Prehospital system delay in patients with ST-segment elevation myocardial infarction in Singapore

Acute Myocardial Infarction (AMI) Treated with Snake Antivenom

Cardiac complications following snakebites are uncommon but fatal. Here, we discuss a case of a snakebite that led to acute myocardial infarction (AMI). Forty-five-year-old male presented to the emergency room with snakebite on the right middle finger. He was given symptomatic treatment and admitted for observation. His vital signs and initial investigations were normal except for the white blood count that was high. During observation, he developed vomiting and bradycardia. He was diagnosed with a right bundle branch block on ECG. The patient developed chest pain after a few hours and was diagnosed with AMI on ECG. The toxicology team started antivenom therapy. His troponin kept rising initially but later started coming down without percutaneous intervention (PCI). He was treated successfully with antivenom therapy and discharged.

Correlates of Delayed Initial Contact to Emergency Services among Patients with Suspected ST-Elevation Myocardial Infarction

Background

Early diagnosis and treatment of a patient displaying symptoms of myocardial ischemia is paramount in preventing detrimental tissue damage, arrhythmias, and death. Patient-related hospital delay is the greatest considerable cause of total delay in treatment for acute myocardial infarction.

Objective

To identify patient characteristics contributing to prehospital delay and ultimately developing health interventions to prevent future delay and improve health outcomes.

Methods

A retrospective chart review of 287 patients diagnosed with ST-elevation myocardial infarction (STEMI) was evaluated to examine correlates of patient-related delays to care.

Results

Stepwise logistic regression modeling with forward selection (likelihood ratio) was performed to identify predictors of first medical contact (FMC) within 120 minutes of symptom onset and door-to-balloon (DTB) time within 90 minutes. Distance from the hospital, being unmarried, self-medicating, disability, and hemodynamic stability emerged as variables that were found to be predictive of FMC within the first 120 minutes after symptom onset. Similarly, patient characteristics of gender and disability and having an initial nondiagnostic electrocardiogram emerged as significant predictors of DTB within 90 minutes.

Conclusions

Individual attention to high-risk patients and public education campaigns using printed materials, public lectures, and entertainment mediums are likely needed to disseminate information to improve prevention strategies. Future research should focus on identifying the strengths of prehospital predictors and finding other variables that can be established as forecasters of delay. Interventions to enhance survival in acute STEMI should continue as to provide substantial advances in overall health outcomes.

The individual and neighborhood factors associated with the use of emergency medical services in patients with ST-elevation myocardial infarction

OBJECTIVE

The utilization of emergency medical services (EMS) varies widely among communities. In this study, we aimed to evaluate the relationship between the use of EMS by patients with ST-elevation myocardial infarction (STEMI) and the individual and neighborhood characteristics of these patients.

METHODS

We performed a secondary analysis of data from the Cardiovascular Disease Surveillance project, which included patients diagnosed with STEMI at 29 emergency centers in South Korea. Our analysis included only patients living in Seoul, and the primary outcome measured was the use of EMS. While the clinical variables of the patients were collected from the Cardiovascular Disease Surveillance registry, the 2010 National Census data was used to identify neighborhood variables such as population density, income, age, and residence type. We used a 3-level hierarchical logistic regression to estimate the effects of neighborhood-level factors on EMS use by individual patients.

RESULTS

We evaluated 1,634 patients with STEMI from 2007 to 2012. The neighborhoods were grouped into 25 counties. The regional rates of EMS use varied from 18.3% to 46.5%. The final adjusted logistic model revealed that the use of EMS was significantly associated with the average number of households (neighborhood level factor) and symptoms of syncope, cardiac arrest, and history of cardiovascular disease (individual level factors).

CONCLUSION

The individual levels factors had a greater influence on the use of EMS compared to the neighborhood-level factors.

Design characteristics of comparative effectiveness trials for the relief of symptomatic dyspepsia: A systematic review

Background

Dyspepsia represents a symptom domain rather than a diagnostic condition and covers a wide range of complex, underlying pathophysiologies that are not well understood. The review explores comparative effectiveness interventions for the treatment of symptomatic dyspepsia along a pragmatic-explanatory continuum. The aim is to identify relevant design characteristics applicable to future upper gastrointestinal comparative effectiveness research employing integrative medicine.

Methods

Medline, CINAHL, Scopus, Cochrane Central Register of Controlled Trials (CENTRAL) and WHO Clinical Trials were systematically searched until January 2019. Included articles were original research with two or more comparative intervention arms for the primary outcome; relief of symptomatic dyspepsia. Evaluation of the studies was conducted using the pragmatic-explanatory continuum indicator summary (PRECIS-2) tool.

Results

Thirty-six articles were included in the review. A total of 68 Patient Reported Outcome Measurements (PROMs), utilizing 50 different formats were deployed across the studies. The appraisal process revealed eligibility, flexibility in adherence, flexibility in delivery and organization domains further aligned towards an explanatory design.

Conclusion

This review identified three design characteristics relevant for future comparative effectiveness research for the treatment of upper gastrointestinal disorders in a community setting. Extensive exclusion eligibility criteria limited the generalization of comparative effectiveness study results by removing sub-groups of the target populations more at risk of dyspeptic symptoms. The requirement for entry endoscopy was found to be common and not always pragmatically justifiable. Development of validated PROMs appropriate for a generic application to upper gastrointestinal disorders would be advantageous for future comparative effectiveness research within integrative medicine.

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.

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

BACKGROUND

Cardiovascular disease accounts for nearly half of all deaths in Poland. The aim of this study was to assess both the duration and the delays of prehospital treatment in ST-segment elevation myocardial infarction (STEMI) patients and how it impacts left ventricle ejection fraction (LVEF) measured at the time of discharge and the frequency of in-hospital patient mortality.

METHODS

This study retrospectively analyzed medical records from January 2011 to December 2015 (excluding the year 2013) of 573 patients who were transported to a hospital with a diagnosis of STEMI.

RESULTS

The mean time of prehospital system delays was 59 min with a maximum time of 152 min and a minimum time of 23 min. The relationship between reduced LVEF (< 55%) and in-hospital patient mortality and the relationship between length of time from first medical contact (FMC) to hospital admission was analysed in 515 respondents. Extending the time of FMC to hospital admission by 1 min increased the chances of lowering LVEF by 2% (95% CI: 1.004-1.041) and increased the chances of death by 2% (95% CI: 1.002-1.04) in STEMI patients.

CONCLUSIONS

This study emphasised how vital it is to minimise time spent with STEMI patients at the scene of their cardiovascular event by performing an ECG as quickly as possible and by immediately transporting the patient to the hospital with the targeted treatment. This may lead to the implementation of additional training in the field of ECG interpretation, increase the prevalence of teletransmission systems, and improve communication between Emergency Medical Services (EMS) and catheterization laboratories ultimately reducing patient mortality.

Time-Stratified Case Crossover Study of the Association of Outdoor Ambient Air Pollution With the Risk of Acute Myocardial Infarction in the Context of Seasonal Exposure to the Southeast Asian Haze Problem

Background Prior studies have demonstrated the association of air pollution with cardiovascular deaths. Singapore experiences seasonal transboundary haze. We investigated the association between air pollution and acute myocardial infarction ( AMI ) incidence in Singapore. Methods and Results We performed a time-stratified case-crossover study on all AMI cases in the Singapore Myocardial Infarction Registry (2010-2015). Exposure on days where AMI occurred (case days) were compared with the exposure on days where AMI did not occur (control days). Control days were chosen on the same day of the week earlier and later in the same month and year. We fitted conditional Poisson regression models to daily AMI incidence to include confounders such as ambient temperature, rainfall, wind-speed, and Pollutant Standards Index. We assessed relationships between AMI incidence and Pollutant Standards Index in the entire cohort and subgroups of individual-level characteristics. There were 53 948 cases. Each 30-unit increase in Pollutant Standards Index was association with AMI incidence (incidence risk ratio [ IRR ] 1.04, 95% CI 1.03-1.06). In the subgroup of ST -segment-elevation myocardial infarction the IRR was 1.00, 95% CI 0.98 to 1.03, while for non-ST-segment-elevation myocardial infarction, the IRR was 1.08, 95% CI 1.05 to 1.10. Subgroup analyses showed generally significant. Moderate/unhealthy Pollutant Standards Index showed association with AMI occurrence with IRR 1.08, 95% CI 1.05 to 1.11 and IRR 1.09, 95% CI 1.01 to 1.18, respectively. Excess risk remained elevated through the day of exposure and for >2 years after. Conclusions We found an effect of short-term air pollution on AMI incidence, especially non-ST-segment-elevation myocardial infarction and inpatient AMI . These findings have public health implications for primary prevention and emergency health services during haze.

Symptom clusters and treatment time delay in Korean patients with ST-elevation myocardial infarction on admission

Most patients with acute myocardial infarction (AMI) experience more than one symptom at onset. Although symptoms are an important early indicator, patients and physicians may have difficulty interpreting symptoms and detecting AMI at an early stage. This study aimed to identify symptom clusters among Korean patients with ST-elevation myocardial infarction (STEMI), to examine the relationship between symptom clusters and patient-related variables, and to investigate the influence of symptom clusters on treatment time delay (decision time [DT], onset-to-balloon time [OTB]). This was a prospective multicenter study with a descriptive design that used face-to-face interviews. A total of 342 patients with STEMI were included in this study. To identify symptom clusters, two-step cluster analysis was performed using SPSS software. Multinomial logistic regression to explore factors related to each cluster and multiple logistic regression to determine the effect of symptom clusters on treatment time delay were conducted. Three symptom clusters were identified: cluster 1 (classic MI; characterized by chest pain); cluster 2 (stress symptoms; sweating and chest pain); and cluster 3 (multiple symptoms; dizziness, sweating, chest pain, weakness, and dyspnea). Compared with patients in clusters 2 and 3, those in cluster 1 were more likely to have diabetes or prior MI. Patients in clusters 2 and 3, who predominantly showed other symptoms in addition to chest pain, had a significantly shorter DT and OTB than those in cluster 1. In conclusion, to decrease treatment time delay, it seems important that patients and clinicians recognize symptom clusters, rather than relying on chest pain alone. Further research is necessary to translate our findings into clinical practice and to improve patient education and public education campaigns.

Neutrophil-to-lymphocyte ratio in occlusive vascular diseases: the literature review of the past 10 years

BACKGROUND

This study aims to evaluate the results of studies investigating neutrophil-to-lymphocyte ratio (NLR) and to identify the prognostic and diagnostic value of NLR in occlusive vascular diseases.

METHODS

With the aim of identifying the studies related to NLR, a search was performed on http://www.ncbi.nlm.nih.gov/pubmed by using the key words "neutrophil lymphocyte ratio" between January 2005 and December 2014. All of the original articles were evaluated according to date of publications, countries, clinics and topics. Studies about occlusive vascular diseases were evaluated according to their qualifications, review methods and results. SPSS for Windows 16.0 was used in data analysis and data were expressed as mean, standard deviation and percentage.

RESULTS

A total of 735 original research articles were investigated. The number of publications have shown a regular logarithmic increase over the years. Thirty-two percent of all publications were performed by clinics in Turkey and 56.4% were performed by general-oncological surgery and cardiology clinics. A total of 107 publications were identified to be about occlusive vascular diseases, 80.3% of these publications were found to be prognostic and 19.6% to be diagnostic, 82.2% of them were found to be planned as retrospective and 17.7% as prospective. In 95.3% of prognostic publications, there was a positive correlation between high NLR values at admission and poor prognosis. In 95.3% of diagnostic publications high NLR values at admission were identified to be significant diagnostically.

CONCLUSION

Elevated neutrophil-to-lymphocyte ratio at admission, could be used as a diagnostic and/or prognostic parameter in occlusive vascular diseases.