State-of-the-art STEMI care: the case for an in-hospital 24/7 ready PCI team integrated in a modern EMS network

Reperfusion Strategies in ST-Elevation Myocardial Infarction

The Need for Uniform Definitions in the Regionalized Care of ST‐segment Elevation Myocardial Infarction

Over the past several years, mounting evidence has shown that emergent angiography and primary angioplasty (or perhaps more appropriately named primary percutaneous coronary intervention [PCI]) are superior to treatment with thrombolytic therapy and watchful waiting for treatment of acute myocardial infarction (AMI).1,2 This is particularly true for patients at high risk for death (eg, those >70 years of age), those who present to hospital late (≥4 hours after AMI), and those with prior myocardial infarction or diabetes.3 Primary PCI has advantages of higher initial TIMI 3 flow rates, less reocclusion, and less recurrent ischemia and reinfarction when compared with thrombolytic drug treatment and watchful waiting. Emergent angiography also permits early risk stratification, assessment of left ventricular function, and identification of other complications. In addition, early intervention has also been shown to be the best therapeutic option in patients with moderate and high-risk features who have non–ST-elevation infarction.4–6 See p 1809 Today, in this country as well as in others, most patients with AMI are admitted to suburban or rural hospitals, many without catheterization labs and many more without angioplasty facilities. Although long ago, we decided that the treatment of serious trauma was best done in specialized centers, patients with AMI, despite an overall mortality rate of ≥10%, are managed in any hospital with a coronary care unit. Few are transferred at the time of admission, and most receive thrombolytic therapy and then watchful waiting for complications. First, it has been generally held that the delay in transferring a patient to a tertiary center for primary PCI would more than offset any treatment advantage favoring emergent catheterization. Second, both physicians and hospital administrators in these smaller centers are reluctant to close their doors to patients with acute infarction, as it makes the hospital appear “second rate,” and many …

<i>Circulation: Cardiovascular Interventions</i> Editors’ Picks

The Society for Cardiovascular Angiography and Interventions (SCAI) coauthored and cosponsored with the American College of Cardiology (ACC) and the American Heart Association (AHA) the percutaneous coronary intervention (PCI) guidelines update, released in November 2005 [1]. This guideline update continued to designate elective PCI without on-site surgery as a Class III indication, and primary PCI for ST-segment elevation myocardial infarction (STEMI) as a class IIb indication in the absence of on-site surgery. The performance of PCI without on-site surgical backup is currently the subject of debate. Although providing the highest quality of care and best outcomes to patients should always be the primary goal, debate on this topic has the potential to supersede quality of patient care issues. Within this context, SCAI developed this Expert Consensus document to determine the current status of PCI without on-site surgery not only in the United States, but globally, and make recommendations regarding the performance of PCI in this circumstance. The focus of this document is to provide a structure that provides the highest quality care to patients undergoing PCI in any circumstance. Over the past 20 years, the use and indications for PCI have greatly expanded. It is now well-recognized that PCI is safer and the need for urgent coronary artery bypass graft (CABG) surgery greatly reduced [2]. Primary PCI, when available, has eclipsed fibrinolytic therapy for reperfusion in the treatment of STEMI [3], but is adversely affected by time delays in initiating the PCI procedure [4]. Studies examining patient transport to PCI hospitals have shown suboptimal initial door-to-balloon times, especially in the United States [5]. Efforts to provide primary PCI services locally at community hospitals without on-site cardiac surgery have developed and demonstrate outcomes comparable to facilities that have on-site cardiac surgery [6]. Because it is difficult to sustain a PCI program solely on STEMI patients, elective PCIs are also being performed at facilities without on-site surgery [7], enhancing the debate regarding PCI without on-site surgery. Data on the prevalence of PCI performed without on-site surgical backup in the United States are not easily found and are changing rapidly. Data gathered from several sources and believed accurate as of July 2006 indicate primary PCI programs without on-site surgical backup exist in all but 10 states (Alaska, Arkansas, Delaware, Georgia, Mississippi, North Dakota, Rhode Island, South Dakota, Vermont, and Wyoming) plus the District of Columbia. Facilities performing both primary and elective PCI without on-site surgery currently exist in 28 states. A large (n = 18,000) randomized trial of elective PCI without on-site surgery (The Atlantic Cardiovascular Patient Outcomes Research Team Elective Angioplasty Study) is currently enrolling patients and includes facilities in several states where elective PCI without on-site backup has been prohibited. The exact number of patients receiving PCI at facilities without on-site surgery is unknown. Data from facilities reporting to the CathPCI Registry™ of the ACC-National Cardiovascular Data Registry (ACC-NCDR®) show an increase in the number of both primary and elective PCIs performed without on-site surgical backup [8]. In 2005, 75 of the 463 facilities reporting to the ACC-NCDR were performing PCI without on-site surgical backup. PCI without on-site surgical backup is being performed in 35 of 39 (90%) countries responding to requests for information and appears to be increasing. For example, 7% of PCI procedures performed in the United Kingdom in 1996 were at facilities without on-site cardiac surgery. By 2004, this increased to 15% with 26% of the PCI centers in the United Kingdom operating without on-site cardiac surgery. In the 2005 update of this guideline, primary PCI without on-site surgical backup remained a Class IIb indication, and elective PCI without on-site surgery remained a Class III indication. Many other programmatic recommendations were made [1]. In contrast to the ACC/AHA/SCAI guidelines, the 2005 European Society of Cardiology (ESC) guidelines do not comment on PCI without on-site cardiac surgery or issues related to institutional or operator competency [9]. The British Cardiac Society and British Cardiovascular Intervention Society (BCIS) guideline, published in 2005, acknowledges and approves PCI without on-site surgical backup and emphasizes a common standard applied across facilities with and without on-site surgical backup so as to avoid two levels of service provision [10]. The only German guidelines found were published in 1987 [11] and thus may not be relevant today. However, there is substantial evidence that PCI without on-site surgical backup is widely performed in Germany. Policy statements on support facilities and on the performance of coronary angiography and PCI at rural sites in Australia and New Zealand were published (on-line) in 2003 and 2005, respectively [12, 13]. The Cardiac Society of Australia and New Zealand (CSANZ) guidelines state that PCI is preferably performed in hospitals with on-site surgical support, but acknowledge that the requirements for on-site cardiac surgical facilities may be omitted in certain circumstances, and that appropriately trained individuals can perform coronary interventional procedures safely in hospitals without on-site surgical backup. Furthermore, these documents acknowledge that rural patients have reduced access to diagnostic angiography and interventional procedures and further state that providing these services as close to the patient's place of residence as possible facilitates equity of access, which should result in improved quality of care. Published in 1999 [14], these guidelines are specific for PCI at hospitals without on-site cardiac surgery. PCI performance without on-site cardiac surgery is not prohibited, provided a program meets certain requirements. Guidelines from the Brazilian Society of Cardiac Hemodynamics and Intervention (Sociedade Brasileira de Hemodinâmica e Cardiologia Intervencionista) [15] were published in 2003. They use a scheme similar to the ACC/AHA/SCAI guidelines [1] and classify elective PCI without on-site surgical backup as Class III. Primary PCI for STEMI in the absence of on-site surgery is a Class IIa indication; their guidelines do not have a IIb category. Published in 2003, these guidelines acknowledge the increasing safety and diminishing risk of PCI but conclude that "the current standard practice for elective PCI remains the presence of on-site surgical standby" [16]. There are over 30 published papers or abstracts reporting PCI results without on-site surgical backup. All published data for both primary and elective PCI were derived from retrospective reviews or registries, and thus are subject to unintentional bias and other methodological concerns. These are summarized and referenced in the on-line version of this document. These studies span a time period from 1990 to 2006, and thus incorporate changing treatment paradigms, including fibrinolytic therapy before PCI, glycoprotein IIb/IIIa inhibitors, and coronary artery stents. The total patient number within some of these reports is not easily derived because the studies listed are expanding experiences within the same registry; thus, simple aggregation of outcome data is not appropriate or meaningful. The more recent reports show that both primary and elective PCI without on-site surgical backup are performed with a high success rate, low in-hospital mortality rate, and a low rate of urgent cardiac surgery. Although no randomized or controlled studies exist and despite the current ACC/AHA/SCAI guideline recommendation, PCI without on-site surgery is being performed in many states and is accepted in many countries throughout the world. Moreover, data from many countries, including the United States, indicate that the use of PCI without on-site surgery is growing [8]. The purpose of this document is neither to challenge the ACC/AHA/SCAI guideline recommendations nor to support PCI without on-site surgery backup. However, with the reality that PCI without on-site surgery is growing, it is both appropriate and necessary to define the best standards of practice such that facilities and physicians operate within the highest possible quality standards. Only operators with complication rates and outcomes equivalent or superior to national benchmarks should perform PCI procedures with or without on-site surgery. The operator also must actively participate in a facility's quality improvement program. In addition to involvement in local continuous quality improvement efforts, participation in a national data registry if available and appropriate continuing medical education is mandatory. A proven record of satisfactory outcomes is of greater importance than simply meeting an arbitrary case volume requirement. However, operators must have sufficient prior experience to allow assessment of their judgment and quality. The initial operators at a facility without on-site backup should not begin performing PCI in such facilities until they have a lifetime experience of >500 PCIs as primary operator after completing fellowship. Interventional cardiologists joining those already engaged in PCI without on-site surgery with <500 cases of lifetime experience should be mentored and monitored by existing physicians until it is determined and certified formally by that hospital that their skills and judgment are excellent and outcomes equivalent or superior to the national benchmarks. Operators performing PCI without on-site surgery should perform ≥100 total PCIs per year, including ≥18 primary PCIs per year. These numbers exceed those currently recommended in the ACC/AHA/SCAI guidelines to reflect the opinion of this writing group that a greater experience level is appropriate for PCI in this setting. In the United States, board certification in interventional cardiology by the American Board of Internal Medicine is strongly recommended for all physicians performing PCI. It is essential that all support personnel have adequate education regarding the management of PCI patients before, during, and after the procedure. This knowledge should include potential procedural complications and their management and the drug therapies used in PCI patients (Table I). Meticulous clinical and angiographic selection criteria for PCI (Tables II and III). Facilities performing both primary and elective procedures without on-site surgery should perform a minimum of 200 PCI/year. Programs with <200 PCI/year should be reviewed on an individual basis. They should remain open only if they are in geographically isolated or under-served areas and their performance metrics are equivalent to accepted benchmarks. We recommend that each country or state review this issue, and establish an absolute minimum annual case volume below which a PCI program must close under any circumstance. In the United States, this minimum should be 150 PCI/year for a program offering both primary and elective PCIs and this must include a minimum of 36 primary PCI/year. Programs offering only primary PCIs must perform a minimum of 36 primary PCIs/year to remain operational. At the present time in the United States, there is no justification for a PCI program without on-site surgery to perform only elective procedures or not provide availability to primary PCI 24 hr/day, but such a situation may exist in other countries and be appropriate. New programs should have 2 years to reach the absolute minimum volume, but after that programs failing to reach this volume for 2 consecutive years should not remain open under any circumstance. Rigorous clinical and angiographic selection criteria are essential for programs performing PCI without on-site surgery. Since the clinical situation and risk-to-benefit ratio are different for primary versus elective PCI, different criteria and standards should apply (Table II). In elective PCI without on-site surgery, it is necessary to assess not only the likelihood of PCI failure, but also the potential patient risk if complications occur since it is possible to have a low-risk lesion in a high-risk patient and vice versa. It is important to consider both the patient and lesion risk when developing criteria for selection of appropriate patients for treatment in facilities without on-site surgery (Table III). A close alliance and cross-communication with cardiovascular surgeons with formalized agreements and periodically tested protocols for the emergency transfer of patients are essential (Table IV). Interventional cardiologists and cardiac surgeons must be actively involved in the program with attendance at regularly scheduled cardiac catheterization conferences and participation in risk management activities. In hospitals with on-site surgery, it is no longer standard for a surgical suite to be held open awaiting the completion of a PCI. Because the need for urgent surgery is so infrequent, there are no current data regarding the actual time required to transport a patient to the operating room and initiate cardiopulmonary bypass should the need arise. Should a patient undergoing PCI at a facility without on-site surgery develop a complication requiring urgent transfer for surgery, it is unclear whether or by how much the facility-to-facility transport would add an additional delay in the current practice environment where operating rooms are not held open at on-site facilities. Minimizing the time to the initiation of cardiopulmonary bypass is the goal in this situation and more likely is feasible with on-site cardiac surgery if that surgery is immediately available. There is no acknowledged goal with supporting data similar to a door-to-balloon time for the initiation of cardiopulmonary bypass in this situation, but this should always be accomplished as rapidly as possible, with the goal of <120 min. Operators at facilities without on-site surgical backup should activate the emergency transport system at the first clear signs of a complication even if they attempt to salvage the situation using percutaneous techniques. Providing the highest quality PCI services to patients mandates the collection of outcome data and comparison of these data to established benchmarks. Regardless of the mechanism, all PCI programs, with or without on-site surgical backup, must collect appropriate outcome data and compare their data to state, national or their country's performance standards. Data submitted must be audited by an independent authority periodically to insure integrity of the entire process. PCI without on-site surgery is a polarizing and emotional issue for many individuals both within and external to the interventional community. Although debate has focused on whether facilities that offer PCI without on-site surgery should exist, a more meaningful approach would focus on the goal of providing the best possible care to patients who require PCI, regardless of the setting. Recent publications suggest this goal is not being consistently met. Data indicate that the number of coronary artery bypass operations is declining. This trend is likely to continue, resulting in the closing of smaller surgical programs and the coalescence of cardiac surgical services to more centralized locations. If cardiac surgery programs begin to shrink, it will become more difficult for all PCI facilities to have on-site cardiac surgery. It is inappropriate to open PCI centers if they are not based on the health needs of the community. Opening a low-volume PCI program within the same geographic area and thereby converting a high-volume program at another facility to a low-volume program is not necessarily in the best interests of patients in the community. There is clearly a potential for unnecessary or inappropriate PCI program development in the same geographic area and this is strongly discouraged. However, the factors that define a geographic area are not consistent throughout the United States or other countries. The level and availability of emergency transport services, response times of emergency medical transport, immediate availability of qualified cath lab personnel, and coverage by interventional cardiologists must be considered. Desires for personal or institutional financial gain, prestige, market share, or other similar motives should not be part of the decision process in determining the need for a PCI program. These considerations apply equally to those wishing to start a new PCI program without on-site backup and those wishing to protect existing programs with on-site backup. In the final analysis, every PCI procedure, regardless of where it is performed, should be of the highest possible quality. This means the PCI is done for appropriate clinical indications, by a skilled operator with documented satisfactory outcomes in a laboratory with appropriate equipment and personnel that has careful tracking of patient outcomes and corrective mechanisms in place to manage individual operator or laboratory outcome data that fall below national standards. Ensuring that all PCI programs meet appropriate performance metrics is likely to save more lives than requiring all PCI programs have on-site surgery. PCI without on-site surgical backup is being performed with acceptable outcomes and risks in the United States and many other countries. The recommendations outlined in this document are made to ensure patient safety and quality outcomes in such a work environment. This is not an open endorsement of PCI without on-site surgery and we do not support the wide-spread use of PCI without on-site surgery especially in the United States, but acknowledge that this practice may be appropriate in some circumstances. The decision to begin or operate a PCI program without on-site surgical backup should be based on the health needs of a local area, not on desires for personal or institutional financial gain, prestige, market share, or other similar motives. Rural communities may have different health care delivery needs than urban centers and this should be considered. It is the goal of SCAI to promote the highest possible program quality. Accordingly, PCI programs both with and without on-site surgical backup must evaluate their outcomes against their countries' benchmark for program performance or other acceptable standard. Operators performing PCI without on-site surgery should perform ≥100 total PCIs per year, including ≥18 primary PCIs per year. The initial operators at a facility without on-site backup should not begin performing PCI in such facilities until they have a lifetime experience of >500 PCIs as primary operator after completing fellowship. Only operators with complication rates and outcomes equivalent or superior to national benchmarks should perform PCI procedures. Independent program oversight should occur either within the context of a local facility's quality assurance program or through an independent government or external agency. Any program failing to perform adequately should close. Further data collection and analysis should be done to more completely understand the role of PCI without on-site surgical backup as a strategy for the delivery of care. The full-length version of this article can be found on the Catheterization and Cardiovascular Interventions website (http://www.mrw.interscience.wiley.com/suppmat/1522-1946-suppmat-index.html) and on the SCAI website at www.scai.org. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Background COVID-19 pandemic has produced a great impact in the STEMI (ST Elevation Myocardial Infarction) care systems across the world. Patient hesitancy to seek medical attention for suspected STEMI, necessity of the health care systems to prioritize COVID-19 care, safety concerns of health care workers etc., have brought in unprecedented times for both patients and health care workers. The impact of COVID-19 pandemic on the establishment of a STEMI care system is less known Purpose To identify the impact of COVID-19 pandemic on a developing public STEMI care system in a low-middle income country in Asia, with reference to the type of reperfusion offered and outcome. Methods Data on number of STEMI admissions, type of reperfusion therapy and outcome are being collected from 12 teaching hospitals as a part of a developing public regional STEMI care system based on a hub and spoke model in a low middle-income country from August 2018. These 12 “thrombolysis only” hospitals were being upgraded as “primary percutaneous coronary intervention (PPCI) capable hub hospitals” in 2019. Though the hassles of COVID-19 pandemic affected this process significantly, daily data collection in our STEMI care system continued. The maximal COVID impacted period in 2020 was identified from the online database (1) as from April to December 2020. The number, type of reperfusion and outcome of the STEMI patients treated during this period were compared to the same data collected during April-December 2019. Results A total of 13,137 STEMI patients were treated in our system during the two time periods “April to December 2019” and “April to December 2020”. There was a 13.3% drop in the number of STEMI treated in 2020, compared to the number treated in 2019 (6101 vs 8925; P&amp;lt;0.001). This drop was in proportion to the number of new cases of COVID-19 reported in our state (Fig. 1a) We also noted a significant drop in the rate of PPCI and Pharmaco-invasive therapy (PIT) offered for STEMI in 2020 compared to 2019 in the same period (PPCI: 0.13% vs 5.9%-P&amp;lt;0.001 and PIT 0.64% vs 11%- P&amp;lt;0.001). This decrease in PPCI and PIT for STEMI also corresponded to the increase in number of new cases of COVID-19 reported (Fig. 1b). More patients received thrombolytic therapy for STEMI in 2020 compared to 2019 (73.6 vs 61.2% P&amp;lt;0.001). There was no change in the mortality of STEMI during this period. (Fig. 2) Conclusion We found a significant drop in number of patients seeking medical care for STEMI during COVID-19 pandemic. There was significant drop in the rate of PPCI and PIT offered in our STEMI care system. Thrombolytic therapy remained the predominant mode of reperfusion as before, but with a significant increased rate of thrombolysis. There was no change in mortality rate in STEMI patients. Thrombolytic therapy is an acceptable mode of reperfusion, when the balance of a STEMI care system is disturbed by extraneous influences like the COVID-19 pandemic. Funding Acknowledgement Type of funding sources: Public hospital(s). Main funding source(s): Tamil Nadu Innovation Initiative- Department of Planning and development, Govt of Tamil NaduNational Health Mission, Government of India

Fibrinolytic therapy (FT) and primary percutaneous coronary intervention (PCI) are both well-accepted reperfusion therapies in ST-segment elevation myocardial infarction (STEMI). The evidence of randomized clinical trials indicates a relatively modest difference in 30-day mortality (≈1%) in favor of primary PCI over fibrin-specific FT and was based on very timely primary PCI (ie, a primary PCI–related delay of 40 minutes [door-to-balloon less door-to-needle time]).1 Longer delays to primary PCI, which are far more frequent in clinical practice,2 are associated with attenuated benefit or no benefit at all, particularly when compared with fibrin-specific FT.3,4 The benefit of timely primary PCI over FT is likely to especially apply to higher-risk patients.5,6 Irrespective of the method of reperfusion, the potential for myocardial salvage and better clinical outcome is inversely proportional to ischemic time or its only available clinical surrogate, symptom duration.7–12 These considerations underpin the notion expressed in the American College of Cardiology/American Heart Association (ACC/AHA) guidelines on the treatment of STEMI that timely reperfusion therapy is likely more important in determining outcome than whether FT or primary PCI is the chosen reperfusion method.13 Response by Armstrong et al p 1310 The ACC/AHA STEMI guidelines highlight the time point of 3 hours of symptom duration in guiding the choice of reperfusion therapy. They state that if symptom duration is <3 hours, no preference exists between FT and primary PCI provided that treatment is timely (for FT, door-to-needle time <30 minutes; for primary PCI, door-to-balloon time <90 minutes and ≤60 minutes between estimated needle time and estimated balloon time). However, if symptom duration exceeds 3 hours, these guidelines favor primary PCI over FT, again provided that primary PCI can be performed in a timely fashion.13 This article reexamines the evidence that may or may not be the basis …

After ST-segment elevation myocardial infarction (STEMI), it is vital to shorten reperfusion time. This study examined data from a pilot project to shorten the door-to-balloon (D2B) time by using prehospital 12-lead electrocardiogram (ECG). Fifteen ambulances equipped with X Series® Monitor/Defibrillator (Zoll Medical Corporation) were deployed to the catchment area of Queen Mary Hospital, Hong Kong, from November 2015 to December 2016. For patients with chest pain, prehospital 12-lead ECG was performed and tele-transmitted to attending physicians at the accident and emergency department for immediate interpretation. The on-call cardiologist was called before patient arrival if STEMI was suspected. Data from this group of patients with STEMI were compared with data from patients with STEMI who were transported by ambulances without prehospital ECG or by self-arranged transport. From 841 patients with chest pain, 731 gave verbal consent and prehospital ECG was performed and transmitted. Of these, 25 patients with clinically diagnosed STEMI required emergency coronary angiogram with or without primary percutaneous coronary intervention. The mean D2B time for these 25 patients (93 minutes) was significantly shorter (P=0.003) than that for 58 patients with STEMI transported by ambulances without prehospital ECG (112 minutes) and that for 41 patients with STEMI with self-arranged transport (138 minutes). However, shorter reperfusion time was only recorded during daytime hours (08:00-17:59). No statistically significant difference in 30-day mortality was found. Prehospital ECG is technologically feasible in Hong Kong and shortens the D2B time. However, shorter reperfusion time was only recorded during daytime hours.

Comparative Early and Late Outcomes After Primary Percutaneous Coronary Intervention in ST-Segment Elevation and Non–ST-Segment Elevation Acute Myocardial Infarction (from the CADILLAC Trial)

Treatment delay in ST elevation myocardial infarction care in a community hospital – a cautionary tale

439 Impact of the type and timeliness of reperfusion on left ventricular dysfunction amongst survivors of ST elevation myocardial infarction (STEMI) within a regional model of stemi care: Insights from the vancouver coastal health authority STEMI initiative

A Multidisciplinary Approach to Reducing Door-to-Balloon Time in a Community Hospital

Transatlantic guidelines endorse quality metrics for timely reperfusion in patients with ST-elevation myocardial infarction (STEMI). Compliance in low- and middle-income countries (LMICs) is largely unknown. We prospectively evaluated 2928 STEMI patients in Kerala, India, across 16 PCI-capable hospitals who received reperfusion with either primary percutaneous coronary intervention (PPCI) or fibrinolysis. Primary endpoint was a major adverse cardiovascular event (MACE) composite of death, non-fatal myocardial infarction, stroke or readmission for heart failure at 1-year. Among reperfused STEMI patients, 320 (10.9%) received timely reperfusion with either PPCI or fibrinolysis, 1985 (67.8%) received delayed PPCI, and 623 (21.3%) received delayed fibrinolysis. Timely reperfusion had lower unadjusted MACE rates than delayed PCI or fibrinolysis (timely reperfusion: 11.9%, delayed PPCI: 13.6%, delayed fibrinolysis: 23.9%, P < 0.001). Mortality was lowest in the timely reperfusion group (timely reperfusion: 6.3%, delayed PPCI: 7.8%, delayed fibrinolysis 18.8%, P < 0.001). After multivariate analysis, delayed fibrinolysis had a higher MACE rate (HR 1.52 95% CI 1.04-2.21) and mortality (HR 1.97, 95% CI 1.18-3.25) compared to timely reperfusion. Total ischemic time > 3h and delayed first medical contact-to-needle time predicted MACE at 1 year. Among STEMI patients in Kerala, India, only one in 10 eligible patients received timely reperfusion. Longer total ischemic times and delayed fibrinolysis were associated with 1-year MACE. Improving timely reperfusion is critical to enhancing STEMI outcomes in LMICs. What is already known on this topic Given the established link between delay to reperfusion and worse major adverse cardiac events (MACE), global efforts have concentrated on minimizing different components of the total ischemic time to improve ST-elevation myocardial infarction (STEMI) outcomes. Compliance in low- and middle-income countries (LMICs) is largely unknown. What this study adds In this cohort of STEMI patients in Kerala, India, total ischemic time and first medical contact-to-needle time correlated with long-term MACE rates, whereas other timeliness indicators did not. How this study might affect research, practice or policy Our study highlights the significant barriers to accessing STEMI care that are prevalent in LMICs despite incremental growth in the number of PCI-capable hospitals. The pre-hospital phase within total ischemic time is the most important quality improvement metric of STEMI care in LMICs, especially for patients chosen for fibrinolysis.

Objective To investigate the delay of door to signature time in primary percutaneous coronary intervention (PCI) and its influence in patients with ST segment elevation myocardial infarction (STEMI), therefore to provide a scientific basis for further effective shortening the time of primary PCI in patients with STEMI. Methods A total of 226 patients who diagnosed with STEMI and underwent primary PCI at Henan Provincial People's Hospital from June 2016 to December 2017 were enrolled in the study. Observation indicators include: (1) baseline data of patients; (2) time segments in primary PCI: total ischemic time (TIT), door to balloon time (DTΒT), door-to-signature time (DTST), signature to balloon time (STΒT); (3) the demographic characteristics of the family members who signed informed consent; and (4) the psychological factors and coping strategies of family members before signing informed consent. All data was analyzed using SPSS software (version 22.0). Multiple linear regression analysis was used to analyze the influencing factors of delay of DTST. A P<0.05 was considered statistically significant. Results In this study, 226 patients with STEMI who were first diagnosed in our hospital had a mean age of 55.23±10.80 years, and 181 (80.1%) were male. The median of TIT, DTΒT, DTST, STΒT were 312 min, 166 min, 82 min, and 80 min. The ratio of DTST in DTBT and TIT was 50% and 28.5%, respectively. The multiple linear regression analysis showed that the number of direct family members (P<0.001), the degree of educational in middle school and below (P=0.010), high school/technical secondary school (P=0. 029), families worrying about the high cost of medical care (P=0.020), families consulted each other repeatedly (P=0.022), and consulted the other medical staff (P=0.022) are risk factors of DTST delay, and city residence (P=0.048) is the protection factor of DTST delay. Conclusions The long time of DTS is a reality of the practice of primary PCI in China. The factors that lead to longer DTST include demographic characteristics, psychological factors and coping strategies of family members. The STBT of primary PCI in China should be taken into the value while emphasizing the DTBT. Key words: ST segment elevation myocardial infarction; Door-to-signature time; Influence factor

ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction--executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction).