Causes of delay in door-to-balloon time in south-east Asian patients undergoing primary percutaneous coronary intervention

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.

The Impact of Emergency Department Arrival Time on Door-to-Balloon Time in Patients with ST-Segment Elevation Myocardial Infarction Receiving Primary Percutaneous Coronary Intervention

Door-to-balloon (DTB) time significantly affects the prognosis of patients with ST-segment elevation myocardial infarction (STEMI). The effects of temporal differences in emergency department (ED) arrival time on DTB time and on different segments of DTB time remain inconclusive. Therefore, we performed a retrospective study in a tertiary hospital between January 2013 and December 2021 and investigated the relationship between a patient's arrival time and both their DTB time and different segments of their DTB time. Of 732 STEMI patients, 327 arrived during the daytime (08:01-16:00), 268 during the evening (16:01-24:00), and 137 at night (00:01-08:00). Significantly higher odds of delay in DTB time were observed during the nighttime (adjusted odds ratio (aOR): 2.87; 95% confidence interval (CI): 1.50-5.51, p = 0.002) than during the daytime. This delay was mainly attributed to a delay in cardiac catheterization laboratory (cath lab) activation-to-arrival time (aOR: 6.25; 95% CI: 3.75-10.40, p < 0.001), particularly during the 00:00-04:00 time range. Age, sex, triage level, and whether patients arrived during the COVID-19 pandemic also had independent effects on different segments of DTB time. Further studies are required to investigate the root causes of delay in DTB time and to develop specific strategies for improvement.

Association of sex and age and delay predictors on the time of primary angioplasty activation for myocardial infarction patients in an emergency department

BACKGROUND

Time between Emergency Department (ED) and ST-segment elevation acute myocardial infarction (STEMI) activation time is a good indicator of ED quality. STEMI delays are of particular importance in some subgroups, such as women and the elderly.

OBJECTIVE

To determine the association of sex and age with activation time in STEMI patients admitted to the ED.

METHODS

An observational retrospective study was conducted including all patients admitted to the ED activated as a STEMI. The main variable was activation time. To evaluate the independent predictors of activation time, a multivariate logistic regression analysis was carried out, variables were sex, age, sex and age combined, chest pain, ST elevation in the electrocardiogram, and first medical contact (FMC) at the hospital's ED.

RESULTS

A total of 330 patients were included. They were classified by sex: 23.9% (78) women and 76.1% (249) men; and age: 51.1% (167) <65 yo and 48.9% (160) ≥65 yo. Women and elderly patients exhibited a more atypical presentation. Multivariate analysis shows that showed that elderly age (OR=1.976 95%; CI=1.257-3.104; p = 0.003) and FMC prior to attending the ED (OR=1.762; 95% CI=1.117-2.779; p = 0.015) were associated with a longer activation time. Women older than 65 years old showed the longest activation time.

CONCLUSION

STEMI delays are longer in women and the elderly with atypical presentation. Age ≥65 and FMC outside the ED were associated with an increase in the activation time. This highlights the need to develop strategies to improve activation time for these specific patient groups.

Artificial intelligence versus physicians on interpretation of printed ECG images: Diagnostic performance of ST-elevation myocardial infarction on electrocardiography

BACKGROUND

Smartphone-based ECG analyzer using camera input can be useful as everyone have it. The purpose of this study was to evaluate whether such a system can outperform clinicians in detecting ST-elevation myocardial infarction (STEMI) regardless of image acquisition conditions.

METHODS

We retrospectively enrolled suspected STEMI patients in an emergency department from January to October 2021. A multifaceted cardiovascular assessment system (Quantitative ECG, QCG™) using ECG images to produce a quantitative score (QCG score, ranging from 0 to 100) was compared to human experts of 7 emergency physicians and 3 cardiologists. Voting scores (number of participants answering "yes" for STEMI) were calculated for comparison. The system's robustness was evaluated using an equivalence test where we prove its performance metric (area under the curve of the receiver operating characteristic curve, AUC-ROC) changes within a predetermined equivalence range (-0.01 to 0.01) in 6 different environments (A combination of three different smartphones and two image sources including computer screen and paper).

RESULTS

187 patients (96 STEMI, 51.3%) were analyzed. AUC-ROC of QCG score was 0.919 (0.880-0.957). AUC-ROCs of voting scores, 0.856 (0.799-0.913) for all clinicians, 0.843 (0.786-0.900) for emergency physicians, 0.817 (0.756-0.877) for cardiologists, and 0.848 (0.790-0.905) for high-performance group were significantly lower compared to that of QCG score. The change in AUC-ROC by image acquisition condition was negligible with a narrow confidence interval within -0.01 to 0.01 confirming the equivalence.

CONCLUSIONS

Image-based AI system can outperform clinicians in STEMI diagnosis and its performance was robust to change in image acquisition conditions.

A Retrospective Clinical Evaluation of an Artificial Intelligence Screening Method for Early Detection of STEMI in the Emergency Department

BACKGROUND

Rapid revascularization is the key to better patient outcomes in ST-elevation myocardial infarction (STEMI). Direct activation of cardiac catheterization laboratory (CCL) using artificial intelligence (AI) interpretation of initial electrocardiography (ECG) might help reduce door-to-balloon (D2B) time. To prove that this approach is feasible and beneficial, we assessed the non-inferiority of such a process over conventional evaluation and estimated its clinical benefits, including a reduction in D2B time, medical cost, and 1-year mortality.

METHODS

This is a single-center retrospective study of emergency department (ED) patients suspected of having STEMI from January 2021 to June 2021. Quantitative ECG (QCG™), a comprehensive cardiovascular evaluation system, was used for screening. The non-inferiority of the AI-driven CCL activation over joint clinical evaluation by emergency physicians and cardiologists was tested using a 5% non-inferiority margin.

RESULTS

Eighty patients (STEMI, 54 patients [67.5%]) were analyzed. The area under the curve of QCG score was 0.947. Binned at 50 (binary QCG), the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were 98.1% (95% confidence interval [CI], 94.6%, 100.0%), 76.9% (95% CI, 60.7%, 93.1%), 89.8% (95% CI, 82.1%, 97.5%) and 95.2% (95% CI, 86.1%, 100.0%), respectively. The difference in sensitivity and specificity between binary QCG and the joint clinical decision was 3.7% (95% CI, -3.5%, 10.9%) and 19.2% (95% CI, -4.7%, 43.1%), respectively, confirming the non-inferiority. The estimated median reduction in D2B time, evaluation cost, and the relative risk of 1-year mortality were 11.0 minutes (interquartile range [IQR], 7.3-20.0 minutes), 26,902.2 KRW (22.78 USD) per STEMI patient, and 12.39% (IQR, 7.51-22.54%), respectively.

CONCLUSION

AI-assisted CCL activation using initial ECG is feasible. If such a policy is implemented, it would be reasonable to expect some reduction in D2B time, medical cost, and 1-year mortality.

Comparison of door-to-balloon time and in-hospital outcomes in patients with ST-elevation myocardial infarction between before versus after COVID-19 pandemic

The situation around primary percutaneous coronary intervention (PCI) has dramatically changed since coronavirus disease 2019 (COVID-19) pandemic. The impact of COVID-19 pandemic on clinical outcomes as well as door-to-balloon time (DTBT), which is known as one of the indicators of early reperfusion, has not been fully investigated in patients with ST-elevation acute myocardial infarction (STEMI). The purpose of this study was to compare DTBT and in-hospital outcomes in patients with STEMI between before versus after COVID-19 pandemic. The primary interest was DTBT and the incidence of in-hospital outcomes including in-hospital death. We included 330 patients with STEMI who underwent primary PCI, and divided them into the pre COVID-19 group (n = 209) and the post COVID-19 group (n = 121). DTBT was significantly longer in the post COVID-19 group than in the pre COVID-19 group (p < 0.001), whereas the incidence of in-hospital death was comparable between the 2 groups (p = 0.238). In the multivariate logistic regression analysis, chest CT before primary PCI (OR 4.64, 95% CI 2.58-8.34, p < 0.001) was significantly associated with long DTBT, whereas chest CT before primary PCI (OR 0.76, 95% CI 0.29-1.97, p = 0.570) was not associated with in-hospital death after controlling confounding factors. In conclusion, although DTBT was significantly longer after COVID-19 pandemic than before COVID-19 pandemic, in-hospital outcomes were comparable between before versus after COVID-19 pandemic. This study suggests the validity of the screening tests including chest CT for COVID-19 in patients with STEMI who undergo primary PCI.

Sex and Medium-term Outcomes of ST-Segment Elevation Myocardial Infarction in Kerala, India: A Propensity Score–Matched Analysis

Background

Sex-based differences have been found in outcomes following ST-segment myocardial infarction (STEMI). Studies assessing sex-based differences in STEMI among Indian patients have reported conflicting results.

Methods

A prospective multicenter registry of consecutive patients with STEMI who presented to percutaneous coronary intervention (PCI)–capable hospitals in the Indian state of Kerala between June 2013 and March 2017 was used to assess 1-year outcomes. The primary endpoint was a composite of major adverse cardiac events (MACE), including death, stroke, nonfatal myocardial infarction, and rehospitalization for heart failure. Outcomes of 2 sex-based propensity score–matched groups were compared.

Results

We included 3194 patients (19.4% women). Women presenting with STEMI were older, had more traditional cardiovascular risk factors, and were more likely to be classified as living in poverty. After propensity-score matching, women experienced greater incidence of MACE (20.9% vs 14.3%, P < 0.01), primarily driven by increased 1-year mortality (14.3% vs 8.6%, P < 0.01). Women were more likely to experience prehospital delays, compared with men. Although reperfusion rates were similar between the groups, men were more likely than women to undergo reperfusion within the first 12 hours of chest pain onset. Among patients undergoing primary PCI, women were more likely to have delayed PCI than were men (80.2% vs 72.9%, P = 0.03). Procedural characteristics were similar between groups.

Conclusions

Women in this cohort experienced higher incidence of MACE at 1 year, compared to men, primarily owing to increased mortality. Timeliness of reperfusion appears to be the primary factor impacting differences in outcomes between the 2 groups and may represent an attractive target for quality-improvement initiatives.

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.

Electrocardiographic criteria for anterior STEMI - Does the cut-off point affect treatment delay?

BACKGROUND

Diagnostic criteria for anterior STEMI differ between the European Society of Cardiology (ESC) and the European Resuscitation Council (ERC). A greater degree of ST-segment elevation is required to meet ERC criteria compared to ESC criteria. This may potentially lead to discrepancies in management between emergency teams and cardiologists, subsequent delay in reperfusion therapy and worse prognosis.

METHODS

We performed an observational study in patients with anterior STEMI routinely treated with primary PCI and assessed whether differing electrocardiographic diagnostic criteria could impact treatment and short-term prognosis. All patients in the study had anterior STEMI confirmed by electrocardiographic ESC criteria and subsequent coronary angiography. Patients were divided into two groups. Those who did not meet ERC criteria in the index ECG were assigned to the "non-ERC" group and were compared with those who met them - the "ERC" group.

RESULTS

Out of 60 patients with anterior STEMI based on ESC criteria (mean age 66.9 ± 13.6 years, 70% males), 26 patients (44%) did not meet ERC criteria ("non-ERC" group) for STEMI. There were no significant differences in age, gender distribution or clinical characteristics between "ERC" and "non-ERC" patients. Total-Ischemic-Time, Patient-Delay, and System-Delay times were significantly longer in "non-ERC" group (433.1 ± 389.9 min vs. 264.2 ± 229.6 min, p = 0.03; 290.8 ± 337.6 min vs. 129.5 ± 144.9 min; p < 0.05 and 158.8 ± 158 vs 134.6 ± 191 min, p < 0.02 respectively). There were no differences in In-Hospital-Delay, procedure duration, and success rate of PCI. Proximal LAD occlusion (64.7%) and TIMI = 0 flow (73.5%) tended to be more frequently observed in "ERC" than in the "non-ERC" group (53.8% and 65.4%, respectively). Hospitalization time and LVEF (44.4 ± 8.7 vs 42.8 ± 9.5%, p = 0.53) were similar between groups.

CONCLUSIONS

Differences in electrocardiographic criteria for anterior STEMI leave a significant proportion of patients undiagnosed. Patients with STEMI who failed to meet less strict ERC criteria had more distal LAD disease with better TIMI flow but received reperfusion therapy later. Thus, character of the disease may compensate for treatment delay but this needs to be further evaluated. Finally, lowering the cut-off point with stricter criteria compromises specificity and is expected to increase the false positive rate, however there were no false positives in this study as all patients were angiographically confirmed to have acute coronary obstruction.

The importance of organizational variables in treatment time for patients with ST-elevation acute myocardial infarction improve delays in STEMI

BACKGROUND

The time between arrival at the emergency department (ED) and balloon (D2B) in STEMI is one of the best indicators of the quality of care. Our aim is to describe treatment times and evaluate the causes of delay.

METHODS

This is an observational retrospective study, including all consecutive STEMI code patients ≥18 years old treated in the ED from 2013 to 2016.All the patients were stratified into two groups: delayed group with D2B>70min and non-delayed ≤70. The primary variable was D2B time.

FINDINGS

In total 327 patients were included, stratified according to their D2B as follows: 166 (67·48%) in the delayed group and 80 (32·52%) in the non-delayed group. The delayed group was older (p=0·005), with more females (p=0·060) and more atypical electrocardiogram (ECG) STEMI signs or symptoms (p=0·058) (p=0·087). Predictors of shorter D2B time were: typical STEMI ECG signs and short training sessions for nurses on identifying STEMI patients.

INTERPRETATION

There are delays particularly in specific groups with atypical clinical presentations. Short training sessions aimed at emergency nurses correlate with shorter delay. This suggests that continuing training for emergency nurses, along with organizational strategies, can contribute to increasing the quality of care.

CLINICAL TRIAL NUMBER

NCT04333381.

WeChat Group of Chest Pain Center for Patients with Acute ST-segment Elevation Myocardial Infarction: Faster Treatment Speed and Better Prognosis

Objective: To explore the effect of establishing a WeChat platform for a chest pain center as a medium to increase the treatment speed and improve the prognosis of patients with acute ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI).Methods: The chest pain center, established by the creation of a WeChat group, included primary hospitals in Chongqing that are not able to perform PPCI and the First Affiliated Hospital of Chongqing Medical University, which is the core of the center and which includes medical staff of the catheter laboratory, the cardiology department, the emergency, the vascular surgery department, and the cardiothoracic surgery department. Patients with acute STEMI who underwent PPCI from January 2017 to November 2018 in the First Affiliated Hospital of Chongqing Medical University were enrolled. The patients (including emergency department visitors, 120 callers, and patients transferred from the critical care unit or other departments) were divided into a WeChat pre-admission startup group (n=311) and a non-WeChat pre-admission startup group (control group, n=172). Patients’ door-to-balloon time, standard door-to-balloon time achievement rate, artery puncture to balloon dilation time, heart failure rate, length of stay, and incidence of adverse events (including fatal arrhythmia, cardiogenic shock, and death) during hospitalization were compared between the two groups.Results: Four hundred eight-three consecutive patients were enrolled. There was no significant difference in patients’ sex, age, length of stay, and cardiovascular events during hospitalization between the two groups (P>0.05). The door-to-balloon time of the patients in the WeChat pre-admission startup group was much shorter than that of patients in the non-WeChat pre-admission startup group (27.35±10.58 min vs. 88.15±53.79 min, P<0.05). The standard door-to-balloon time achievement rate was significantly higher in the WeChat pre-admission startup group than in the non-WeChat pre-admission startup group (100% vs. 72.09%, P<0.05).Conclusion: The application of a WeChat platform significantly shortened the door-to-balloon time of patients receiving PPCI and increased the standard door-to-balloon time achievement rate for patients with STEMI. In addition, the platform is also conducive to integrating medical resources and sharing medical information. The establishment of the platform increased the treatment speed and improved the prognosis of patients with STEMI.

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.