Effect of age, gender, and time of day on pain-to-call times in patients with acute ST-segment elevation myocardial infarction: the CLOC’AGE study

BACKGROUND

The time lapse between onset of symptoms and a call to an emergency dispatch center (pain-to-call time) is a critical prognostic factor in patients with chest pain. It is therefore important to identify factors related to delays in calling for help.

OBJECTIVES

To analyze whether age, gender, or time of day influence the pain-to-call delay in patients with acute STsegment elevation myocardial infarction (STEMI).

MATERIAL AND METHODS

Data were extracted from a prospective registry of STEMI cases managed by 39 mobile intensive care ambulance teams before hospital arrival within 24 hours of onset in our region, the greater metropolitan area of Paris, France. We analyzed the relation between pain-to-call time and the following factors: age, gender, and the time of day when symptoms appeared. We also assessed the influence of pain-to-call time on the rate of prehospital decisions to implement reperfusion therapy.

RESULTS

A total of 24 662 consecutive patients were included; 19 291 (78%) were men and 4371 (22%) were women. The median age was 61 (interquartile range, 52-73) years (men, 59 [51-69] years; women, 73 [59-83] years; P .0001). The median pain-to-call time was 60 (24-164) minutes (men, 55 [23-150] minutes; women, 79 [31-220] minutes; P .0001). The delay varied by time of day from a median of 40 (17-101) minutes in men between 5 pm and 6 pm to 149 (43-377) minutes in women between 2 am and 3 am. The delay was longer in women regardless of time of day and increased significantly with age in both men and women (P .001). A longer pain-to-call time was significantly associated with a lower rate of implementation of myocardial reperfusion (P .001).

CONCLUSION

Pain-to-call delays were longer in women and older patients, especially at night. These age and gender differences identify groups that would benefit most from health education interventions.

Nationwide temporal trend analysis of reperfusion therapy utilization and mortality in acute ischemic stroke patients in Japan

This study aimed to elucidate nationwide trends in reperfusion therapy utilization and subsequent 30-day mortality in acute ischemic stroke patients in Japan. The analysis focused on intravenous recombinant tissue plasminogen activator (IV rt-PA) and endovascular thrombectomy (EVT). Using health insurance claims data, we calculated the age- and sex-adjusted monthly number of acute ischemic stroke patients who received IV rt-PA and/or EVT in Japan from April 2010 to March 2016, and investigated the 30-day all-cause mortality rates after undergoing these therapies. Through an interrupted time-series analysis, we examined the: (1).. trends prior to extension of the IV rt-PA therapeutic time window from 3 hours to 4.5 hours in September 2012, (2).. changes that occurred immediately after the extension, and (3).. differences in trends between the pre- and post-extension periods. During the study period, 69,920 patients with acute ischemic stroke (mean age ± standard deviation: 74.9 ± 12.0 years; 41.4% women) received IV rt-PA and/or EVT. The age- and sex-adjusted number of patients receiving IV rt-PA monotherapy increased immediately after the time window extension (<rk-italic > P < .001), but did not change during the pre- (P = .90) and post-extension (P = .58) periods. In contrast, the number of patients receiving EVT with or without IV rt-PA continuously increased during the pre-extension period (P < .001), and further increased during the post-extension period (P <.001); however, this number decreased immediately after the extension (P < .001). There were no significant changes in 30-day all-cause mortality during the pre- (P = .40) and post-extension (P = .64) periods, as well as immediately after the extension (P = .53). The extension of the IV rt-PA therapeutic time window and progressively widespread use of EVT in Japan have increased the number of acute ischemic stroke patients eligible for reperfusion therapy. These trends were not accompanied by a higher risk of post-reperfusion mortality.

Frequency and factors related to not receiving acute reperfusion therapy in patients with ST elevation myocardial infarction; a single specialty cardiac center

OBJECTIVE

To determine the frequency of no reperfusion therapy, its reasons, hospital management and intermediate-term outcome s of ST- elevation my ocardial in farction patients .

METHODS

The retrospective ambi-directional observational study was conducted at Tabba Heart Institute, Karachi, and comprised record of ST-elevation myocardial infarction patients without immediate reperfusion therapy with symptom onset time of 12 hours who presented between January 2013 and December 2017. Prospective follow-up of all patients was performed till June 2018. Coronary angiography, non-invasive stress tests, medications and late revascularisation were explored. Predictors of hospital mortality and major adverse cardiovascular events at follow-up were analysed. Data was analysed using SPSS 19.

RESULTS

Of the 1977 records evaluated, 218(11%) patients of mean age 60.3±12.4 years did not receive immediate reperfusion therapy. Coronary angiography was done in 163(74.7%) patients of whom 45(27.6%) were taken for immediate procedure. Besides, 26 (11.9%) patients died during hospital stay. Predictors of hospital mortality were no revascularisation (odds ratio: 24.1, 95% confidence interval: 1.3-500), cardiogenic shock (odds ratio: 65, 95% confidence interval: 5.7-745) and tachycardia (odds ratio: 17, 95% confidence interval: 1.2-254.5) at presentation. Predictor of major adverse cardiovascular events was guideline-directed medical therapy (hazard ratio 2.6, 95% confidence interval: 1.16-6.2) at discharge, while revascularisation was not a significant predictor (p>0.05).

CONCLUSION

A huge number of salvageable ST-elevation myocardial infarction patients failed to receive reperfusion therapy. There is a huge potential of improvement in ST-elevation myocardial infarction care in terms of increasing community awareness, prompt reperfusion therapy and usage of optimal medical therapy.

Acute reperfusion for ST-elevation myocardial infarction in New Zealand (2015-2017): patient and system delay (ANZACS-QI 29)

AIM

Prompt access to cardiac defibrillation and reperfusion therapy improves outcomes in patients with ST-segment elevation myocardial infarction (STEMI). The study aim was to describe the 'patient' and 'system' delay in patients who receive acute reperfusion therapy for ST-elevation myocardial infarction (STEMI) in New Zealand.

METHODS

In 2015-17, 3,857 patients who received acute reperfusion therapy were captured in the All New Zealand Acute Coronary Syndrome Quality Improvement (ANZACS-QI) registry. 'Patient delay' is the time from symptom onset to first medical contact (FMC), and 'system delay' the time from FMC until reperfusion therapy (primary percutaneous coronary intervention (PCI) or fibrinolysis).

RESULTS

Seventy percent of patients received primary PCI and 30% fibrinolysis. Of those receiving fibrinolysis, 122 (10.5%) received pre-hospital fibrinolysis. Seventy-seven percent were transported to hospital by ambulance. After adjustment, people who were older, male and presented to a hospital without a routine primary PCI service were less likely to travel by ambulance. Patient delay: The median delay was 45 minutes for ambulance-transported patients and 97 minutes for those self-transported to hospital, with a quarter delayed by >2 hours and >3 hours, respectively. Delay >1 hour was more common in older patients, Māori and Indian patients and those self-transported to hospital. System delay: For ambulance-transported patients who received primary PCI, the median time was 119 minutes. For ambulance-transported patients who received fibrinolysis, the median system delay was 86 minutes, with Māori patients more often delayed than European/Other patients. For patients who received pre-hospital fibrinolysis the median delay was 46 minutes shorter. For the quarter of patients treated with rescue PCI after fibrinolysis, the median needle-to-rescue time was prolonged-four hours.

CONCLUSIONS

Nationwide implementation of the NZ STEMI pathway is needed to reduce system delays in delivery of primary PCI, fibrinolysis and rescue PCI. Ongoing initiatives are required to reduce barriers to calling the ambulance early after symptom onset.

Presentation, management and mortality after a first MI in people with and without asthma: A study using UK MINAP data

Asthma has been associated with a higher incidence of myocardial infarction (MI), higher prevalence of MI risk factors and higher burden of cardiovascular diseases. However, detailed associations between the presentation and initial management at the time of MI and post-MI outcomes in people with asthma compared to the general population have not been studied. A total of 300,161 people were identified with a first MI over the period 2003-2013 in the Myocardial Ischaemia National Audit Project database, of whom 8922 (3%) had asthma. Logistic regression was used to compare presentation, in-hospital care, in-hospital and 180-day post-discharge all-cause mortality in people with and without asthma adjusting for demographics and comorbidities, diagnosis on arrival and secondary prevention. People with asthma were more likely to have a delay in their MI diagnosis following an STEMI (ST-elevation myocardial infarction; odds ratio (OR) 1.38, confidence interval CI 1.06-1.79) but not an nSTEMI (non-ST-elevation myocardial infarction; OR 1.04, CI 0.92-1.17) compared to people without asthma and a delay in reperfusion (OR 1.19, CI 1.09-1.30) following an STEMI. They were much less likely to be discharged on a beta blocker following an STEMI or nSTEMI (OR 0.24, CI 0.21-0.28 and OR 0.27, CI 0.24-0.30, respectively). There was no difference in in-hospital or 180-day mortality (OR 0.98, CI 0.59-1.62 and OR 0.99, CI 0.72-1.36) following an STEMI or nSTEMI (OR 0.89, CI 0.47-1.68 and OR 1.05, CI 0.85-1.28). Although people with asthma were more likely to have a delay in diagnosis following an STEMI but not an nSTEMI compared to the general population, were more likely to have a delay in reperfusion therapy and were much less likely to receive beta blockers following an STEMI or nSTEMI, there was no difference in the prescriptions of other secondary prevention medications. None of the differences in presentation or management were associated with an increase in all-cause in-hospital or 180-day mortality in people with asthma compared to the general population.

Performance of hospitals according to the ESC ACCA quality indicators and 30-day mortality for acute myocardial infarction: national cohort study using the United Kingdom Myocardial Ischaemia National Audit Project (MINAP) register

Aims

To investigate the application of the European Society of Cardiology Acute Cardiovascular Care Association quality indicators (QI) for acute myocardial infarction for the study of hospital performance and 30-day mortality.

Methods and results

National cohort study (n = 118,075 patients, n = 211 hospitals, MINAP registry), 2012-13. Overall, 16 of the 20 QIs could be calculated. Eleven QIs had a significant inverse association with GRACE risk adjusted 30-day mortality (all P < 0.005). The association with the greatest magnitude was high attainment of the composite opportunity-based QI (80-100%) vs. zero attainment (odds ratio 0.04, 95% confidence interval 0.04-0.05, P < 0.001), increasing attainment from low (0.42, 0.37- 0.49, P < 0.001) to intermediate (0.15, 0.13-0.16, P < 0.001) was significantly associated with a reduced risk of 30-day mortality. A 1% increase in attainment of this QI was associated with a 3% reduction in 30-day mortality (0.97, 0.97-0.97, P < 0.001). The QI with the widest hospital variation was 'fondaparinux received among NSTEMI' (interquartile range 84.7%) and least variation 'centre organisation' (0.0%), with seven QIs depicting minimal variation (<11%). GRACE risk score adjusted 30-day mortality varied by hospital (median 6.7%, interquartile range 5.4-7.9%).

Conclusions

Eleven QIs were significantly inversely associated with 30-day mortality. Increasing patient attainment of the composite quality indicator was the most powerful predictor; a 1% increase in attainment represented a 3% decrease in 30-day standardised mortality. The ESC QIs for acute myocardial infarction are applicable in a large health system and have the potential to improve care and reduce unwarranted variation in death from acute myocardial infarction.

Direct Transfer From the Referring Hospitals to the Catheterization Laboratory to Minimize Reperfusion Delays for Primary Percutaneous Coronary Intervention: Insights From the National Cardiovascular Data Registry

BACKGROUND

For patients with ST-segment-elevation myocardial infarction (STEMI) requiring interhospital transfer for primary percutaneous coronary intervention, direct transfer from the STEMI referral hospital to the catheterization laboratory (cath lab) at the STEMI receiving hospital may expedite reperfusion, but can be logistically challenging.

METHODS AND RESULTS

We studied 33,901 STEMI patients transferred for primary percutaneous coronary intervention in the Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines from July 2008 to December 2012. The majority of patients were transferred directly to the cath lab (26,510 [78.2%]), and 7391 patients (21.8%) were transferred first to the hospital emergency department/ward. We observed significant interhospital variation in transfer patterns; only 21% of STEMI receiving hospitals routinely transferred >90% of STEMI patients to the cath lab directly. Compared with patients transferred first to the emergency department/ward, STEMI patients transferred to the cath lab had significantly lower first door-to-balloon times (median 191 versus 116 minutes, P<0.0001). After multivariable logistic regression, patients transferred directly to the cath lab also had lower adjusted mortality risk (odds ratio 0.58, 95% confidence interval 0.51-0.66, P<0.0001). Cardiogenic shock, heart failure signs/symptoms, and nonsystem reasons for reperfusion delay were present in 11%, 15%, and 28% of patients transferred first to the emergency department/ward, respectively. The association of direct cath lab transfer with lower mortality persisted after excluding patients with these reasons for delay to primary percutaneous coronary intervention (adjusted odds ratio 0.62, 95% confidence interval 0.46-0.84, P=0.002).

CONCLUSIONS

Direct transfer of STEMI patients to the cath lab for primary percutaneous coronary intervention was associated with significantly faster reperfusion and lower mortality risk compared with transfer first to the emergency department/ward.

[Clinical and surgical gender differences in patients older than 75 years who underwent emergency percutaneous coronary intervention in acute myocardial infarction]

There were 85 cases of endovascular treatment of acute myocardial infarct (AMI) in patients older than 75 years old in our investigation. The age of patients was from 75 to 96 years, the average age - 82,6±1,3 years. As for gender, all patients were divided into 2 groups: men - 37 (43,5 %) and female - 48 (56,5 %). The study was conducted in the following areas: determination of the baseline status of patients, analysis of technical aspects of diagnostic and medical percutaneous coronary interventions (PCI), as well as the comparison of results.

RESULTS

apart from gender identities, the following results were obtained (p>0,05): high prevalence of cardiac diseases and basic somatic diseases; the acute cardiac failure (pulmonary edema, cardiogenic shock) was registered in 25,8 % of cases; the proportion of patients who were admitted 6 hours later from the onset of disease and who have had delayed reperfusion therapy, was 37,5 %; significant improvement of coronary blood flow in infarct-related coronary artery (TIMI classification), from an average index 1,4±0,2 before coronary stenting to 2,7±0,1 after interventions; endovascular operations were conducted in patients with multiple pathology of coronary arteries in the setting of extended occlusive lesions of infarct-related coronary artery; high efficiency of application of aspiration catheters for the removal of thrombotic masses in acute occlusion, as well as special devices for closing a puncture hole in the femoral arteries. Reduction of mortality in AMI patients over 75 years old of both sexes is associated with an increase in the proportion of emergency PCI. In both gender groups endovascular intervention was characterized by a clinically significant restoration of coronary circulation. Specific complications of PCI are rare, and it proves the safety of reperfusion therapy in the studied age group.

[Acute myocardial infarction in Morocco: FES-AMI registry data]

BACKGROUND

Acute myocardial infarction is the most dangerous complication of coronary atherothrombosis. There are several disparities in regard to its management around the world. The aim of this study is to analyze the specificities of management of acute myocardial infarction in Morocco.

METHODS

FES-AMI (Fès Acute Myocardial Infarction) is a prospective monocentric registry conducted in cardiology department of Hassan II university hospital in Fès. In this registry, we enrolled patients with acute myocardial infarction who presented within 5 days after symptom onset.

RESULTS

From January 2005 to August 2015, we enrolled 1835 patients. Seventy-five percent of patients were males and mean age was 60 years old. Fifty-one percent of patients were smokers, 27% were hypertensives and 14% were diabetics. Sixty-six percent of patients had more than 2 risk factors. Time from symptom onset to hospital admission was less than six hours for 40% of the patients. Thirty-six percent of patients were admitted more than twelve hours after the onset of chest pain. Only 37% of patients received reperfusion therapy, 31% with in-hospital thrombolysis and 6% with primary angioplasty. In-hospital mortality was 7.6%.

CONCLUSION

The patients enrolled in our registry have late presentation of acute myocardial infarction and less rate of reperfusion therapy. Furthermore, the majority of our patients have multiple risk factors and this result underlines the failure of preventive interventions.

Ex-vivo perfusion of donor hearts for human heart transplantation (PROCEED II): a prospective, open-label, multicentre, randomised non-inferiority trial

BACKGROUND

The Organ Care System is the only clinical platform for ex-vivo perfusion of human donor hearts. The system preserves the donor heart in a warm beating state during transport from the donor hospital to the recipient hospital. We aimed to assess the clinical outcomes of the Organ Care System compared with standard cold storage of human donor hearts for transplantation.

METHODS

We did this prospective, open-label, multicentre, randomised non-inferiority trial at ten heart-transplant centres in the USA and Europe. Eligible heart-transplant candidates (aged >18 years) were randomly assigned (1:1) to receive donor hearts preserved with either the Organ Care System or standard cold storage. Participants, investigators, and medical staff were not masked to group assignment. The primary endpoint was 30 day patient and graft survival, with a 10% non-inferiority margin. We did analyses in the intention-to-treat, as-treated, and per-protocol populations. This trial is registered with ClinicalTrials.gov, number NCT00855712.

FINDINGS

Between June 29, 2010, and Sept 16, 2013, we randomly assigned 130 patients to the Organ Care System group (n=67) or the standard cold storage group (n=63). 30 day patient and graft survival rates were 94% (n=63) in the Organ Care System group and 97% (n=61) in the standard cold storage group (difference 2·8%, one-sided 95% upper confidence bound 8·8; p=0·45). Eight (13%) patients in the Organ Care System group and nine (14%) patients in the standard cold storage group had cardiac-related serious adverse events.

INTERPRETATION

Heart transplantation using donor hearts adequately preserved with the Organ Care System or with standard cold storage yield similar short-term clinical outcomes. The metabolic assessment capability of the Organ Care System needs further study.

FUNDING

TransMedics.

Effects of valsartan versus amlodipine in diabetic hypertensive patients with or without previous cardiovascular disease

Recently, we reported that angiotensin II receptor blocker (ARB), valsartan, and calcium channel blocker (CCB), amlodipine, had similar effects on the prevention of cardiovascular disease (CVD) events in diabetic hypertensive patients. We assessed the difference of cardiovascular protective effects between ARB and CCB in patients with and without previous CVD, respectively. A total of 1,150 Japanese diabetic hypertensive patients were randomized to either valsartan or amlodipine treatment arms, which were additionally divided into 2 groups according to the presence of previous CVD at baseline (without CVD, n = 818; with CVD, n = 332). The primary composite outcomes were sudden cardiac death, acute myocardial infarction, stroke, coronary revascularization, or hospitalization for heart failure. The incidence of primary end point events in patients with previous CVD was 3.5-times greater than that in patients without previous CVD (64.1 vs 17.9/1,000 person-years). The ARB- and the CCB-based treatment arms showed similar incidence of composite CVD events in both patients without previous CVD (hazard ratio [HR] 1.35, 95% confidence interval [CI] 0.76 to 2.40) and those with previous CVD (HR 0.79, 95% CI 0.48 to 1.31). The ARB-treatment arm showed less incidence of stroke compared with the CCB-based treatment arm in patients with previous CVD (HR 0.24, 95% CI 0.05 to 1.11, p = 0.068), whereas the 2 treatment arms showed similar incidence of stroke in patients without previous CVD (HR 1.52, 95% CI 0.59 to 3.91). In conclusion, the ARB- and the CCB-based treatments exerted similar protective effects of CVD events regardless of the presence of previous CVD. For stroke events, the ARB may have more protective effects than the CCB in diabetic hypertensive patients with previous CVD.

A prospective regional registry of ST-elevation myocardial infarction in Central Romania: impact of the Stent for Life Initiative recommendations on patient outcomes

BACKGROUND

Reperfusion therapy is the treatment of choice in patients with ST-elevation myocardial infarction (STEMI) presenting within 12 hours after the onset of symptoms. However, a significant number of patients do not benefit from it because of the lack of access to well-organized emergency care. We aimed to investigate the evolution of STEMI treatment and mortality between 2004 and 2011 in an unselected population from central Romania and to demonstrate the role of a regional network in increasing the rates of reperfusion therapy with associated reduction of STEMI-related mortality in a region with very low primary percutaneous coronary intervention (pPCI) rates at baseline.

METHODS

We analyzed the data of 5,899 consecutive patients with STEMI enrolled in this prospective study since 2004, after the initiation of an STEMI network in Central Romania and with continuous support of the Stent for Life Initiative.

RESULTS

Introduction of the network was associated with an absolute change in the use of reperfusion therapy from 2004 to 2011 (26.94% vs 87.15%, P < .001) and of pPCI (10.88% vs 78.64%, P < .001) for patients presenting within 12 hours after the onset of symptoms, with a decrease of inhospital mortality from 20.73% to 6.35% (P < .001). In addition, the global inhospital mortality of all the STEMI population showed a significant decrease (23.18% vs 13.39%, P < .001).

CONCLUSIONS

Reduction of STEMI-related mortality was possible via implementation of pPCI, even in a region with low health care expenditures. The organization of an STEMI network led to a significant decrease in STEMI-related mortality, revealing the significant impact of the Stent for Life Initiative recommendations on patient outcomes.

[Primary percutaneous coronary intervention as a national Danish reperfusion strategy of ST-elevation myocardial infarction]

The use of primary percutaneous coronary intervention (PCI) as the preferred reperfusion strategy in ST-elevation myocardial infarction (STEMI) requires optimal systems-of-care and logistics in order to enable rapid treatment of all patients. In Denmark, this has been achieved through prehospital electrocardiogram diagnosis, field triage and dedicated PCI centres 24/7. Today, primary PCI is an option for all Danish patients with STEMI, regardless of the distance to a PCI centre. This has led to a decline in both mortality and morbidity.

[Features of reperfusion therapy in old patients at acute coronary syndrome with segment st elevation and moderately reduced kidney function]

The article discusses approaches to reperfusion strategy in old patients according to baseline GFR defined by MDRD formula for admission to the hospital with a diagnosis of STEMI. The authors analyzed the complications and mortality rates, depending on the method of reperfusion while GFR < 60 mL/min per 1,73 m2. GFR is an aggravating factor that increases frequency of hospital and annual mortality and complication of AMI.

Association of changes in clinical characteristics and management with improvement in survival among patients with ST-elevation myocardial infarction

CONTEXT

The contemporary decline in mortality reported in patients with ST-segment elevation myocardial infarction (STEMI) has been attributed mainly to improved use of reperfusion therapy.

OBJECTIVE

To determine potential factors-beyond reperfusion therapy-associated with improved survival in patients with STEMI over a 15-year period.

DESIGN, SETTING, AND PATIENTS

Four 1-month French nationwide registries, conducted 5 years apart (between 1995, 2000, 2005, 2010), including a total of 6707 STEMI patients admitted to intensive care or coronary care units.

MAIN OUTCOME MEASURES

Changes over time in crude 30-day mortality, and mortality standardized to the 2010 population characteristics.

RESULTS

Mean (SD) age decreased from 66.2 (14.0) to 63.3 (14.5) years, with a concomitant decline in history of cardiovascular events and comorbidities. The proportion of younger patients increased, particularly in women younger than 60 years (from 11.8% to 25.5%), in whom prevalence of current smoking (37.3% to 73.1%) and obesity (17.6% to 27.1%) increased. Time from symptom onset to hospital admission decreased, with a shorter time from onset to first call, and broader use of mobile intensive care units. Reperfusion therapy increased from 49.4% to 74.7%, driven by primary percutaneous coronary intervention (11.9% to 60.8%). Early use of recommended medications increased, particularly low-molecular-weight heparins and statins. Crude 30-day mortality decreased from 13.7% (95% CI, 12.0-15.4) to 4.4% (95% CI, 3.5-5.4), whereas standardized mortality decreased from 11.3% (95% CI, 9.5-13.2) to 4.4% (95% CI, 3.5-5.4). Multivariable analysis showed a consistent reduction in mortality from 1995 to 2010 after controlling for clinical characteristics in addition to the initial population risk score and use of reperfusion therapy, with odds mortality ratios of 0.39 (95%, 0.29-0.53, P <.001) in 2010 compared with 1995.

CONCLUSION

In France, the overall rate of cardiovascular mortality among patients with STEMI decreased from 1995 to 2010, accompanied by an increase in the proportion of women younger than 60 years with STEMI, changes in other population characteristics, and greater use of reperfusion therapy and recommended medications.

[Predictors of non-fulfillment of reperfusion therapy in patients with ST-elevation acute coronary syndrome]

At present reperfusion therapy in ST-elevation (STE) acute coronary syndrome (ACS) is carried out in majority of countries not more than in 70% of cases. We analyzed predictors of non-fulfillment of reperfusion therapy in patients with STEACS included into ACS registry conducted in the Kemerovo cardiological dispensary. Reperfusion therapy was not carried out in 154 patients with STEACS (36.2%). Main predictors of non-fulfillment of reperfusion were age older than 75 years (odds ratio [OR] 47.97, 95% confidence interval [CI] 19.47-118.21), admission later than in 12 hours after onset of disease (OR 4.29, 95%CI 1.52-12.13), history of myocardial infarction (OR 2.68, 95%CI 1.11-6.48). Thus there are factors including subjective ones which preclude full-fledged use of contemporary recommendations on the management of patients with STEACS.

Recording of quality indicators in the management of acute coronary syndromes: predictors of reperfusion times

BACKGROUND

There is wide variation in recording of reperfusion times in the management of ST segment elevation acute coronary syndromes (ACS). We investigated factors that could predict time to reperfusion.

METHODS

Single-centre, retrospective study of all consecutive patients admitted for primary PCI from June 2009 to October 2010. Door-to-artery (D2A) and Door-to-balloon (D2B) times were calculated from times noted by cathlab. nurses and compared with times from digital recordings of PCI procedures. Predictors of time to reperfusion were identified by logistic regression.

RESULTS

300 patients were included. Median (interquartile range) D2B time recorded by cathlab. nurses (D2B-CN) was 35.5 (24; 52) minutes, 32 (20; 51) min from PCI recordings (D2B-PCI). Average difference between D2B-CN and D2B-PCI was 6.2 min (P < 0.0001). Concordance of percent patients with a D2B time < 90 and < 45 min was mediocre, kappa coefficients 0.44 (95% CI: 0.10-0.79) and 0.68 (95% CI: 0.57-0.80) respectively. By multivariate analysis, older patients had longest D2A times (P = 0.04); patients with longest D2A and D2B times more frequently had elevated creatinine (P = 0.002 (D2A), P = 0.0003 (D2B). Organizational aspects did not influence reperfusion times.

CONCLUSION

Data regarding reperfusion times are unreliable when recorded by nurses. Age and creatinine levels are significantly associated with reperfusion times, whereas organizational aspects are not.

Association of door-in to door-out time with reperfusion delays and outcomes among patients transferred for primary percutaneous coronary intervention

CONTEXT

Patients with ST-elevation myocardial infarction (STEMI) requiring interhospital transfer for primary percutaneous coronary intervention (PCI) often have prolonged overall door-to-balloon (DTB) times from first hospital presentation to second hospital PCI. Door-in to door-out (DIDO) time, defined as the duration of time from arrival to discharge at the first or STEMI referral hospital, is a new clinical performance measure, and a DIDO time of 30 minutes or less is recommended to expedite reperfusion care.

OBJECTIVE

To characterize time to reperfusion and patient outcomes associated with a DIDO time of 30 minutes or less.

DESIGN, SETTING, AND PATIENTS

Retrospective cohort of 14,821 patients with STEMI transferred to 298 STEMI receiving centers for primary PCI in the ACTION Registry-Get With the Guidelines between January 2007 and March 2010.

MAIN OUTCOME MEASURES

Factors associated with a DIDO time greater than 30 minutes, overall DTB times, and risk-adjusted in-hospital mortality.

RESULTS

Median DIDO time was 68 minutes (interquartile range, 43-120 minutes), and only 1627 patients (11%) had DIDO times of 30 minutes or less. Significant factors associated with a DIDO time greater than 30 minutes included older age, female sex, off-hours presentation, and non-emergency medical services transport to the first hospital. Patients with a DIDO time of 30 minutes or less were significantly more likely to have an overall DTB time of 90 minutes or less compared with patients with DIDO times greater than 30 minutes (60% [95% confidence interval {CI}, 57%-62%] vs 13% [95% CI, 12%-13%]; P < .001). Among patients with DIDO times greater than 30 minutes, only 0.6% (95% CI, 0.5%-0.8%) had an absolute contraindication to fibrinolysis. Observed in-hospital mortality was significantly higher among patients with DIDO times greater than 30 minutes vs patients with DIDO times of 30 minutes or less (5.9% [95% CI, 5.5%-6.3%] vs 2.7% [95% CI, 1.9%-3.5%]; P < .001; adjusted odds ratio for in-hospital mortality, 1.56 [95% CI, 1.15-2.12]).

CONCLUSION

A DIDO time of 30 minutes or less was observed in only a small proportion of patients transferred for primary PCI but was associated with shorter reperfusion delays and lower in-hospital mortality.

Patients admitted with an acute coronary syndrome (ACS) in New Zealand in 2007: results of a second comprehensive nationwide audit and a comparison with the first audit from 2002

AIMS

To audit all patients admitted to a New Zealand (NZ) Hospital with an acute coronary syndrome (ACS) over a 14-day period, to assess their number, presentation type and patient management during the hospital admission and at discharge. To compare patient management in 2007 with the 1st NZ Cardiac Society ACS Audit from 2002.

METHODS

We updated the established NZ ACS Audit group of 36 hospitals to 39 hospitals now admitting ACS patients across New Zealand. A comprehensive data form was used to record individual patient information for all patients admitted between 00.00 hours on 14 May 2007 to 24.00 hours on 27 May 2007.

RESULTS

1003 patients, 9% more than in 2002 (n=930), were admitted with a suspected or definite ACS: 8% with a ST-segment-elevation myocardial infarction (STEMI), 41% with a non-STEMI (NSTEMI), 33% with unstable angina pectoris (UAP), and 17% with another cardiac or medical condition. In 2007 non-invasive risk stratification following presentation remained similar to 2002 and was suboptimal: exercise treadmill tests (21% vs 20%, p=0.62), echocardiograms (19% vs 20%, p=0.85). An increase in utilisation of coronary angiography was noted (32% vs 21%, p<0.0001). In hospital revascularisation rates remained low in patients with diagnosed ACS (n=828): STEMI (45%), NSTEMI (23%) and UAP (7.3%). In comparison to 2002, changes were noted in revascularisation techniques with percutaneous coronary intervention (PCI) performed in 19% vs 7% (p<0.0001). The use of coronary artery bypass grafting (CABG) remained extremely low: 2.8% vs 3.5% (p=0.20). The use of hospital and discharge medication of proven benefit was also limited.

CONCLUSIONS

A collaborative group of clinicians and nurses has performed a second nationwide audit of ACS patients. Despite a small increase in access to cardiac angiography, guideline recommended risk stratification following the index suspected ACS admission with a treadmill test or cardiac angiogram occurred in only 1 in 2 (48%) patients. Furthermore, in patients with a definite ACS, levels of revascularisation are low. (PCI 19%, CABG 2.8%). These aspects of care remain of significant concern and have not substantially changed in 5 years. There remains an urgent need to develop a comprehensive national strategy to improve all aspects of ACS patient management.

Inappropriate dispatcher decision for emergency medical service users with acute myocardial infarction

OBJECTIVES

Current guidelines recommend utilization of prehospital emergency medical services (EMSs) by patients with ST-elevation myocardial infarction (STEMI). The aims of this study were to estimate the percentage of inappropriate initial dispatcher decisions and determine their impact on delays in reperfusion therapy for EMS users with STEMI.

METHODS

As part of a prospective regional registry of patients with STEMI, we analyzed the original data for 245 patients who called a university hospital-affiliated EMS call center in France. The primary study outcome was time to reperfusion therapy calculated from the documented date and time of the first patient call.

RESULTS

The initial EMS dispatcher's decision was appropriate (ie, dispatching a mobile intensive care unit staffed by an emergency or critical care physician) for 171 (70%) patients and inappropriate for 74 (30%) patients. Inappropriate decisions included referring the patient to a family physician (n = 59), providing medical advice (n = 9), and dispatching an ambulance (n = 6). Inappropriate initial decisions resulted in increased median time to reperfusion for 140 patients receiving fibrinolysis (95 vs 53 minutes; P < .001) and 91 patients undergoing primary percutaneous coronary intervention (170 vs 107 minutes; P < .001). In-hospital mortality was not different between the 2 study groups (6.8% vs 9.9%; P = .42).

CONCLUSION

The initial dispatcher's decision is inappropriate for 30% of EMS users with STEMI and results in substantial delays in time to reperfusion therapy. Accuracy of telephone triage should be improved for patients who activate EMSs in response to symptoms suggestive of acute coronary syndrome.

[Evolution of acute myocardial infarction treatment in Argentina from 1987 to 2005]

In Argentina, one out of three deaths is of cardiovascular origin and acute myocardial infarction (AMI) is one of the most aggressive and frequent. In our country epidemiological data related to infarction are scarce. Various surveys and reports have been carried out in the past 25 years by different scientific societies, which, even though they provide valuable information, enclose only a small range of the population with access to high complexity centers. Though these records show a gradual increase in the rate of reperfusion, this has not resulted in a mortality reduction. This review is committed to provide all available information about the AMI in Argentina, in order to provide the necessary resources to the right diagnosis and therapeutic handling of this disease.

Asessement of myocardial infarction therapy development in diabetics

INTRODUCTION

A considerable development of myocardial infarction treatment including invasive strategy and supportive pharmacotherapy ought to result in prognostic benefits for the high risk diabetic population.

OBJECTIVES

The aim of the present study was the evaluation of myocardial infarction treatment efficacy in diabetics from Swietokrzyskie province.

PATIENTS AND METHODS

Two groups of diabetics hospitalized because myocardial infarction were compared: group 1 included 183 patients treated during the years 1992-1996, group 2 was comprised of 168 patients treated in the years 2005-2006.

RESULTS

Population of diabetic patients treated in the years 2005-2006 was older and presented more coronary risk factors than patients hospitalized in the years 1992-1996. A significant more frequent use of myocardial infarction reperfusion treatment in diabetic patients was demonstrated. In 1992-1996, fibrinolytic therapy was used in 18% of diabetics, while currently the reperfusion strategy was performed in 47.2% of the study patients including fibrinolysis in 8.5% of patients, primary percutaneous coronary intervention in 38.7% of patients. In both study groups a comparably high mortality observed during the hospitalization and the 6-month follow-up incidence was observed. In the years 1992-1996 a significant decrease of mortality among diabetics who were treated by fibrinolytic methods compared to diabetics treated by conservative methods, was observed. In the years 2005-2006 in-hospital and long-term mortality were significantly reduced among diabetics who had undergone invasive therapy.

CONCLUSIONS

A significant development of myocardial infarction treatment in diabetics, particularly in those who underwent reperfusion methods, was demonstrated. The absence of reduction in overall mortality ought to be attributed to the worse clinical characteristics of recently treated patients and lower frequency of reperfusion treatment in high risk patients.

Implementation of a statewide system for coronary reperfusion for ST-segment elevation myocardial infarction

CONTEXT

Despite 2 decades of evidence demonstrating benefits from prompt coronary reperfusion, registries continue to show that many patients with ST-segment elevation myocardial infarction (STEMI) are treated too slowly or not at all.

OBJECTIVE

To establish a statewide system for reperfusion, as exists for trauma care, to overcome systematic barriers.

DESIGN AND SETTING

A quality improvement study that examined the change in speed and rate of coronary reperfusion after system implementation in 5 regions in North Carolina involving 65 hospitals and associated emergency medical systems (10 percutaneous coronary intervention [PCI] hospitals and 55 non-PCI hospitals).

PATIENTS

A total of 1164 patients with STEMI (579 preintervention and 585 postintervention) eligible for reperfusion were treated at PCI hospitals (median age 61 years, 31% women, 4% Killip class III or IV). A total of 925 patients with STEMI (518 preintervention and 407 postintervention) were treated at non-PCI hospitals (median age 62 years, 32% women, 4% Killip class III or IV).

INTERVENTIONS

Early diagnosis and the most expedient coronary reperfusion method at each point of care: emergency medical systems, emergency department, catheterization laboratory, and transfer. Within 5 regions, PCI hospitals agreed to provide single-call catheterization laboratory activation by emergency medical personnel, accept patients regardless of bed availability, and improve STEMI care for the entire region regardless of hospital affiliation.

MAIN OUTCOME MEASURES

Reperfusion times and rates 3 months before (July to September 2005) and 3 months after (January to March 2007) a year-long implementation.

RESULTS

Median reperfusion times significantly improved according to first door-to-device (presenting to PCI hospital 85 to 74 minutes, P < .001; transferred to PCI hospital 165 to 128 minutes, P < .001), door-to-needle in non-PCI hospitals (35 to 29 minutes, P = .002), and door-in to door-out for patients transferred from non-PCI hospitals (120 to 71 minutes, P < .001). Nonreperfusion rates were unchanged (15%) in non-PCI hospitals and decreased from 23% to 11% in the PCI hospitals. For patients presenting to or transferred to PCI hospitals, clinical outcomes including death, cardiac arrest, and cardiogenic shock did not significantly change following the intervention.

CONCLUSIONS

A statewide program focused on regional systems for reperfusion for STEMI can significantly improve quality of care. Further research is needed to ensure that programs that result in improved application of reperfusion treatments will lead to reductions in mortality and morbidity from STEMI.

Discordance between level of risk and intensity of evidence-based treatment in patients with acute coronary syndromes

OBJECTIVES

To examine the relation between treatment intensity and level of risk in routine hospital care of patients with acute coronary syndromes (ACS), and to identify independent predictors of use or omission for each of eight evidence-based treatments.

DESIGN

Retrospective cohort study of patients fulfilling case definition for ACS in whom absolute risk of adverse outcomes was quantified (as low, moderate, or high risk) using formal prediction rules, and for whom treatment eligibility was determined using expert-agreed criteria.

PARTICIPANTS AND SETTING

3912 consecutive or randomly selected patients admitted to 21 hospitals in Queensland, Australia between 1 August 2001 and 31 December 2005.

RESULTS

The proportions of eligible patients receiving treatment varied inversely with risk level in regard to reperfusion therapies of fibrinolytic therapy or primary angioplasty (low risk, 88.3%; moderate risk, 61.9%; high risk, 18.2%; P < 0.001), heparin (91.4%; 83.7%; 72.8%; P < 0.001) and early invasive intervention (33.6%; 24.0%; 18.5%; P < 0.001). Significantly more low- and moderate- than high-risk patients received beta-blockers (87.0%; 88.5%; 79.1%; P < 0.001), lipid-lowering agents (87.3%; 84.8%; 65.8%; P < 0.001), and referral to cardiac rehabilitation (51.8%; 46.0%; 34.4%; P < 0.001) at discharge. The most frequent independent predictors of treatment omission in all patients included increasing age (5 of 8 treatments), previous ACS or atrial tachyarrhythmias (4 of 8), and past history of cerebrovascular accident or congestive heart failure (3 of 8).

CONCLUSION

In routine care of ACS, eligible patients at high risk receive treatment less frequently than those at low and moderate risk. Reforms in professional education, routine use of risk stratification tools, guideline recommendations tailored to population-specific reductions in absolute risk, and better hospital networking with standardised triage and referral procedures for invasive procedures may help reduce selection bias in the delivery of indicated care.

Acute reperfusion therapy in ST-elevation myocardial infarction from 1994-2003

BACKGROUND

Appropriate utilization of acute reperfusion therapy is not a national performance measure for ST-elevation myocardial infarction at this time, and the extent of its contemporary use among ideal patients is unknown.

METHODS

From the National Registry of Myocardial Infarction, we identified 238,291 patients enrolled from June 1994 to May 2003 who were ideally suited for acute reperfusion therapy with fibrinolytic therapy or primary percutaneous coronary intervention. We determined rates of not receiving therapy across 3 time periods (June 1994-May 1997, June 1997-May 2000, June 2000-May 2003) and evaluated factors associated with underutilization.

RESULTS

The proportion of ideal patients not receiving acute reperfusion therapy decreased by one half throughout the past decade (time period 1: 20.6%; time period 2: 11.4%; time period 3: 11.6%; P <.001). Utilization remained significantly lower in key subgroups in the most recent time period: those without chest pain (odds ratio [OR] 0.29; 95% confidence interval [CI], 0.27-0.32); those presenting 6 to 12 hours after symptom onset (OR 0.57; 95% CI, 0.52-0.61); those 75 years or older (OR 0.63 compared with patients <55 years old; 95% CI, 0.58-0.68); women (OR 0.88; 95% CI, 0.84-0.93); and non-whites (OR 0.90; 95% CI, 0.83-0.97).

CONCLUSIONS

Utilization of acute reperfusion therapy in ideal patients has improved over the last decade, but more than 10% remain untreated. Measuring and improving its use in this cohort represents an important opportunity to improve care.

Do race-specific models explain disparities in treatments after acute myocardial infarction?

BACKGROUND

Racial differences in healthcare are well known, although some have challenged previous research where risk-adjustment assumed covariates affect whites and blacks equally. If incorrect, this assumption may misestimate disparities. We sought to determine whether clinical factors affect treatment decisions for blacks and whites equally.

METHODS

We used data from the Cardiovascular Cooperative Project for 130,709 white and 8286 black patients admitted with an acute myocardial infarction. We examined the rates of receipt of 6 treatments using conventional common-effects models, where covariates affect whites and blacks equally, and race-specific models, where the effect of each covariate can vary by race.

RESULTS

The common-effects models showed that blacks were less likely to receive 5 of the 6 treatments (odds ratios 0.64-1.10). The race-specific models displayed nearly identical treatment disparities (odds ratios 0.65-1.07). We found no interaction effect, which systematically suggested the presence of race-specific effects.

CONCLUSIONS

Race-specific models yield nearly identical estimates of racial disparities to those obtained from conventional models. This suggests that clinical variables, such as hypertension or diabetes, seem to affect treatment decisions equally for whites and blacks. Previously described racial disparities in care are unlikely to be an artifact of misspecified models.

Validation of the Thrombolysis In Myocardial Infarction (TIMI) risk index for predicting early mortality in a population-based cohort of STEMI and non-STEMI patients

BACKGROUND

The Thrombolysis In Myocardial Infarction (TIMI) risk index for the prediction of 30-day mortality was developed and validated in patients with ST-segment elevation myocardial infarction (STEMI) who were being treated with thrombolytics in randomized clinical trials. When tested in clinical registries of patients with STEMI, the index performed poorly in an older (65 years and older) Medicare population, but it was a good predictor of early death among the more representative population on the National Registry of Myocardial Infarction-3 and -4 databases. It has not been tested in a population outside the United States or among non-STEMI patients.

METHODS

The TIMI risk index was applied to the Enhanced Feedback for Effective Cardiac Treatment (EFFECT) study cohort of 11,510 acute MI patients from Ontario. The model's discriminatory capacity and calibration were tested in all patients and in subgroups determined by age, sex, diagnosis and reperfusion status.

RESULTS

The TIMI risk index was strongly associated with 30-day mortality for both STEMI and non-STEMI patients. The C statistic was 0.82 for STEMI and 0.80 for non-STEMI patients, with overlapping 95% CI. The discriminatory capacity was somewhat lower for patients older than 65 years of age (0.74). The model was well calibrated.

CONCLUSIONS

The TIMI risk index is a simple, valid and moderately accurate tool for the stratification of risk for early death in STEMI and non-STEMI patients in the community setting. Its routine clinical use is warranted.

Right bundle-branch block in anterior acute myocardial infarction in the coronary intervention era: Acute angiographic findings and prognosis

BACKGROUND

Previous studies in the prethrombolytic or thrombolytic era have reported that right bundle-branch block (RBBB) is associated with poor clinical outcome in patients with acute myocardial infarction (AMI).

METHODS AND RESULTS

The purpose of this study was to examine the relations between RBBB and angiographic findings or clinical outcomes in patients with AMI in the coronary intervention era. A total of 430 patients with a first anterior AMI who underwent coronary angiography within 12 h after the onset were enrolled in this study. Seventy-one patients (17%) had RBBB documented during their hospital stay. RBBB was documented on admission in 35 patients. Patients with RBBB were older (p<0.01) and had prodromal angina less frequently (p=0.03) than those without. On the initial angiograms, patients with RBBB had an occluded left anterior descending artery (p<0.01) and multivessel disease (p=0.01) more frequently than those without. Thirty-day mortality rate was significantly higher in patients with RBBB than in those without (14.0% vs 1.9%, p<0.01). Multiple logistic-regression analysis demonstrated that RBBB (odds ratio 5.89, p<0.01) and multivessel disease (odds ratio 4.36, p=0.01) were independent predictors of 30-day mortality.

CONCLUSIONS

Our data suggested that RBBB was still associated with poor clinical outcome in patients with anterior AMI even in the coronary intervention era.

Do Orders Limiting Aggressive Treatment Impact Care for Acute Myocardial Infarction?

OBJECTIVES

Little is known about whether advance directives impact inpatient care for a condition with clear treatment guidelines. The goal of this research was to determine the association between limitation of aggressive treatment (LAT) orders and guideline adherence for acute myocardial infarction (AMI).

DESIGN

Secondary examination of data from the national Cooperative Cardiovascular Project (CCP) baseline data. We used seemingly unrelated regression to correct for potential selection bias between patients with and without LAT orders and to determine whether such orders predict guideline adherence for several treatments related to acute myocardial infarction.

SETTING

The setting included 4111 short-term non-federal acute care hospitals in the United States.

PARTICIPANTS

Participants were 147,475 AMI cases with complete data abstracted from inpatient hospital charts, representing most fee-for-service Medicare patients who were hospitalized with AMI between February 1994 and July 1995.

MEASUREMENTS

Adherence to guidelines for treating acute myocardial infarction, including aspirin, Beta blockers, and reperfusion via thrombolytics or PTCA.

RESULTS

Patients with LAT orders are less likely to receive care in accordance with guidelines when controlling for other factors that may explain a lower likelihood of guideline adherence. After adjustment for selection effects, we found a lower predicted probability that patients received more invasive treatments.

CONCLUSION

Patients with LAT orders appear to receive care that is less aggressive and less congruent with acute myocardial infarction care guidelines compared with patients without such orders. Quality improvement measures will need to take this difference into account and ensure that physicians are not penalized for complying with patient care preferences.

Diferencias de género en el tratamiento de revascularización precoz del infarto agudo de miocardio

BACKGROUND AND OBJECTIVE

Clinical variability in myocardial infarction (MI) regarding age, comorbidities and atypical symptoms could determine gender differences in inhospital care. This study analyzes the magnitude and determinants of differences between men and women in early reperfusion therapy in people hospitalized after MI.

PATIENTS AND METHOD

2,836 patients who arrived to hospital with MI were studied (IBERICA-Basque Country study). The relative risk (RR) of receiving early reperfusion for men versus women, adjusted by age, clinical characteristics, risk factors, and pre-hospital delay was estimated. The effect decomposition methodology and the log binomial regression were applied.

RESULTS

29% of patients were women with a median age of 77 years. The RR of revascularization in men compared to women was different according to age. When factors such as hypertension diabetes, Killip III-IV at admission and atypical symptoms were taken into account, statistically significant differences between sexes were not detected at 45 years old (RR=0.91; 95% CI=0.77-1.07). However, for 64 years old and over, the RR of reperfusion was 1.24 (95% CI=1.05-1.47). Both the differences by sex and the sex-age interaction were no longer statistically significant after adjusting by pre-hospital delay.

CONCLUSIONS

The delay to receive medical care in elderly women is responsible of gender differences in early reperfusion. It is necessary to analyze the reasons for treatment-seeking delay.

Trombolysis in acute stroke

BACKGROUND

Rapid restoration of cerebral blood flow is the principle goal of acute ischemic stroke therapy. Intravenous recombinant tissue plasminogen activator is an effective therapy for acute ischemic stroke. It has been available in the United States for over a decade and was approved for use in Israel at the end of 2004.

OBJECTIVES

To assess the implementation of intravenous rt-PA in routine clinical care at our center after its formal approval in Israel, and the therapeutic and logistic implications for reperfusion therapy for acute ischemic stroke in Israel.

METHODS

Patients with acute ischemic stroke admitted between January 2005 and June 2006 who were treated with intravenous rt-PA or endovascular-based reperfusion were reviewed. Implementation, timing, safety and clinical outcomes were assessed.

RESULTS

Forty-six patients received reperfusion therapy (37 with intravenous rt-PA and 9 with endovascular-based therapy), corresponding to 4.0% of ischemic stroke patients in 2005 and a projection of 6.2% in 2006. The mean age of intravenously treated patients was 67 years (range 22-85 years), median baseline NIHSS score was 14 (25-75%, 10-18) and the median 'onset to drug time' was 150 minutes (25-75%, 120-178). Symptomatic intracerebral hemorrhage and orolingual angioedema each occurred in one patient (2.7%). Significant clinical improvement occurred in 54% of treated patients, and 38% of patients were independent at hospital discharge.

CONCLUSIONS

The use of reperfusion therapy for acute ischemic stroke has increased in our center after the formal approval of rt-PA therapy to over 5%, with 'onset to drug time', safety and outcome after intravenous rt-PA treatment comparing favorably with worldwide experience. A prerequisite for the implementation of effective reperfusion therapy and expansion of the proportion of patients treated nationwide is the establishment of a comprehensive infrastructure.

Bypassing the emergency room reduces delays and mortality in ST elevation myocardial infarction: the USIC 2000 registry

OBJECTIVE

To study the impact on outcomes of direct admission versus emergency room (ER) admission in patients with ST-segment elevation myocardial infarction (STEMI) DESIGN: Nationwide observational registry of STEMI patients

SETTING

369 intensive care units in France.

INTERVENTIONS

Patients were categorised on the basis of the initial management pathway (direct transfer to the coronary care unit or catheterisation laboratory versus transfer via the ER).

MAIN OUTCOME MEASURES

Delays between symptom onset, admission and reperfusion therapy. Mortality at five days and one year.

RESULTS

Of 1204 patients enrolled, 66.9% were admitted direct and 33.1% via the ER. Bypassing the ER was associated with more frequent use of reperfusion (61.7% v 53.1%; p = 0.001) and shorter delays between symptom onset and admission (244 (interquartile range 158) v 292 (172) min; p < 0.001), thrombolysis (204 (150) v 258 (240) min; p < 0.01), hospital thrombolysis (228 (156) v 256 (227) min, p = 0.22), and primary percutaneous coronary intervention (294 (246) v 402 (312) min; p < 0.005). Five day mortality rates were lower in patients who bypassed the ER (4.9% v 8.6%; p = 0.01), regardless of the use and type of reperfusion therapy. After adjusting for the simplified Thrombolysis in Myocardial Infarction (TIMI) risk score, admission via the ER was an independent predictor of five day mortality (odds ratio 1.67, 95% confidence interval 1.01 to 2.75).

CONCLUSIONS

In this observational analysis, bypassing the ER was associated with more frequent and earlier use of reperfusion therapy, and with an apparent survival benefit compared with admission via the ER.

The use of myocardial contrast echocardiography in the assessment of left ventricular function recovery after primary percutaneous coronary intervention in the setting of acute myocardial infarction

BACKGROUND

Despite successful reperfusion therapy of acute myocardial infarction and complete restoration of infarct-related artery patency, the improvement of systolic function in long-term outcome depends on preserved microvasculature integrity. Myocardial contrast echocardiography (MCE) is a useful technique for identification of viable myocardium.

AIM

To assess the value of real-time myocardial contrast echocardiography (rt-MCE) in prediction of left ventricular function improvement in patients with anterior wall acute myocardial infarction as well as selection of the optimal cut-off value for the number of dysfunctional segments with preserved complete perfusion, in order to predict the global left ventricular function improvement during one-month observation.

METHODS

Rt-MCE was performed in 74 patients (50 men, aged 58+/-11 years) with anterior wall myocardial infarction, treated with primary percutaneous coronary intervention (PCI) within 12 hours from the onset of symptoms. After estimation of regional contractility disturbances and global systolic function of the left ventricle, rt-MCE was performed with contrast assessment of dysfunctional segments (normal contrast pattern=2, heterogeneous=1, lack of contrast=0). Regional perfusion score index (RPSI) was calculated by adding the perfusion indices and dividing by the number of dysfunctional segments.

RESULTS

Of a total of 1184 visualised segments, 344 (29.1%) were dysfunctional (189 hypokinetic, 155 akinetic). Contractility improvement was observed in 192 segments (preserved viability in 105 hypokinetic and 37 akinetic segments). In a group of 44 patients with systolic function improvement, 34 of them had preserved viability, and in a group of 30 patients without LVEF improvement, in 22 of them myocardium viability was not observed. Sensitivity, specificity and accuracy of rt-MCE in prediction of left ventricular global improvement were 72.7%, 73.3% and 73%, respectively, whereas in prediction of regional function improvement these values were 73.9%, 77% and 75.5%, respectively.

CONCLUSION

Rt-MCE performed in the early phase of myocardial infarction enables the prediction of left ventricular regional and global function improvement in patients treated with primary PCI.

Present treatment of acute myocardial infarction in patients over 75 years--data from the Berlin Myocardial Infarction Registry (BHIR)

AIMS

Guidelines issued by European and German cardiology societies clearly define procedures for treatment of acute myocardial infarction (AMI). These guidelines, however, are based on clinical studies in which older patients are underrepresented. Older patients, on the other hand, represent a large and growing portion of the infarction population. It was our goal in the present paper to analyse the present treatment of AMI patients over 75 years of age in the city of Berlin, Germany, with data gained from the Berlin Myocardial Infarction Registry (BHIR).

METHODS

We prospectively collected data from 5079 patients (3311 men and 1768 women, mean age 65.6) with acute myocardial infarction who were treated in 25 hospitals in Berlin during the period 1999-2003. 1319 patients (25.9%) were older than 75 (mean age 82.5 years).

RESULTS

Overall hospital mortality rate was 11.6%. In patients over 75, this rate was 23.9%; among the younger infarction population, it was 7.3%. In contrast to the younger AMI patients, the majority of those over 75 were female (62.5 vs 25.1% for the younger) and demonstrated a significantly higher frequency of all prognostically meaningful comorbidities (heart failure 14.4% vs. 3.5%; renal failure 11.5 vs 3.9%; diabetes 37.3 vs 24.3%). Clinical signs of severe infarction, moreover, were more common among the aged patients (pulmonary congestion 45.4 vs 19.7%; left bundle branch block 12.7 vs 3.6%). Pre-hospital time was prolonged (2.8 vs 2 h) and guideline-recommended therapy was applied significantly less frequently to AMI patients over 75 (reperfusion therapy 39.8 vs 71.7%, beta-blockers 62.8 vs 78.3%, statins 26.5 vs 45.5%). Multivariate analysis revealed the following factors to be independent predictors of hospital mortality in patients over 75: age (OR 1.05 per year), acute heart failure (OR 2.39), pre-hospital resuscitation (OR 10.6), cardiogenic shock (OR 2.73), pre-hospital delay >12 h (OR 1.68), and ST elevation in the first ECG (OR 2.09). Independent predictors of a favourable hospital course were as follows: admission to a hospital >600 beds (OR 0.64), reperfusion therapy (OR 0.63), early betablocker treatment (OR 0.46), and early application of ACE inhibitors (OR 0.48).

CONCLUSION

Infarction patients over 75 have a very high hospital complication and mortality rate. They are typically treated with delay, and with less adherence to relevant guidelines than are younger patients. Reperfusion therapy, early administration of beta-blockers and ACE inhibitors, as well as admission to large medical centres are all factors that contribute to a favourable prognosis of high-aged AMI patients.

Factors explaining the under-use of reperfusion therapy among ideal patients with ST-segment elevation myocardial infarction

AIMS

To determine the relative impact of time to hospital arrival, baseline cardiovascular risk (i.e.TIMI mortality risk index), intracerebral haemorrhage risk, and comorbid disease burden on the likelihood of not receiving reperfusion therapy among ST-segment elevation myocardial infarction (STEMI) patients without contraindications to treatment.

METHODS AND RESULTS

Retrospective population-based cohort of 3994 patients admitted to 103 acute care hospitals with chest pain and STEMI within 12 h of symptom onset in Ontario, Canada, between 1999 and 2001. Patients with one or more documented absolute or relative contraindication (n = 909) were excluded from the analyses. Reperfusion therapy was defined as the receipt of either fibrinolysis or primary percutaneous coronary intervention. Multivariable analysis and likelihood chi2 was used to quantify the importance of each factor in predicting the non-utilization of therapy. In total, 23.1% of patients received no reperfusion therapy. Listed in order from greatest to least importance, predictors of non-utilization of reperfusion therapy included increasing time to hospital presentation (likelihood chi2 31.6, P < 0.001), higher intracerebral haemorrhage risk (likelihood chi2 27.1, P < 0.001), higher baseline cardiovascular risk (likelihood chi2 25.4, P < 0.001), and greater number of chronic comorbid conditions (likelihood chi2 15.4, P < 0.001). The importance of each factor on non-utilization was independent, additive, not explained by age effects alone, or driven by subgroups traditionally under-represented in clinical trials.

CONCLUSION

Care gaps in the use of reperfusion therapy widen with both increasing baseline cardiovascular risk and increasing intracerebral haemorrhage risk. Future studies should examine whether the implementation of clinical decision tools which allow for more accurate risk-benefit tradeoff predictions improve the treatment gaps when using life-saving therapies in this patient population.

Impact of specialty of admitting physician and type of hospital on care and outcome for myocardial infarction in England and Wales during 2004-5: observational study

OBJECTIVE

To examine process of care and outcome for patients admitted with acute myocardial infarction to hospitals in England and Wales in relation to type of consultant care and type of hospital.

DESIGN

Observational study of 88,782 patients admitted with myocardial infarction during 2004-5, using records from the national audit of myocardial infarction project (MINAP) database.

OUTCOME MEASURES

Use of reperfusion treatment and secondary prevention drugs, use of angiography, and 90 day mortality of patients admitted under the care of cardiologists and non-cardiologists in hospitals with and without facilities for coronary intervention.

FINDINGS

36% of patients were admitted under the care of a cardiologist and 20% to a hospital with coronary interventional facilities. Patients admitted under cardiologists had fewer comorbidities than other patients and were more likely to have reperfusion treatment (12,266/14,433 (85%) v 13,682/17,064 (80%)) and appropriate secondary prevention drugs. Overall, 27,431/79,374 (35%) of patients had angiography. Relatively more patients admitted to interventional hospitals (8167/14,661; 56%) than to other hospitals had angiography (19,264/64,713; 30%). The adjusted risk of death by 90 days for patients treated in interventional compared with non-interventional hospitals was 0.93 (95% confidence interval 0.82 to 1.06). The adjusted risk of death at 90 days for patients admitted under cardiologists compared with non-cardiologists was 0.86 (0.81 to 0.91).

CONCLUSIONS

Patients cared for by cardiologists had less comorbidity than other patients. They were more likely to receive proved treatments and angiography, and they had a lower adjusted 90 day mortality. Large differences existed in the use of angiography between interventional and non-interventional hospitals. These findings show wide variations in the management and outcome of patients with myocardial infarction in England and Wales.

Treatment of acute ST-segment elevation myocardial infarction in West Pomerania province of Poland. Comparison between primary coronary intervention and thrombolytic therapy

INTRODUCTION

The majority of randomised studies on reperfusion in acute ST-segment elevation myocardial infarction (STEMI) show the advantage of primary percutaneous coronary intervention (PCI) over thrombolysis. However, the real world registers' data are not so unequivocal.

AIM

To evaluate the way acute STEMI is treated in West Pomerania province with emphasis on comparison of two reperfusion strategies, primary PCI vs thrombolytic therapy, in early and long-term perspective.

METHODS

Medical records of 961 STEMI patients treated between 1 January 2003 and 31 December 2003 were analysed. Data were collected from 3 centres with emergency cath lab availability and 15 regional sites. Long-term mortality was assessed based on regional provincial office database data.

RESULTS

69.9% of the study group received reperfusion (44.6% primary PCI, 25.3% thrombolysis). Mean age of patients was 62 (21 to 91) years. Patients referred for PCI were younger compared to the thrombolysis group. The percentage of females was similar in both groups. The majority of patients treated with PCI or thrombolysis were admitted to the hospital between 2 and 6 hours after symptoms--268 patients (46.4%). Seventy-nine patients (8.3%) died in the early (30-day) period. Mean age at time of death was 73 +/-8 years, whereas survivors' age was 61.5 (+/-12) years (p <0.001). Significantly higher mortality was observed in the conservative treatment group (12.7%) compared to patients treated with reperfusion. Forty-two out of 662 patients treated with PCI and thrombolysis died. The group of thrombolytic therapy tended to have higher mortality (7.9%) than PCI patients (5.5%); the difference however was not significant. Early mortality was influenced by older age (73.4 vs 59.5), female gender, low ejection fraction, and previous myocardial infarction. Current smoking has a positive effect on survival (mortality rate in smokers was 2.6%, in non-smokers 8.2%; p=0.0001). In long-term follow-up overall mortality in the entire group of 961 patients was 15.7% (12.1% in the reperfusion group). Long-term prognosis was worsened by older age, low ejection fraction, diabetes mellitus and non-smoking.

CONCLUSIONS

Treatment of STEMI in West Pomerania province is similar to that used in Europe and the USA. No significant difference in 30-day and long-term mortality between the two types of reperfusion were seen.

[Temporal trends in treatment of ST segment elevation myocardial infarction in Switzerland from 1997 to 2005]

From 1997 to 2005, 19461 patients admitted for acute coronary syndrome in 68 hospitals in Switzerland were included in the AMIS Plus registry, of whom 11 543 showed ST segment elevation or left bundle branch block on the ECG at admission. During this period, there was an important increase in the proportion of patients treated by primary percutaneous coronary intervention (8% to 74%), and a marked reduction in the use of thrombolysis (47% to 6%) and also in the proportion of patients who did not receive any reperfusion treatment (45% to 20%). Furthermore, there was a decrease in hospital mortality (12% to 7%). Main predictors of hospital mortality were withholding PCI and thrombolysis, advanced age and the presence of cardiogenic shock. Moreover, primary PCI was associated with lower hospital mortality when compared to thrombolysis.

Reperfusion therapy

In this article Nick Castle explains that, with significant improvements being made to the emergency management of cardiac patients, emergency nurses should challenge and develop their clinical practice to ensure patients receive prompt and evidence based treatment.

Impact of chronic oral anticoagulation on management and outcomes of patients with acute myocardial infarction: data from the RICO survey

OBJECTIVE

To determine the prevalence of chronic oral anticoagulant drug treatment (COA) among patients with acute myocardial infarction (AMI) and its impact on management and outcome.

METHODS

All patients with ST segment elevation AMI on the RICO (a French regional survey for AMI) database were included in this analysis. COA was defined as continuous use >or= 48 hours before AMI.

RESULTS

Among the 2112 patients with ST elevation myocardial infarction (STEMI), 93 (4%) patients were receiving COA. These patients were older and more likely to have a history of hypertension, diabetes and prior myocardial infarction than patients without COA. In addition, fewer patients who received COA underwent reperfusion therapy or received an antiplatelet agent (aspirin/thienopyridines). Moreover, patients receiving COA experienced a higher incidence of in-hospital major adverse events (death, recurrent myocardial infarction or major bleeding, p = 0.005). Multivariate analysis showed that only ejection fraction, current smoking and multiple vessel disease, but not COA, were independent predictive factors for major adverse events. In contrast, COA was an independent predictive factor for heart failure when adjusted for age, diabetes, creatinine clearance, reperfusion, heparin and glycoprotein IIb/IIIa inhibitors (odds ratio 2.06, CI 95% 1.23 to 3.43, p = 0.005).

CONCLUSION

In this population based registry, patients with STEMI with prior use of COA constituted a fairly large group (4%) with an overall higher baseline risk profile than that of patients without COA. Fewer in the COA group received reperfusion therapy or aggressive antithrombotic treatment and they experienced more adverse in-hospital outcomes. Thus, further studies are warranted to develop specific management strategies for this high risk group.

Factors Affecting the Management of Outcome in Elderly Patients with Acute Myocardial Infarction Particularly with Regard to Reperfusion

BACKGROUND

Acute myocardial infarction (AMI) in elderly patients is often unrecognized and associated with poor prognosis.

OBJECTIVES

To investigate management and efficacy of reperfusion therapy to the elderly patients with AMI.

METHODS

From the January 1, 2001 to October 31, 2002, 964 patients with AMI were included in the French regional RICO survey. The patients were divided into three groups: younger (<70 years old), elderly (70-79 years old) and very elderly (>or=80 years old).

RESULTS

Distribution of groups was 56, 27, and 16%, respectively. The longest time delay to first request for medical attention was found in the very elderly group (30 and 55 vs. 90 min, respectively, p < 0.05). Rate of lysis fell significantly with increasing age (35, 22 and 9%, respectively, p < 0.001) but the time delay to lysis was similar for the 3 groups. The proportion of patients who benefited from primary percutaneaous transluminal coronary angioplasty decreased with age (21, 15, 11%, respectively, p < 0.001), but time delay to balloon angioplasty was similar and no difference in mortality rate was observed between the three groups after reperfusion. The incidence of in-hospital cardiovascular events (cardiogenic shock and recurrent myocardial infarction/ischemia) and in-hospital mortality increased with age (5, 13, 17%, respectively, p < 0.001). Moreover, multivariate analysis showed that only ejection fraction and Killip >1 were independent predictive factors for in-hospital cardiovascular mortality, respectively (OR 5.15, 95% CI 2.08-12.74, p < 0.0001 and OR 3.81, 95% CI 1.90-7.65, p < 0.0001), whereas age, sex, diabetes and anterior location were not significant.

CONCLUSION

Our data in an unselected population indicate that very elderly patients were characterized by increased pre-hospital delays and less frequent utilization of reperfusion therapy, although no difference in the mortality in reperfused patients could be observed between the three age groups.

[Management of patients admitted for acute myocardial infarction in France from 1995 to 2000: time to admission dependent improvement in outcome]

The in-hospital management and short- and long-term outcomes was assessed in 2 registries of consecutive patients admitted for acute myocardial infarction, 5 years apart, in France. The 2000 cohort was younger and with a less frequent history of cardiac diseases, but was more often diabetic and with anterior infarcts. Time to admission was actually longer in 2000 than in 1995 (median 5.25 hours vs 4.00 hours). Overall, reperfusion therapy was used in 43% of the patients in both registries. However, the use of reperfusion therapy increased from 1995 to 2000 in patients admitted within 6 hours of symptom onset (64 vs 58%), with an increasing use of primary angioplasty (from 12 to 30%). Five-day mortality significantly improved from 7.7 to 6.1% (p < 0.03) and one-year survival was also less in the most recent period (85 vs 81%, p < 0.01). Multivariate analyses showed that the period of inclusion (2000 vs 1995) was an independent predictor of both short- and long-term mortality in patients admitted within 6 hours of symptom onset. Thus, in the real world setting, a continued decline in one-year mortality was observed in patients admitted to intensive care units for recent acute myocardial infarction, especially for patients admitted early. This goes along with a shift in reperfusion therapy towards a broader use of primary angioplasty, and with an increased use of the early prescription of recognised secondary prevention medications.