Balloon Time Research Articles

Does adjunctive oxytocin infusion during balloon cervical ripening improve labor induction?

Evidence-Based Answer: Yes. Compared to the use of a transcervical balloon alone, combined cervical ripening with a balloon catheter and oxytocin shortens the time to overall delivery by 3 hours and the time to vaginal delivery by 4 hours, without altering the rate of cesarean section (strength of recommendation [SOR]: A, network meta-analysis). The effect is more pronounced in nulliparous patients (SOR: A, meta-analysis).When combined therapy is used, 6 hours of balloon time may result in faster delivery than 12 hours (SOR: B, single randomized controlled trial [RCT]). Fixed-dose oxytocin and titrated oxytocin appear to have similar effect when combined with a cervical ripening balloon (SOR: C, underpowered RCT).

Anatomical obstacles and their impact on the sheath to balloon time while intervening through a trans-radial approach in patients undergoing primary percutaneous coronary intervention

Abstract Funding Acknowledgements Type of funding sources: None. Background Trans-radial approach has been considered a safe and useful vascular access site for cardiac catheterization in comparison with the conventional trans-femoral approach. However, radial access has many challenges, such as access difficulty related to anatomical variations, radial artery spasm, occlusion, loops, tortuosities, and aberrant origin of radial and subclavian arteries. These factors were ignored in the large randomized trials that might have a significant impact on the outcome. Purpose To determine the predictors of anatomical obstacles and their impact on the sheath to balloon time while intervening through a trans-radial approach in patients undergoing primary percutaneous coronary intervention. Methods This was a case-control study comprised of 466 patients who underwent primary percutaneous coronary intervention to determine the predictors of anatomical obstacles including radial artery spasm, radioulnar loops, aberrant radial artery, tortuous configuration, and subclavian tortuosity. Sheath to balloon time was determined in both the groups with and without anatomical obstacles. Results Patients with and without anatomical obstacles were recruited in a 1:3 ratio. Female gender was found to be associated with anatomical obstacles with the distribution of 28.6% (32/112) vs. 19.2% (68/354); p = 0.035 for the patients with and without anatomical obstacles. Patients with obstacles were comparatively older than patients without obstacles with the mean age of 59.11 ± 8.86 vs. 55.6 ± 9.45 years; p < 0.001. Diabetes as co-morbid was another clinical factor observed to be associated with the presence of anatomical obstacles with the distribution of 50.9% (57/112) vs. 40.1% (142/354); p = 0.044 for with and without obstacles cohort respectively. Among patients with anatomical obstacles, the most common type of obstacle was observed to be subclavian tortuosity (40.2%) followed by radial artery spasm (25.9%), tortuous configuration (17.0%), radioulnar loop (12.5%), and abnormal origin of the RA (4.5%). A significantly higher sheath to balloon time was observed for the patients with anatomical obstacles as compared to those without with a mean duration of 30.92 ± 13.25 vs. 19.42 ± 6.2 minutes; p < 0.001. Conclusion Older age, female gender, and diabetes were found to be the major predictors for anatomical obstacles and hence significantly increasing the sheath to balloon time. Moreover, Subclavian tortuosity was the most common obstacle followed by the radial artery spasm. Therefore, predicting the factors prolonging the procedure time could be beneficial to select the access site and can improve the overall outcome.

Impact of SARS-CoV2 pandemic onto acute ST-elevation myocardial infarction care and patient outcomes in a large tertiary cardiac center

Abstract Funding Acknowledgements Type of funding sources: None. Background SARS-CoV2 pandemic has caused major impact on patient care worldwide. We experienced a surge of cases beginning March 2020 leading to the government imposing a movement control order, more commonly known as ‘lockdown’ starting 18th March 2020. As such, various changes were implemented by our center to the clinical pathway for STEMI patients including using thrombolysis as the preferred initial treatment modality. Purpose We aim to determine the impact of SARS-CoV2 pandemic on the clinical outcome of acute STEMI patients in our center which is a large regional tertiary hospital for cardiology. Methods and results: This is a single center retrospective cross-sectional study from 1st January 2020 until 31st May 2020. We compared clinical outcomes of patients admitted for acute STEMI before (group 1) and after (group 2) 15th March 2020 which is the date our center implemented changes to our STEMI care pathway. A total of 172 cases of acute STEMI was admitted to our center during this period. Admission for STEMI was noticeably lower after the lockdown implementation (group 1, n = 97 vs group 2, n = 75). The median time from symptom to presentation at our center did not differ between the two groups being 4.15h[2.78,7.28] vs 4.42h[2.97,8.01] p = 0.702, suggesting no out-of-hospital delays in management. Majority of the patients in group 1 (n = 75, 77.2%) received primary percutaneous coronary intervention (PCI) vs only 17 (22.7%) in group 2. Most in group 2 (n = 54, 72%) received thrombolytic therapy and subsequently underwent coronary intervention within the same admission. This shows a shift in the preferred initial treatment modality for STEMI at our center during this period. The door to balloon time for patients undergoing primary PCI during this period was also numerically higher in group 2 but the difference was not statistically significant at 46min [38,63] vs 59min [45,72], p = 0.063, most likely due to the additional preparation needed in terms of SARS-CoV2 testing and personal protective equipment (PPE) prior to the procedure. The primary composite endpoint of in-hospital mortality and cardiogenic shock between the two groups (17.5% vs 24.3%, p = 0.275) did not show any significant difference. The incidence of in-hospital mortality and cardiogenic shock were 4.1% vs 6.7% (p = 0.458) and 15.5% vs 21.9% (p = 0.281) respectively. Conclusions This study suggests that thrombolysis as the preferred initial treatment modality for STEMI could be a reasonable temporary measure during the initial phase of a global pandemic to reduce infection risk of healthcare providers without compromising patient outcomes until adequate PPE and testing modalities are available for primary PCI to be performed safely. A follow-up study is needed to determine the long-term outcome of these patients.

Reducing the Wire Crossing Time in Primary Percutaneous Coronary Angioplasty: A Study From a Tier II City in India.

Acute coronary syndrome is a major cause of morbidity and mortality all over the world. Timely intervention in ST-elevation myocardial infarction (STEMI) in the form of primary angioplasty is the gold standard of treatment to reduce mortality and morbidity. “Time is muscle” is the phrase to impress upon the importance of time in treating patients with STEMI. Traditional treatment target included “door to balloon time” of 90 min or less. This “door to balloon time” is now rephrased as the “wire crossing time” (WCT). The European Society of Cardiology (ESC) updated its guidelines further, reducing the target of wire crossing time to 60 min.The present study is a brief report on the door to wire crossing time status in one of the tertiary care centers of a nonmetro city. Retrospective analysis of case records was done for 79 patients admitted with acute MI who underwent primary angioplasty between November 2018 and June 2019 (pre-corrective action group). Various reasons for the delay, right from the time of the patient reaching the emergency room (ER) to the time of wire crossing, were analysed and measures were taken to reduce the delay. The post-corrective action group comprised 77 patients. The major causes of a prolonged WCT in our setup were delayed diagnosis of STEMI in ER, delay in giving consent by the patient’s relatives, financial issues, and availability of cath lab technicians during the off-duty hour. The delay in WCT in our center was 121 min. Remedial actions were taken to mitigate the problems at each step, which resulted in a reduction of delay by 20 min, i.e., to 101 min leading to a significant difference in the outcome in view of morbidity and mortality.

Incidence and clinical predictors of the development of cardiogenic shock after primary angioplasty in patients with ST elevation myocardial infarction

There is a rich literature on ST elevation myocardial infarction (STEMI) complicated by cardiogenic shock (CS). However, little is known about patients who are initially hemodynamically stable and develop CS after percutaneous coronary intervention (PCI). To determine incidence and evaluate clinical characteristics as well as in-hospital outcomes of patients with STEMI who develop cardiogenic shock after PCI. A total of 352 consecutive patients were retrospectively enrolled in the PAMI registry of the cardiology B department of Fattouma Bourguiba university hospital between January 2000 and March 2017. Patients with hemodynamic instability at presentation prior to PCI were excluded. Out of 352 patients with STEMI, 35 patients (9.9%) develop cardiogenic shock after PCI. These patients were older (age > 65 years; P = 0.021), more often diabetic (68.3% vs. 37.2%; P = 0.002), and had prior stroke/transient ischemic attack (22.2% vs. 10.5%; P = 0.027). Cardiogenic shock after PCI occured more frequently in patients with anterior STEMI ( P = 0.012), door to balloon time > 120 minutes ( P = 0.02), and systolic blood pressure at admission < 120 mmHg ( P < 0.001). On the electrocardiogram, wide QRS at presentation ( P = 0.033), presence of bundle branch block ( P = 0.021) and persistence of ST segment elevation after PCI ( P < 0.001) were associated with higher incidence of CS after PCI. The overall in-hospital mortality of patients with post procedural CS was 64.3% vs. 3.5%, P < 0.001. At multivariate analysis, significant predictors of an increased risk of CS after PCI were: age > 65 years (odd ratio = 1.05;95% CI:0.49-2.33; P = 0.02), systolic blood pressure < 120 mmHg (odd ratio = 3.9,95% CI: 1.95–7.78, P < 0.001) and door to balloon time > 120 minutes (odd ratio =1.07, 95% CI 0.49–2.33; P = 0.02). Cardiogenic shock after PCI in STEMI carries an extremely high mortality. These patients had unfavourable premorbid conditions and poor outcomes.

Impact of the COVID-19 Pandemic on Patient Delay and Clinical Outcomes for Patients With Acute Myocardial Infarction.

BackgroundIt has been known that the fear of contagion during the coronavirus disease 2019 (COVID-19) creates time delays with subsequent impact on mortality in patients with acute myocardial infarction (AMI). However, difference of time delay and clinical outcome in patients with ST-segment elevation myocardial infarction (STEMI) or non-STEMI between the COVID-19 pandemic and pre-pandemic era has not been fully investigated yet in Korea. The aim of this study was to investigate the impact of COVID-19 pandemic on time delays and clinical outcome in patients with STEMI or non-STEMI compared to the same period years prior.MethodsA total of 598 patients with STEMI (n = 195) or non-STEMI (n = 403) who underwent coronary angiography during the COVID-19 pandemic (February 1 to April 30, 2020) and pre-pandemic era (February 1 to April 30, 2017, 2018, and 2019) were analyzed in this study. Main outcomes were the incidence of time delay, cardiac arrest, and in-hospital death.ResultsThere was 13.5% reduction in the number of patients hospitalized with AMI during the pandemic compared to pre-pandemic era. In patients with STEMI, door to balloon time tended to be longer during the pandemic compared to pre-pandemic era (55.7 ± 12.6 minutes vs. 60.8 ± 13.0 minutes, P = 0.08). There were no significant differences in cardiac arrest (15.6% vs. 10.4%, P = 0.397) and in-hospital mortality (15.6% vs. 10.4%, P = 0.397) between pre-pandemic and the pandemic era. In patients with non-STEMI, symptom to door time was significantly longer (310.0 ± 346.2 minutes vs. 511.5 ± 635.7 minutes, P = 0.038) and the incidence of cardiac arrest (0.9% vs. 3.5%, P = 0.017) and in-hospital mortality (0.3% vs. 2.3%, P = 0.045) was significantly greater during the pandemic compared to pre-pandemic era. Among medications, angiotensin converting enzyme inhibitors/angiotensin type 2 receptor blockers (ACE-I/ARBs) were underused in STEMI (64.6% vs. 45.8%, P = 0.021) and non-STEMI (67.8% vs. 57.0%, P = 0.061) during the pandemic.ConclusionDuring the COVID-19 pandemic, there has been a considerable reduction in hospital admissions for AMI, time delay, and underuse of ACE-I/ARBs for the management of AMI, and this might be closely associated with the excess death in Korea.

The analysis of in-hospital and long-term results of percutaneous coronary intervention supported by extracorporeal membrane oxygenation in patients with coronary artery disease

Aim. To analyze in-hospital and long-term (12 months) results of percutaneous coronary intervention (PCI) supported by extracorporeal membrane oxygenation (ECMO) in patients with stable coronary heart disease and multivessel coronary artery disease, and to justify the use of such approach in the treatment of this group of patients.Methods. The retrospective analysis included 13 patients with stable coronary artery and multivessel coronary disease. The mean SYNTAX score before the intervention was 31.4±10.8. Between 30 days and 12 months in the postoperative period, the frequency and type of the following major adverse cardiovascular events (MACE) was assessed: all-cause death, myocardial infarction, stroke, repeat revascularization. Twelve months after the event, the data on the frequency and type of adverse cardiovascular events were collected by means of telephone follow-up.Results. Coronary intervention supported by ECMO was performed in all patients. 8 (61.6%) patients required an open surgical approach for ECMO cannula insertion. Door to balloon time was 109.6±79.2 minutes. The mean duration of ECMO support was 101.7±45.4 minutes. Haemodynamic instability, abnormalities in pulmonary gas exchange and rhythm disturbances were not revealed during primary PCI, making it possible to wean off the ECMO post-PCI. The mean residual SYNTAX score was 9.3±11.8. BARC class ≥3 bleeding complications were observed in 6 of 13 patients. Long-term major adverse cardiovascular events with fatal outcomes occurred in 3 (23.1%) patients.Conclusion. Supporting high-risk PCI with ECMO in patients with stable coronary artery disease, multivessel coronary artery disease and low left ventricular ejection fraction made it possible to successfully perform the intervention in all patients. Nevertheless, the long-term (12 months) results show a high percentage of recurrent myocardial infarction, which can be associated with high residual SYNTAX score.

Impact of Pre-Hospital Activation of STEMI on False Positive Activation Rate and Door to Balloon Time

Pre-hospital identification of ST-segment elevation myocardial infarction (STEMI) by paramedical staff reduces reperfusion time. However, the impact of this approach on the rate of unnecessary activation of coronary catheterisation lab (CCL) remains unclear. The study reviewed consecutive STEMI patients over 3 years (July 2015 to June 2018) from all primary percutaneous coronary intervention (PPCI) centres and inter-hospital transfers (IHT) from non-PPCI capable centres in Western Australia. Out-of-hospital cardiac arrests (OOHCA) and STEMI calls for in-patients receiving treatment for other medical reasons were excluded. During the 3 years study period, 1,736 STEMI cases were recorded. Pre-hospital (PH) activation occurred in 799 (46%) cases. Median door to balloon time (D2BT) was 68 minutes (IQR 63 mins). D2BT for PH activation (40 min [IQR 25 min]) was significantly lower than both the PPCI centre emergency department (ED) activation (86 min [IQR 55 min]) and IHT activation groups (108 min [IQR 55 min]), p-value <0.00001. In PH activation group 98% patients received primary PCI in less than 90 minutes compared to 54% and 26% patients in the ED and the IHT activation groups, respectively. False positive STEMI activation rate was lower in the PH activation group (2.75%) compared to ED activation (5.4%) and IHT group (6%), p-value 0.0115. The false positive rate did not vary significantly between working hours and out-of-hour calls (5% vs 4%, p-value=0.304). Pericarditis, coronary artery disease other than STEMI, atypical chest pain, and stress induced cardiomyopathy were the common diagnoses in false positive activations. Pre-hospital activation of STEMI leads to reduced door to balloon times without a significant increase in inappropriate procedures, though false positive activation rates are unclear. The majority of STEMI patients transferred from non-PPCI centres failed to receive reperfusion therapy within 90 minutes of initial hospital presentation. Further studies are required to assess the benefits of thrombolysis in selected patients in inter-hospital transfer group.

105 An intriguing case of pericardial effusion after acute coronary syndrome

Abstract Aims Left ventricular free wall rupture is one of the mechanical complications of myocardial infarction with an incidence of 2–4%. Sometimes the myocardial rupture hasn’t an immediate fatal evolution, nor is easy to be diagnosed because it is contained by the pericardium and thrombus formation, leading to pseudoaneurysm of the left ventricle. Pseudoaneurysms need a prompt surgical correction for their high risk of rupture both in the acute phase and later. Methods and results A 57 years old, smoker, woman with no previous cardiological history was admitted to our cardiological department for acute coronary syndrome with persistent ST segment elevation involving the postero-lateral wall (door to balloon time about 10 h, Killip class I and peak hs-TnI value was 27.67 ng/ml n.v. ˂0.02 ng/ml). The echocardiography showed mild left ventricular disfunction (LV EF 45%), postero lateral akinesia and moderate mitral regurgitation; ubiquitous pericardial effusion (1 cm) was present, particularly along the anterior left ventricular wall, with irregular echo-dense aspect. She underwent urgent coronarography that showed a critical stenosis of the distal third of the left circumflex and a thrombotic occlusion of the first marginal branch. The distal circumflex was treated with angioplasty and stent implantation but we couldn’t obtain the reperfusion of the marginal branch. Post procedural echocardiogram was unchanged and no free wall rupture was detected. 7 days after the admission, the patient showed persistent elevation of white blood count and CRP and developed fever, promptly empirically treated with a cephalosporin (blood cultures collected before were negative). After two new episode of fever with persisting biochemical flogistic parameters, a rheumatologic cause of the pericardial effusion was considered in the presence of positive antinuclear antibodies suggesting the diagnosis of Systemic Lupus Erythematosus. Steroidal therapy was prescribed which caused clinical improvement without complete resolution of the pericardial effusion. On day 20 of hospital stay a new echocardiographic evaluation showed a discontinuation of the postero lateral myocardial wall (Figure 1), about 1 cm in width, widely communicating with the left ventricular cavity and suggestive for a left postero-lateral ventricular pseudoaneurysm. The patient underwent surgical intervention and it was possible to expose a big clot occluding the pseudoaneurysmatic cavity communicating with the left ventricular chamber through an inlet about 1 cm in diameter, that was repaired with a bovine pericardial patch (Bard Sauvage technique). After surgery the patient was supported with an IABP and inotropes and was discharged to a rehabilitation structure on day 29 of hospital stay. Four months after the hospital discharge the patient died for a recently diagnosed pancreatic cancer. Conclusions Pseudoaneurisms are life-threatening complications of myocardial infarction that sometimes are hardly diagnosed. When correctly recognized surgical correction can lead to a good prognosis.

C91. “Successful management of ventricular septal rupture after myocardial infarction in elderly: the role of intra-aortic balloon pump and timing for surgery”: A Case Report

Abstract Background Ventricular septal rupture (VSR) after myocardial infarction (MI) is a case with a high mortality rate, early diagnosis and appropriate treatment are essential. Surgical VSR closure though challenging and associated with high mortality, remains one of the main therapy in VSR closure. Case Presentation A 70-year-old woman had a complaint about the shortness of breath (SoB). From anamnesis, 17 days before admission, she complained of chest pain. 15 days before admission, she was taken to a local hospital and got hospitalized for 7 days in the intensive care unit. ECG showed anterior MI. During admission, patient developed SoB. From echocardiography, it showed VSR at apical. She was referred to dr. Kariadi hospital for further management. Coronary angiography showed total occlusion in mid LAD. An intra-aortic balloon pump (IABP) was inserted for stabilized hemodynamic and as bridging. Inotropic support was given and afterload reduction was also administered. Surgical VSR closure and coronary artery bypass grafting (CABG) was successfully performed on the 22nd day after the onset of MI. The patient was discharged 10 days after surgery in a good condition. Discussion The mortality of VSR varied significantly depending on the timing of surgery. Patients who underwent surgery within 7 days of presentation had a 54.1% mortality compared with 10 % mortality if the repair was delayed until after 21 days. The cornerstone of preoperative management of VSR is afterload reduction. IABP provides mechanical afterload reduction and augmentation of cardiac output.

C91. “Successful management of ventricular septal rupture after myocardial infarction in elderly: the role of intra-aortic balloon pump and timing for surgery”: A Case Report

Abstract Background Ventricular septal rupture (VSR) after myocardial infarction (MI) is a case with a high mortality rate, early diagnosis and appropriate treatment are essential. Surgical VSR closure though challenging and associated with high mortality, remains one of the main therapy in VSR closure. Case Presentation A 70-year-old woman had a complaint about the shortness of breath (SoB). From anamnesis, 17 days before admission, she complained of chest pain. 15 days before admission, she was taken to a local hospital and got hospitalized for 7 days in the intensive care unit. ECG showed anterior MI. During admission, patient developed SoB. From echocardiography, it showed VSR at apical. She was referred to dr. Kariadi hospital for further management. Coronary angiography showed total occlusion in mid LAD. An intra-aortic balloon pump (IABP) was inserted for stabilized hemodynamic and as bridging. Inotropic support was given and afterload reduction was also administered. Surgical VSR closure and coronary artery bypass grafting (CABG) was successfully performed on the 22nd day after the onset of MI. The patient was discharged 10 days after surgery in a good condition. Discussion The mortality of VSR varied significantly depending on the timing of surgery. Patients who underwent surgery within 7 days of presentation had a 54.1% mortality compared with 10 % mortality if the repair was delayed until after 21 days. The cornerstone of preoperative management of VSR is afterload reduction. IABP provides mechanical afterload reduction and augmentation of cardiac output.

Abstract 11722: Assessing Disparity of Performance Measure by Door-to-Balloon Time Between Rural and Urban Area for Management of Patients with ST-Segment Elevation Myocardial Infarction -Insights from the Nationwide Japan Acute Myocardial Infarction Registry-

Background: Door to balloon time (D2B) ≤90 minutes is a key indicator of quality of care for ST-segment elevation myocardial infarction (STEMI). The development of standardized management for STEMI may narrow the performance gap between rural and urban hospitals. However, there are few studies to explore the disparity of D2B and outcomes between rural and urban areas. Methods and Results: The Japan Acute Myocardial Infarction Registry (JAMIR) is a nationwide, real-world registry study. We retrospectively analyzed 17,938 STEMI patients (68±13 years, female 22.4%) treated with percutaneous coronary intervention, who were divided into the following two groups according to population density of 1147 persons/km 2 ; patients hospitalized in rural area and those in urban area. Overall, the median D2B was 72 mins and 73% achieved the target D2B ≤90 mins. Patients with D2B ≤90 mins had a lower in-hospital mortality compared with those with D2B &gt;90 mins (4.7% vs. 8,4%, P&lt;0.001). Rural patients were characterized by higher age, more accumulation of coronary risk factors and a higher prevalence of Killip class ≥2 at presentation compared with urban patients. The median D2B was longer (70 mins vs. 62 mins, P&lt;0.001) and achievement rate for D2B ≤90 mins was lower (70% vs. 75%, P&lt;0.001) in rural group than urban group ( Figure A ). In-hospital mortality tended to be higher in rural group (6.1% vs. 5.5%, P=0.06), whereas the benefit in shortening of D2B was noted equally in both groups ( Figure B ). Conclusions: The real-world nationwide study of JAMIR demonstrated that shortening of D2B time was significantly associated with survival benefit of STEMI in both rural and urban area.

Abstract 11895: Impact of Prehospital Mobile Cloud ECG System to Reduce Door to Balloon Time and Onset to Recanalization Time in STEMI

Background: Clinical guidelines strongly recommend patients with ST-elevation myocardial infarction (STEMI) receive timely mechanical reperfusion, defined as door-to-balloon time (DTBT) ≤90 minutes. Recently, mobile cloud 12-lead ECG transmission system (C-ECG) were becoming popular at low cost. Medical staff can immediately review the ECG via PC or personal hand-held devices, and also track the location of the ambulance in a real time manner. Objective: Evaluate the impact of the prehospital C-ECG on DTBT and mortality in patients with STEMI. Methods: In June 2018, eight mobile C-ECG systems (SCUNA®, MEHERGEN GROUP) were integrated into the Uki city and Kamimashiki city regional EMS departments in Kumamoto Prefecture, We compared the DTBT, onset to recanalization time (OTRT) and mortality rates of STEMI cases for 3 years prior to and 3 years after the C-ECG system. Results: For 6 years study period, 267 STEMI patients were transferred by ambulances from two EMS departments. After excluding 14 patients with onset to arrival time more than 24 hours and 54 patients who were transferred without C-ECG, 199 consecutive STEMI cases underwent emergency PCI in which 100 were prior to C-ECG introduction (Pre-C-ECG, from June 2015 to May 2018) and 99 were after C-ECG (Post-C-ECG, from June 2018 to May 2021). Results: No significant differences were found in age, gender, and Killip classification between the groups. The DTBT and OTRT were significantly shorter in the post-C-ECG compared to the pre-C-ECG (Pre: 68 min [IQR; 43-76] vs. Post: 50 min [IQR; 43-76]; p=0.005, Pre: 190 min [IQR; 138-294] vs. Post: 157 min [IQR; 112-276]; P=0.04, respectively). However, peak-CPK and the in-hospital mortality were not significantly different (Pre: 2068 IU/L [IQR; 1168-4200] vs. Post: 2105 IU/L [IQR; 872-4528]; p=0.8, Pre: 7.0% vs. Post: 5.1%; p=0.6, respectively). Conclusion: Although the prehospital mobile C-ECG system significantly reduced both DTBT and OTRT, the DTBT at our institution was short enough that C-ECG did not reduce the peak CPK or mortality.

Abstract 14163: Mathematical Model for Predicting Survival in Elderly (Above 80 Years) Population After Primary Percutaneous Coronary Intervention for ST Elevation Myocardial Infarction

Introduction: Advancement in interventional cardiology has increased the number of percutaneous coronary intervention (PCI) in the elderly. However, clinicians still face tough decision making to select elderly patients who can receive Primary PCI and have improved survival. This study aimed to identify factors that influence the survival in elderly population undergoing PPCI for treatment of ST elevation myocardial infraction (STEMI). Methods: We analyzed the data at our cardiac center prospectively during 2010- 2019 and developed a mathematical model using multi-parameter regression analysis using SPSS and OriginPro data visualization. Results: The factors which may predict survival were identified with help of mathematical model developed on the basis of clinical parameters reported at the time of STEMI presentation and details of the PCI procedure in 248 patients (male = 124, Age 85.78±3.43 years, , female= 124, Age 85.78± 4.08 years, ). The data visualization is shown in figure 1 and the developed model equation is as follows: Y (survival in months) = 126.865 - 0.258 (± 0.030) (Hb in g/dl) - 0.105(± 0.034) (Creatinine in umol/L) - 0.228 (± 0.112) (eGFR in ml/min/1.73 m 2 ) - 4.174 (±2.443) (triglycerides in mmol/l) - 1.201 (± 1.232) (LDL in mmol/l) - 0.001(±0.002) (Call to balloon time in minutes) + 16.874 (±3.119) (log 10 radiation dose)- 1.224(±0.352) Age at time of presentation) (N = 248, R = 0.636, F= 18.043, p = 0.00) Conclusions: Our study shows that hemoglobin, kidney function, lipid profile, call to balloon time, age of the patient at time of STEMI presentation and radiation dose used during the procedure may be important predictors for the survival of patient after PPCI. Nevertheless the patient age at the time of STEMI is negatively correlated with survival period. Similarly, early intervention in event of STEMI will decrease call to balloon time thereby increasing post-procedure survival in elderly patients .

Abstract 12267: Impact of a Comprehensive ST-Elevation Myocardial Infarction Protocol on Key Process Metrics in African American STEMI Patients

Background: Optimizing STEMI care processes for African Americans is a critical matter with important public health implications. We aimed to study if a comprehensive ST-elevation myocardial infarction (STEMI) protocol (CSP) could improve key process metrics in the African American (AA) population. Methods: We developed a 4-step CSP which included, 1) Emergency Department catheterization lab activation; (2) STEMI Safe Handoff Checklist; (3) immediate catheterization lab transfer; (4) and radial-first percutaneous coronary intervention (PCI). Baseline characteristics and procedural characteristics were compared between all consecutive STEMI patients who underwent PCI at the Cleveland Clinic main campus between January 1, 2011, to July 14, 2014 (pre-CSP group) and July 15, 2014, to July 15, 2019 (post-CSP group). Results: There were a total of 208 AA patients in the pre-CSP group compared to 271 AA patients in the post-CSP group. Baseline characteristics were quite similar between the two groups except for a lower rate of MI in the post-CSP group (45% vs 30%, P=0.001). After implementation of our CSP, guideline-directed medical therapy increased from 71.6% to 81.9% (P=0.011), radial utilization went up from 14.4% to 73.8% (P&lt;0.001), door to balloon time decreased from 90 minutes (median IQR 64-120) to 70 minutes (median IQR 45-95) (P&lt;0.001), fluoro dose decreased from 1610 mGy (median IQR 980.25-2592.25) to 1147 mGy (median IQR 742-1844) (P&lt;0.001), and contrast dose decreased from 197.07 ml to 152.98 ml (P&lt;0.001). Conclusion: Implementing a CSP was able to significantly improve the key STEMI process metrics for African American patients. Optimizing key STEMI process metrics is an important initiative to ensure equitable STEMI care.

Abstract 11327: Relationship of Neighborhood Socioeconomic Deprivation with Outcomes of a Comprehensive STEMI Protocol

Introduction: Social determinants of health have an established impact on cardiovascular outcomes. STEMI quality improvement programs have resulted in reductions in door to balloon time (D2BT) and improved STEMI outcomes nationally. We evaluated whether a comprehensive STEMI protocol (CSP) improves care and outcomes in patients with moderate and high socioeconomic deprivation. Methods: Patients with STEMI treated with PCI at a single tertiary care hospital before (1/1/11-7/14/14, n=674) and after (7/15/14-7/15/19, n=1087) implementation of a CSP were included. Patients were stratified into low ( &lt; 50 th percentile), medium (51-90 th percentile), and high (&gt;90 th percentile) deprivation groups based on census block group level area deprivation index. Outcomes were D2BT and mortality. Results: Neighborhood deprivation was 29.0% low (174 pre-CSP, 338 post-CSP), 40.8% moderate (268 pre, 450 post), and 30.2% high (232 pre, 299 post). Female sex (low 28.3%, moderate 31.9%, high 38.6%, p=0.001) and black race (2.5%, 20.7%, 61.8%, p&lt;0.001) were associated with higher levels of deprivation. Improvements in median D2BT were observed in all deprivation groups after CSP implementation (Figure). Risk-adjusted median D2BT among ER/hospital patients from higher neighborhood deprivation levels was significantly non-inferior (non-inferiority limit = 5m) to those from lower deprivation levels after CSP implementation. In-hospital mortality was similar before and after CSP implementation in the low deprivation group (4.6% vs. 3.6%, p=0.56), and decreased significantly in moderate/high deprivation groups (7.0% vs. 3.1%, p=0.001). Conclusions: A CSP was associated with improvements in D2BT across all deprivation groups and a substantial mortality reduction in moderate/high deprivation groups. Standardized quality improvement initiatives may mitigate social determinants of health in time-sensitive high acuity conditions such as STEMI.

Abstract 14267: Comprehensive STEMI Protocol Enhances Process and Care Metrics in Patients With In-Hospital STEMI

Introduction: Patients who experience in-hospital ST-elevation myocardial infarction (iSTEMI) represent a uniquely high-risk cohort owing to delays in diagnosis and time to reperfusion as well as substantially increased mortality. Quality initiatives aimed at improving the care of this vulnerable, yet understudied population are needed. Methods: This study included consecutive patients with iSTEMI treated with percutaneous coronary intervention (PCI) between 01/01/2011-07/15/2019 at a single, tertiary referral center. A comprehensive iSTEMI protocol (CSP) was implemented on 7/15/2014, incorporating: (1) nursing chest pain protocol, (2) improved electronic access to ECG images, (3) checklist for initial triage and management, (4) 24/7/365 catheterization lab readiness, and (5) radial-first PCI approach. Key metrics and outcomes were compared before and after CSP implementation. Results: Among 132 total subjects, the post-CSP cohort (n=84) were older with more males and active smoking relative to the pre-CSP cohort (n=48). After CSP adoption, we observed significant reductions in median door-to balloon time (D2BT) from 107 minutes to 64 minutes (p&lt;0.001), median fluoroscopy dose from 1.6 Gy to 1.2 Gy (p=0.04), and mean contrast load from 181mL to 148mL (p=0.02), with simultaneous increases in goal D2BT from 39% to 74% of patients (p&lt;0.001) as well as radial use from 15% to 70% (p&lt;0.001). Despite a numerical decrease in in-hospital mortality after CSP application from 17% to 10% (p=0.35), no significant differences were found in all outcomes including 30-day and 1-year mortality between groups. Conclusion: The implementation of a CSP was associated with marked improvements in critical process and care metrics among vulnerable patients who experience STEMI while hospitalized. Interestingly, these benefits failed to improve short or long-term outcomes including mortality, highlighting the underlying high-risk nature of this population.

The impact of chest pain center on treatment delay of STEMI patients: a time series study

ObjectiveTo study the effect of the establishment of a Chest Pain Center (CPC) on the treatment delay of ST-elevation myocardial infarction (STEMI) patients and the influencing factors of treatment delay in a large hospital in China.MethodsThe study subjects are 318 STEMI patients admitted between August 2016 and July 2019 to a large general hospital in Henan, China. Data were extracted from the electronic medical records after removing personal identifiable information. The interrupted time series regression was used to analyze the treatment delay of patients before and after the CPC establishment.ResultsAfter the CPC establishment, the patients’ pre-hospital and in-hospital treatment delays were significantly reduced. SO-to-FMC (Symptom Onset to First Medical Contact time) decreased by 49.237 min and D-to-B (Door to Balloon time) decreased by 21.931 min immediately after the CPC establishment. In addition, SO-to-FMC delay is significantly correlated with age, occupation, nocturnal onset, and the way to hospital. D-to-B delay is significantly associated with time from initial diagnosis to informed consent of percutaneous coronary intervention (PCI), catheterization lab activation time, and time for PCI informed consent.ConclusionThe CPC significantly reduced the treatment delay of STEMI patients undergoing PCI.

Contemporary Implications of ECG to Activation Time on Long-term Outcomes in Patients With ST-Segment Elevation Myocardial Infarction Treated With Primary Percutaneous Coronary Intervention

PurposeThe prognosis of door to balloon time (DBT) after primary percutaneous coronary intervention (PPCI) in ST-segment elevation myocardial infarction (STEMI) has been extensively studied. However, the clinical implications of the ECG to activation time (EAT), as a component of DBT, on long-term outcomes are less well established. This study evaluates the association of EAT with major adverse cardiovascular events (MACEs) in more contemporary patients undergoing PPCI and investigates factors that influence EAT. MethodsA total of 1082 consecutive patients with STEMI who underwent PPCI from 2013 to 2019 were classified into 3 groups according to EAT: EAT ≤30 minutes, EAT of 30 to 60 minutes, and EAT >60 minutes. We analyzed the incidence of MACEs, including all-cause death, nonfatal recurrence of MI, or nonfatal stroke during a median follow-up of 37 months. FindingsThe median EAT was 58 minutes (interquartile range, 44–80 minutes), which explained 90% of the variability in DBT and had the strongest correlation with DBT (r = 0.95, P < 0.001). Achieving an EAT of ≤30 minutes resulted in a 94.1% chance of achieving a DBT ≤90 minutes. The incidence of MACEs had a concurrent increase with increased EAT (10.2% for EAT ≤30 minutes, 14.3% for EAT of 30–60 minutes, and 17.3% for EAT >60 minutes; P = 0.027) that was driven by more mortality (4.2% for EAT ≤30 minutes, 6.9% for EAT of 30–60 minutes, and 9.8% for EAT >60 minutes; P = 0.020). An EAT >30 minutes was independently associated with risk-adjusted long-term MACEs (hazard ratio = 1.99; 95% CI, 1.07–3.69; P = 0.030). Critically ill status in emergency department (P = 0.001) and time required for consent of revascularization (P < 0.001) were significantly associated with delayed EAT. ImplicationsAchieving an EAT ≤30 minutes was key to achieving the guideline-recommended target time of DBT in contemporary practice. As a strong driver of overall DBT, EAT >30 minutes was associated with worse clinical outcome in patients with STEMI undergoing PPCI. These data suggest that efforts to minimize EAT are needed to reduce long-term MACEs in contemporary population. © 2021 Elsevier HS Journals, Inc.

Time to think beyond door to balloon time: significance of total ischemic time in STEMI

BackgroundSignificance of total ischemic time (TIT) in the context of ST-segment elevation myocardial infarction (STEMI) is still controversial. Therefore, in this study, we have evaluate the association of TIT with immediate outcomes in STEMI patients in whom recommended door to balloon (DTB) time of less than 90 min was achieved.ResultsA total of 5730 patients were included in this study, out of which 80.9% were male and median age was 55 [61–48] years. The median DTB was observed to be 60 [75–45] min and onset of chest pain to emergency room (ER) arrival time was 180 [300–120] min. Prolonged TIT was associated with poor pre-procedure thrombolysis in myocardial infarction (TIMI) flow grade (p = 0.022), number of diseased vessels (p = 0.002), use of intra-aortic balloon pump (p = 0.003), and in-hospital mortality (p = 0.002). Mortality rate was 4.5%, 5.7%, and 7.8% for the patients with TIT of ≤ 120 min, 121 to 240 min, and > 240 min, respectively. Thirty days’ risk of mortality on TIMI score was 4.97 ± 7.09%, 5.01 ± 6.99%, and 7.12 ± 8.64% for the patients with TIT of ≤ 120 min, 121 to 240 min, and > 240 min, respectively.ConclusionsProlonged total ischemic was associated with higher in-hospital mortality. Therefore, TIT can also be considered in the matrix of focus, along with DTB time and other clinical determinants to improve the survival from STEMI.