Pre-hospital delay and emergency medical services in acute myocardial infarction

Factors affecting stroke pre-hospital delay behavioral intention among community residents: A path analysis

BACKGROUND

Pre-hospital delay is the major cause of stroke treatment delay, and behavioral intention is considered to be the most direct predictor of behavior. Therefore, to effectively reduce stroke pre-hospital delay, it is essential to further understand the relationship between stroke pre-hospital delay intention (SPDBI) and its social-psychological influencing factors, namely personality traits, social support and coping style.

AIM

This study aims at examining the relationships among personality traits, coping style, social support, and SPDBI.

METHODS

A cross-sectional, self-administered questionnaire was distributed to 845 residents. The content of the questionnaire included demographic information, the knowledge of "Stroke 120", Ten-Item Personality Inventory-Chinese version, Simplified Coping Style Questionnaire, Perceived Social Support Scale and SPDBI Scale. Path analysis was used to investigate the relationship among SPDBI and its psychosocial influencing factors.

RESULTS

The final path model showed a good fit to the data (χ2/df = 2.981, RMSEA = 0.048, GFI = 0.936, CFI = 0.941). Extroversion (β = 0.106), positive coping (β = -0.110), negative coping (β = 0.150) and the knowledge of "Stroke 120" (β = -0.152) had only direct effects on SPDBI. While agreeableness (β = 0.113), openness (β = -0.121) and social support (β = -0.118) had direct effects on SPDBI, they also had indirect effects (β = -0.009; -0.022; -0.049) on SPDBI though positive coping.

CONCLUSIONS

Adequate social support and positive coping of health threat may reduce residents' SPDBI. Meanwhile, the interventions to reduce SPDBI should take personality differences into consideration.

Pre-Hospital Delay and Outcomes in Myocardial Infarction With Nonobstructive Coronary Arteries

BACKGROUND AND OBJECTIVES

Real-world evidence on the relationship between delayed hospitalization and outcomes in myocardial infarction with nonobstructive coronary arteries (MINOCA) is lacking. Hence, we aimed to evaluate the clinical characteristics of patients with MINOCA and the 2-year mortality outcomes in this patient population according to the symptom-to-door time (SDT).

METHODS

Overall, 861 patients with MINOCA from 2 Korean nationwide observational registries (2011-2020) were included and categorized as early or late presenters. Late presentation was defined as SDT ≥12 hours in patients with ST-segment elevation myocardial infarction (STEMI) and SDT ≥24 hours in patients with non-STEMI. The primary outcome was 2-year all-cause mortality. Propensity score matching (PSM) and age-sex adjusted analysis were used to determine whether late presentation independently affected mortality. Multivariate logistic regression analysis was used to examine the independent factors correlated with late presentation.

RESULTS

In unadjusted data, late presenters had a notably higher risk of 2-year all-cause mortality than early presenters (hazard ratio [HR], 2.44; 95% confidence interval [CI], 1.47-4.08). This trend persisted in age-sex adjusted analysis (adjusted HR, 2.29; 95% CI, 1.36-3.84) and PSM-adjusted analysis (adjusted HR, 2.18; 95% CI, 1.05-4.53). The positive independent factors for late presentation included female sex, no emergency medical service use and high creatinine level, whereas the negative independent factor was a dyslipidemia.

CONCLUSIONS

Late presentation is associated with higher mortality in patients with MINOCA. Multidisciplinary efforts are needed to reduce pre-hospital delay, thereby improving the clinical outcomes in these patients.

Development and validation of a nomogram model for predicting the risk of pre-hospital delay in patients with acute myocardial infarction

BACKGROUND

Acute myocardial infarction (AMI) is a severe cardiovascular disease caused by the blockage of coronary arteries that leads to ischemic necrosis of the myocardium. Timely medical contact is critical for successful AMI treatment, and delays increase the risk of death for patients. Pre-hospital delay time (PDT) is a significant challenge for reducing treatment times, as identifying high-risk patients with AMI remains difficult. This study aims to construct a risk prediction model to identify high-risk patients and develop targeted strategies for effective and prompt care, ultimately reducing PDT and improving treatment outcomes.

AIM

To construct a nomogram model for forecasting pre-hospital delay (PHD) likelihood in patients with AMI and to assess the precision of the nomogram model in predicting PHD risk.

METHODS

A retrospective cohort design was employed to investigate predictive factors for PHD in patients with AMI diagnosed between January 2022 and September 2022. The study included 252 patients, with 180 randomly assigned to the development group and the remaining 72 to the validation group in a 7:3 ratio. Independent risk factors influencing PHD were identified in the development group, leading to the establishment of a nomogram model for predicting PHD in patients with AMI. The model's predictive performance was evaluated using the receiver operating characteristic curve in both the development and validation groups.

RESULTS

Independent risk factors for PHD in patients with AMI included living alone, hyperlipidemia, age, diabetes mellitus, and digestive system diseases (P < 0.05). A nomogram model incorporating these five predictors accurately predicted PHD occurrence. The receiver operating characteristic curve analysis indicated area under the receiver operating characteristic curve values of 0.787 (95% confidence interval: 0.716-0.858) and 0.770 (95% confidence interval: 0.660-0.879) in the development and validation groups, respectively, demonstrating the model's good discriminatory ability. The Hosmer-Lemeshow goodness-of-fit test revealed no statistically significant disparity between the anticipated and observed incidence of PHD in both development and validation cohorts (P > 0.05), indicating satisfactory model calibration.

CONCLUSION

The nomogram model, developed with independent risk factors, accurately forecasts PHD likelihood in AMI individuals, enabling efficient identification of PHD risk in these patients.

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.

Identifying and Solving Gaps in Pre- and In-Hospital Acute Myocardial Infarction Care in Asia-Pacific Countries

Acute myocardial infarction (AMI) is a major cause of morbidity and mortality in the Asia-Pacific region, and mortality rates differ between countries in the region. Systems of care have been shown to play a major role in determining AMI outcomes, and this review aims to highlight pre-hospital and in-hospital system deficiencies and suggest possible improvements to enhance quality of care, focusing on Korea, Japan, Singapore and Malaysia as representative countries. Time to first medical contact can be shortened by improving patient awareness of AMI symptoms and the need to activate emergency medical services (EMS), as well as by developing robust, well-coordinated and centralized EMS systems. Additionally, performing and transmitting pre-hospital electrocardiograms, algorithmically identifying patients with high risk AMI and developing hospital networks that appropriately divert such patients to percutaneous coronary intervention-capable hospitals have been shown to be beneficial. Within the hospital environment, developing and following clinical practice guidelines ensures that treatment plans can be standardised, whilst integrated care pathways can aid in coordinating care within the healthcare institution and can guide care even after discharge. Prescription of guideline directed medical therapy for secondary prevention and patient compliance to medications can be further optimised. Finally, the authors advocate for the establishment of more regional, national and international AMI registries for the formal collection of data to facilitate audit and clinical improvement.

Association of Symptoms and Mode of Transportation to Emergency Department in Patients With Acute Coronary Syndrome

BACKGROUND

Patients with acute coronary syndrome (ACS) with symptoms matching their expectations of a heart attack are more likely to use emergency medical services (EMS) than not.

OBJECTIVE

To determine whether presenting symptom clusters are associated with EMS use in ACS patients and if EMS use or symptom clusters are associated with prehospital delay.

METHODS

This secondary analysis used data from the PROMOTION trial, a randomized clinical trial that enrolled 3522 subjects with a history of or at risk for ACS from 5 sites in the United States, Australia, and New Zealand. Subjects were randomized to usual care or an educational intervention to reduce prehospital delay. During the 2-year follow-up, subjects admitted for ACS were asked about symptoms, time of symptom onset, and mode of transportation to the hospital. Symptoms were grouped into classic ACS, pain symptoms, and stress symptoms clusters.

RESULTS

Of 3522 subjects enrolled, 331 sought care for ACS during follow-up; 278 had transportation mode documented; 121 (44%) arrived via EMS. Classic ACS plus pain symptoms (adjusted odds ratio [AOR], 2.66; P = .011), classic ACS plus stress symptoms (AOR, 2.61; P = .007), and classic ACS plus both pain and stress symptoms (AOR, 3.90; P = .012) were associated with higher odds of EMS use versus classic ACS symptoms alone. Emergency medical services use resulted in a 68.5-minute shorter median delay (P = .002) versus non-EMS use. Symptom clusters were not predictive of delay time in the adjusted model (P = .952).

DISCUSSION

Although chest symptoms were the most prevalent symptoms for most (85%), the combination of classic ACS symptoms with other symptom clusters was associated with higher EMS use. Further research is needed to determine whether a combination of symptom clusters helps patients correctly interpret ACS symptoms to better understand how symptom clusters influence EMS use.

Off-hour presentation and outcomes for percutaneous coronary intervention in acute myocardial infarction with Killip III-IV

BACKGROUND/AIMS

Acute myocardial infarction (AMI) is conventionally recognized as an urgent medical condition requiring timely and effective reperfusion therapy. However, the results of studies on the clinical outcomes in AMI according to hospital visit timings are inconclusive. To explore the difference in long-term outcomes between off- and on-hour percutaneous coronary interventions (PCI) in patients with AMI of Killip functional classification III-IV (Killip III-IV AMI).

METHODS

Data on the characteristics and clinical outcomes of 1,751 patients with Killip III-IV AMI between November 2011 and June 2015 from the Korea Acute Myocardial Infarction Registry-National Institutes of Health registry were analyzed. All participants were allocated into two groups: off-hour (weekdays from 6:00 PM to 8:00 AM, weekends, and legal holidays) and on-hour (weekdays from 8:00 AM to 6:00 PM) groups. The incidence of major adverse cardiac and cerebrovascular events, defined as a composite of all-cause mortality, nonfatal myocardial infarction, any revascularization, cerebrovascular accident, and stent thrombosis, was the primary endpoint.

RESULTS

Among the 1,751 patients, 572 (39.1%) underwent PCI during on-hours and 892 (60.9%) during off-hours. At the 3-year follow-up, no significant difference was found in the clinical outcomes between the two groups in both the unadjusted and propensity-score weighing-adjusted analyses.

CONCLUSION

The outcomes of patients with Killip III-IV AMI admitted during off- and on-hours were similar.

Long-term outcomes in ST-elevation myocardial infarction patients treated according to hospital visit time

BACKGROUND/AIMS

Rapid percutaneous coronary intervention (PCI) is the cornerstone of treatment for ST-elevation myocardial infarction (STEMI). However, there have been conflicting results regarding the differences in clinical outcomes between on-hours and off-hours presentation in STEMI patients. We aimed to examine the difference in long-term outcomes between off-hours and on-hours PCI in patients with STEMI.

METHODS

The characteristics and clinical outcomes of 5,364 STEMI patients between November 2011 and June 2015 from the Korea Acute Myocardial Infarction Registry-National Institutes of Health (KAMIR-NIH) registry were analyzed. Patients were divided into two groups: the off-hours group (weekdays from 6:01 PM to 7:59 AM, weekends, and legal holidays) and the on-hours group (weekdays from 8:00 AM to 6:00 PM). Major adverse cardiac and cerebrovascular events (MACCEs) were defined as a composite of allcause mortality, non-fatal myocardial infarction, any revascularization, cerebrovascular accident, and stent thrombosis. The primary endpoint was the occurrence of MACCEs, and all other clinical outcomes were analyzed.

RESULTS

A total of 3,119 patients (58.1%) underwent primary PCI due to STEMI during off-hours and 2,245 patients (41.9%) during on-hours. At 36 months, the clinical outcomes of the off-hours group were similar to those of the on-hours group in both the unadjusted and propensity score weighting-adjusted analyses.

CONCLUSION

Our analysis revealed that the long-term outcomes in STEMI patients admitted to hospitals during off-hours were similar to outcomes of those admitted during on-hours.

The relationship between symptom onset-to-needle time and ischemic outcomes in patients with acute myocardial infarction treated with primary PCI: Observations from Prague-18 Study

OBJECTIVES

Based on previous studies with clopidogrel, the time between acute myocardial infarction (AMI) symptoms onset and primary percutaneous coronary intervention (PCI) was proven as important prognostic factor. Our aim was to assess the relationship between symptoms onset to needle time (SNT) and procedural results and the occurrence of ischemic endpoints in primary angioplasty patients treated with potent P2Y12 inhibitors.

METHODS

A total of 1,131 out of 1,230 patients randomized to the Prague-18 study (prasugrel vs. ticagrelor in primary PCI) were divided into a high and a low-risk group. The effect of defined SNT on patients' ischemic endpoints and prognosis by their risk status at admission was tested.

RESULTS

The median SNT was 3.2 hours. Longer SNTs resulted in a more frequent incidence of TIMI flow <3 post PCI (p=0.015). There were significant differences in the occurrence of the combined ischemic endpoint among the compared SNT groups at 30 days (p=0.032), and 1 year (p=0.011), with the highest incidence in the ≤1 h SNT group of patients. "Latecomers" (SNT>4 hs) in the high-risk group experienced more reinfarction within 1 year [OR (95% CI) 3.23 (1.09-9.62) p=0.035]; no difference was found in the low-risk group.

CONCLUSIONS

In the era of intense antithrombotic medication, stratification of MI patients undergoing primary angioplasty, based on initial ischemic risk assessment affected prognosis more than symptom onset to needle time. Longer time delay was significantly related to increased incidence of ischemic events and all-cause mortality only in patients with high ischemic risk.

Barriers to the Implementation of Primary PCI in the Management of STEMI in Egypt

Introduction: Evidence-based guidelines recommend primary percutaneous coronary intervention (PPCI) be the mainstay reperfusion strategy for the treatment of ST-segment elevation myocardial infarction (STEMI) if it is performed in the proper time window. However, the Egyptian health care system is still struggling to provide such an important service. The aim of the present study, through a quantitative questionnaire, is to explore the current practice of STEMI management in Egypt, and to identify the barriers, opportunities, and potential areas for improvement.Methods and Results: The questionnaire was conducted in Egypt via face-to-face qualitative in-depth interviews with cardiologists from 14 PPCI-capable hospitals and 26 non-PPCI-capable hospitals. Participants were selected in view of their experience and knowledge. The study identified potential barriers to the implementation of PPCI among STEMI patients in Egypt. These barriers included the prehospital patient delay and emergency medical service delay, delay in the emergency department and delay in patient transfer to the CCU, unavailable equipment, catheterization laboratory activation delay, lack of trained interventional cardiologists, lack of regional STEMI networks and hospital policies, and insufficient ICU beds.Conclusion: Limited resources and health care system inadequacies have led to potential barriers that prevent suboptimal implementation of PPCI in Egypt. Efforts from all health care providers should be directed to overcome these identified barriers.

Unexpected high level of severe events even in low-risk profile chest pain unit patients

AIMS

Early heart attack awareness programs are thought to increase efficacy of chest pain units (CPU) by providing live-saving information to the community. We hypothesized that self-referral might be a feasible alternative to activation of emergency medical services (EMS) in selected chest pain patients with a specific low-risk profile.

METHODS AND RESULTS

In this observational registry-based study, data from 4743 CPU patients were analyzed for differences between those with or without severe or fatal prehospital or in-unit events (out-of-hospital cardiac arrest and/or in-unit death, resuscitation or ventricular tachycardia). In order to identify a low-risk subset in which early self-referral might be recommended to reduce prehospital critical time intervals, the Global Registry of Acute Coronary Events (GRACE) score for in-hospital mortality and a specific low-risk CPU score developed from the data by multivariate regression analysis were applied and corresponding event rates were calculated. Male gender, cardiac symptoms other than chest pain, first onset of symptoms and a history of myocardial infarction, heart failure or cardioverter defibrillator implantation increased propensity for critical events. Event rates within the low-risk subsets varied from 0.5-2.8%. Those patients with preinfarction angina experienced fewer events.

CONCLUSIONS

When educating patients and the general population about angina pectoris symptoms and early admission, activation of EMS remains recommended. Even in patients without any CPU-specific risk factor, self-referral bears the risk of severe or fatal pre- or in-unit events of 0.6%. However, admission should not be delayed, and self-referral might be feasible in patients with previous symptoms of preinfarction angina.