Acute Myocardial Infarction Care Research Articles

THE ROLE OF NT-PROBNP AND ST2 BIOMARKERS IN PATIENTS WITH ACUTE CORONARY SYNDROME

The aim: To determine the diagnostic value of serum levels of ST2 in patients with the acute coronary syndrome (ACS) and its correlation with NT-proBNP levels. Materials and methods: NT-proBNP and ST2 concentration in serum of patients was measured on admission to the hospital and on the 10th day of the treatment using NT-proBNP ELISA (Biomedica, Slovakia) and Presage ST2 assay (Critical Diagnostics, USA), respectively. Results: Statistically significant direct correlations (p<0.05). The simultaneous increase of ST2 and NT-proBNP serum levels above their threshold in patients with ACSelST (sensitivity – 92.5 %, specificity – 74.2 %, AUC – 0.893, р<0.05) indicated a significant risk of cardiovascular (CV) complications of acute myocardial infarction (AMI) during the inpatient period, e.g. acute heart failure, acute LV aneurysm, recurrent AMI, as well as rhythm and conductivity disturbances. Conclusions: The data suggest that both ST2 and NT-proBNP may prove useful in predicting unfavorable prognosis during the inpatient care of AMI, as the simultaneous increase of these biomarkers above their threshold values indicates a significant risk of CV complications.

Abstract 12645: National Trends, Predictors and Outcomes of Inpatient Palliative Care Use in Cardiac Arrest Complicating Acute Myocardial Infarction

Introduction: Multi-disciplinary care with integration of the palliative care services (PCS) in acutely ill cardiac patients is known to improve resource utilization and overall patient care. However, there are limited data on the role of PCS in the care of acute myocardial infarction (AMI) patients with cardiac arrest (CA). Methods: We used the National Inpatient Sample (2000-2017) to identify adult AMI admissions with concomitant CA. We evaluated temporal trends and predictors of PCS use, and in-hospital mortality, length of stay, and discharge disposition in AMI-CA admissions with and without PCS use. A propensity matching analysis using 1:1 nearest neighbor matching was performed between cohorts with and without PCS use to derive a propensity-matched sample with standardized differences <5% for all baseline characteristics. Results: During the study period, there were a total of 584,263 AMI-CA admissions, of which 26,919 (4.6%) received PCS. PCS use increased from <1% in 2000 to 11.5% by 2017. AMI-CA admissions that received PCS were on an average older (70.1 ± 13.0 vs 66.7 ± 13.5), had greater comorbidity with higher rates of cardiogenic shock (44.5% vs 26.6%) and non-cardiac organ failure (80.6% vs 41.6%)(all p<0.001). Admissions receiving PCS had lower rates of angiography (48.6% vs 63.3%) and percutaneous coronary intervention (37.4% vs 46.9%) use (p<0.001). Older age, greater comorbidity, and acute organ failure were independently associated with PCS use. In-hospital mortality was higher in the PCS cohort (84.6% vs 42.9%, adjusted odds ratio 3.62 [95% CI 3.48-3.76]; p<0.001). Similar findings were seen in the propensity-matched cohort with higher in-hospital mortality for AMI-CA admissions receiving PCS (84.7% vs 66.2%, p<0.001) The PCS cohort had higher do-not-resuscitate status use (47.6% vs. 3.7%), shorter hospital stays (4 vs 5 days), and more frequent skilled nursing facility discharges (73.6% vs. 20.4%); p<0.001. Conclusions: Despite an increase in PCS use in AMI-CA, it remains significantly underutilized, highlighting the need to further integrate PCS specialists into the care of high-risk conditions such as cardiac arrest to deliver holistic patient care.

Abstract 11311: Geographic Variation and Temporal Trends in Management and Outcomes of Cardiac Arrest Complicating Acute Myocardial Infarction in the United States

Introduction: Regional variation in the uptake of newer techniques, procedures, and management strategies have been previously reported with acute cardiac care. Limited contemporary information exists on regional differences in the care of acute myocardial infarction (AMI) patients with cardiac arrest (CA). Methods: Using the National Inpatient Sample (2000-2017), we identified adults with AMI and concomitant CA admitted to the United States census regions of Northeast, Midwest, South, and West. Clinical outcomes of interest including in-hospital mortality, use of coronary angiography, percutaneous coronary intervention (PCI), mechanical circulatory support (MCS), hospitalization costs, and length of stay were compared across these four regions. Results: Of 9,680,257 admissions for AMI, 494,083 (5.1%) had concomitant CA. The prevalence of CA in AMI was highest in the West (6.0%) compared to the Northeast (4.4%), Midwest (5.0%), and South (5.1%), p<0.001. Admissions in the West had higher rates of STEMI presentation, cardiogenic shock, multiorgan failure, mechanical ventilation, and hemodialysis. Northeast AMI-CA admissions had lower use of coronary angiography (52.0% vs. 67.9% vs. 60.9% vs. 61.5%), PCI (38.7% vs. 51.9% vs. 44.8% vs. 46.7%), and MCS (18.4% vs. 21.8% vs. 18.1%, vs. 20.0%) compared to the Midwest, West and South (all p<0.001). Compared with the Northeast, adjusted in-hospital mortality for AMI-CA was higher in the Midwest (odds ratio [OR] 1.06 [95% confidence interval {CI} 1.03-1.08]; p<0.001), South (OR 1.11 [95% CI 1.09-1.13]; p<0.001), and highest in the West (OR 1.16 [95% CI 1.13-1.18]; p<0.001). Temporal trends showed a decline in in-hospital mortality except in the West, which showed a slight increase. Compared to other regions, AMI-CA admissions from the Northeast had longer in-hospital stays and less frequent palliative care consultations (all p<0.001). Admissions in the West had higher rates of palliative care consultations, DNR status, and highest hospitalization costs. Conclusions: We identified significant regional disparities in the management and outcomes of AMI-CA. Efforts to improve and provide uniform care for AMI-CA across regions may be essential.

Effectiveness of applying clinical simulation scenarios and integrating information technology in medical-surgical nursing and critical nursing courses

BackgroundTo determine the impact of combining clinical simulation scenario training and Information Technology Integrated Instruction (ITII) on the teaching of nursing skills.Methods120 4th-year students in a nursing program who were enrolled in medical and surgical nursing courses. 61 received innovative instruction (experimental group) and 59 received conventional instruction (control group). The ADDIE model, systematic method of course development that includes analysis, design, development, implementation, and evaluation,was used to build simulation teaching and clinical scenarios and to create and modify objective structure clinical examination (OSCE) scenario checklists for acute myocardial infarction (AMI) care, basic life support and operation of automated external defibrillator (BLS), and subdural hemorrhage (SDH) care. The modified OSCE checklists were assessed for reliability, consistency, and validity. The innovative training included flipped classrooms, clinical simulation scenarios, ITII and blended learning formats.ResultsThe reliability and validity of the OSCE checklists developed in this study were acceptable and comparable or higher than checklists in past studies and could be utilized as an OSCE performance tool. Students in innovative instruction obtained significantly better OSCE performance, lab scores and improvements from the previous year’s grades. Significant differences were found in situational awareness (SA). No strong correlations were found between OSCE scores and clinical internship scores, and no significant differences were found between the groups in overall clinical internship performance.ConclusionsInnovative instruction showed better performance than conventional methods in summative evaluation of knowledge components, OSCE formative evaluation and clinical nursing internship scores, as well as improved situational awareness in nursing students.

Geographic variation and temporal trends in management and outcomes of cardiac arrest complicating acute myocardial infarction in the United States

BackgroundLimited studies have evaluated regional disparities in the care of acute myocardial infarction (AMI) patients with cardiac arrest (CA). This study sought to evaluate 18-year national trends, resource utilization, and geographical variation in outcomes in AMI-CA admissions. Methods and resultsUsing the National Inpatient Sample (2000–2017), we identified adults with AMI and concomitant CA admitted to the United States census regions of Northeast, Midwest, South, and West. Clinical outcomes of interest included in-hospital mortality, use of coronary angiography, percutaneous coronary intervention (PCI), mechanical circulatory support (MCS), hospitalization costs and length of stay. Of 9,680,257 admissions for AMI, 494,083 (5.1%) had concomitant CA. The West (6.0%) had higher prevalence compared to the Northeast (4.4%), Midwest (5.0%), and South (5.1%), p < 0.001. Admissions in the West had higher rates of STEMI, cardiogenic shock, multiorgan failure, mechanical ventilation, and hemodialysis. Northeast admissions had lower use of coronary angiography (52.0% vs. 67.9% vs. 60.9% vs. 61.5%), PCI (38.7% vs. 51.9% vs. 44.8% vs. 46.7%), and MCS (18.4% vs. 21.8% vs. 18.1%, vs. 20.0%) compared to the Midwest, West and South (all p < 0.001). Compared with the Northeast, adjusted in-hospital mortality was higher in the Midwest (odds ratio [OR] 1.06 [95% confidence interval {CI} 1.03–1.08]), South (OR 1.11 [95% CI 1.09–1.13]) and highest in the West (OR 1.16 [95% CI 1.13–1.18]), all p < 0.001. Temporal trends showed a decline in in-hospital mortality except in the West, which showed a slight increase. ConclusionsThere remain significant regional disparities in the management and outcomes of AMI-CA.

Variations in Quality of Care by Sex and Social Determinants of Health Among Younger Adults With Acute Myocardial Infarction in the US and Canada

Quality of care of young adults with acute myocardial infarction (AMI) may depend on health care systems in addition to individual-level factors such as biological sex and social determinants of health (SDOH). To examine whether the quality of in-hospital and postacute care among young adults with AMI differs between the US and Canada and whether female sex and adverse SDOH are associated with a low quality of care. This retrospective cohort analysis used data from 2 large cohorts of young adults (aged ≤55 years) receiving in-hospital and outpatient care for AMI at 127 centers in the US and Canada. Data were collected from August 21, 2008, to April 30, 2013, and analyzed from July 12, 2019, to March 10, 2021. Sex, SDOH, and health care system. Opportunity-based quality-of-care score (QCS), determined by dividing the total number of quality indicators of care received by the total number for which the patient was eligible, with low quality of care defined as the lowest tertile of the QCS. A total of 4048 adults with AMI (2345 women [57.9%]; median age, 49 [interquartile range, 44-52] years; 3004 [74.2%] in the US) were included in the analysis. Of 3416 patients with in-hospital QCS available, 1061 (31.1%) received a low QCS, including more women compared with men (725 of 2007 [36.1%] vs 336 of 1409 [23.8%]; P < .001) and more patients treated in the US vs Canada (962 of 2646 [36.4%] vs 99 of 770 [12.9%]; P < .001). Conversely, low quality of post-AMI care (748 of 2938 [25.5%]) was similarly observed for both sexes, with a higher prevalence in the US (678 of 2346 [28.9%] vs 70 of 592 [11.8%]). In adjusted analyses, female sex was not associated with low QCS for in-hospital (odds ratio [OR], 1.05; 95% CI, 0.87-1.28) and post-AMI (OR, 1.07; 95% CI, 0.88-1.30) care. Conversely, being treated in the US was associated with low in-hospital (OR, 2.93; 95% CI, 2.16-3.99) and post-AMI (OR, 2.67; 95% CI, 1.97-3.63) QCS, regardless of sex. Of all SDOH, only employment was associated with higher quality of in-hospital care (OR, 0.72; 95% CI, 0.59-0.88). Finally, only in the US, low quality of in-hospital care was associated with a higher 1-year cardiac readmissions rate (234 of 962 [24.3%]). These findings suggest that beyond sex, health care systems and SDOH that depict social vulnerability are associated with quality of AMI care. Taking into account SDOH among young adults with AMI may improve quality of care and reduce readmissions, especially in the US.

Association of quality indicators for acute myocardial infarction and mortality: feasibility and validation study using linked nationwide registry data

BackgroundQuality indicators (QIs) have been increasingly used as tools to assess and improve the quality of care for acute myocardial infarction (AMI). However, it is not known if it is feasible to use the 2020 iteration of international AMI QIs using routinely collected data and, if so, whether higher performance is associated with improved outcomes.ObjectiveTo investigate if routine data are available to measure care quality against the 2020 European Society of Cardiology (ESC) Association for Acute Cardiovascular Care (ACVC) QIs for AMI, investigate whether higher performance is associated with reduced mortality, and to report quality of care during the COVID-19 pandemic.MethodsCohort study of linked data from the AMI and percutaneous coronary intervention (PCI) registries in England and Wales with outcome data from the Civil Registration of Deaths Register between 2017 and 2020 (representing 236 743 patients from 186 hospitals). Baseline ischaemic risk was estimated using the Global Registry of Acute Coronary Events (GRACE) risk score. The likelihood of attainment for each QI based on GRACE risk was quantified using logistic regression and the association with mortality at 30 days, 6 months, 1 year and long-term (maximum 1243 days) was obtained from Cox proportional hazard models.ResultsOf 26 QIs, 17 (65.3%) could be directly measured using nationwide registry data and were each inversely associated with risk-adjusted 1-year and long-term mortality. At 30 days, the measured QIs with exception of early invasive coronary angiography for non-ST elevation myocardial infarction, were associated with improved survival, and the QIs that had the greatest magnitude for a reduction in mortality were the prescription of secondary prevention medications at discharge; hazard ratio 0.13 (95% CI 0.12–0.14) for statins, 0.16 (95% CI 0.15–0.18) for adequate P2Y12 inhibition, and 0.18 (95% CI 0.17–0.20) for dual antiplatelet therapy (Figure 1). The magnitude of association between the composite QI (CQI) and survival attenuated over time, with greater long-term survival gains observed for the high GRACE risk compared with low- and intermediate-risk (Figure 2). During the first UK lockdown there was an improvement in the attainment for 62.5% of the measured QIs compared with before the COVID-19 pandemic, with a higher attainment for the CQI (43.8% to 45.2%, odds ratio 1.06, 95% CI 1.02–1.10).ConclusionCare quality for AMI may be evaluated using routinely collected clinical data from the national registries, whereby higher performance is associated with reduced mortality. Such QIs will have a role in monitoring hospital care as demonstrated for COVID-19.Funding AcknowledgementType of funding sources: None. Figure 2. QI association with long-term mortality

Public awareness of acute myocardial infarction symptoms and emergency response in community residents

Abstract Background Patient delay in seeking help has been reported to be a major factor that related to delay in care of acute myocardial infarction (AMI). Lack the knowledge of symptoms may translate to behavioral deficiencies which lead up to failing to seek medical assistant at early stage of AMI. Purpose The aim of present study is to investigate the awareness of AMI symptoms and the emergency responses among community residents over 35 years old. Methods The sample was proportionally distributed by age according to the national census data. The sex ratio was 1:1. The sample size is calculated according to the significance level of 0.05, the allowable error of 0.1, and the estimated Excellent awareness level of 10%. The final sample size is adjusted to 4200, considering non-response rate of 20%. Multi-stage stratified random sampling was used. On the first stage, two districts each in urban and rural regions were randomly selected. On the second stage, 3–10 community health service centers were randomly selected in each district. On the third stage, residents over 35 managed by the community health service center were proportionally sampled to be interviewed. A structured questionnaire was used and the survey was conducted in a face-to-face interview by clinical physicians. Logistic regression was applied to analyze factors related to Good knowledge. Results The top three symptom recognized by public is “pain or discomfort in the chest” (71.3%), followed by “difficulty breathing” (65.1%) and “pain or discomfort in the jaw, neck, or back” (60.9%). 85.0% chose to call an ambulance as first response when witness others having an AMI. Those who lives alone (OR=1.408; 95% CI, 1.005–1.972) and whose immediate family had been diagnosed with AMI (OR=1.510; 95% CI, 1.040–2.192) has better knowledge. A significant positive correlation was observed for those with hypertension (OR=1.199; 95% CI, 1.007–1.429), while a negative correlation was observed for those with diabetes (OR=0.788; 95% CI, 0.626–0.992). Public education could improve Good knowledge (OR=1.662; 95% CI, 1.388–1.990), while doctoral advise has been shown negative impact (OR=0.824; 95% CI, 0.691–0.984). Conclusions Our data provide first population-based estimates of public awareness in our country. Further promotional strategies to increase overall awareness in general public are seriously needed. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): Major Science and Technology Projects of Tianjin Science and Technology Commission Multivariable logistic regression

The impact of COVID-19 pandemic on AMI and stroke mortality in Lombardy: Evidence from the epicenter of the pandemic.

BackgroundThe first Covid-19 epidemic outbreak has enormously impacted the delivery of clinical healthcare and hospital management practices in most of the hospitals around the world. In this context, it is important to assess whether the clinical management of non-Covid patients has not been compromised. Among non-Covid cases, patients with Acute Myocardial Infarction (AMI) and stroke need non-deferrable emergency care and are the natural candidates to be studied. Preliminary evidence suggests that the time from onset of symptoms to emergency department (ED) presentation has significantly increased in Covid-19 times as well as the 30-day mortality and in-hospital mortality.MethodsWe check, in a causal inference framework, the causal effect of the hospital’s stress generated by Covid-19 pandemic on in-hospital mortality rates (primary end-point of the study) of AMI and stroke over several time-windows of 15-days around the implementation date of the State of Emergency restrictions for COVID-19 (March, 9th 2020) using two quasi-experimental approaches, regression-discontinuity design (RDD) and difference-in-regression-discontinuity (DRD) designs. Data are drawn from Spedali Civili of Brescia, one of the most hit provinces in Italy by Covid-19 during March and May 2020.FindingsDespite the potential adverse effects on expected mortality due to a longer time to hospitalization and staff extra-burden generated by the first wave of Covid-19, the AMI and stroke mortality rates are overall not statistically different during the first wave of Covid-19 than before the first peak. The obtained results provided by RDD models are robust also when we account for seasonality and unobserved factors with DRD models.InterpretationThe non-statistically significant impact on mortality rates for AMI and stroke patients provides evidence of the hospital ability to manage -with the implementation of a dual track organization- the simultaneous delivery of high-quality cares to both Covid and non-Covid patients.

Impact of Race on the In-Hospital Quality of Care Among Young Adults With Acute Myocardial Infarction.

BackgroundThe extent to which race influences in‐hospital quality of care for young adults (≤55 years) with acute myocardial infarction (AMI) is largely unknown. We examined racial disparities in in‐hospital quality of AMI care and their impact on 1‐year cardiac readmission.Methods and ResultsWe used data from the VIRGO (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients) study enrolling young Black and White US adults with AMI (2008–2012). An in‐hospital quality of care score (QCS) was computed (standard AMI quality indicators divided by the total a patient is eligible for). Multivariable logistic regression was performed to identify factors associated with the lowest QCS tertile, including interactions between race and social determinants of health. Among 2846 young adults with AMI (median 48 years [interquartile range 44–52], 67.4% women, 18.8% Black race), Black individuals, especially women, exhibited a higher prevalence of cardiac risk factors and social determinants of health and were more likely to experience a non–ST‐segment–elevation myocardial infarction than White individuals. Black individuals were more likely in the lowest QCS tertile than White individuals (40.8% versus 34.7%; P=0.003). The association between Black race and low QCS (odds ratio [OR], 1.25; 95% CI, 1.02–1.54) was attenuated by adjustment for confounders. Employment was independently associated with better QCS, especially among Black participants (OR, 0.76; 95% CI, 0.62–0.92; P‐interaction=0.02). Black individuals experienced a higher rate of 1‐year cardiac readmission (29.9% versus 20.0%; P<0.0001).ConclusionsBlack individuals with AMI received lower in‐hospital quality of care and exhibited a higher rate of cardiac readmissions than White individuals. Black individuals had a lower quality of care if unemployed, highlighting the intersection of race and social determinants of health.

1394Better Cardiac Care Data Linkage Project: utilising cross-jurisdictional data to improve patient-flow capture

Abstract Background For patients experiencing acute myocardial infarction (AMI), particularly ST-elevation myocardial infarction (STEMI), timely revascularisation is important to optimise prognosis. The AMI patient journey often involves presentation to the closest appropriate facility and transfers between hospitals, including across jurisdictions. The Better Cardiac Care (BCC) dataset consists of cross-jurisdictional linked ambulance, emergency, hospital, outpatient, deaths, Medicare and Pharmaceutical Benefits Scheme records for residents of New South Wales (NSW), Australia. This dataset will be updated annually. Methods The BCC dataset comprises 332 million records, from 18 datasets, across 6 jurisdictions. For NSW residents hospitalised for STEMI between 2013 to 2018, we compared the number of STEMI hospitalisations, the proportion of patients receiving revascularisation procedures, and the time to procedures using only NSW records versus records from all jurisdictions and Medicare Benefits Scheme. Results Compared with NSW hospital data, including data from other jurisdictions increased the ascertainment of STEMI hospitalisations by 8.0% and procedures by 11.2% for NSW residents. This increase was greatest for residents living near state borders, increasing the number of STEMI hospitalisations by up to 210% and the percentage receiving procedures by up to 70%. Conclusions Cross-jurisdictional data is essential to understand patient journeys of residents who live in border areas and to evaluate patient care for STEMI and AMI more broadly. Key messages The BCC dataset is a vital asset that enables a more comprehensive view of care for AMI than has been possible to date.

Association of entirely claims-based frailty indices with long-term outcomes in patients with acute myocardial infarction, heart failure, or pneumonia: a nationwide cohort study in Turkey.

BackgroundSeveral countries have increasingly focused on improving care for acute myocardial infarction (AMI), heart failure (HF), and pneumonia to reduce their readmissions and mortality rates. Frailty is becoming increasingly important to accurately predict healthcare utilization for the aging population. The preferred method for the measurement of frailty remains unclear, and current risk-adjustment models do not account for frailty. We sought to compare commonly used frailty indices in terms of the ability to predict clinical adverse outcomes in AMI, HF, and pneumonia patients.MethodsA nationwide cohort study included AMI, HF, and pneumonia with 65 years and older patients in the Turkey between January 1 and December 31, 2018. The primary predictor of interest was frailty. We used two claims-based frailty indices (Johns Hopkins Claims-Based Frailty Index and Hospital Frailty Risk Score) to assess frailty. The main outcome was all-cause long-term mortality up to 3 years. Time to death was calculated as the time period between the date of first admission and the date of death. Patients were censored as of September 30, 2020, which marked the end of the follow-up period.FindingsOf the 200,948 patients, 35,096 (17.5%) had AMI, 62,403 (31.1%) had HF, and 103,449 (51.5%) had pneumonia. Johns Hopkins Claims-Based Frailty Index (c-statistics for long-term mortality: 0.68 in AMI, 0.61 in HF, 0.64 in pneumonia) was better compared to Hospital Frailty Risk Score (c-statistics for long-term mortality: AMI=0.62, HF=0.58, pneumonia=0.62) (DeLong p<0.001 in all).InterpretationReadmission and mortality rates after AMI, HF, and pneumonia gradually increases with increasing frailty score. While the Hospital Frailty Risk Score had a better discrimination for predicting readmissions, Johns Hopkins Claims-Based Frailty Index had a better discrimination for predicting mortality. These findings should be taken into account for a better evaluation of hospital performance.FundingThis study was supported by funding from The Scientific and Technological Research Council of Turkey (grant 120S422, HK).

Telemedicine Improves the Short-Term Medical Care of Acute ST-Segment Elevation Myocardial Infarction After Primary Percutaneous Coronary Intervention.

Objectives: Telemedicine appears to be a promising tool for healthcare professionals to deliver remote care to patients with cardiovascular diseases especially during the COVID-19 pandemic. We aimed in this study to evaluate the value of telemedicine added to the short-term medical care of acute ST-segment elevation myocardial infarction (STEMI) after primary percutaneous coronary intervention (PCI).Methods: Two hundred acute STEMI patients after primary PCI were randomly divided into two groups. One hundred patients in group A (study group) received a monthly videoconferencing teleconsultation using a smartphone application for 3 months starting 1 week after discharge and at least a single face-to-face (F2F) clinic visit. We reviewed in each virtual visit the symptoms of patients, adherence to healthy lifestyle measures, medications, smoking cessation, and cardiac rehabilitation. Group B (control group) included 100 patients who received at least a single F2F clinic visit in the first 3 months after discharge. Both groups were interviewed after 4 months from discharge for major adverse cardiac events (MACE), adherence to medications, smoking cessation, and cardiac rehabilitation. A survey was done to measure the satisfaction of patients with telemedicine.Results: There was no significant difference between both groups in MACE and their adherence to aspirin, P2Y12 inhibitor, and beta-blockers. However, group A patients had better adherence to statins, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, smoking cessation, and cardiac rehabilitation. Sixty-one percent of patients stated that these videoconferencing teleconsultations were as good as the clinic visits, while 87% of patients were satisfied with telemedicine.Conclusions: Telemedicine may provide additional benefit to the short-term regular care after primary PCI to STEMI patients through videoconferencing teleconsultations by increasing their adherence to medications and healthy lifestyle measures without a significant difference in the short-term MACE. These virtual visits gained a high level of satisfaction among the patients.

Impact of a telemedicine-guided, population-based, STEMI network on reperfusion strategy, efficiency, and outcomes: Impact of telemedicine on STEMI management.

A telemedicine-guided strategy increases the access to and efficiency of ST-elevation myocardial infarction (STEMI) networks resulting in increased access to, and reduced disparities in, acute myocardial infarction (AMI) care between rural and urban areas. The Latin America Telemedicine Infarct Network (LATIN) was developed for poor and remote regions in Brazil and Colombia that lacked coordinated AMI systems of care. It strategically connects small clinics and primary care health centres (spokes) to hubs with 24/7 percutaneous coronary intervention (PCI) capability. Experts at three remote sites provide urgent electrocardiogram (ECG) diagnosis and tele-consultation for the entire network. Data from the busiest LATIN site, the Santa Marcelina Hospital in Sao Paolo, Brazil, were compared with health statistics from Sistema Unico de Saude (Brazilian Public Health System - SUS). A total of 192 centres were networked using standardised and guideline-based protocols for AMI care. Overall, 313,897 patients were remotely screened, 3,572 AMI diagnosed (1.1%), and 1,636 AMI urgently reperfused (45.8%), mainly by primary PCI (n=1,351; 83%). In conclusion, a comparison between a pre-LATIN cohort from SUS (1,015) and a LATIN cohort from Santa Marcelina Hospital (1,247) revealed increased reperfusion with PCI (65.52% vs 75.2%), increased cost ($2,037.12 vs $2,246.40, p<0.005), a statistically significant reduction in PCI mortality (8.5% vs 4.3% p<0.01) and a non-significant reduction in mortality overall amongst all treatment pathways (9.69% vs 9.43%, p=0.931).

Quality of acute myocardial infarction care in England and Wales during the COVID-19 pandemic: linked nationwide cohort study

Background and objectiveThe impact of the COVID-19 pandemic on the quality of care for patients with acute myocardial infarction (AMI) is uncertain. We aimed to compare quality of AMI care...

Impact of COVID-19 pandemic lockdown on myocardial infarction care

The aim of this study was to evaluate the impact of the COVID-19 pandemic lockdown on acute myocardial infarction (AMI) care, and to identify underlying stressors in the German model region for complete AMI registration. The analysis was based on data from the population-based KORA Myocardial Infarction Registry located in the region of Augsburg, Germany. All cases of AMI (n = 210) admitted to one of four hospitals in the city of Augsburg or the county of Augsburg from February 10th, 2020, to May 19, 2020, were included. Patients were divided into three groups, namely pre-lockdown, strict lockdown, and attenuated lockdown period. An additional survey was conducted asking the patients for stress and fears in the 4 weeks prior to their AMI. The AMI rate declined by 44% in the strict lockdown period; in the attenuated lockdown period the rate was 17% lower compared to the pre-lockdown period. The downward trend in AMI rates during lockdown was seen in STEMI and NSTEMI patients, and independent of sex and age. The door-to-device time decreased by 70–80% in the lockdown-periods. In the time prior to the infarction, patients felt stressed mainly due to fear of infection with Sars-CoV-2 and less because of the restrictions and consequences of the lockdown. A strict lockdown due to the Covid-19 pandemic had a marked impact on AMI care even in a non-hot-spot region with relatively few cases of COVID-19. Fear of infection with the virus is presumably the main reason for the drop in hospitalizations due to AMI.

Long term survival after acute myocardial infarction in Australia and New Zealand, 2009-2015: a population cohort study.

To assess long term survival and patient characteristics associated with survival following acute myocardial infarction (AMI) in Australia and New Zealand. Cohort study. All patients admitted with AMI (ICD-10-AM codes I21.0-I21.4) to all public and most private hospitals in Australia and New Zealand during 2009-2015. All-cause mortality up to seven years after an AMI. 239402 initial admissions with AMI were identified; the mean age of the patients was 69.3 years (SD, 14.3 years), 154287 were men (64.5%), and 64335 had ST-elevation myocardial infarction (STEMI; 26.9%). 7-year survival after AMI was 62.3% (STEMI, 70.8%; non-ST-elevation myocardial infarction [NSTEMI], 59.2%); survival exceeded 85% for people under 65 years of age, but was 17.4% for those aged 85 years or more. 120155 patients (50.2%) underwent revascularisation (STEMI, 72.2%; NSTEMI, 42.1%); 7-year survival exceeded 80% for patients in each group who underwent revascularisation, and was lower than 45% for those who did not. Being older (85 years or older v 18-54 years: adjusted hazard ratio [aHR], 10.6; 95% CI, 10.1-11.1) or a woman (aHR, 1.15; 95% CI, 1.13-1.17) were each associated with greater long term mortality during the study period, as was prior heart failure (aHR, 1.79; 95% CI, 1.76-1.83). Several non-cardiac conditions and geriatric syndromes common in these patients were independently associated with lower long term survival, including major and metastatic cancer, cirrhosis and end-stage liver disease, and dementia. AMI care in Australia and New Zealand is associated with high rates of long term survival; 7-year rates exceed 80% for patients under 65 years of age and for those who undergo revascularisation. Efforts to further improve survival should target patients with NSTEMI, who are often older and have several comorbid conditions, for whom revascularisation rates are low and survival after AMI poor.

Development of Acute Myocardial Infarction Mortality and Readmission Models for Public Reporting on Hospital Performance in Canada

BackgroundGiven changes in the care and outcomes of acute myocardial infarction (AMI) patients over the past several decades, we sought to develop prediction models that could be used to generate accurate risk-adjusted mortality and readmission outcomes for hospitals in current practice across Canada.MethodsA Canadian national expert panel was convened to define appropriate AMI patients for reporting and develop prediction models. Preliminary candidate variable evaluation was conducted using Ontario patients hospitalized with a most responsible diagnosis of AMI from April 1, 2015 to March 31, 2018. National data from the Canadian Institute for Health Information was used to develop AMI prediction models. The main outcomes were 30-day all-cause in-hospital mortality and 30-day urgent all-cause readmission. Discrimination of these models (measured by c-statistics) was compared with that of existing Canadian Institute for Health Information models in the same study cohort.ResultsThe AMI mortality model was assessed in 54,240 Ontario AMI patients and 153,523 AMI patients across Canada. We observed a 30-day in-hospital mortality rate of 6.3%, and a 30-day all-cause urgent readmission rate of 10.7% in Canada. The final Canadian AMI mortality model included 12 variables and had a c-statistic of 0.834. For readmission, the model had 13 variables and a c-statistic of 0.679. Discrimination of the new AMI models had higher c-statistics compared with existing models (c-statistic 0.814 for mortality; 0.673 for readmission).ConclusionsIn this national collaboration, we developed mortality and readmission models that are suitable for profiling performance of hospitals treating AMI patients in Canada.

Comparison of Major Clinical Outcomes between Accredited and Nonaccredited Hospitals for Inpatient Care of Acute Myocardial Infarction.

Hospital accreditation programs are used worldwide to improve the quality of care and improve patient safety. It is of great help in improving the structure of hospitals, but there are mixed research results on improving the clinical outcome of patients. The purpose of this study was to compare the levels of core clinical outcome indicators after receiving inpatient services from accredited and nonaccredited hospitals in patients with acute myocardial infarction (AMI). For all patients with AMI admitted to general hospitals in Korea from 2010 to 2017, their 30-day mortality and readmissions and length of stay were compared according to accreditation status. In addition, through a multivariate model that controls various patients’ and hospitals’ factors, the differences in those indicators were analyzed more accurately. The 30-day mortality of patients admitted to accredited hospitals was statistically significantly lower than that of patients admitted to nonaccredited hospitals. However, for 30-day readmission and length of stay, accreditation did not appear to yield more desirable results. This study shows that when evaluating the clinical impact of hospital accreditation programs, not only the mortality but also various clinical indicators need to be included, and a more comprehensive review is needed.

Abstract P536: Impact of the Covid-19 Pandemic on the Volumes and Outcomes of Acute Ischemic Stroke and Myocardial Infarction

Introduction: The COVID-19 pandemic has wreaked havoc on the presentation, care and outcomes of patients with acute cerebrovascular and cardiovascular conditions. We sought to measure the national impact of COVID-19 on the care for acute ischemic stroke (AIS) and acute myocardial infarction (AMI). Methods: In this retrospective, observational study, we used the Premier Healthcare Database to evaluate the changes in the volume of care and hospital outcomes for AIS and AMI in relation to the pandemic. The pandemic months were defined from March 1, 2020- April 30, 2020 and compared to the same period in the year prior. Outcome measures were volumes of hospitalization and reperfusion treatment for AIS and AMI (including intravenous thrombolysis [IVT] and/or mechanical thrombectomy [MT] for AIS and percutaneous coronary interventions [PCI] for AMI) as well as in-hospital mortality, hospital length of stay (LOS) and hospitalization costs were compared across a 2-month period at the height of the pandemic versus the corresponding period in the prior year. Results: There were 95,453 AIS patients across 145 hospitals and 19,744 AMI patients across 126 hospitals. There was a significant nation-wide decline in the absolute number of hospitalizations for AIS (-38.94%;95%CI,-34.75% to -40.71%) and AMI (-38.90%;95%CI,-37.03% to -40.81%) as well as IVT (-30.32%;95%CI,-27.02% to -33.83%), MT (-23.54%;95%CI,-19.84% to -27.70%), and PCI (-35.05%;95%CI,-33.04% to -37.12%) during the first two months of the pandemic. This occurred across low-, mid-, and high-volume centers and in all geographic regions. Higher in-hospital mortality was observed in AIS patients (5.7% vs.4.2%, p=0.0037;OR 1.41,95%CI 1.1-1.8) but not AMI patients. A shift towards an increase in the proportion of admitted AIS and AMI patients receiving reperfusion therapies suggests a greater clinical severity among patients that were hospitalized for these conditions during the pandemic. A shorter length of stay (AIS: -17%, AMI: -20%), and decreased hospitalization costs (AIS: -12%, AMI: -19%) were observed. Conclusions: Our findings shed light on the combined health outcomes and economic impact the COVID-19 pandemic has had on acute stroke and cardiac emergency care.