 21.5%) and V/CrCl ratio > 3 (37.3% vs. 20.4%) were predominant in the low-BMI group. Indeed, low BMI was a significant predictor of a V/CrCl ratio > 3 (OR per unit decrease in BMI, 1.08 [1.05–1.10]; P < 0.001).

Conclusions

A V/CrCl ratio > 3 was strongly associated with the occurrence of CI-AKI. Importantly, we also identified a tendency for physicians to use higher V/CrCl ratios in lean patients. Thus, recognizing this trend may provide a therapeutic target for reducing the incidence of CI-AKI.

Occurrence and Impact of Time Delay to Primary Percutaneous Coronary Intervention in Patients With ST-Segment Elevation Myocardial Infarction

Background

The aim of the study was to evaluate the occurrence, duration and impact of time delays to primary percutaneous coronary intervention (pPCI) in ST-segment elevation myocardial infarction (STEMI).

Methods

A total of 357 consecutive STEMI patients enrolled in the prospective Special Program University Medicine ACS (SPUM-ACS) cohort were included. In order to identify the causes behind a possible treatment delay, we constructed four different time points which included: 1) symptom onset to hospital arrival, 2) hospital arrival to arrival in the catheterization laboratory, 3) hospital arrival to first balloon inflation, and 4) time from arrival in the catheterization laboratory to first balloon inflation in addition to total ischemic time. Patients were stratified according to a delay > 3 h, > 30 min, > 90 min and > 1 h, respectively and major adverse events at 0, 30 and 365 days were analyzed.

Results

Resuscitated STEMI patients (23 patients) and STEMI patients presenting at weekends (101 patients) and to lesser extent at night hours (100 patients) experienced more time delays than stable patients and those presenting at office hours. Median door-to-balloon time averaged 93 min in resuscitated, but 65 min in stable patients. Median door-to-balloon time at weekends and public holidays was 89 min, but 68 min at office hours. Median time from hospital arrival to cathlab arrival at weekends and public holidays was 30 min, but 15 min during office hours. Corresponding times for resuscitated patients was 45 and 15 min in stable patients. Of note, resuscitated patients were late presenters as regards time from symptoms onset to hospital arrival with a median time of 180 min compared to 155 min in stable patients. Median total ischemic time was 225 min for all patients, 223 min at day hours, 239 at night hours, 244 min at weekends, 233 min at office days, 220 min in stable patients and 273 min in resuscitated patients. Patients with STEMI who arrived > 3 h after symptom onset had a higher rate of myocardial infarction (MI) at 1 year (1.6% vs. 9% in < 3 h; P = 0.008). Furthermore, STEMI patients who had a delay of > 1 h from cathlab arrival to first balloon inflation had a higher rate of in hospital reinfarction at 0 day (0.6% vs. 0% in < 1 h; P = 0.007), MI at 30 days (0.8% vs. 0% in < 1 h; P = 0.001) and MI at 1 year (1.4% vs. 1.1% in < 1 h; P = 0.012). Similarly, in these patients, cardiac deaths at 0 day (0.8% vs. 0.6% in < 1 h; P = 0.035) and at 30 days (0.8% vs. 0.6% in < 1 h; P = 0.035) were higher as were major adverse cardiovascular events (MACCE) at 0 day (1.4% vs. 0.8% in < 1 h; P = 0.004).

Conclusion

Resuscitated STEMI patients and those presenting at weekends and to lesser extent at night hours experienced more time delays and longer ischemic time than stable patients and those presenting at office hours. In STEMI patients, any delay in treatment increased their risk of MACCE. Efforts should focus on improving patient’s awareness along with minimizing in-hospital transfer to the catheterization laboratory especially at weekends and in resuscitated patients.