In-hospital ST-segment Elevation Myocardial Infarction Research Articles

Implementing a comprehensive STEMI protocol to improve care metrics and outcomes in patients with in-hospital STEMI: an observational cohort study

BackgroundPatients who experience in-hospital ST-segment elevation myocardial infarction (iSTEMI) represent a uniquely high-risk cohort owing to delays in diagnosis, prolonged time to reperfusion and increased mortality. Quality initiatives aimed at...

In-depth look into urban and rural disparities in prehospital delay in patients with acute ST-elevation myocardial infarction and its impact on prognosis: a prospective observational study

ObjectivesIn line with the cardiac fast track, the ‘green pathway for patients with heart attack’ policy in China is implemented to reduce door-to-balloon time in patients with ST-segment elevation myocardial...

North American COVID-19 Myocardial Infarction (NACMI) Risk Score for Prediction of In-Hospital Mortality.

BackgroundIn-hospital mortality in patients with ST-segment elevation myocardial infarction (STEMI) is higher in those with COVID-19 than in those without COVID-19. The factors that predispose to this mortality rate and their relative contribution are poorly understood. This study developed a risk score inclusive of clinical variables to predict in-hospital mortality in patients with COVID-19 and STEMI.MethodsBaseline demographic, clinical, and procedural data from patients in the North American COVID-19 Myocardial Infarction registry were extracted. Univariable logistic regression was performed using candidate predictor variables, and multivariable logistic regression was performed using backward stepwise selection to identify independent predictors of in-hospital mortality. Independent predictors were assigned a weighted integer, with the sum of the integers yielding the total risk score for each patient.ResultsIn-hospital mortality occurred in 118 of 425 (28%) patients. Eight variables present at the time of STEMI diagnosis (respiratory rate of >35 breaths/min, cardiogenic shock, oxygen saturation of <93%, age of >55 ​years, infiltrates on chest x-ray, kidney disease, diabetes, and dyspnea) were assigned a weighted integer. In-hospital mortality increased exponentially with increasing integer risk score (Cochran-Armitage χ2, P ​< ​.001), and the model demonstrated good discriminative power (c-statistic ​= ​0.81) and calibration (Hosmer-Lemeshow, P ​= ​.40). The increasing risk score was strongly associated with in-hospital mortality (3.6%-60% mortality for low-risk and very high–risk score categories, respectively).ConclusionsThe risk of in-hospital mortality in patients with COVID-19 and STEMI can be accurately predicted and discriminated using readily available clinical information.

Association Between COVID-19 Diagnosis and In-Hospital Mortality in Patients Hospitalized With ST-Segment Elevation Myocardial Infarction

There has been limited research on patients with ST-segment elevation myocardial infarction (STEMI) and COVID-19. To compare characteristics, treatment, and outcomes of patients with STEMI with vs without COVID-19 infection. Retrospective cohort study of consecutive adult patients admitted between January 2019 and December 2020 (end of follow-up in January 2021) with out-of-hospital or in-hospital STEMI at 509 US centers in the Vizient Clinical Database (N = 80 449). Active COVID-19 infection present during the same encounter. The primary outcome was in-hospital mortality. Patients were propensity matched on the likelihood of COVID-19 diagnosis. In the main analysis, patients with COVID-19 were compared with those without COVID-19 during the previous calendar year. The out-of-hospital STEMI group included 76 434 patients (551 with COVID-19 vs 2755 without COVID-19 after matching) from 370 centers (64.1% aged 51-74 years; 70.3% men). The in-hospital STEMI group included 4015 patients (252 with COVID-19 vs 756 without COVID-19 after matching) from 353 centers (58.3% aged 51-74 years; 60.7% men). In patients with out-of-hospital STEMI, there was no significant difference in the likelihood of undergoing primary percutaneous coronary intervention by COVID-19 status; patients with in-hospital STEMI and COVID-19 were significantly less likely to undergo invasive diagnostic or therapeutic coronary procedures than those without COVID-19. Among patients with out-of-hospital STEMI and COVID-19 vs out-of-hospital STEMI without COVID-19, the rates of in-hospital mortality were 15.2% vs 11.2% (absolute difference, 4.1% [95% CI, 1.1%-7.0%]; P = .007). Among patients with in-hospital STEMI and COVID-19 vs in-hospital STEMI without COVID-19, the rates of in-hospital mortality were 78.5% vs 46.1% (absolute difference, 32.4% [95% CI, 29.0%-35.9%]; P < .001). Among patients with out-of-hospital or in-hospital STEMI, a concomitant diagnosis of COVID-19 was significantly associated with higher rates of in-hospital mortality compared with patients without a diagnosis of COVID-19 from the past year. Further research is required to understand the potential mechanisms underlying this association.

First Asian validation of ORBI score in predicting in-hospital cardiogenic shock in patients with ST-segment elevation myocardial infarction treated by primary percutaneous coronary intervention

Abstract Background Cardiogenic shock (CS) complicating an acute coronary syndrome still worsening the prognosis with 30-day mortality rates approximating 40–45%, despite improvements in the acute management of ST-segment elevation myocardial infarction (STEMI), particularly the widespread use of timely primary percutaneous coronary intervention (pPCI). The ORBI risk score provides a readily useable and efficient tool to identify patients at high-risk of developing CS during hospitalization following STEMI which may aid in further risk-stratification and thus potentially facilitate pre-emptive clinical decision making. This is essential in developing countries with wide variation in health care facilities, scarce resources and increasing burden of cardiovascular diseases. Purpose To validate ORBI Score in identifying patients at high-risk of in-hospital STEMI related cardiogenic shock in a multi-ethnic developing country. Method The ORBI risk score was evaluated in 1934 patients STEMI without CS on admission and treated by primary percutaneous coronary intervention (pPCI) in our national cardiovascular centre included this study. Model discrimination and calibration was tested in the overall population. Eleven variables from the ORBI score were independently associated with the development of in-hospital CS: age &amp;gt;70 years, prior stroke/transient ischaemic attack, cardiac arrest upon admission, anterior STEMI, first medical contact-to-pPCI delay &amp;gt;90min, Killip class, heart rate &amp;gt;90/min, a combination of systolic blood pressure &amp;lt;125 mmHg and pulse pressure &amp;lt;45 mmHg, glycaemia &amp;gt;10 mmol/L, culprit lesion of the left main coronary artery, and post-pPCI thrombolysis in myocardial infarction flow grade &amp;lt;3. The score derived from these variables allowed the classification of patients into four risk categories: low (0–7), low- to-intermediate (8–10), intermediate-to-high (11–12), and high (≥13). Results Observed in-hospital CS rates were 0.3%, 6.4%, 19.5%, and 32.12%, across the four risk categories, respectively. The score demonstrated high discrimination (c-statistic of 0.91 (CI 95% 0.88–0.93), p&amp;lt;0.001 in the validation cohort) Conclusion The ORBI risk score is valid and can be used for predicting the development of cardiogenic shock in STEMI patients for better targeted treatment. Funding Acknowledgement Type of funding sources: None. ROC curveObserved in-hospital CS rates

In-hospital mortality from ST-segment elevation myocardial infarction (STEMI): Evolution and predictors according to the MIRAMI registry

STEMI is the leading cause of death in the world. Thanks to urgent reperfusion endeavours, a significant reduction in the in-hospital mortality has been reported worldwide. To describe the evolution of the in-hospital mortality post STEMI between 1995 and 2015 and to identify the predictors of this mortality. This is a retrospective, mono-centric, descriptive and analytical study from the MIRAMI (MonastIR Acute Myocardial Infarction) registry including 1686 patients admitted for STEMI in the cardiology department of the “Fattouma Bourguiba” University Hospital in Monastir-Tunisia between January 1995 and December 2015. The mean age was 60.48 ± 12.64 years; 80.8% were male. The main cardio-vascular risk factors were smoking (66.5%), diabetes (37.8%), and hypertension (31.3%). In-hospital mortality was 9.6% (162 patients), but statistically insignificant fluctuations over the years were reported ( P = 0.133). The two leading causes of death were cardiogenic shock (43.20%) and ventricular arrhythmia (20.37%). A higher in-hospital mortality was associated with female (< 0,001),elderly patients (< 0,001),and first medical contact (FMC) >6 h ( P = 0.002). Urgent reperfusion was achieved in 58.7% of cases with a general trend towards primary angioplasty ( P < 0.001). Nevertheless, it was associated with higher mortality ( P = 0.005). In univariate analysis, angioplasty with balloon and TIMI 0/1 flow post angioplasty were predictors of in-hospital mortality ( P < 0.001). Four independent predictors of in-hospital mortality were reported: Mechanical ventilation (OR = 36.65, 95% CI = 17.28–77.75, P < 0.001), the use of inotropes/vasopressors (OR = 7.25, 95% CI = 3.75–14.01, P < 0.001), anaemia (Hb <12 g/dl) (OR = 2.13; 95% CI = 1.13–4.02, P = 0.02) and FMC >3 h (OR = 1.07, 95% CI = 1.02–1.13, P = 0.002). Despite improvement in the management of STEMI, in-hospital mortality has remained relatively stable. However, in the last years this mortality has experienced a significant decline.

Presentation, management and outcomes of acute coronary syndrome: a registry study from Kenyatta National Hospital in Nairobi, Kenya.

SummaryBackgroundAcute coronary syndrome (ACS) is understudied in sub-Saharan Africa despite its increasing disease burden. We sought to create an ACS registry at Kenyatta National Hospital to evaluate the presentation, management and outcomes of ACS patients.MethodsFrom November 2016 to April 2017, we conducted a retrospective review of ACS cases managed at Kenyatta National Hospital between 2013 and 2016, with a primary discharge diagnosis of ACS, based on International Classification of Diseases (ICD) 10 coding (I20-I24). We compared the presentation, management and outcomes by ACS subtype using analysis of variance testing. We created multivariable logistic regression models using the Global Registry of Acute Coronary Events (GRACE) risk score to evaluate the association between clinical variables, including guideline-directed medical therapy and in-hospital outcomes.ResultsAmong 196 ACS admissions, the majority (65%) was male, and the median age was 58 years. Most (57%) ACS admissions were for ST-segment-elevation myocardial infarction (STEMI). In-hospital dual antiplatelet ( > 85%), beta-blockade (72%) and anticoagulant (72%) therapy was common. A minority (33%) of patients with STEMI was eligible for reperfusion therapy but only 5% received reperfusion. In-hospital mortality rate was 17%, and highest among individuals presenting with STEMI (21%). After multivariable adjustment, higher serum creatinine level was associated with higher odds of in-hospital death (OR = 1.84, 95% CI: 1.21– 2.78), and STEMI and Killip class > 1 were associated with in-hospital composite of death, re-infarction, stroke, major bleeding or cardiac arrest (STEMI: OR = 8.70, 95% CI: 2.52–29.93; Killip > 1: OR = 10.7, 95% CI: 3.34–34.6).ConclusionsWe describe the largest ACS registry at Kenyatta National Hospital to date and identify potential areas for improved ACS care related to diagnostics and management to optimise in-hospital outcomes.

Predicting the development of in-hospital cardiogenic shock in patients with ST-segment elevation myocardial infarction treated by primary percutaneous coronary intervention: the ORBI risk score.

To derive and validate a readily useable risk score to identify patients at high-risk of in-hospital ST-segment elevation myocardial infarction (STEMI)-related cardiogenic shock (CS). In all, 6838 patients without CS on admission and treated by primary percutaneous coronary intervention (pPCI), included in the Observatoire Régional Breton sur l'Infarctus (ORBI), served as a derivation cohort, and 2208 patients included in the obseRvatoire des Infarctus de Côte-d'Or (RICO) constituted the external validation cohort. Stepwise multivariable logistic regression was used to build the score. Eleven variables were independently associated with the development of in-hospital CS: age >70 years, prior stroke/transient ischaemic attack, cardiac arrest upon admission, anterior STEMI, first medical contact-to-pPCI delay >90 min, Killip class, heart rate >90/min, a combination of systolic blood pressure <125 mmHg and pulse pressure <45 mmHg, glycaemia >10 mmol/L, culprit lesion of the left main coronary artery, and post-pPCI thrombolysis in myocardial infarction flow grade <3. The score derived from these variables allowed the classification of patients into four risk categories: low (0-7), low-to-intermediate (8-10), intermediate-to-high (11-12), and high (≥13). Observed in-hospital CS rates were 1.3%, 6.6%, 11.7%, and 31.8%, across the four risk categories, respectively. Validation in the RICO cohort demonstrated in-hospital CS rates of 3.1% (score 0-7), 10.6% (score 8-10), 18.1% (score 11-12), and 34.1% (score ≥13). The score demonstrated high discrimination (c-statistic of 0.84 in the derivation cohort, 0.80 in the validation cohort) and adequate calibration in both cohorts. The ORBI risk score provides a readily useable and efficient tool to identify patients at high-risk of developing CS during hospitalization following STEMI, which may aid in further risk-stratification and thus potentially facilitate pre-emptive clinical decision making.

In-Hospital ST-Segment Elevation Myocardial Infarction

ImportanceIn-hospital ST-segment elevation myocardial infarction (STEMI) is a unique clinical entity with epidemiology, incidence, and outcomes distinct from that of out-of-hospital STEMI and has only within the past 10 years begun to receive increased attention and research. Patients with in-hospital STEMI are older, have more comorbidities, and more frequently have coagulopathies and contraindications for anticoagulation and fibrinolytic therapy. A standardized clinical definition of in-hospital STEMI is lacking. The objectives of this special communication are to (1) summarize the knowledge base regarding in-hospital STEMI; (2) review the challenges of diagnosis and treatment of patients with in-hospital STEMI; (3) present a standardized clinical definition for in-hospital STEMI; and (4) provide a quality improvement protocol to improve diagnosis, triage, and treatment of patients with in-hospital STEMI.ObservationsPatients with in-hospital STEMI less frequently present with typical angina symptoms, and an electrocardiogram is often obtained owing to changes in clinical status, changes on telemetry, or a finding of elevated cardiac biomarker. The frequent nontypical presentations often lead to substantial delays in the diagnosis of STEMI. Only 34% to 71% of patients with in-hospital STEMI undergo diagnostic catheterization, and only 22% to 56% undergo percutaneous coronary intervention. Even in contemporary reports, some studies report in-hospital mortality in the range of 31% to 42%. Three areas of delay in the treatment of patients with in-hospital STEMI that merit particular attention are (1) delays in electrocardiogram acquisition, (2) delays in electrocardiogram interpretation, and (3) delays in activation of existing STEMI systems of care.Conclusions and RelevanceTreatment of patients with in-hospital STEMI is more complex and challenging than treatment of patients who develop out-of-hospital STEMI, leading to delays in diagnosis and triage and less frequent use of reperfusion therapy. Quality improvement programs targeted at decreasing delays and streamlining treatment of such patients may improve treatment and outcome.

Characteristics, management, and prognosis of patients under 35 years old with ST-segment elevation myocardial infarction: Insights from the multicenter prospective ORBI registry

Recent data regarding ST-segment Elevation Myocardial Infarction (STEMI) in young adults are limited. Currently, long-term prognosis is poorly described. Data from a prospective multicenter registry were analyzed. STEMI patients ≤ 35 years old were compared with their older counterparts. The primary endpoint was 1-year major adverse cardiac events (MACE), defined as the composite of cardiovascular-death, STEMI, non-STEMI, new revascularization procedure and stroke. Multivariable Cox regression was performed to assess the impact of age on 1-year MACEs while adjusting for confounders. Moreover, long-term MACEs rates among young patients were assessed. Hundred and three STEMI in patients ≤ 35 years old were compared with 1073 in patients > 35 years old with available 1-year follow-up data. Young adults were more likely current smokers (86% vs. 40%; P < 0.001). Other cardiovascular risk factors were more common among older patients. There were no significant differences in in-hospital STEMI management. One year MACEs rates were 8% and 10% in young and older patients respectively ( P < 0.001). After adjustment for confounders, age ≤ 35 years was not associated with lower 12-month MACEs rate (HR = 2.049 [95% CI 0.748–4.805, P = 0.124]). At a median 54 months follow-up, mortality rate was low (2.4%) but MACEs recurrence was frequent (24%) in young patients, who reported persistent smoking in 45% of cases. In the contemporary era of STEMI management, young and older patients have the same prognosis at 1 year post-STEMI. However, considering the high rate of morbidity after a premature STEMI, the importance of risk factors modification must be stressed.

Gender differences in the decrease of in-hospital mortality in patients with acute myocardial infarction during the last 20 years in Switzerland

ObjectiveTo assess temporal trends of in-hospital mortality in patients with acute myocardial infarction (AMI) enrolled in the Swiss nationwide registry (AMIS Plus) over the last 20 years with regard to...

In-hospital 'CODE STEMI' improves door-to-balloon time in patients undergoing primary percutaneous coronary intervention.

Reducing time to reperfusion for ST-segment elevation myocardial infarction (STEMI) is essential in improving outcomes. Consequently, numerous strategies have been employed to reduce median door-to-balloon time (DTBT). CODE STEMI is an ED physician-activated STEMI notification system. On activation, an announcement is made over the hospital's public announcement (PA) system. We prospectively analysed all in-hours STEMI patients who had primary percutaneous coronary intervention (PPCI) Pre-CODE STEMI (2014) and after CODE STEMI was implemented (2015). The primary end-points were median DTBT and the proportion of STEMI patients achieving a DTBT ≤90 min. The secondary end-points were in-hospital outcomes, and a composite of major adverse cardiac events (MACE) and hospital readmission rates at 30 days and 12 months. There were 41 and 42 patients in Pre-CODE STEMI and CODE STEMI groups respectively. Baseline characteristics were similar. DTBT was significantly reduced by 22.1 min from 67.1 ± 34.9 min Pre-CODE STEMI to 45.0 ± 22.7 min (P = 0.001) in the CODE STEMI group. Door-to-door time (DTDT) was also reduced from 46.3 ± 30.9 min to 29.4 ± 23.3 min (P = 0.006). A greater proportion of CODE STEMI patients achieved the target DTBT ≤90 min (95.2% vs 73.2%, P = 0.007). CODE STEMI patients had less systolic dysfunction measured by a left ventricle ejection fraction of ≤40% (10.0% vs 27.8%, P = 0.07). There were trends to lower in-hospital mortality rates (4.8% vs 9.8%, P = 0.43), MACE at 30 days and 12 months (4.8% vs 9.8%, P = 0.43; 11.9% vs 22.0%, P = 0.25). The novel in-hospital in-hours CODE STEMI notification system significantly reduced DTBT in patients undergoing PPCI.

Exploring In-hospital Death from Myocardial Infarction in Eastern Europe: From the International Registry of Acute Coronary Syndromes in Transitional Countries (ISACS-TC); on the Behalf of the Working Group on Coronary Pathophysiology &amp; Microcirculation of the European Society of Cardiology

The aim of the current study was to investigate the outcomes of coronary reperfusion therapies and ST-segment elevation myocardial infarction (STEMI) in patients of Eastern countries with economies in transition. Federation, and Serbia. The overall population consisted of 23,486 consecutive patients admitted to hospitals from January 1(st) to December 31(st) 2009. Registry data and statistics from the Organization for Economic Cooperation and Development (OECD) countries for the same period were used for comparison (2009-2010). In-hospital mortality was between 4% and 5% in the Western countries. In comparison mortality data were significantly larger in Serbia (10.8%) and Bosnia and Herzegovina (11.2%), intermediate in Russian Federation (7.2%) and similar in Hungary (5.0%). The rates of primary percutaneous coronary intervention (primary PCI) were very low in Bosnia and Herzegovina (18.3%), low in Russian Federation (20.6%) and Serbia (22%), and high in Hungary (70%). Major risk factors for death appear to be lack of reperfusion therapy, longer time delay from symptoms onset to hospital presentation as well as the higher percentage of patients with clinical presentation in Killip class III/IV. In-hospital STEMI case-fatality rates ranges widely in the former Eastern Bloc countries. Beyond the quality of care provided in hospitals, differences in time delay from symptoms onset to hospital admission may strongly influence STEMI patients' outcome.

Abstract 18753: ST Elevation Myocardial Infarction in Hospitalized Patients is Associated with Delayed Recognition, Low Rate of Early Revascularization and High Mortality

Background ---- Efforts to improve the management of ST segment elevation myocardial infarction (STEMI) have focused on patients whose symptoms begin outside of the hospital. Relatively little is known about STEMI that occurs in patients hospitalized for another condition. Methods ---- In-patient STEMI at a university hospital with primary percutaneous coronary intervention (PCI) center were identified by searching the Discharge Database and Cardiac Catheterization Laboratory Database. The diagnosis of STEMI was confirmed by two cardiologists. Non-normally distributed data are presented as median [25%,75%]. Comparison between groups was done using Mann-Whitney rank sum test for continuous variables and χ 2 for categorical variables. Results - A total of 48 in-patient STEMI cases were identified from 139,410 adult discharges from 2007 to 2011. In comparison with 184 out-patient STEMIs who presented directly to the same hospital during the same time span, in-patient STEMI patients were older (69 ± 13 vs 60 ± 13 years; p &lt; 0.01) and more often female (50% vs 33%; p &lt; 0.01). Symptoms were the reason for the index ECG more often in outpatient STEMIs (99% vs 33%; p &lt; 0.01); for in-patient STEMIs a change in clinical status (60%) and/or changes on telemetry (7%) also precipitated an ECG. The median time between the onset of symptoms or change in clinical status to ECG for in-patient STEMI was much greater than door to ECG time for outpatient STEMI (30 [10, 600] vs 5 [2, 10] minutes; p &lt; 0.001). Coronary angiography (71% vs 97%; p &lt; 0.01) and PCI (56% vs 95%; p &lt; 0.01) were performed less frequently in in-patient STEMI. The median ECG to angiography time (91 [45,197] vs. 34 [24,47] minutes; p &lt; 0.001) and the ECG to first device activation (129 [65,250] vs. 51 [40,70] minutes; p &lt; 0.001) were longer with in-patient STEMI. The in-hospital mortality for the in-patient STEMI group was 39.6% but revascularization within 3 hours from the onset of STEMI related event was associated with lower in-hospital mortality compared to patients who had delayed or no revascularization (15% vs 50%; p = 0.02). Conclusion ---- In-hospital STEMI is associated with atypical clinical presentation, delayed ECG interpretation, low rate of rapid revascularization and high mortality.

Abstract P135: An Independent Initiative to Improve Door-to-Balloon Times: Results From the Aurora 24x7 STEMI Program

BACKGROUND: To improve hospital performance in door-to-balloon (D2B) times, an independent initiative - the Aurora St. Luke's 24x7 STEMI (ST-segment elevation myocardial infarction) program - was launched on April 1, 2004, as part of a system-wide quality improvement effort. We evaluated recent changes in D2B times within the program. METHODS: The program involves 24 hours a day, 7 days a week in-hospital call for the interventional cardiologist and the cardiac catheterization laboratory (CCL) staff and includes the following strategies: 1) rapid electrocardiogram acquisition and emergency department (ED) physician interpretation in ≤10 min of hospital arrival; 2) ED physician activation of the 24x7 team with a single call; 3) calibration of the clocks in the ED and the CCL checked monthly; and 4) feedback provided to staff within 24-72 hours. We studied D2B times in non-transferred patients with STEMI treated with primary PCI (PPCI) from July 2007 to June 2009. RESULTS: A total of 251 consecutive non-transfer patients (median age 60, women 30.7% [77 of 251]) underwent PPCI for acute STEMI. Median D2B was 52 min (interquartile range 41-64) with a 93.6% (n=235 of 251) rate of D2B &lt;90 min. Secondary analyses of this cohort demonstrated a 69.3% rate (175 of 251) of D2B &lt;60 min. CONCLUSION: An innovative in-hospital 24x7 interventional STEMI program has dramatically increased the percentage of patients reperfused within 90 min and consistently exceeds the American College of Cardiology Door-to-Balloon (D2B) Alliance benchmark (93.6% vs. 75% rate of D2B &lt;90 min). The 24x7 STEMI program is an important demonstration model in systems improvement for care of patients with STEMI.