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

Optimal door-to-balloon time for primary percutaneous coronary intervention for ST-elevation myocardial infarction

BACKGROUND

Door-to-balloon time (DTBT) for ST-elevation myocardial infarction (STEMI) is a performance metric by which primary percutaneous coronary intervention (PPCI) services are assessed.

METHODS

Consecutive patients presenting with STEMI undergoing PPCI between January 2007 to December 2019 from the Singapore Myocardial Infarction Registry were included. Patients were stratified based on DTBT (≤60 min, 61-90 min, 91-180 min) and Killip status (I-III vs. IV). Outcomes assessed included all-cause mortality and major adverse cardiovascular events (MACE) at 30-days and 1-year.

RESULTS

In total, 13,823 patients were included, with 82.59% achieving DTBT ≤90 min and 49.77% achieving DTBT ≤60 min. For Killip I-III (n = 11,591,83.85%), the median DTBT was 60[46-78]min. The 30-day all-cause mortality for DTBT of ≤60 min, 61-90 min and 91-180 min was 1.08%, 2.17% and 4.33% respectively (p < 0.001). On multivariate analysis, however, there was no significant difference for 30-day and 1-year outcomes across all DTBT (p > 0.05). For Killip IV, the median DTBT was 68[51-91]min. The 30-day all-cause mortality for DTBT of ≤60 min, 61-90 min and 91-180 min was 11.74%, 20.48% and 35.06% respectively (p < 0.001). On multivariate analysis for 30-day and 1-year outcomes, DTBT 91-180 min was an independent predictor of worse outcomes (p < 0.05), but there was no significant difference between DTBT of ≤60 min and 61-90 min (p > 0.05).

CONCLUSION

In Killip I-III patients, DTBT had no significant impact on outcomes upon adjustment for confounders. Conversely, for Killip IV patients, a DTBT of >90 min was associated with significantly higher adverse outcomes, with no differences between a DTBT of ≤60 min vs. 61-90 min. Outcomes in STEMI involve a complex interplay of factors and recommendations of a lowered DTBT of ≤60 min will require further evaluation.

Gender Differences in Trends in Incidence and Mortality of Acute Myocardial Infarction in the Small Island Developing State of Barbados

Objective To determine trends, identify predictors of acute myocardial infarction (AMI) incidence and mortality, and explore performance metrics for AMI care in Barbados. Methods Data on all cases diagnosed with AMI were collected by the Barbados National Registry for Non-Communicable Diseases (BNR) from the island's only tertiary hospital, the Queen Elizabeth Hospital, and the National Vital Registration Department. Participants who survived hospital admission were then followed up at 28 days and one year post event via telephone survey and retrieval of death certificates. Age-standardized incidence and mortality rates were calculated. Determinants of mortality at 28 days were examined in multivariable logistic regression models. Median and interquartile ranges (IQR) were calculated for performance metrics (e.g., time from pain onset to reperfusion). Results In a 10-year period between 2010 and 2019, 4,065 cases of myocardial infarction were recorded. The median age of the sample was 73 years (IQR: 61,83), and approximately half (47%) were female. Over a 10-year period, standardized incidence increased in women on average yearly by three per 100,000 (95% CI: 1 to 6; p=0.02), while in men, the average increase per year was six per 100,000 (95% CI: 4 to 8; p<0.001). There was no increase in 28-day mortality in women; mortality in men increased each year by 2.5 per 100,000 (95% CI: 0.4 to 4.5; p=0.02). The time from arrival at the hospital to the ECG was 44 minutes IQR (20,113). Conclusion AMI incidence and mortality are increasing in Barbados, and men have a higher velocity of mortality rate increase than women, which contradicts global data.

Mind the Gap: Model-Based Switching from Selatogrel to Maintenance Therapy with Oral P2Y12 Receptor Antagonists

Background: The P2Y12 receptor antagonist selatogrel is being developed for subcutaneous self-administration with a ready-to-use autoinjector at the onset of acute myocardial infarction (AMI) symptoms. The unique pharmacological profile of selatogrel (fast, potent, and short-acting) can bridge the time gap between the onset of AMI and first medical care. A clinical Phase 1 study showed a time-dependent pharmacodynamic interaction between selatogrel and loading doses of clopidogrel and prasugrel. As treatment switching is a common clinical practice, the assessment of subsequent switching from a clopidogrel loading dose to the first maintenance dose of oral P2Y12 receptor antagonists is highly relevant. Objectives: Model-based predictions of inhibition of platelet aggregation (IPA) for the drugs triggering pharmacodynamic interactions were to be derived to support clinical guidance on the transition from selatogrel to oral P2Y12 receptor antagonists. Methods: Scenarios with selatogrel 16 mg administration or placebo followed by a clopidogrel loading dose and, in turn, prasugrel or ticagrelor maintenance doses at different times of administration were studied. Population pharmacokinetic/pharmacodynamic modeling and simulations of different treatment scenarios were used to derive quantitative estimates for IPA over time. Results: Following selatogrel/placebo and a clopidogrel loading dose, maintenance treatment with ticagrelor or a prasugrel loading dose followed by maintenance treatment quickly achieved sustained IPA levels above 80%. Prior to maintenance treatment, a short time span from 18 to 24 h was identified where IPA levels were predicted to be lower with selatogrel than with placebo if clopidogrel was administered 12 h after selatogrel or placebo. Predicted IPA levels reached with placebo alone and a clopidogrel loading dose at 4 h were consistently lower than with selatogrel administration, followed by a clopidogrel loading dose at 12 h. If a clopidogrel loading dose is administered at 12 h, selatogrel maintains higher IPA levels up to 16 h. IPA levels are subsequently lower than on the placebo until the administration of the first maintenance dose. Conclusions: Model-based predictions informed the transition from selatogrel subcutaneous administration to oral P2Y12 therapy. The application of modeling techniques illustrates the value of employing pharmacokinetic and pharmacodynamic modeling for the simulation of various clinical scenarios of switching therapies.

Prognosis Analysis of Delayed Call Time for Chest Pain in Patients With Acute ST-Segment Elevation Myocardial Infarction Undergoing Direct Percutaneous Coronary Intervention

To describe the impact of delayed call time for chest pain in the salvage of ST-segment elevation myocardial infarction (STEMI) patients and its associated independent risk factors, and to identify risk factors associated with cumulative morbidity and mortality in STEMI patients at 4 years after percutaneous coronary intervention (PCI). Retrospective analysis of 398 patients diagnosed with STEMI and treated with emergency PCI within 24 hours of symptom onset in Fuyang People's Hospital from April 2018 to April 2021. The enrolled patients were divided into ≤60 minutes group (193 cases), and > 60 minutes group (205 cases), according to the delayed call time of patients with chest pain. Analysis of basic clinical data, rescue time, and major cardiovascular adverse events in the 2 groups. Multifactorial logistic regression analysis of independent correlates of delayed chest pain calls and Cox proportional risk regression modeling of risk factors for cumulative morbidity and mortality at 4 years after surgery. Compared to the delayed call time ≤ 60 minutes group, the > 60 minutes group had a higher proportion of females, a history of diabetes, rural remote areas, and farmer occupation (P < .05). Binary logistic regression analysis shows the history of diabetes and female as independent risk factors for delayed call time >60 minutes for chest pain. In the delayed call time ≤60 minutes group, the time from symptom onset-to-balloon (S0-to-B) and from symptom onset-to-first medical contact (SO-to-FMC) were smaller than in the delayed call time >60 minutes group (P < .05). The sum of postinfarction angina and major cardiovascular adverse events was lower in the group with delayed call time ≤60 minutes than in the group with delayed call time >60 minutes (P < .05). The Kaplan-Meier survival curve and the survival curve without the occurrence of major adverse cardiovascular events were statistically significant in both groups (P < .05). Multifactorial Cox regression analysis showed that delayed call time for chest pain >60 minutes, left main + 3 branch lesions, and cardiac function Killip ≥ III were all risk factors for cumulative morbidity and mortality at 4 years after PCI in patients with STEMI. Delayed call time for chest pain >60 minutes, left main + 3 branch lesions, and cardiac function Killip ≥ III are all risk factors for cumulative morbidity and mortality in STEMI patients at 4 years after PCI. Reducing the delayed call time for chest pain can improve the long-term prognosis of patients.

Factors Responsible for Prehospital Delay in Patients with Acute Coronary Syndrome in Bangladesh

Background: Acute coronary syndrome (ACS) remains a cause of high morbidity and mortality among adults, despite advances in treatment. Treatment modality and outcomes of ACS mainly depend on the time yielded since the onset of symptoms. Prehospital delay is the time between the onset of myocardial ischemia/infarction symptoms and arrival at the hospital, where either pharmacological or interventional revascularization is available. This delay remains unacceptably long in many countries worldwide, including Bangladesh. The current study investigates several sociodemographic characteristics as well as clinical, social, and treatment-seeking behaviors, with an aim to uncover the factors responsible for the decision time to get medical help and home-to-hospital delay. Materials and Methods: A prospective cross-sectional study was conducted between July 2019 and June 2020 in 21 district hospitals and 6 medical college hospitals where cardiac care facilities were available. The population selected for this study was patients with ACS who visited the studied hospitals during the study period. Following confirmation of ACS, a semi-structured data sheet was used to collect the patient data and was subsequently analyzed. Results: This study evaluated 678 ACS patients from 30 districts. The majority of the patients were male (81.9%), married (98.2%), rural residents (79.2), middle-aged (40–60 years of age) (55.8%), low-income holders (89.4%), and overweight (56.9%). It was found that 37.5% of the patients received their first medical care after 12 h of first symptom presentation. The study found that the patients’ age, residence, education, and employment status were significant factors associated with prehospital delay. The patients with previous myocardial infarction (MI) and chest pain arrived significantly earlier at the hospital following ACS onset. Location of symptom onset, first medical contact with a private physician, distance from symptom onset location to location of first medical contact, the decision about hospitalization, ignorance of symptoms, and mode of transportation were significantly associated with prehospital delay. Conclusions: Several factors of prehospital delay of the ACS patients in Bangladesh have been described in this study. The findings of this study may help the national health management system identify the factors related to treatment delay in ACS and thus reduce ACS-related morbidity and mortality.

Risk Factors of Ischemia Reperfusion Injury After PCI in Patients with Acute ST-Segment Elevation Myocardial Infarction and its Influence on Prognosis

Purpose

To explore the risk factors of ischemia reperfusion injury (IRI) after percutaneous coronary intervention (PCI) in patients with acute ST-segment elevation myocardial infarction (STEMI) and its influence on prognosis.

Methods

The clinical data of 80 patients with STMEI undergoing PCI in our hospital from June 2020 to June 2021 were collected. According to whether IRI occurred after PCI, STMEI patients were divided into IRI group and non-IRI group. The basic information, clinical characteristics, examination parameters and other data of all patients were collected, and the prognosis of the two groups was observed. Risk factors were analyzed by fitting binary Logistic regression model. The survival prognosis was analyzed by Kaplan-Meier survival curve.

Results

Logistic regression analysis showed that type 2 diabetes mellitus (T2DM), pre-hospital delay time (PHD) and door-to-balloon expansion time (DTB) were the influencing factors of IRI in patients with STMEI (p < 0.05). MACE occurred in 11 cases (32.35%) in the IRI group and 13 cases (28.26%) in the non-IRI group. Log-rank test showed p = 0.503, indicating no statistically significant difference.

Conclusion

T2DM, PHD and DTB were the influencing factors of IRI in patients with STMEI, and IRI will not reduce the prognosis of patients.

Gender Particularities and Prevalence of Atypical Clinical Presentation in Non-ST Elevation Acute Coronary Syndrome

Clinical presentation is one of the factors that can influence how quickly a patient with an acute coronary syndrome is treated, particularly if it is atypical. The purposes of this study are to explore gender-related differences in patients presenting with non-ST elevation acute coronary syndromes (NSTEACS) from the perspective of a series of common risk factors as well as treatment strategies and to evaluate the prevalence of atypical clinical presentation of NSTEACS in the study group. In addition, we explored the differences between the two entities that define NSTEACS: unstable angina (UA) and non-ST elevation myocardial infarction (NSTEMI). We conducted a retrospective study by reviewing discharge documents of patients admitted in the cardiology department of the Clinical Rehabilitation Hospital in Cluj-Napoca with NSTEACS between January 2014 and December 2015. We retrieved demographic data, clinical presentation and history, laboratory tests, and coronary angiography records as well as the implemented treatment strategies. Women in the study group were more frequently hypertensive than men (89.5% vs. 75.4%; p = 0.043), had a higher mean serum HDL cholesterol value (43 vs. 38 mg/dL p = 0.022), were more frequently diagnosed with microvascular coronary heart disease (32% vs. 9.8%, p = 0.036), and were more often treated conservatively (49.1% vs. 30.8%, p = 0.038), while men were significantly more prone to smoking than women (30.8% vs. 14%, p = 0.028) and had higher mean serum creatinine (1.2 vs. 0.8 mg/dL; p = 0.022) and uric acid values (6.9 vs. 6.2 mg/dL; p = 0.048). Out of the 122 included patients, 109 had documented information regarding symptoms. The prevalence of atypical presentation was 4.6% (95% CI 0.7–8.5%). In our study group, patients with UA had a more frequent history of cardiovascular ischemic diseases (77.4% vs. 56.7%, p = 0.015), the mean value for BUN was higher in NSTEMI patients compared to patients with UA (47 vs. 39 mg/dL, p = 0.038) and NSTEMI patients more frequently received interventional treatment compared to patients with UA (60% vs. 41.9%; p = 0.046).