Delay In Acute Myocardial Infarction Research Articles

Patient delay in acute myocardial infarction: a long journey still ahead

Abstract Background It is overly known that time delays in acute myocardial infarction (AMI) strongly influence its outcomes. Patient delay (PD) is repeatedly pointed out as the longer one in this context, as well as it is the less modifiable one by organizational measures. Therefore, it is crucial to understand the reasons for longer PD in our population, to define proper strategies to improve PD and, ultimately, AMI-outcomes. Methods In this six-month prospective study of patients (pts) admitted in a tertiary hospital due to type-1 AMI, 194 pts were consecutively enrolled between May and October 2021. Data was based on a pts well-structured interview within 48h after admission and review of medical records. Results Our work spotted several aspects significantly influencing PD in AMI context (Figure 1). Concerning pts cardiovascular background, a trend towards a shorter PD was found in pts with at least one cardiovascular risk factor (CVRF) (p=0,08) and with a previous history of AMI (p=0,08). Regarding clinical presentation, a significantly shorter PD was found in pts presenting with associated symptoms (p=0,02), higher chest pain intensity (chest pain intensity ≥7 vs <7 in a 0–10 scale; p=0,03) and symptoms onset on weekdays rather than weekends (p=0,003). Regarding pts knowledge, significant differences were found when pts recognized their symptoms as AMI, presenting a shorter PD in this context (p=0,006). Curiously, pts ability to correctly identify AMI symptoms, when asked, or to acknowledge their CVRF (when present), did not influence PD. Considering sociodemographic factors, higher incomes (p=0,03) and non-rural residence (p=0,03) significantly translated into shorter PD. No differences were found in PD according to pts age, gender or educational level. After this initial univariate analysis, multiple linear regression was performed to identify possible predictors of PD. Four variables were identified: pts ability to recognize their symptoms as AMI (β −0.199; 95% CI: −277 to −34,87; p=0.012), living in a non-rural residence (β 0.154; 95% CI: 0.12–161.44; p=0.05), presenting associated symptoms (β −0.194; 95% CI: −257.43 to −28.84; p=0.014) and occurrence of symptoms on weekdays (β 0.170; 95% CI: 12.73–259.49; p=0.031) predicted shorter patient delays. Conclusion Our study clearly points to the need for increasing public awareness and educational measures, mainly in pts living in rural areas, in order to: 1) Improve pts knowledge about AMI symptoms, clarifying that atypical symptoms can happen; 2) Reinforce the importance of shortening AMI time delays, clearly explaining the concept “time is muscle”. Funding Acknowledgement Type of funding sources: None.

Prognostic Impact of Clopidogrel Pretreatment in Patients With Acute Coronary Syndrome Managed Invasively

Pretreatment with antiP2Y12 agents before angiography in acute coronary syndrome (ACS) is associated with a reduction in thrombotic events. However, recent evidences have questioned the benefits of upstream antiP2Y12, reporting a higher incidence of bleeding. We analyzed the prognostic impact of clopidogrel pretreatment in a large cohort of invasively managed patients with ACS. In hospital, safety and efficacy of clopidogrel pretreatment were retrospectively analyzed in patients included in the ARIAM-Andalucía Registry (Analysis of Delay in Acute Myocardial Infarction). Propensity score and inverse probability of treatment weighting analysis were performed to control treatment selection bias. Results were stratified by ACS type. Sensitivity analyses were used to explore stability of the overall treatment effect. Of 9,621 patients managed invasively, 69% received clopidogrel before coronary angiography. In the ST-elevation myocardial infarction group, pretreatment was associated with a significant reduction in reinfarction (odds ratio 0.53, 95% confidence interval [CI] 0.27 to 0.96; p = 0.027), stent thrombosis (odds ratio 0.15, 95% CI 0.06 to 0.38; p <0.0001), and mortality (odds ratio 0.67, 95% CI 0.48 to 0.94; p = 0.020), with an increase in minor bleeding but remained as a net clinical benefit strategy. Those benefits were not present in patients without ST elevation (non-ST elevation ACS). The weighting and propensity analysis confirmed the same results. An interaction between pretreatment duration and bleeding was observed. In conclusion, pretreatment with clopidogrel reduced the occurrence of death and thrombotic outcomes at the cost of minor bleeding. Those benefits exclusively affected ST-elevation myocardial infarction cases. The potential benefit of routine upstream pretreatment in patients with non-ST-elevation ACS should be reappraised at the present.

Pre-hospital delay in acute myocardial infarction: judgement of symptoms and resistance to pain.

To estimate the time of decision (TD) to look for medical care and the time of arrival (TA) at the health service for men (M) and women (W) suffering from acute myocardial infarction and to analyze the influence of the interpretation of pain and pain resistance behaviors during these times. This is an exploratory research, performed at the university hospital in Salvador/Bahia. 43 W and 54 M were interviewed. To study the dependence among sociodemographic and gender variables, the Fisher Exact Test was used. To analyze times, a geometric mean (GM) was used. In order to verify the association between the GM of TD and TA and the judgment of pain, and between the GM of TD and TA and the behavior of resistance to pain, as well as to test the time of interaction between the gender variable and other variables of interest, the robust regression model was used. The statistical significance adopted was 5%. The GM of the TD for M was 1.13 h; for W, 0.74 h. The GM of the TA was 1.74 h for M and 1.47 h for W. Those who did not recognize the symptoms of AMI and presented behavior of resistance to pain had higher TD and TA, being the associations significant. Gender did not change the associations of interest. The findings demonstrate the importance of health education aiming at the benefits of early treatment.

Cognitive and Emotional Factors Affecting Avoidable Decision-Making Delay in Acute Myocardial Infarction Male Adults

Background: To study the potentially avoidable decision-making delay in acute myocardial infarction (AMI) adults male with different psychological characteristics a nationwide multicentre study was conducted in Italy by the 118 Coronary Care Units (CCUs).Method: 929 AMI patients consecutively presented to the CCU in a conscious condition less than two hours, 2-6 hours, 6-12 hours, and more than 12 hours after symptom onset and completing the Disease Distress Questionnaire (DDQ) were enrolled in a multicentre case-control study. The DDQ collects information regarding the decision time to seek help, and includes a set of items assessing psychological factors and pain-related symptoms. The relationship between the perceived threat and the delay due to decision-making was evaluated by means of a multivariate model using LISREL 8 structural equation modelling.Results: The delay significantly correlated with perceived threat, which was mainly related to somatic awareness. It was only slightly related to pain and was not associated with any of the other variables. Perceived threat was also related to psychological upset, fear and health worries, the first of which was considerably influenced by emotional instability.Conclusion: Somatic awareness is the main dimension affecting perceived threat, but subjective pain intensity affects the delay both directly and indirectly. The core of the model is the relationship between perceived threat and the delay due to decision-making. The importance of subjective pain intensity is well documented, but it is still not clear how subjective and objective pain interact.

The investigation of treatment-seeking decision on patients with acute myocardial infarction and related factors

Objective To explore the treatment-seeking delay time and the main factors associated with decisional delay for Acute Myocardial Infarction(AMI) patients. Methods A total of 150 cases of patient in two hospitals of Shanghai were selected by purposive sampling from January to May 2008. Participates were asked to fdl out the Chinese version of behavior questionnaire for AMI within 48 hours of hospital admission. Results The median length of time for patients with to make a treatment-seeking decision was 180 minutes , and the mean time was 417minutes, the median time for transportation to seek hospital care was about 30 minutes and in-hospital delay was about 20 minutes, and the mean time was 63 minutes and 37minutes, there were 72% patients delayed to make treatment-seeking decision for more than 1 hour. In the Logistic analysis, educational level, medical insurance and degree of the pain appeared as predictors to decrease the delay for making a treatment-seeking decision. In addition, recurrent MI, attacked at home and was forced to go to hospital appeared to be predictors to influence the decision for making a prompt treatment-seeking decision. Conclusions Patients show significant delay in making treatment-seeking decision, which is mainly affected by the patients' psychological factors and social support system. Key words: Factor analysis; Treatment-seeking decision; Delay; Acute myocardial infarction

Abstract P182: Usefulness of Mobile Telemedicine System in Real-time Transmission of Out-of-hospital 12-lead ECG

[Purpose] AHA/ACC guidelines recommend routine use of 12-lead ECG and advance notification for patients with acute coronary syndrome. However, transmission of out-of-hospital 12-lead ECG to emergency department is still not spread and ECG interpretation on the prehospital and emergency department is not established. Therefore, we have developed and tested the clinical usefulness of the mobile telemedicine system to transmit 12-lead ECG between moving ambulances and physicians in cardiovascular emergency. [Method] We set up the mobile telemedicine using the third-generation digital mobile phone to promote communications between an ambulance and diverse hospital. Compatibility issue among device vendors was solved by the implementation of open-standard medical waveform encoding rule with motion noise-reduction system. Real time 12-lead ECG was transferred together with vital signs and live video during transfer the patient by an ambulance. The performance of the mobile telemedicine system in the field-test was checked to transfer 12-lead ECG in different scenarios such as transferred ECG from a volunteer moving hand or leg, coughing or twisting body in an ambulance driving on common road or highway. In the next step, we set up the mobile telemedicine on an ambulance to promote communications between moving 5 ambulances in Suita-city and National Cardiovascular Center since 2008 June 2. To establish the efficacy of real-time transmission of out-of-hospital 12-lead ECG, the time-line from the onset of acute myocardial infarction to reperfusion is analyzed. [Results] Totally 36 patters of 12-lead ECG were checked in the field test and all of them were comparable than those original one in the ambulance. Time-delay for transmission of 12 lead ECG was within 10seconds and for one-lead ECG monitoring and vital signs including BP, HR and oxygen saturation was 1 second without the difficulties for the interpretation. [Conclusion] Those results indicate the usefulness and reliability of transmission of 12-lead ECG using the mobile telemedicine system from the ambulance. Further investigation is on-going to determine the efficacy in clinical conditions to reduce the treatment delay for acute myocardial infarction.

New Insights into the Circadian Rhythm of Acute Myocardial Infarction in Subgroups

The aim of this study was to determine the existence of the circadian rhythm (CR) in the onset of acute myocardial infarction (AMI) in different patient subgroups. Information was collected about 41,244 infarctions from the database of the ARIAM (Analysis of Delay in AMI) Spanish multicenter study. CR in AMI were explored in subgroups of cases categorized by age, gender, previous ischemic heart disease (PIHD), outcome in coronary care unit, infarction electrocardiograph (ECG) characteristics (Q wave or non‐Q wave), and location of AMI. Cases were classified according to these variables in the different subgroups. To verify the presence of CR, a simple test of equality of time series based on the multiple‐sinusoid (24, 12, and 8 h periods) cosinor analysis was developed. For the groups as a whole, the time of pain onset as an indicator of the AMI occurrence showed a CR (p<0.0001), with a morning peak at 10:10 h. All the analyzed subgroups also showed CR. Comparison between subgroups showed significant differences in the PIHD (p<0.01) and infarction ECG characteristics (p<0.01) groups. The CR of the subgroup with Q‐wave infarction differed from that of non‐Q wave subgroup (p<0.01) when the patients had PIHD (23% in Q wave infarction vs. 39.2% in non‐Q wave). AMI onset followed a CR pattern, which is also observed in all analyzed subgroups. Differences in the CR according to the Q/non‐Q wave infarction characteristics could be determined by PIHD. The cosinor model fit with three components (24, 12, and 8 h periods) showed a higher sensitivity than the single 24 h period analysis.

When analyses are invalidated by erroneous assumptions

In a recent publication in the “International Journal of Technology Assessment in Health Care” (7), Kildemoes and Kristiansen claim to address “Cost-effectiveness of interventions to reduce the thrombolytic delay for acute myocardial infarction.” Their study is based on a “Master of Public Health Assessment” thesis published by Kildemoes in the year 2001 (6). Three years ago, the author was informed that several of her assumptions were incorrect. In this letter, we will address six of the erroneous assumptions made by Kildemoes and Kristiansen.

Diferencias en el ritmo circadiano del infarto de miocardio según su extensión electrocardiográfica

To determine the existence of circadian rhythm in the time of onset of acute myocardial infarction (AMI) according to their extension type (Q-wave vs. non-Q-wave). We studied a retrospective cohort of patients from a multicentre study of myocardial infarction (ARIAM study group). We collected information about 54,249 infarctions from the data base of the ARIAM (Analysis of Delay in AMI) Spanish multicentre study. The following variables were analysed: general variables --age, gender, previous ischemic heart disease, outcome at coronary care unit, infarction electrocardiograph type (Q wave or non-Q wave) and location of AMI--, cardiovascular risk factors, and previous drug treatment of the patients. To verify the presence of circadian rhythm we developed a simple test of equality of time series based on the multiple-sinusoid cosinor analysis. Three sinusoids (24-12-8 h periods) were used. The time of pain onset shows circadian rhythm (p < 0.0000), which also is observed in both infarction electrocardiograph characteristics subgroups (Q-wave infarction and non-Q-wave infarction) (p < 0.0000). Q-wave infarction shows sinusoid curve with one maximum morning peak and non-Q-wave shows bimodal curve, with two peaks. Comparison between their curves shows statistical significance (p < 0.0000). AMI onset follows a circadian rhythm pattern, which is also observed in analysed subgroups. Differences in the circadian rhythm according to the Q/non-Q wave infarction characteristics, could be determined by different physiopathologic mechanism. The cosinor model fit with three components (24, 12 and 8-hour-periods) show good sensitivity to determine circadian rhythm.

Cost-effectiveness of interventions to reduce the thrombolytic delay for acute myocardial infarction.

The objective of the study was to estimate the costs and health benefits of a public awareness campaign aimed at shortening the delay for thrombolytic therapy in patients with acute myocardial infarction (AMI) and to estimate the incremental costs and benefits of an additional telemedicine program. By using trial data on the impact of a Swedish campaign, a model was developed to simulate the current distribution of thrombolytic delay in Denmark and the delay after a campaign. The reduction in delay was translated into reduced fatality assuming reductions from the campaign and additional effects of a telemedicine program. The costs of the campaign were based on trial data and Danish unit costs while telemedicine costs were taken from a Danish demonstration program. The analyses indicate that the awareness campaign will translate into five fewer fatal AMIs (sixty-two life years gained) and a cost per life year of DKK283,300, with both costs and benefits discounted at 5 percent. When combining the public campaign with prehospital telemedicine diagnostics, the incremental cost per life year gained was DKK854.700. Programs aimed at reducing delay of thrombolysis in patients with AMI are likely to have a limited impact on AMI fatality. Information campaigns may have acceptable cost-effectiveness ratios, while telemedicine programs lead to threefold greater ratios. Whether such programs can be considered cost-effective will depend on how life year gains are valued by society.

Ventricular fibrillation in acute myocardial infarction in Spanish patients: Results of the ARIAM database.

The aim of this study has been to investigate the factors predisposing to primary or secondary ventricular fibrillation (VF) and the prognosis in Spanish patients with acute myocardial infarction (AMI) during their admission to the intensive care unit or the coronary care unit. A retrospective, observational study. The intensive care units and coronary care units of 119 Spanish hospitals. A retrospective cohort study including all the AMI patients listed in the ARIAM registry (Analysis of Delay in Acute Myocardial Infarction), a Spanish multicenter study. The study period was January 1995 to January 2001. Factors associated with the onset of VF were studied by univariate analysis. Multivariate analysis was used to evaluate the independent factors for the onset of VF and for mortality. A total of 17,761 patients with AMI were included in the study; 964 (5.4%) developed VF (primary in 735 patients, secondary in 229). In multivariate analysis, the variables that continued to show an association with the development of VF were the Killip and Kimball class, peak creatine kinase, APACHE II score, age, and time from the onset of symptoms to the initiation of thrombolysis. The mortality in the patients with any VF was 31.8% (27.8% in patients with primary VF and 49.1% in patients with secondary VF). The development of VF is an independent predictive factor for mortality in patients with AMI, with a crude odds ratio of 5.12 (95% confidence interval, 4.41-5.95) and an adjusted odds ratio of 2.73 (95% confidence interval, 2.12-3.51). Despite the considerable improvement in the treatment of AMI in recent years, the onset of either primary or secondary VF is associated with a poor prognosis. It is usually accompanied by extensive necrosis.

Influence of age on clinical course, management and mortality of acute myocardial infarction in the Spanish population

Background: To assess age-related differences in cardiovascular risk factors, clinical course and management of patients with acute myocardial infarction (AMI) in intensive care (ICU) or coronary care units (CCU). Methods: A retrospective cohort study was conducted of all AMI patients listed in the ARIAM register (Analysis of Delay in AMI), a multi-centre register in which 119 Spanish hospitals participated. The study period was from January 1995 to January 2001. A univariate analysis was carried out to evaluate differences between different age groups. Multivariate analysis was used to assess whether age difference was an independent predisposing factor for mortality and for differences in patient management. Results: 17,761 patients were admitted to the ICUs/CCUs with a diagnosis of AMI. The distribution by ages was: <55 years, 3954 patients (22.3%); 55–64 years, 3593 (22.2%); 65–74 years, 5924 (33.4%); 75–84 years, 3686 (20.8%); and >84 years, 604 (3.4%) ( P<0.0001); 24.6% of the patients were female, and the relative proportion of females increased with age. There were clear differences in risk factors between the different age groups, with a predominance of tobacco, cholesterol and family history of heart disease in the younger patients. The incidence of complications, including haemorrhagic complications, increased significantly with age. The older age groups had a lower rate of thrombolysis and less use of revascularisation techniques. The mortality of the above groups was 2.6, 5.4, 10.7, 17.7 and 25.8%, respectively. Age difference was an independent predictive variable for mortality and the administration of thrombolysis. Conclusions: The distinct age groups differed in cardiovascular risk factors, management and mortality. Age is a significant independent predictive variable for mortality and for the administration of thrombolysis.

Efficacy of thrombolysis in patients with acute myocardial infarction requiring cardiopulmonary resuscitation.

To evaluate the efficacy and safety of systemic thrombolysis administered to resuscitated patients after cardiac arrest (CA) due to an acute myocardial infarction (AMI), through a study of their mortality and haemorrhagic complications. We studied a retrospective cohort of patients with ischaemic heart disease gathered from the database of the Spanish multi-centre project "Analysis of Delay in AMI" (ARIAM). Intensive care (ICU) and coronary care (CCU) units of 77 Spanish hospitals. The study period was from 1 January 1995 to 1 January 2000, when 22,922 patients were included in the ARIAM database register; 13,704 were diagnosed with AMI and we studied 303 of these AMI patients admitted after resuscitation for CA. Of the 303 patients studied, 228 were male (75.25%); the mean age was 64.57 +/- 12.48 years. Systemic thrombolysis was administered to 67 patients (group I) and the remaining 236 patients were managed without this treatment (group II). The ICU/CCU mortality rate of the series was 39.93 % (121 patients); that of group I was 17.91% (12 patients) and that of group II 46.18% (109 patients) (P < 0.00001). Group I required less mechanical ventilation (group I, 42.85% vs group II, 80.76 %; P < 0.00001) and fewer cardiopulmonary resuscitation attempts (33.34% vs 60.98%, P < 0.0001). Group I also showed a lower incidence of cardiogenic shock (14.28% vs 39.01%, P < 0.0001) and anoxic encephalopathy (8.62% vs 39.89% P = 0.006). There were no fatal haemorrhagic complications in either group. Logistic regression analysis showed the administration of thrombolysis to be an independent variable that protected against mortality. The administration of thrombolysis to patients with AMI who require resuscitation may be efficacious in reducing mortality and is safe, with no increase in haemorrhagic complications.

Women's risk of decision delay in acute myocardial infarction: implications for research and practice.

Cardiovascular disease is the leading cause of death for women in the United States. Despite recent advances in treatment options for acute myocardial infarction (AMI), there has not been similar progress in decreasing the time between symptom onset and the decision to seek medical help (labeled "decision delay") and therefore availability of such treatments. Women delay longer than men before seeking help for symptoms of AMI, yet few studies have analyzed decision delay by gender. Factors studied to date do not adequately explain the differences in decision delay among women or between women and men with AMI. Additional research is needed to guide interventions to limit decision delay in women at risk for AMI. Until then, clinicians should use existing general guidelines to assist women at risk of AMI to avoid decision delay.

Longer pre-hospital delay in acute myocardial infarction in women because of longer doctor decision time.

STUDY OBJECTIVE: To measure the pre-hospital delay times in patients with proven acute myocardial infarction (AMI) and to identify possibilities for reduction of treatment delay. DESIGN: Descriptive three centre study....

Consequences of a media campaign focusing on delay in acute myocardial infarction

Consequences of a media campaign focusing on delay in acute myocardial infarction

Sudden death and hospitalization delay in acute myocardial infarction

Sudden death and hospitalization delay in acute myocardial infarction