In-hospital Thrombolysis Research Articles

Strategy to Reduce Mortality Rates of ST-elevation Acute Myocardial Infarction Using Prehospital Thrombolysis: A Meta-analysis

Abstract Importance: Ischemic heart disease is the leading cause of death worldwide. In ST-elevation myocardial infarction (STEMI), delaying reperfusion from the onset of chest pain increases the incidence of mortality and morbidity. Prehospital thrombolysis (PHT) has been evaluated in the setting of STEMI. We performed a systematic analysis of studies of PHT in acute STEMI. Objective: The objective of this study was to evaluate the all-cause mortality benefit in STEMI with PHT during short-term and long-term follow-up. Data Sources: In December 2020, the Cochrane search strategy was used to analyze randomized control trials, nonrandomized control studies, and registry studies in PubMed, EMBASE, Cochrane Library, Google Scholar, ClinicalKey, and Clinical Trial Registries. The search was repeated, and the included studies were updated in June 2023 to include more recent literature. We restricted the analysis to full-text publications in English. Study Selection: Studies using any thrombolytic agent in treating acute myocardial infarction in prehospital and inhospital settings with or without percutaneous Coronary intervention (PCI) were included in the analysis. Selection criteria included patient history and symptoms, electrocardiogram findings, and cardiac markers. Data Extraction: We used the Cochrane Handbook for Systematic Reviews of Interventions for assessing bias, the PRISMA flow diagram to show the process of inclusion and exclusion of studies, and RevMan software to perform meta-analysis. Main Outcomes and Measures: Outcomes include all-cause hospital mortality rate of PHT versus inhospital thrombolysis (IHT), influence of ischemic median time on all-cause mortality with PHT, and effect of PHT before PCI. The measures must have been observed for a follow-up period of up to 35 days, 1-year, and 5-years. Results: Data from 63,814 patients from 32 studies were reviewed. Results indicate a reduction in all-cause mortality in patients assigned to PHT (odds ratio [OR] −0.68, P < 0.00001) compared to IHT. There was a significant reduction in mortality when thrombolytics were administered before PCI (OR − 0.78, P = 0.0001). The overall survival was better with an ischemic time of <2 h. Mortality was higher with longer ischemic time (3 h and 6 h). Among patients who presented within 2 h of the onset of chest pain, mortality was lower compared to primary PCI (pPCI). Conclusion: PHT offers faster reperfusion and reduces all-cause mortality compared to IHT. A strategy of PHT within the first 2-3 h of ischemic pain followed by PCI (if indicated) could offer better survival than pPCI.

Outcomes among heart failure patients hospitalized for acute pulmonary embolism and COVID-19 infection: Insight from the National Inpatient Sample.

There is paucity of data regarding the outcomes of hospitalized acute pulmonary embolism (PE) patients with heart failure (HF) and Coronavirus Disease 2019 (COVID-19) infection. We utilized the 2020 National Inpatient Sample (NIS) Database in conducting a retrospective cohort study to investigate the outcomes of hospitalized acute PE patients with HF and COVID-19, looking at its impact on in-hospital mortality, thrombolysis, and thrombectomy utilization as well as hospital length of stay (LOS). A total of 23,413 hospitalized acute PE patients with HF were identified in our study, of which 1.26% (n = 295/23,413) had COVID-19 infection. Utilizing a stepwise survey multivariable logistic regression model that adjusted for confounders, COVID-19 infection among acute PE patients with HF was found to be an independent predictor of overall in-hospital mortality (adjusted odds ratio [aOR]: 2.77; 95% confidence interval [CI], 1.15-6.67; p = 0.023) and thrombolysis utilization (aOR: 5.52; 95% CI, 2.57-11.84; p ≤ 0.001) compared to those without COVID-19. However, there were comparable rates of thrombectomy utilization and LOS among acute PE patients with HF regardless of the COVID-19 infection status. On subgroup analysis, patients with HF with reduced ejection fraction was found to be associated with increased risk for in-hospital mortality (aOR: 3.89; 95% CI, 1.33-11.39; p = 0.013) and thrombectomy utilization (aOR: 4.58; 95% CI, 1.08-19.41; p = 0.042), whereas both HF subtypes were associated with increased thrombolysis utilization. COVID-19 infection among acute PE patients with HF was associated with higher over-all in-hospital mortality and increased thrombolysis utilization but had comparable hospital LOS as well as thrombectomy utilization.

The Barriers to Rapid Reperfusion in Acute ST-Elevation Myocardial Infarction.

This study aimed to quantify the contribution of various obstacles to timely reperfusion therapy in acute ST-elevation myocardial infarction (STEMI) and to improve performance in a mixed remote rural/urban region. From November1, 2020 to April23, 2021, patients with acute STEMI were prospectively monitored with the critical time intervals, treatment modalities, and outcomes registered. Selected clinical decision-makers in 11 hospitals were appointed as improvement agents and systematically provided with weekly updated information about absolute and relative performance. Suggestions for improvements were invited and shared. Only 29% of the 146 patients received reperfusion therapy within recommended time limits [prehospital thrombolysis, 2/48; in-hospital thrombolysis, 0/20; primary percutaneous coronary intervention (pPCI), 37/68, with median intervals from the first medical contact of 44, 49, and 133min, respectively]. Efficiency varied considerably between health trusts: median time from the first medical contact to prehospital thrombolysis ranged from 29 to 54min (hazard ratio 4.89). The predominant, remediable causes for delays were erroneous tactical choices and protracted electrocardiographic diagnostication, decision-making, and administration of fibrinolytic medication. During the trial, the time to pPCI was non-significantly reduced. We found several targets for system improvements in order to mitigate reperfusion delays along the entire chain of care, regardless of reperfusion modality chosen. More patients should receive prehospital thrombolysis. The most important measures will be training to ensure a more efficient on-site workflow, improved protocols and infrastructure facilitating the communication between first responders and in-hospital clinicians, and education emphasizing prehospital transport times. NCT04614805.

The Incidence and Impact of In-Hospital Bleeding in Patients with Acute Coronary Syndrome during the COVID-19 Pandemic.

Background: The COVID-19 pandemic increased the complexity of the clinical management and pharmacological treatment of patients presenting with an Acute Coronary Syndrome (ACS). Aim: to explore the incidence and prognostic impact of in-hospital bleeding in patients presenting with ACS before and during the COVID-19 pandemic. Methods: We evaluated in-hospital Thrombolysis In Myocardial Infarction (TIMI) major and minor bleeding among 2851 patients with ACS from 17 Italian centers during the first wave of the COVID-19 pandemic (i.e., March–April 2020) and in the same period in the previous two years. Results: The incidence of in-hospital TIMI major and minor bleeding was similar before and during the COVID-19 pandemic. TIMI major or minor bleeding was associated with a significant threefold increase in all-cause mortality, with a similar prognostic impact before and during the COVID-19 pandemic. Conclusions: the incidence and clinical impact of in-hospital bleeding in ACS patients was similar before and during the COVID-19 pandemic. We confirmed a significant and sizable negative prognostic impact of in-hospital bleeding in ACS patients.

Collaborative Heart Attack Management Program (CHAMP): use of prehospital thrombolytics to improve timeliness of STEMI management in British Columbia

Coronary artery disease is the second leading cause of death in Canada. Time to treatment in ST-elevation myocardial infarction (STEMI) is directly related to morbidity and mortality. Thrombolysis is the...

In-Hospital Intravenous Thrombolysis Offers No Benefit in Mechanical Thrombectomy in Optimized Tertiary Stroke Center Setting

PurposeMechanical thrombectomy (MT) is the first-line treatment in acute stroke patients presenting with large vessel occlusion (LVO). The efficacy of intravenous thrombolysis (IVT) prior to MT is being contested. The objective of this study was to evaluate the efficacy of MT without IVT in patients with no contraindications to IVT presenting directly to a tertiary stroke center with acute anterior circulation LVO.Materials and MethodsWe collected the data of 106 acute stroke patients who underwent MT in a single high-volume stroke center. Patients with anterior circulation LVO eligible for IVT and directly admitted to our institution who subsequently underwent MT were included. We recorded baseline clinical, laboratory, procedural, and imaging variables and technical, imaging, and clinical outcomes. The effect of intravenous thrombolysis on 3-month clinical outcome (mRS) was analyzed with univariate tests and binary and ordinal logistic regression analysis.ResultsFifty-eight out of the 106 patients received IVT + MT. These patients had 2.6-fold higher odds of poorer clinical outcome in mRS shift analysis (p = 0.01) compared to MT-only patients who had excellent 3-month clinical outcome (mRS 0–1) three times more often (p = 0.009). There were no significant differences between the groups in process times, mTICI, or number of hemorrhagic complications. A trend of less distal embolization and higher number of device passes was observed among the MT-only patients.ConclusionsMT without prior IVT was associated with an improved overall three-month clinical outcome in acute anterior circulation LVO patients.

Treatment delay and reperfusion management of acute ST-segment elevation myocardial infarction: analysis of the China STEMI Care Project Phase 1.

The China ST-segment elevation myocardial infarction (STEMI) Care Project (CSCAP) was launched in 2011 to address the problems of insufficient reperfusion and long treatment delay in STEMI care in China. To describe the baseline status of STEMI emergency care in Tertiary PCI Hospitals using Phase 1 (CSCAP-1) data. CSCAP-1 is a prospective multi-center STEMI registry. A total of 4191 patients with symptom onset within 12 or 12-36 h requiring primary percutaneous coronary intervention (PCI), were enrolled from 53 tertiary PCI hospitals in 14 provinces, municipalities, and autonomous regions of China in CSCAP-1. Among them, 49.0% were self-transported to the hospital, 26.5% were transferred to the hospital by calling the emergency medical services directly, and 24.5% were transferred from other hospitals. In patients with symptom onset within 12 h, 83.2% received primary PCI, 5.9% received thrombolysis and 10.9% received conservative medications. The median door-to-balloon time was 115 (85-170) min and the median door-to-needle time for in-hospital thrombolysis was 80 (50-135) min. The overall in-hospital all-cause mortality was 2.4%, while it was 5.3% in the non-reperfusion group and 2.1% in the reperfusion group (P < 0.001). Although a long treatment delay and a high proportion of patients transporting themselves to the hospital were observed, trends were positive with greater adoption of primary PCI and lower in-hospital mortality in tertiary hospitals in China. Our results provided important information for further integrated STEMI network construction in China.

The application of optimisation modelling and geospatial analysis to propose a coronary care network model for patients with ST-elevation myocardial infarction.

BackgroundThe incidence of myocardial infarction is increasing in South Africa. Prompt treatment is indicated to reduce mortality. One way of expediting treatment is to set up regional referral recommendations that can guide prehospital providers on the best reperfusion strategy for a particular patient. A coronary care network model for patients who present with ST-elevation myocardial infarction is proposed, using the North West province, of South Africa as a case study.MethodsGeospatial analysis with network optimisation modelling was applied, to determine which strategy (prehospital thrombolysis, in-hospital thrombolysis or percutaneous coronary intervention) was most appropriate for patients presenting within each of the municipal wards of the North West province.ResultsAn efficient and swift recommendation for the optimal reperfusion strategy is obtained using the current model, even in the instance of a large amount of ward data with additional constraints. For most municipal wards (204, 53%) percutaneous coronary intervention is the preferred reperfusion strategy based on proximity. For the remainder of the wards prehospital (138, 36%) or in-hospital (44, 11%) thrombolysis is recommended.ConclusionA scalable and efficient method of determining the optimal reperfusion strategy for a patient presenting with ST-elevation myocardial infarction in the North West province, is presented. This approach can serve as a model which can be applied to other settings and can form the basis of regional coronary care network development priorities and resource allocations.

P4369Direct comparison of prognostic value of echocardiographic parameters of right ventricular dysfunction in normotensive patients with acute pulmonary embolism

Abstract Background Although various echocardiographic parameters of right ventricular dysfunction (RVD) were reported to be of prognostic value in normotensive patients with acute pulmonary embolism (APE), an optimal definition of RVD on echocardiography is missing. Purpose We performed a direct comparison of prognostic value of RV/LV ratio, TAPSE, and TRPG/TAPSE for complicated clinical course that included: in-hospital APE related mortality, hemodynamic collapse or rescue thrombolysis. Methods Prospective cohorts of APE patients normotensive at admission, managed according to the ESC Guidelines 2014 were merged in a collaborative database. Transthoracic echocardiography was performed at admission, as soon as possible. All studied parameters were available in each patient. AUC in ROC analysis were assessed for each parameter and were compared between them. Multivariable Cox regression analysis was performed to assess the combination of echo-parameters. Results Overall, 490 pts were included in the study (229F), aged 64±18 years. Clinical endpoint occurred in 31 pts including 8 APE related deaths. AUC for SAE of RV/LV, TAPSE and TRPG/TAPSE were similar (Figure 1). TAPSE &lt;16mm compared to other echo-parameters showed the highest PPV and NPV (Table 1). Cox regression analysis including SBP, HR, age, elevated troponin and echo-parameters showed that only blood pressure, RV/LV &gt;1 and TAPSE &lt;16mm were identified as independent predictors of outcome (HR 0.98 (95% CI: 0.96–0.99), p=0.03; 2,53 (95% CI: 1.2–5.7), p&lt;0.03 and 3,76 (95% CI: 1.74–8.11), p&lt;0.001). Table 1. Predictive values of proposed cut offs of echocardiographic parameters Parameter Sensitivity Specificity PPV NPV TAPSE &lt;16mm 52% 85% 18% 96% RV/LV &gt;1.0 74% 63% 12% 95% TAPSE&lt;20 &amp; TRPG/TAPSE &gt;4.5 10% 94% 10% 94% Figure 1 Conclusions Although all TAPSE, RV/LV ratio and TRPG/TAPSE showed similar performance for prognosticating of in-hospital outcome in normotensive PE patients, TAPSE&lt;16mm showed the highest predictive value for identification of patients at risk of complicated clinical course.

Review article: Impact of 12-lead electrocardiography system of care on emergency medical service delays in ST-elevation myocardial infarction: A systematic review and meta-analysis.

To assess the impact of prehospital 12-lead electrocardiography (PH ECG) on emergency medical service (EMS) delay in patients with ST-elevation myocardial infarction (STEMI), we systematically searched five online electronic databases, including MEDLINE, Embase, Emcare, Cochrane Library and CINAHL, between 1990 and August 2017. Controlled trials and observational studies comparing EMS time delays with and without PH ECG in STEMI patients were eligible. Two reviewers independently screened studies for eligibility, extracted data and appraised study quality. The primary outcome was the time elapsed between scene arrival and hospital arrival. The secondary outcomes were response time, scene time, transport time and emergency call-to-hospital arrival time. Random effects models were used to pool weighted mean differences in EMS delay. Seven moderate-quality studies (two controlled trials and five observational) involving 81 005 participants were included in the data synthesis. The primary treatment strategy was in-hospital thrombolysis and percutaneous coronary intervention in four and three studies, respectively. PH ECG was associated with a 7.0 min increase in scene arrival-to-hospital arrival time (three studies; n = 80 628; 95% CI 6.7-7.2; I2 = 0.0%) and a 2.9 min increase in scene time (four studies; n = 377; 95% CI 1.2-4.6; I2 = 0.0%). PH ECG had no effect on transport or call-to-hospital intervals, although both measures showed evidence of heterogeneity. In patients with STEMI, PH ECG is associated with a modest increase in EMS delays. Measurement and improvement of EMS system delays may help to expedite treatment for STEMI.

Abstract TP291: Melbourne Mobile Stroke Unit Increases Stroke Treatment Rates and Treatment Opportunities

Background: The Melbourne Mobile Stroke Unit (MSU) is the first stroke ambulance in Australia. The MSU aims to provide rapid access to time critical treatments to acute stroke patients in the pre-hospital setting, thereby increasing the number of patients eligible for treatment. This is achieved by providing immediate access to expert stroke and ambulance personnel and the use of a mobile CT scanner. Methods: Data are prospectively collected on all MSU dispatches and compared to our local hospital database and Australian national standards. Results: The Melbourne MSU launched November 20 th 2017. It has been dispatched to 970 cases, of which 400 patients (41%) were attended by the MSU. Forty-two patients were thrombolysed (28% of all ischemic stroke versus the Australian average of 13% in-hospital thrombolysis), with a median scene-needle time of 40 mins (23-80mins). The median Australian door-needle time is 72 mins, with only 30% of patients treated within the internationally recommended 60 mins. Of the MSU thrombolysed patients, 12% were treated 3.5-4.5 hours from symptom onset; given ambulance transport and standard door-to-needle times, these patients would have been excluded from hospital-based lysis due to time. Additionally, the number of “golden hour” (onset-needle &lt;60mins) thrombolysis patients has increased from 2% within our hospital to 12% on the MSU. Three patients had their anticoagulation reversed on the MSU with idarucizumab prior to thrombolysis and 1 patient received prothrombinex to manage a warfarin-related ICH. Nicardipine, labetalol and hydralazine are routinely used to manage BP. The MSU also provides a unique platform for hyperacute research trials, enrolling 10 patients into both ischemic and hemorrhagic stroke trials (utilising tenecteplase and tranexamic acid respectively). Conclusion: The Melbourne MSU more than doubles the rate of thrombolysis compared to in-hospital treatment and provides a comprehensive range of other novel treatments and opportunities. Consequently, the MSU allows more patients to be treated than the standard ambulance-hospital paradigm.

Nursing Management Method for Thrombolysis Time Window of Cerebral Ischemic Stroke

This paper aims to analyse the reasons for hospital-visit and in-hospital thrombolysis delays about the cerebral ischemic stroke patients, and then makes a related countermeasure study. In the study, at stage 1, the analysis was made for the reasons of stroke patients’ thrombolysis delay by tracking the treatment process of stroke patients, and making questionnaire survey to understand the patients’ cognition about cerebral stroke; at stage 2, based on reasons for thrombolysis delay, the countermeasures were studied, e.g. optimize the thrombolysis process on the basis of process management theory, formulate the illustrated health educational manual, and analyse the application effect of measures. Besides, the SPSS17.0 software was adopted to make statistical analysis. With the multi-level stroke management team (incl. nursery and administration etc.) established, the first-aid process can be optimized and the medical and nursing quality process control management system be improved. At last, considering the lack of related knowledge about cerebral stroke disease, the related health education should be enhanced, and the public awareness of hospital treatment in time should be improved, in order to reduce the patient’s clinic time and improve the thrombolytic ratio.

Comparison of prasugrel versus clopidogrel in Korean patients with acute myocardial infarction undergoing successful revascularization

BackgroundAlthough there have been several reports that prasugrel can improve clinical outcomes, the efficacy and safety of prasugrel is unknown in Korean patients with acute myocardial infarction (AMI) undergoing successful revascularization. MethodsA total of 4421 patients [637 patients were prescribed prasugrel (60/10 or 5mg, loading/maintenance dose) and 3784 patients clopidogrel (600 or 300/75mg)] with AMI undergoing successful revascularization were enrolled from the core clinical cohort of Korea Acute Myocardial Infarction Registry-National Institute of Health. ResultsAfter propensity score matching (637 pairs), there were no significant differences in baseline clinical and procedural characteristics and in-hospital medications between the two groups. The primary efficacy endpoint, defined as the composite of cardiac death, MI, stroke, or target vessel revascularization at 6 months showed no significant difference between prasugrel and clopidogrel (2.4% vs. 2.9%, p=0.593). Also, no difference was observed in the composite of cardiac death, MI, or stroke during hospitalization between two groups (0.8% vs. 0.9%, p=0.762). However, the incidence of in-hospital Thrombolysis in Myocardial Infarction (TIMI) major or minor bleeding was significantly higher in prasugrel compared with clopidogrel (5.3% vs. 2.7%, p=0.015). In multivariate linear regression analysis, trans-femoral intervention, use of glycoprotein IIb/IIIa inhibitors, use of calcium channel blocker, and use of prasugrel were independent predictors of in-hospital TIMI major or minor bleeding [odds ratio (OR)=6.918; 95% confidence interval (CI)=2.453–19.510, OR=2.577; 95% CI=1.406–4.724, OR=4.016; 95% CI=1.382–11.668, OR=2.022; 95% CI=1.101–3.714]. ConclusionsOur study shows that the recommended dose of prasugrel had significantly higher in-hospital bleeding complications without reducing ischemic events compared with clopidogrel. However, further large-scale, long-term, randomized clinical trials are required to accurately assess the efficacy and safety of prasgurel and to find out the optimal dose for Korean AMI patients.

Improved Survival of Patients with ST-Segment Elevation Myocardial Infarction 3–6 Hours After Symptom Onset Is Associated with Inter-Hospital Transfer for Primary Percutaneous Coronary Intervention (PCI) at a Large Regional ST-Segment Elevation Myocardial Infarction (STEMI) Program vs. In-Hospital Thrombolysis in a Community Hospital

BackgroundThis study sought to compare the 30-day and 1-year survival of patients diagnosed with ST-segment elevation myocardial infarction (STEMI), whose symptom onset to in-hospital first medical contact (IHFMC) was 3–6 h, who received either in-hospital thrombolysis (IHT) in the nearest county hospital or direct transfer to a larger hospital in Henan province, China for primary percutaneous coronary intervention (PPCI).Material/MethodsPatients were allocated into 2 groups: one group received IHT in the local county hospital, whereas the other group were transferred to the PCI centers to receive PPCI. Patient demographic data, baseline characteristics, and time between different stages of patient contact to the initiation of treatment for IHT or PPCI were recorded for analysis.ResultsNo significant difference was identified between the 2 groups with the baseline characteristics and demographic data. The all-cause mortality was not significantly different between the IHT and PPCI group at 30 days (13.0% vs. 9.9%, p=0.386). However, a significant difference in mortality between the IHT and PPCI group was observed at 1 year (23.4% vs. 14.1%, p=0.035). Inter-hospital transfer time for PPCI tended to be the independent predictor for survival (OR: 4.4 CI 95%: 1.9–14.5, p 0.001). Overall, the patients undergoing PPCI in inter-hospital transfer had a higher survival rates for 1 year compared with patients receiving IHT.ConclusionsDespite the delay associated with inter-hospital transfer for PPCI, patients with STEMI 3–6 h after symptom onset have improved survival with PPCI over patients treated locally with IHT.

Functional outcomes of pre-hospital thrombolysis in a mobile stroke treatment unit compared with conventional care: an observational registry study

Specialised CT-equipped mobile stroke treatment units shorten time to intravenous thrombolysis in acute ischaemic stroke by starting treatment before hospital admission; however, direct effects of pre-hospital thrombolysis on clinical outcomes have not been shown. We aimed to compare 3-month functional outcomes after intravenous thrombolysis in patients with acute ischaemic who had received emergency mobile care or and conventional care. In this observational registry study, patients with ischaemic stroke received intravenous thrombolysis (alteplase) either within a stroke emergency mobile (STEMO) vehicle (pre-hospital care covering 1·3 million inhabitants of Berlin) or within conventional care (normal ambulances and in-hospital care at the Charité Campus Benjamin Franklin in Berlin). Patient data on treatment, outcome, and demographics were documented in STEMO (pre-hospital) or conventional care (in-hospital) registries. The primary outcome was the proportion of patients who had lived at home without assistance before stroke and had a 3-month modified Rankin Scale (mRS) score of 1 or lower. Our multivariable logistic regression was adjusted for demographics, comorbidities, and stroke severity. This study is registered with ClinicalTrials.gov, number NCT02358772. Between Feb 5, 2011, and March 5, 2015, 427 patients were treated within the STEMO vehicle and their data were entered into a pre-hospital registry. 505 patients received conventional care and their data were entered into an in-hospital thrombolysis registry. Of these, 305 patients in the STEMO group and 353 in the conventional care group met inclusion criteria and were included in the analysis. 161 (53%) patients in the STEMO group versus 166 (47%) in the conventional care group had an mRS score of 1 or lower (p=0·14). Compared with conventional care, adjusted odds ratios (ORs) for STEMO care for the primary outcome (OR 1·40, 95% CI 1·00-1·97; p=0·052) were not significant. Intracranial haemorrhage (p=0·27) and 7-day mortality (p=0·23) did not differ significantly between treatment groups. We found no significant difference between the proportion of patients with a mRS score of 1 or lower receiving STEMO care compared with conventional care. However, our results suggest that pre-hospital start of intravenous thrombolysis might lead to improved functional outcome in patients. This evidence requires substantiation in future large-scale trials. Zukunftsfonds Berlin, the Technology Foundation Berlin with EU co-financing by the European Regional Development Fund via Investitionsbank Berlin, and the German Federal Ministry for Education and Research via the Center for Stroke Research Berlin.

Sex differences in the management of acute coronary syndromes in Italy: data from the MANTRA registry.

Several studies have shown sex differences in acute coronary syndromes (ACS), but their understanding is far from complete. Thus, the study aims to evaluate sex differences in management and outcomes of unselected patients with ACS. From 22 April 2009 to 29 December 2010, 6394 consecutive patients with ACS (44.7% ST-elevation myocardial infarction) were prospectively enrolled and followed for 6 months. Women (N = 1894, 29.6%) were older, had more comorbidities, and worse clinical presentation than men. Fewer women underwent reperfusion [68.0% women vs. 84.1% men, P < 0.0001, adjusted odds ratio (OR): 0.53, 95% confidence interval (CI): 0.43-0.66] in ST-elevation myocardial infarction, and coronary angiography during hospitalization (72.2% women vs. 81.1% men, P < 0.0001, adjusted OR: 0.70, 95% CI: 0.57-0.85) in no-ST-elevation ACS. Women had worse outcomes than men during hospitalization, and at 6-month follow-up. At multivariable analysis, female sex was significantly associated with a higher risk of in-hospital Thrombolysis in Myocardial Infarction major bleedings (OR: 1.80, 95% CI: 1.09-2.96, P = 0.02), but not of 6-month death. Women with ACS in clinical practice present a clustering of high-risk features that may contribute to their worse outcomes as compared with men, although female sex is not an independent predictor of death at 6-month follow-up.

Comparison of short-term clinical outcomes between ticagrelor versus clopidogrel in patients with acute myocardial infarction undergoing successful revascularization; from Korea Acute Myocardial Infarction Registry—National Institute of Health

BackgroundAlthough ticagrelor has been well-known to improve clinical outcomes in patients with acute myocardial infarction (AMI) without increased bleeding risk, its clinical impacts have not been well established in East Asian patients. MethodsBetween November 2011 and June 2015, a total of 8010 patients (1377 patients were prescribed ticagrelor and 6633 patients clopidogrel) undergoing successful revascularization were analyzed from Korea Acute Myocardial Infarction Registry—National Institute of Health. The patients who discontinued or occurred in-hospital switching between two antiplatelet agents were excluded. ResultsAfter propensity score matching (1377 pairs), no difference in the composite of cardiac death, MI, stroke, or target vessel revascularization at 6months was observed between two groups (4.2% vs. 4.9%, p=0.499). However, the incidences of in-hospital Thrombolysis In Myocardial Infarction (TIMI) major and minor bleeding were higher in ticagrelor than clopidogrel (2.6% vs. 1.2%, p=0.008; 3.8% vs. 2.5%, p=0.051). The in-hospital mortality was higher in patients with than those without TIMI major bleeding (11.3% vs. 0.9%, p<0.001). In a subgroup analysis, a higher risk for in-hospital TIMI major bleeding with ticagrelor was observed in patients≥75years or with body weight<60kg (odd ratio [OR]=3.209; 95% confidence interval [CI]=1.356–7.592) and in those received trans-femoral intervention (OR=1.996; 95% CI=1.061–3.754). ConclusionsOur study shows that ticagrelor did not reduce ischemic events yet, however, was associated with increased risk of bleeding complications compared with clopidogrel. Further large-scale, long-term, randomized trials should be required to assess the outcomes of ticagrelor for East Asian patients with AMI.

Abstract 179: Functional Outcomes of Pre-hospital Stroke Thrombolysis Compared to Conventional Care; the Stroke Emergency Mobile (STEMO) Project

Background: Specialized CT-equipped stroke ambulances can shorten time to intravenous thrombolysis (IVT) in acute ischemic stroke. Although efficacy of thrombolytic treatment is known to be time-sensitive, effects of pre-hospital thrombolysis on functional outcomes have not yet been evaluated. Methods: We compared outcomes of all consecutive stroke patients who received thrombolysis during the same period cared for either by the Berlin Stroke Emergency Mobile (STEMO) or within conventional care (normal ambulance and in-hospital thrombolysis). Treatment and outcomes were documented in prospective registries. Patients who lived at home without assistance prior to their stroke were included. Primary outcome was modified Rankin Scale (mRS) ≤1 at 3 month. Secondary outcome was 3-month mortality. Outcomes were adjusted in multivariable regression for demographics, co-morbidities and stroke severity. Results: From Feb. 5, 2011 to Mar 5, 2015, 427 patients were treated on STEMO and 513 in conventional care. 303 (mean age: 71y, female gender: 48%, median NIHSS: 7) and 357 (mean age: 70y, female gender: 36%, median NIHSS: 7) of them had lived at home without assistance pre-stroke, respectively. Mean onset to treatment time was 34 minutes shorter in STEMO care (96±60 vs. 130±56min). The primary outcome of mRS≤1 was observed in 167 (55%) and 168 (47%) patients (p=0.039); 17 (6%) vs 38 (11%) had died (p=0.02), respectively. Adjusted odds ratios were favorable for STEMO care: OR 1.56 (95%-CI: 1.11-2.20; p=0.01) for mRS≤1 and OR 0.50 (95%-CI: 0.26-0.98; p=0.04) for death. Conclusions: The data suggest that earlier start of IVT by specialized prehospital stroke care leads to improved outcome.

L’infarctus du myocarde au Maroc : les données du registre FES-AMI

BackgroundAcute myocardial infarction is the most dangerous complication of coronary atherothrombosis. There are several disparities in regard to its management around the world. The aim of this study is to analyze the specificities of management of acute myocardial infarction in Morocco. MethodsFES-AMI (Fès Acute Myocardial Infarction) is a prospective monocentric registry conducted in cardiology department of Hassan II university hospital in Fès. In this registry, we enrolled patients with acute myocardial infarction who presented within 5 days after symptom onset. ResultsFrom January 2005 to August 2015, we enrolled 1835 patients. Seventy-five percent of patients were males and mean age was 60 years old. Fifty-one percent of patients were smokers, 27% were hypertensives and 14% were diabetics. Sixty-six percent of patients had more than 2 risk factors. Time from symptom onset to hospital admission was less than six hours for 40% of the patients. Thirty-six percent of patients were admitted more than twelve hours after the onset of chest pain. Only 37% of patients received reperfusion therapy, 31% with in-hospital thrombolysis and 6% with primary angioplasty. In-hospital mortality was 7.6%. ConclusionThe patients enrolled in our registry have late presentation of acute myocardial infarction and less rate of reperfusion therapy. Furthermore, the majority of our patients have multiple risk factors and this result underlines the failure of preventive interventions.

Evaluación de resultados tras la implantación de un protocolo de fibrinólisis extrahospitalaria en zonas rurales

IntroductionThe aim is to evaluate the outcomes obtained from the implementation of a pre-hospital thrombolysis protocol in 3 rural emergency care teams, as well as delays and strategies of reperfusion applied in the treatment of the ST-segment elevation myocardial infarction. Material and methodsRetrospective cohort study (n=52) with historical control (n=20) of the patients assisted for ST-segment elevation myocardial infarction. Medical emergency care teams, hospital, computerized medical history and ARIAM register reports were revised, obtaining epidemiological and clinical features, off-hospital management, reperfusion, time intervals and mortality. ResultsThe baseline features in both groups were not significantly different. There was a non-significant improvement of emergency care teams-hospital diagnostic concordance (85.3 versus 76.9%). We found a similar use of nitroglycerin, morphine and aspirin; significant increase (P<0.0001) of clopidogrel/prasugrel (55 versus 90.4%) and enoxaparin/fondaparinux (35 versus 76.9%), as well as pre-hospital thrombolysis (5 versus 30,8%, P<0.03), that was applied within the first 2h to 71.4%, with a median door-needle of 40min, whereas in-hospital thrombolysis and primary angioplasty were performed after 3h from the symptoms onset (P<0.01). Delays are associated with the patient's own lateness (P<0.02). Pharmaco-invasive strategy increases (62.5 versus 84.6%) more than primary angioplasty (15 versus 17.3%), reducing in-hospital thrombolysis (35 versus 19.2%), all of them non-significant. Complications are similar and one-year mortality is reduced (P<0.67). ConclusionsThe protocol is effective, safe, and reliable. It reduces delays and improves pre-hospital attention. The pharmaco-invasive strategy is a valid option.