Acute Myocardial Infarction Care Research Articles

Regional variations in primary percutaneous coronary intervention for acute myocardial infarction patients: A trajectory analysis using the national claims database in Japan.

Previous studies have demonstrated geographical disparities regarding the quality of care for acute myocardial infarction (AMI). The aim of this study was two-fold: first, to calculate the proportion of patients with AMI who received primary percutaneous coronary interventions (pPCIs) by secondary medical areas (SMAs), which provide general inpatient care, as a quality indicator (QI) of the process of AMI practice. Second, to identify patterns in their trajectories and to investigate the factors related to regional differences in their trajectories. We included patients hospitalized with AMI between April 2014 and March 2020 from the national health insurance claims database in Japan and calculated the proportion of pPCIs across 335 SMAs and fiscal years. Using these proportions, we conducted group-based trajectory modeling to identify groups that shared similar trajectories of the proportions. In addition, we investigated area-level factors that were associated with the different trajectories. The median (interquartile range) proportions of pPCIs by SMAs were 63.5% (52.9% to 70.5%) in FY 2014 and 69.6% (63.3% to 74.2%) in FY 2020. Four groups, named low to low (LL; n = 48), low to middle (LM; n = 16), middle to middle (MM; n = 68), and high to high (HH; n = 208), were identified from our trajectory analysis. The HH and MM groups had higher population densities and higher numbers of physicians and cardiologists per capita than the LL and LM groups. The LL and LM groups had similar numbers of physicians per capita, but the number of cardiologists per capita in the LM group increased over the years of the study compared with the LL group. The trajectory of the proportion of pPCIs for AMI patients identified groups of SMAs. Among the four groups, the LM group showed an increasing trend in the proportions of pPCIs, whereas the three other groups showed relatively stable trends.

The processes of care and long-term mortality of acute myocardial infarction with cardiogenic shock survivors: A nationwide cohort study

BackgroundAcute myocardial infarction with cardiogenic shock (AMI-CS) carries a significant risk of inpatient mortality compared with AMI alone, although it is unclear what the longer-term outcomes of AMI-CS survivors is, and whether the inpatient quality of care received influences this. MethodsUsing the Myocardial Ischaemia National Audit Project (MINAP) registry, linked to Office for National Statistics (ONS) mortality data, we analyzed 330,517 UK AMI patients; 3330 (1 %) with CS. Patients dying within thirty-days of admission were excluded. Median follow-up for patients included was 1642 days. Cox regression models were fitted, adjusting for demographics and management strategy. ResultsAMI-CS survivors were younger (median years) (67 vs. 69, p < 0.001), less often female (29 % vs. 32 %, p < 0.001) and more likely to present with STEMI (81 % vs. 37 %, p < 0.001). Mortality risk was highest at one-year for AMI-CS survivors compared to patients that did not suffer CS (adjusted hazard ratio [HR] 1.85; 95 % CI; 1.68–2.04, p < 0.001), and remained elevated at five-years (HR 1.55; 95 % CI; 1.43–1.68, p < 0.001). ‘Excellent-care’ according to mean opportunity-based quality indicator (OBQI) score compared to ‘Poor-care’, showed reduced risk of long-term mortality with AMI-CS (HR: 0.46, CI; 0.39–0.54, P < 0.001). Of patients that received “Excellent-care”, AMI-CS survivors had elevated risk of long-term mortality (HR 1.45, 95 % CI; 1.34–1.57, P < 0.001). ConclusionAMI-CS survivors have elevated risk long-term mortality risk when compared with AMI patients, which persists beyond five years. AMI-CS patients that receive higher-quality inpatient care have better longer-term survival compared to those with poorer inpatient care.

Multicomponent Intervention to Improve Acute Myocardial Infarction Care in Tanzania: Protocol for a Pilot Implementation Trial.

Although the incidence of acute myocardial infarction (AMI) is rising in sub-Saharan Africa, the uptake of evidence-based care for the diagnosis and treatment of AMI is limited throughout the region. In Tanzania, studies have revealed common misdiagnosis of AMI, infrequent administration of aspirin, and high short-term mortality rates following AMI. This study aims to evaluate the implementation and efficacy outcomes of an intervention, the Multicomponent Intervention to Improve Acute Myocardial Infarction Care (MIMIC), which was developed to improve the delivery of evidence-based AMI care in Tanzania. This single-arm pilot trial will be conducted in the emergency department (ED) at a referral hospital in northern Tanzania. The MIMIC intervention will be implemented by the ED staff for 1 year. Approximately 400 adults presenting to the ED with possible AMI symptoms will be enrolled, and research assistants will observe their care. Thirty days later, a follow-up survey will be administered to assess mortality and medication use. The primary outcome will be the acceptability of the MIMIC intervention, which will be measured by the Acceptability of Intervention Measurement (AIM) instrument. Acceptability will further be assessed via in-depth interviews with key stakeholders. Secondary implementation outcomes will include feasibility and fidelity. Secondary efficacy outcomes will include the following: the proportion of participants who receive electrocardiogram and cardiac biomarker testing, the proportion of participants with AMI who receive aspirin, 30-day mortality among participants with AMI, and the proportion of participants with AMI taking aspirin 30 days following enrollment. Implementation of MIMIC began on September 1, 2023. Enrollment is expected to be completed by September 1, 2024, and the first results are expected to be published by December 31, 2024. This study will be the first to evaluate an intervention for improving AMI care in sub-Saharan Africa. If MIMIC is found to be acceptable, the findings from this study will inform a future cluster-randomized trial to assess effectiveness and scalability. ClinicalTrials.gov NCT04563546; https://clinicaltrials.gov/study/NCT04563546. DERR1-10.2196/59917.

QUALITY OF CARE FOR PATIENTS WITH ACUTE MYOCARDIAL INFARCTION: RESULTS OF THE FIRST 3 MONTHS OF THE QUALITY IN CARDIOLOGY (QIC) PROJECT

Abstract Background Assessing the quality of care is the first step for improve the management of patients with acute myocardial infarction (AMI). The European Society of Cardiology (ESC) and the Acute Cardiovascular Care Association (ACCA) recently defined a set of quality indicators (QI) of care for AMI. Aim To evaluate the quality of care of patients admitted to the Cardiology ward of our first level hospital for an AMI using the ESC ACCA QI. Methods QiC project is a prospective quality improvement study in real–world practice on all patients admitted to our ward for an AMI from 1.5.2023 to 30.4.25 with six–monthly audit activities. Case record forms were filled in by doctors during admission and were attached to the patient’s discharge letter. Thirty–day mortality was assessed by telephone interviews. The ESC ACCA QI include 18 main and 8 secondary QI on centre organization, reperfusion and invasive strategy, risk assessment, antithrombotic treatment, secondary prevention discharge treatments, and patient experience. For each IQ was evaluated the percentage of QI assessable and attained. Results A total of 78 patients were admitted for AMI in our Cardiology Department in the first 3 months. No one patient denied consent, one died during hospitalization, 7 patients had to be transferred to another hospital, and 3 patients did not have their record form filled in. The median age of the 67 patients discharged alive was 66 (IQR 58–75) years, 45 (67.2%) were males, 35 (52.2%) had a ST–segment elevation myocardial infarction (STEMI) and 32 (47.8%) a non–ST–segment myocardial infarction (NSTEMI). The percentages of non–assessment, non–attainment and attainment for each QI are reported in the Figure: the degree of non–assessment of the 26 QI ranged from 0 to 22% and the degree of QI attainment from 25 to 100%. Conclusions Quality of care for acute myocardial infarction can be measured in the majority of patients admitted to our Cardiology Department using the ESC ACCA quality indicators. Although most quality indicators are met in our patients, a large room for improvement is present in the reperfusion and invasive strategy (mainly in timely reperfusion of STEMI patients) and in the patient’s satisfaction (discharge letter sent to patient).

Attention to STEMI patients in our region: what is the adherence to the quality indicators from a population perspective?

Abstract Funding Acknowledgements None. Introduction The use of quality indicators (QI) proposed by the Association for Acute Cardiovascular Care (ACVC) for processes carried out in cardiology services represents an excellent internal quality control of their operation. Purpose The aim is to assess adherence to the main QI in the care of acute ST-elevation myocardial infarction (STEMI) in our region, according to data from the population-based registry of myocardial infarction in that area. Methods Evaluation of adherence to the main QI proposed by the ESC Association for ACVC, by retrospective analysis (data from in-hospital and out-of-hospital care) of patients with STEMI from our regional Infarction Registry attended between 2017 and 2020, in both tertiary and secondary hospitals of the public and private care network, providing data with a population-based character. Results QI were analysed in 1355 patients categorised as STEMI in our regional Infarction Registry between 2017 and 2020. 71% of patients were male. The number of STEMI per year ranged from 358 in 2019 to 316 in 2020. Primary percutaneous coronary intervention (PCI) was performed in 87% of patients. In 53% the first medical contact occurs in out-of-hospital care, while 25% occur in emergency departments (ED) of PCI capable hospitals and 12% in emergency departments of non-PCI hospitals. Forty-two percent of patients firstly attended out-of-hospital or in non-PCI centres achieve revascularisation in less than 90 minutes, but less than 30% of patients seen in PCI centres achieve revascularisation in less than 60 minutes. Radial access was used in 92% of cases. LVEF was assessed during admission in 98% and LDL-cholesterol was determined in 87%. Ninety-one per cent of patients were discharged on dual antiplatelet therapy, 96% on statins and a large proportion of patients with left ventricular dysfunction received angiotensin-converting enzyme inhibitors (78%) and beta-blockers (88%). Conclusion There is good overall adherence to major QI related to care of patients with STEMI in our region. However, there are indicators that could be optimised, particularly those related to timely primary reperfusion. Networked care thanks to the local Infarction Code means a significant reduction in reperfusion times, avoiding unnecessary referrals to Emergency Departments.

Trends of Acute Myocardial Infarction Mortality in People Over 65 Years Old in the United States From 1999-2020: Insight From the CDC-WONDER Database.

Background Over the past two decades, there have been numerous advances in acute myocardial infarction (AMI) care. We assessed the impact of these advances on the trend of AMI-related mortality. Methods This retrospective analysis of the Centers for Disease Control's Wide-ranging Online Data for Epidemiologic Research (CDC_WONDER) database focused on AMI-related mortality in individuals aged 65 and older in the United States from 1999 to 2020. Trends -n crude and age-adjusted mortality rates (AAMR) were assessed based on socio-demographic and regional variables using Joinpoint Regression software (Joinpoint Regression Program, Version 5.0.2 - May 2023; Statistical Methodology and Applications Branch, Surveillance Research Program,National Cancer Institute Bethesda, Maryland). Annual percentage change (APC) with 95% confidence intervals (CIs) for the AAMRs were calculated for the line segments linking a Joinpoint using a data-driven weighted Bayesian Information Criterion (BIC) model. Results There were 2,354,971 AMI-related deaths with an overall decline in the AAMR from 474.6 in 1999 to 153.2 in 2020 and an average annual percentage change (AAPC) of -5.3 (95% CI -5.4 to -5.2). Notable declines were observed across gender, race, age groups, and urbanization levels. However, the rate of AMI-related deaths at decedents' homes slowed down between 2008 and 2020 and climbed up between 2018 and 2020. In addition to this, nonmetropolitan areas were found to have a significantly lower decline in mortality when compared to large and medium/small metropolitan areas. Conclusion While there is an overall positive trend in reducing AMI-associated mortality, disparities persist, emphasizing the need for targeted interventions.

Improving acute myocardial infarction care in northern Tanzania: barrier identification and implementation strategy mapping

BackgroundEvidence-based care for acute myocardial infarction (AMI) reduces morbidity and mortality. Prior studies in Tanzania identified substantial gaps in the uptake of evidence-based AMI care. Implementation science has been used to improve uptake of evidence-based AMI care in high-income settings, but interventions to improve quality of AMI care have not been studied in sub-Saharan Africa.MethodsPurposive sampling was used to recruit participants from key stakeholder groups (patients, providers, and healthcare administrators) in northern Tanzania. Semi-structured in-depth interviews were conducted using a guide informed by the Consolidated Framework for Implementation Research (CFIR). Interview transcripts were coded to identify barriers to AMI care, using the 39 CFIR constructs. Barriers relevant to emergency department (ED) AMI care were retained, and the Expert Recommendations for Implementing Change (ERIC) tool was used to match barriers with Level 1 recommendations for targeted implementation strategies.ResultsThirty key stakeholders, including 10 patients, 10 providers, and 10 healthcare administrators were enrolled. Thematic analysis identified 11 barriers to ED-based AMI care: complexity of AMI care, cost of high-quality AMI care, local hospital culture, insufficient diagnostic and therapeutic resources, inadequate provider training, limited patient knowledge of AMI, need for formal implementation leaders, need for dedicated champions, failure to provide high-quality care, poor provider-patient communication, and inefficient ED systems. Seven of these barriers had 5 strong ERIC recommendations: access new funding, identify and prepare champions, conduct educational meetings, develop educational materials, and distribute educational materials.ConclusionsMultiple barriers across several domains limit the uptake of evidence-based AMI care in northern Tanzania. The CFIR-ERIC mapping approach identified several targeted implementation strategies for addressing these barriers. A multi-component intervention is planned to improve uptake of evidence-based AMI care in Tanzania.

Gender Differences in Trends in Incidence and Mortality of Acute Myocardial Infarction in the Small Island Developing State of Barbados.

Objective To determine trends, identify predictors of acute myocardial infarction (AMI) incidence and mortality, and explore performance metrics for AMI care in Barbados. Methods Data on all cases diagnosed with AMI were collected by the Barbados National Registry for Non-Communicable Diseases (BNR) from the island's only tertiary hospital, the Queen Elizabeth Hospital, and the National Vital Registration Department. Participants who survived hospital admission were then followed up at 28 days and one year post event via telephone survey and retrieval of death certificates. Age-standardized incidence and mortality rates were calculated. Determinants of mortality at 28 days were examined in multivariable logistic regression models. Median and interquartile ranges (IQR) were calculated for performance metrics (e.g., time from pain onset to reperfusion). Results In a 10-year period between 2010 and 2019, 4,065 cases of myocardial infarction were recorded. The median age of the sample was 73 years (IQR: 61,83), and approximately half (47%) were female. Over a 10-year period, standardized incidence increased in women on average yearly by three per 100,000 (95% CI: 1 to 6; p=0.02), while in men, the average increase per year was six per 100,000 (95% CI: 4 to 8; p<0.001). There was no increase in 28-day mortality in women; mortality in men increased each year by 2.5 per 100,000 (95% CI: 0.4 to 4.5; p=0.02). The time from arrival at the hospital to the ECG was 44 minutes IQR (20,113). Conclusion AMI incidence and mortality are increasing in Barbados, and men have a higher velocity of mortality rate increase than women, which contradicts global data.

Adapting an Intervention to Improve Acute Myocardial Infarction Care in Tanzania: Co-Design of the MIMIC Intervention.

Uptake of evidence-based care for acute myocardial infarction (AMI) is suboptimal in Tanzania, but there are currently no published interventions to improve AMI care in sub-Saharan Africa. Co-design a quality improvement intervention for AMI care tailored to local contextual factors. An interdisciplinary design team consisting of 20 physicians, nurses, implementation scientists, and administrators met from June 2022 through August 2023. Half of the design team consisted of representatives from the target audience, emergency department physicians and nurses at a referral hospital in northern Tanzania. The design team reviewed multiple published quality improvement interventions focusing on ED-based AMI care. After selecting a multicomponent intervention to improve AMI care in Brazil (BRIDGE-ACS), the design team used the ADAPT-ITT framework to adapt the intervention to the local context. The design team audited current AMI care processes at the study hospital and reviewed qualitative data regarding barriers to care. Multiple adaptations were made to the original BRIDGE-ACS intervention to suit the local context, including re-designing the physician reminder system and adding patient educational materials. Additional feedback was sought from topical experts, including patients with AMI. Draft intervention materials were iteratively refined in response to feedback from experts and the design team. The finalized intervention, Multicomponent Intervention to Improve Myocardial Infarction Care in Tanzania (MIMIC), consisted of five core components: physician reminders, pocket cards, champions, provider training, and patient education. MIMIC is the first locally tailored intervention to improve AMI care in sub-Saharan Africa. Future studies will evaluate implementation outcomes and efficacy.

Using geographic rescue time contours, point-of-care strategies, and spatial care paths to prepare island communities for global warming, rising oceans, and weather disasters

ObjectivesTo perform geographic contour analysis of sea and land ambulance rescue times in an archipelago subject to super typhoons; to design point-of-care testing strategies for medical emergencies and weather disasters made more intense by global warming and rising oceans; and to assess needs for prehospital testing on spatial care paths that accelerate decision making, increase efficiency, improve outcomes, and enhance standards of care in island nations.MethodsWe performed needs assessments, inspected healthcare facilities, and collected ambulance rescue times from professionals in the Bantayan Archipelago, Philippines. We mapped sea/land ambulance rescue routes and time contours. To reveal gaps, we statistically compared the fastest and slowest patient rescue times from islands/islets and barangays to the District Hospital on Bantayan Island. We developed spatial care paths (the fastest routes to care) for acute myocardial infarction, community care, and infectious diseases. We generated a compendium of prehospital diagnostic testing and integrated outcomes evidence, diagnostic needs, and public health goals to recommend point-of-care strategies that build geographic health resilience.ResultsWe observed limited access to COVID-19 assays, absence of blood gas/pH testing for critical care support, and spatial gaps in land and airborne rescues that worsened during inclement weather and sea swells. Mean paired differences (slowest-fastest) in ambulance rescue times to the District Hospital for both islands and barangays were significant (P < 0.0001). Spatial care path analysis showed where point-of-care cardiac troponin testing should be implemented for expedited care of acute myocardial infarction. Geospatial strengths comprised distributed primary care that can be facilitated by point-of-care testing, logical interisland transfers for which decision making and triage could be accelerated with onboard diagnostics, and healthcare networks amenable to medical advances in prehospital testing that accelerate treatment.ConclusionsPoint-of-care testing should be positioned upstream close to homes and island populations that have prolonged rescue time contours. Geospatially optimized point-of-need diagnostics and distributed prehospital testing have high potential to improve outcomes. These improvements will potentially decrease disparities in mortality among archipelago versus urban dwellers, help improve island public health, and enhance resilience for increasingly adverse and frequent climate change weather disasters that impact vulnerable coastal areas. [350 words].

Mind the Gap: Model-Based Switching from Selatogrel to Maintenance Therapy with Oral P2Y12 Receptor Antagonists.

Background: The P2Y12 receptor antagonist selatogrel is being developed for subcutaneous self-administration with a ready-to-use autoinjector at the onset of acute myocardial infarction (AMI) symptoms. The unique pharmacological profile of selatogrel (fast, potent, and short-acting) can bridge the time gap between the onset of AMI and first medical care. A clinical Phase 1 study showed a time-dependent pharmacodynamic interaction between selatogrel and loading doses of clopidogrel and prasugrel. As treatment switching is a common clinical practice, the assessment of subsequent switching from a clopidogrel loading dose to the first maintenance dose of oral P2Y12 receptor antagonists is highly relevant. Objectives: Model-based predictions of inhibition of platelet aggregation (IPA) for the drugs triggering pharmacodynamic interactions were to be derived to support clinical guidance on the transition from selatogrel to oral P2Y12 receptor antagonists. Methods: Scenarios with selatogrel 16 mg administration or placebo followed by a clopidogrel loading dose and, in turn, prasugrel or ticagrelor maintenance doses at different times of administration were studied. Population pharmacokinetic/pharmacodynamic modeling and simulations of different treatment scenarios were used to derive quantitative estimates for IPA over time. Results: Following selatogrel/placebo and a clopidogrel loading dose, maintenance treatment with ticagrelor or a prasugrel loading dose followed by maintenance treatment quickly achieved sustained IPA levels above 80%. Prior to maintenance treatment, a short time span from 18 to 24 h was identified where IPA levels were predicted to be lower with selatogrel than with placebo if clopidogrel was administered 12 h after selatogrel or placebo. Predicted IPA levels reached with placebo alone and a clopidogrel loading dose at 4 h were consistently lower than with selatogrel administration, followed by a clopidogrel loading dose at 12 h. If a clopidogrel loading dose is administered at 12 h, selatogrel maintains higher IPA levels up to 16 h. IPA levels are subsequently lower than on the placebo until the administration of the first maintenance dose. Conclusions: Model-based predictions informed the transition from selatogrel subcutaneous administration to oral P2Y12 therapy. The application of modeling techniques illustrates the value of employing pharmacokinetic and pharmacodynamic modeling for the simulation of various clinical scenarios of switching therapies.

Trends in Short-, Intermediate-, and Long-Term Mortality Following Hospitalization for Myocardial Infarction Among Medicare Beneficiaries, 2008 to 2018.

Background Advances in technology and care quality have transformed the care of acute myocardial infarction (AMI), but little is known about trends in mortality rates across separate time periods after hospitalization. Methods and Results We identified all Medicare fee-for-service beneficiaries hospitalized with incident AMI from 2008 to 2018. We calculated unadjusted mortality rates by dividing the number of all-cause deaths by the number of patients with incident AMI for the following time periods: acute (in hospital), post acute (0-30 days after hospital discharge), short term (31 days to 1 year after discharge), intermediate term (1-2 years after discharge), and long term (2-3 years after discharge). Each period was considered separately (ie, patients who died during one period were not counted in subsequent periods). Using logistic regression to account for differences in patient characteristics, we calculated annual risk standardized mortality ratios defined as observed over expected mortality based on 2008 rates. Among 768 084 patients with incident AMI (mean age 81 years, 48% male, 87% White), declines in observed-to-expected mortality ratios were observed for each time period: acute (0.68 [95% CI, 0.66-0.71]), postacute (0.72 [95% CI, 0.71-0.75]), short term (0.77 [95% CI, 0.75-0.78]), intermediate term (0.79 [95% CI, 0.77-0.81]), and long term (0.77 [95% CI, 0.75-0.79]). Declines were observed both for patients with and without ST-segment-elevation AMI. Conclusions For patients with incident AMI, there have been improvements in mortality rates across periods spanning the hospital stay through 3 years after discharge, reflecting advances in AMI care from hospitalization through long-term outpatient follow-up.

EASY-NET Program: Methods and Preliminary Results of an Audit and Feedback Intervention in the Emergency Care for Acute Myocardial Infarction in the Lazio Region, Italy.

Within the EASY-NET network program (NET-2016-02364191), Work Package 1 Lazio evaluates the effectiveness of a structured audit and feedback (A&F) intervention compared with the web-based regional periodic publication of indicators in improving the appropriateness and timeliness of emergency healthcare for acute myocardial infarction (AMI). This work describes the A&F methodology and presents the results of the first feedback delivered. The intervention involves sending periodic reports via e-mail to participating hospitals. The feedback reports include a set of volume and quality (process and outcome) indicators, calculated by facility through the health information system of the Lazio Region and compared with regional mean, target values and values calculated for hospitals with similar volumes of activity. Health managers and clinicians of each participating hospital represent the "feedback recipients". They are invited to organize clinical and organizational audit meetings to identify possible critical issues in the care pathway and define, where necessary, improvement actions. A total of 16 facilities are involved. Twelve facilities present high volumes in all volume indicators, while three facilities present low volumes for each indicator. Concerning the quality indicators, four facilities do not present critical indicators or had average results, three facilities do not present critical indicators but show average results in at least one of the indicators and six facilities present a critical value for at least one of the indicators. The first report highlighted some critical issues in some facilities on several indicators. During the audit meetings, each facility analyzes these issues, defining appropriate improvement actions. The outcome of these actions will be monitored through subsequent reporting to support the continuous care quality improvement process.

Impact of a Prior Cancer Diagnosis on Quality of Care and Survival Following Acute Myocardial Infarction: Retrospective Population-Based Cohort Study in England.

An increasing proportion of patients with cancer experience acute myocardial infarction (AMI). We investigated differences in quality of AMI care and survival between patients with and without previous cancer diagnoses. A retrospective cohort study using Virtual Cardio-Oncology Research Initiative data. Patients aged 40+ years hospitalized in England with AMI between January 2010 and March 2018 were assessed, ascertaining previous cancers diagnosed within 15 years. Multivariable regression was used to assess effects of cancer diagnosis, time, stage, and site on international quality indicators and mortality. Of 512 388 patients with AMI (mean age, 69.3 years; 33.5% women), 42 187 (8.2%) had previous cancers. Patients with cancer had significantly lower use of ACE (angiotensin-converting enzyme) inhibitors/angiotensin receptor blockers (mean percentage point decrease [mppd], 2.6% [95% CI, 1.8-3.4]) and lower overall composite care (mppd, 1.2% [95% CI, 0.9-1.6]). Poorer quality indicator attainment was observed in patients with cancer diagnosed in the last year (mppd, 1.4% [95% CI, 1.8-1.0]), with later stage disease (mppd, 2.5% [95% CI, 3.3-1.4]), and with lung cancer (mppd, 2.2% [95% CI, 3.0-1.3]). Twelve-month all-cause survival was 90.5% in noncancer controls and 86.3% in adjusted counterfactual controls. Differences in post-AMI survival were driven by cancer-related deaths. Modeling improving quality indicator attainment to noncancer patient levels showed modest 12-month survival benefits (lung cancer, 0.6%; other cancers, 0.3%). Measures of quality of AMI care are poorer in patients with cancer, with lower use of secondary prevention medications. Findings are primarily driven by differences in age and comorbidities between cancer and noncancer populations and attenuated after adjustment. The largest impact was observed in recent cancer diagnoses (<1 year) and lung cancer. Further investigation will determine whether differences reflect appropriate management according to cancer prognosis or whether opportunities to improve AMI outcomes in patients with cancer exist.

The impact of the COVID-19 Pandemic on Emergency Care of Acute Myocardial Infarction: Findings from the Taiwan Clinical Performance Indicator (TCPI).

Acute myocardial infarction (AMI) treatment requires timely diagnosis and treatment for optimal health outcomes. The COVID-19 pandemic has caused changes in healthcare delivery and utilisation; therefore, our study explored the changes in emergency care quality indicators for patients with AMI before and during different periods of government response to the COVID-19 outbreak in Taiwan. The Taiwan Clinical Performance Indicators (TCPI) database was used to evaluate the impact of COVID-19 on acute care quality indicators for patients with AMI during four periods: before the COVID-19 outbreak (Period I, 1 January to 31 December 2019) and during three periods in which the central government imposed different levels of epidemic prevention and response alerts (Period II, 1 January 2020, to 30 April 2021; Period III, 1 May to 31 July 2021; and Period IV, 1 August to 31 December 2021) . A 15.9% decrease in monthly emergency department admission for patients with AMI occurred during Period III. The hospital "door-to-electrocardiogram time being <10 min" indicator attainment was significantly lower during Periods III and IV. The attainment of "dual antiplatelet therapy (DAPT) received within 6 hours of emergency department arrival" indicator improved in Period IV, whereas "the primary percutaneous coronary intervention (PCI) being received within 90 min of hospital arrival" indicator significantly decreased during Periods III and IV. The indicator "in-hospital mortality" was unchanged within our study duration. Overall, the quality of care for patients with AMI was mildly influenced during the assessed pandemic periods, especially in terms of door-to- electrocardiogram times of <10 min and primary PCI received within 90 min of hospital arrival (Period III). Using our study results, hospitals can develop strategies regarding care delivery for patients with AMI during a COVID-19 outbreak on the basis of central government alert levels, even during the height of the pandemic.

Impact of COVID-19 pandemic early response measures on myocardial infarctions and acute cardiac care in Singapore.

The COVID -19 pandemic impacted acute myocardial infarction (AMI) attendances, ST-elevation myocardial infarction (STEMI) treatments, and outcomes. We collated data from majority of primary percutaneous coronary intervention (PPCI)-capable public healthcare centres in Singapore to understand the initial impact COVID-19 had on essential time-critical emergency services. We present data comparisons from 'Before Disease Outbreak Response System Condition (DORSCON) Orange', 'DORSCON Orange to start of circuit breaker (CB)', and during the first month of 'CB'. We collected aggregate numbers of weekly elective PCI from four centres and AMI admissions, PPCI, and in-hospital mortality from five centres. Exact door-to-balloon (DTB) times were recorded for one centre; another two reported proportions of DTB times exceeding targets. Median weekly elective PCI cases significantly decreased from 'Before DORSCON Orange' to 'DORSCON Orange to start of CB' (34 vs 22.5, P = 0.013). Median weekly STEMI admissions and PPCI did not change significantly. In contrast, the median weekly non-STEMI (NSTEMI) admissions decreased significantly from 'Before DORSCON Orange' to 'DORSCON Orange to start of CB' (59 vs 48, P = 0.005) and were sustained during CB (39 cases). Exact DTB times reported by one centre showed no significant change in the median. Out of three centres, two reported significant increases in the proportion that exceeded DTB targets. In-hospital mortality rates remained static. In Singapore, STEMI and PPCI rates remained stable, while NSTEMI rates decreased during DORSCON Orange and CB. The severe acute respiratory syndrome (SARS) experience may have helped prepare us to maintain essential services such as PPCI during periods of acute healthcare resource strain. However, data must be monitored and increased pandemic preparedness measures must be explored to ensure that AMI care is not adversely affected by continued COVID fluctuations and future pandemics.

EASY-NET program: methods and preliminary results of an audit and feedback intervention in the emergency care for Acute Myocardial Infarction in the Lazio region, Italy

EASY-NET program: methods and preliminary results of an audit and feedback intervention in the emergency care for Acute Myocardial Infarction in the Lazio region, Italy

Application of health equity audit to emergency care for acute myocardial infarction

Application of health equity audit to emergency care for acute myocardial infarction

Revealing concealed cardioprotection by platelet Mfsd2b-released S1P in human and murine myocardial infarction

Antiplatelet medication is standard of care in acute myocardial infarction (AMI). However, it may have obscured beneficial properties of the activated platelet secretome. We identify platelets as major source of a sphingosine-1-phosphate (S1P) burst during AMI, and find its magnitude to favorably associate with cardiovascular mortality and infarct size in STEMI patients over 12 months. Experimentally, administration of supernatant from activated platelets reduces infarct size in murine AMI, which is blunted in platelets deficient for S1P export (Mfsd2b) or production (Sphk1) and in mice deficient for cardiomyocyte S1P receptor 1 (S1P1). Our study reveals an exploitable therapeutic window in antiplatelet therapy in AMI as the GPIIb/IIIa antagonist tirofiban preserves S1P release and cardioprotection, whereas the P2Y12 antagonist cangrelor does not. Here, we report that platelet-mediated intrinsic cardioprotection is an exciting therapeutic paradigm reaching beyond AMI, the benefits of which may need to be considered in all antiplatelet therapies.

Contemporary Trends in Acute Myocardial Infarction in the American Indian/Alaska Native U.S. Population, 2000 to 2018

Coronary heart disease is disproportionately prevalent in the American Indian/Alaska Native (AI/AN) population. As care for acute myocardial infarction (AMI) continues to advance, equitable distribution and access for the AI/AN population is essential. Primary AMI hospitalizations for adults ≥18years of age were identified from the Healthcare Cost and Utilization Project National Inpatient Sample from 2000 to 2018. Related co-morbidities, procedures of interest, and in-hospital mortality were also identified. These rates were stratified by race then trended over years using Poisson regression. Overall, 9,904,714 weighted hospitalizations for primary AMI were identified. From 2000 to 2018, AI/AN adults had relatively high rates of primary AMI hospitalization, second only to non-Hispanic (NH) White adults. The AMI rate increased from 14.0/1,000 to 16.1/1,000 among AI/AN adults, remaining higher than NH Black adults (12.1/1,000 to 13.0/1,000) and Hispanic adults (10.3/1,000 and 12.7/1,000) and becoming increasingly closer to NH White adults (25.1/1,000 to 20.0/1,000) (p <0.001 for each). AI/AN adults presented 5years earlier than their NH White counterparts (64 vs 69 years old; p <0.001). In-hospital mortality was approximately 5% for all race categories and decreased in all groups but decreased at a much greater rate for NH White, NH Black and Hispanic adults (0.2% per year) compared with AI/AN adults (0.08% per year; p <0.001 for each comparison). Rates of coronary angiography and percutaneous coronary intervention increased in all groups, but coronary artery bypass graft utilization increased only in AI/AN adults (from 7% to 10%, p <0.001). In conclusion, from 2000 to 2018, AI/AN adults had a high rate of AMI hospitalizations (second only to NH White adults) that increased significantly over time. AI/AN adults were 5years younger than their NH White counterparts at index AMI hospitalization. Care during these hospitalizations was similar among all racial groups, and in-hospital mortality decreased for all groups, albeit to a lesser degree among AI/AN adults. This study highlights the need for improved access to outpatient primary AMI prevention in the AI/AN population.