Minutes Of First Medical Contact Research Articles

Risk of Delayed Percutaneous Coronary Intervention for STEMI in the Southeast United States.

Emergent reperfusion by percutaneous coronary intervention (PCI) within 90 minutes of first medical contact (FMC) is indicated in patients with ST-segment elevation myocardial infarction (STEMI). However, long transport times in rural areas in the Southeast US make meeting this goal difficult. The objective of this study was to determine the number of Southeast US residents with prolonged transport times to the nearest 24/7 primary PCI (PPCI) center. A cross-sectional study of residents in the Southeastern US was conducted based on geographical and 2022 5-Year American Community Survey data. The geographic information system (GIS) ArcGIS Pro was used to estimate Emergency Medical Services (EMS) transport times for Southeast US residents to the nearest PPCI center. All 24/7 PPCI centers in North Carolina, South Carolina, Georgia, Florida, Mississippi, Alabama, and Tennessee were included in the analysis, as well as nearby PPCI centers in surrounding states. To identify those at risk of delayed FMC-to-device time, the primary outcome was defined as a >30-minute transport time, beyond which most patients would not have PCI within 90 minutes. A secondary outcome was defined as transport >60 minutes, the point at which FMC-to-device time would be >120 minutes most of the time. These cutoffs are based on national median EMS scene times and door-to-device times. Within the Southeast US, we identified 62,880,528 residents and 350 PPCI centers. Nearly 11 million people living in the Southeast US reside greater than 30 minutes from a PPCI center (17.3%, 10,866,710, +/- 58,143), with 2% (1,271,522 +/- 51,858) living greater than 60 minutes from a PPCI hospital. However, most patients reside in short transport zones; 82.7% (52,013,818 +/- 98,741). Within the Southeast region, 8.4% (52/616) of counties have more than 50% of their population in a long transport zone and 42.3% (22/52) of those have more than 90% of their population in long transport areas. Nearly 11 million people in the Southeast US do not have access to timely PCI for STEMI care. This disparity may contribute to increased morbidity and mortality.

CHA2DS2 - Vasc Score Predict No Reflow Phenomenon in Primary Percutaneous Coronary Intervention

Purpose: ST-Elevation Myocardial Infarction is the most acute manifestation of Coronary artery disease, with substantial morbidity and mortality. Early reperfusion (re-establishing the blood flow in the occluded artery) is the most effective way to preserve the viability of the ischaemic myocardium and limit infarct size. Early diagnosis of STEMI is crucial to initiate appropriate treatment and should ideally be made within 10 minutes of first medical contact. This study aimed to evaluate the CHA2DS2-VASc score as a simple tool for predicting the no-reflow among patients with STEMI who underwent primary percutaneous coronary intervention.
 Methodology: This was a case-control study which was conducted on 100 patients, diagnosed with acute STEMI and underwent primary PCI, who was admitted to Cardiology Department, Benha University Hospital and National Heart Institute. Patients were classified into two groups, control and no-flow, according to their final angiographic TIMI flow rates resulting from primary PCI. The control group: 78 patients with TIMI flow rate >2. The no-reflow group: 22 patients with TIMI flow rate ≤2, despite mechanical reopening of the infarct-related artery in patients without dissection of the coronary artery.
 Findings: In this study, LVEF was significantly lower in patients with no-reflow compared to patients with normal TIMI flow (p <0.001), but LVEDV was significantly higher (p =0.01). There was no significant difference in LVESV between patients with no-reflow compared to patients with normal TIMI flow. CHA2DS2VASC score was significantly higher in patients with no-reflow compared to patients with normal TIMI flow (p <0.001). CHA2DS2VASC score is a significant predictor of occurrence of no reflow phenomenon (AUC: 0.689, p =0.006). At a cut off value of ≥ 2it has a sensitivity of 68.2%, specificity of 58.9%, PPV of 31.9% and NPV of 86.8%.
 Recommendation: The study suggest that the CHA2DS2‑VASc score can be an independent predictor of no‑reflow phenomenon in patients undergoing primary PCI. As a simple and easy‑to‑calculate score, it might be a useful assessment tool to predict no‑reflow phenomenon before primary PCI interventions in patients with STEMI. Thus we recommend using CHA2DS2-VASc score as it is very simple and a quick tool to predict no-reflow before primary PCI

CHA2DS2-VASC Score as a Predictor of Coronary Artery Disease: A Cross Sectional Observational Study

Background: The CHA2Ds2-VASC was was revealed to be a predictor for thromboembolism event in patients who do not have atrial fibrillation or who have supra ventricular arrhythmia. The aim of this work was to evaluate the role of CHA2DS2 – VASC score in prediction of coronary artery disease.
 Methods: This cross sectional observational study included 150 patients underwent coronary angiography for diagnosis and treatment of CAD. There were 59 patients with ACS (including STEMI and Non-STEMI) and 91 patients with no ACS. All patients were subjected to complete history taking, clinical, general examination and local cardiac examination. Standard 12-lead ECG was obtained within 10 minutes of first medical contact (FMC) according to ESC guidelines. Baseline laboratory tests were done including serum creatinine, INR, hemoglobin, platelets, cholesterol and triglycerides. Arterial coronary angiography (Femoral approach), right and left coronary imaging and echocardiographs were performed.
 Results: The incidence of HTN, CHF, DM and Vascular disease was statistically significantly higher in the cases with ACS as compared with the cases with no ACS. The total mean Gensini score was significantly higher in the cases with ACS as compared with the cases with no ACS. There was a statistically significantly strong positive correlation between CHA2DS2‐VASc Score and Gensini score. The best cut-off point of CHA2DS2‐VASc Score to differentiate between cases with ACS and no ACS WAS > 2 with 79.7% sensitivity and 56% specificity. With univariate regression analysis, increasing age, CHF, DM, previous stroke, vascular disease and increasing CHADS-VASC score were reported as risk factors for vessel affection, however with multivariate regression analysis CHF, DM and increasing CHADS-VASC score were shown as independent risk factors of vessel affection
 Conclusions: CHA2DS2-VASc score could be utilized as a useful diagnostic and predictor tool in cases with CAD. Patients with higher CHA2DS2-VASc scores had higher risks of cardiovascular disease severity.

Door to Balloon Time Audit of ST Elevation Myocardial Infarctions in a Newly Established 24/7 PrimaryPercutaneous Coronary Intervention Centre

Primary percutaneous coronary intervention (PPCI) for ST-elevation myocardial infarction (STEMI) is superior to thrombolysis if performed within 120 minutes of first medical contact and 90 minutes of hospital arrival. Rigorous review is necessary to ensure a recognised benchmark 75% of cases achieve reperfusion within targeted times.

Clinical performance in patients with acute coronary syndrome in 2018: the national registry

Aim . To evaluate the quality of reperfusion, medical therapy, as well as the short-term outcomes in patients with acute coronary syndrome (ACS) in 2018 using the data of the national ACS registry. Methods . Medical records of 30,594 ACS patients (62% - men, the mean age of 65±11,2 years) treated in 30 regions of the Russian Federation in 2018 were selected in the National ACS Registry and analyzed. The rate and timing of percutaneous coronary intervention (PCI) and fibrinolysis, prescription of aspirin, clopidogrel, beta-blockers, statins, and in-hospital mortality rate were assessed. Results. Fibrinolysis was performed in 29.9% of patients with ST-segment elevation acute coronary syndrome. 54,3% of patients with ST-segment elevation ACS underwent PCI. 47.7% and 60.5% of patients were treated within 30 minutes of first medical contact to fibrinolysis and 90 minutes to primary PCI. 95.6% of patients received aspirin, 84.9% - clopidogrel, 88.8% - beta-blockers, and 93.4% - statins. The inhospital mortality was 2.9%. Conclusion . The main clinical performance and quality measures for medical therapy in 2018 were high according to the National ACS Registry. PCI prevailed among the selected reperfusion strategies. However, the timing of both, PCI and fibrinolysis, was insufficient.

Reperfusion times for ST elevation myocardial infarction: a prospective audit

New published guidelines recommend treatment of ST elevation myocardial infarction (STEMI) within 30 minutes of first medical contact to thrombolysis and 90 minutes to primary percutaneous coronary intervention (PCI). To determine how a tertiary care center compares to these new guidelines and to evaluate the success of measures directed to shorten delays. This was a prospectively designed audit loop using retrospective chart review. Specific time intervals were evaluated: 1) T2 (ER presentation to diagnostic EKG; 2) T ER (ER presentation to reperfusion); and 3) T AHA (first medical contact to reperfusion). Results of the initial 12-month data were conveyed to Emergency Room staff and a dedicated EKG machine was placed in the ER for the subsequent 12 months, and the results were then re-analyzed. In 2003-4, 58 patients with STEMI were identified, with 41 (70.7%) receiving reperfusion. Of those receiving thrombolysis, median T AHA was 54 [37-72] minutes, with 12.0%<30 minutes, while those receiving PCI, median T AHA was 58 [43-78] minutes, with 25.0%<90 minutes. In 2004-5, 52 patients had STEMI, with 40 (76.9%) receiving reperfusion. The percentage of patients meeting the guidelines was 14.3% for the thrombolysis group and 11.1% for the PCI group. Introduction of a dedicated EKG machine led to a strong trend towards improvement in median T2 (22 vs 10 minutes; P=0.07), but other treatment times remained unchanged. Treatment times are longer than recommended guidelines. More comprehensive strategies and improved coordination of medical services are required to shorten pre-contact and post-contact response times.

Extending Time to Reperfusion with Mild Therapeutic Hypothermia: A New Paradigm for Providing Primary Percutaneous Coronary Intervention to Remote ST Segment Elevation Myocardial Infarction Patients.

Primary percutaneous coronary intervention (PPCI) is the preferred treatment for acute ST segment elevation myocardial infarction (STEMI). The goal is reperfusion within 90 minutes of first medical contact (FMC) or 120 minutes if transfer is needed. Otherwise, fibrinolytic therapy is recommended. Mild therapeutic hypothermia (MTH) (≤35°C) before coronary reperfusion decreases myocardial infarct size. If applied before reperfusion, hypothermia could potentially lengthen the FMC-reperfusion time without increasing infarct size. Thirty-six swine had their mid left anterior descending coronary artery acutely occluded. All animals had an initial 30 minutes of occlusion to simulate typical delay before seeking medical attention. Eighteen animals were studied under normothermic conditions with reperfusion after an additional 40 minutes (the porcine equivalent of a 120-minute clinical FMC to reperfusion time) and 18 were treated with hypothermia but not reperfused until another 80 minutes (clinical equivalent of 240 minutes). Primary outcome was myocardial infarct size (infarct/area at risk [AAR]) at 24 hours. The two groups differed in systemic temperature at the time of reperfusion (39.1°C ± 1.0°C vs. 35.5°C ± 0.7°C; p < 0.0001). Myocardial infarct size was not significantly different despite the longer time to reperfusion in those treated with hypothermia (60.6% ± 12% of the AAR [normothermic] vs. 65.8% ± 11.8% of the AAR [hypothermic]; p = 0.39). Rapid induction of MTH during an anterior STEMI made it possible to extend the FMC to reperfusion time by the equivalent of an extra two clinical hours (120-240 minutes) without increasing the myocardial infarct size. This strategy could allow more STEMI patients to receive PPCI rather than the less effective intravenous fibrinolysis.

822 Drip or Ship? Real-world STEMI Management and Concordance With Guidelines for Patients From Outer-Metropolitan and Semi-Rural Centres

Deciding between intravascular thrombolytic therapy (TL) and percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) is influenced by location. Australian guidelines recommend metropolitan patients receive PCI within 90 minutes of first medical contact while rural and remote patients receive TL before transfer and angiography within 24 hours. For outer-metropolitan patients with perceived transfer times to PCI-capable centres of 30-60 minutes, the decision becomes complex despite clear guideline criteria. Patients presenting to South Australian outer-metropolitan locations 30-80 kilometres from a PCI-capable centre between 2013 and 2019 with STEMI or cardiac arrest with ST-elevation were included. The initial location, transfer time, door to balloon time and first-medical-contact to balloon time were recorded. Incidence of MACE (combined incidence of mortality, re-infarction and revascularisation) at 12 months was recorded. 46 Patients were included (mean age 63, 60.9% male). Median time from first-medical-contact to balloon was 116 minutes (IQR 95,148). When seen initially and directly transferred for PCI by ambulance (n=20), the median time to balloon was 96 minutes (IQR 92,114). When seen initially at peripheral hospitals (n=26), median was 137 minutes (IQR 113,171). Only 7(15.2%) patients achieved revascularisation within 90 minutes. MACE at 12 months occurred in 15.2% of patients. The vast majority of patients transferred for primary-PCI in locations with perceived transfer times of 30-60 minutes failed to have revascularisation within guideline recommended timeframes. The auditing of transport times is important to calibrate perceived transfer times and inform this infrequent but vital clinical decision.

The proportion of South Africans living within 60 and 120 minutes of a percutaneous coronary intervention facility.

SummaryIntroductionTimely reperfusion, preferably via percutaneous coronary intervention (PCI) following myocardial infarction, improves mortality rates. Emergency medical services play a pivotal role in recognising and transporting patients with ST-elevation myocardial infarction directly to a PCI facility to avoid delays to reperfusion. Access to PCI is, in part, dependant on the geographic distribution of patients around PCI facilities. The aim of this study was to determine the proportion of South Africans living within 60 and 120 minutes of a PCI facility.MethodsPCI facility and population data were subjected to proximity analysis to determine the average drive times from municipal ward centroids to PCI facilities for each province in South Africa. Thereafter, the population of each ward living within 60 and 120 minutes of a PCI facility was extrapolated.ResultsApproximately 53.8 and 71.53% of the South African population live within 60 and 120 minutes of a PCI facility. The median (IQR, range) drive times and distances to a PCI facility are 100 minutes (120.4 min, 0.7–751.8) across 123.6 km (157.6 km, 0.3–940.8).ConclusionBased on the proximity of South Africans to PCI facilities, it seems possible that most patients could receive timely PCI within 120 minutes of first medical contact. However, this may be unlikely for some due to a lack of medical insurance, under-developed referral networks or other system delays. Coronary care networks should be developed based on the proximity of communities to 12-lead ECG and reperfusion therapies (such as PCI facilities). Public and private healthcare partnerships should be fortified to allow for patients without medical insurance to have equal accesses to PCI facilities.

Keys to Achieving Target First Medical Contact to Balloon Times and Bypassing Emergency Department More Important Than Distance.

Background Australian guidelines advocate primary percutaneous coronary intervention (PPCI) as the reperfusion strategy of choice for ST elevation myocardial infarction (STEMI) in patients in whom it can be performed within 90 minutes of first medical contact; otherwise, fibrinolytic therapy is preferred. In a large health district, the reperfusion strategy is often chosen in the prehospital setting. We sought to identify a distance from a PCI centre, which made it unlikely first medical contact to balloon time (FMCTB) of less than 90 minutes could be achieved in the Hunter New England health district and to identify causes of delay in patients who were triaged to a PPCI strategy. Methods and Results We studied 116 patients presenting via the ambulance service with STEMI from January 2016 to December 2016. In patients who were taken directly to the cardiac catheterisation lab, a maximum distance of 50 km from hospital resulted in 75% of patients receiving PCI within 90 minutes and approximately 95% of patients receiving PCI within 120 minutes. Patients who bypassed the emergency department (ED) were significantly more likely to have FMCTB of less than 90 minutes (p < 0.001) despite having a longer travel distance (28.5 km versus 17.4 km, p < 0.001). Patients transiting via the ED were significantly more likely to present out of hours (60 versus 24.2% p < 0.001). Conclusions Patients who do not bypass the ED have a longer FMCTB across all spectrum of distances from the PCI centre; therefore, bypassing the ED is key to achieving target FMCTB times. Using a cutoff distance of 50 km may reduce human error in estimating travel time to our PCI centre and thereby identifying patients who should receive prehospital thrombolysis.

Acute Coronary Syndrome - What should the general practitioner do?

Acute myocardial infarction is the second most common cause of mortality in Germany after chronic ischemic cardiac disease. It is essential to think of acute coronary syndrome also in patients who do not present with typical signs (pressure, tightness, pain, or a squeezing or aching sensation in the chest or arms that may spread to the neck, jaw or back) in the general practitioner's practice. Vital signs (blood pressure, heart rate and oxygen saturation) must be measured; an ECG should be recorded and analyzed within ten minutes of first medical contact. The patient should be sedated, head and shoulders should be supported and an intravenous access should be established. Emergency medication that should be administered in practice is acetylsalicylic acid, an ADP receptor antagonist, morphine, nitrates, low molecular weight heparin and where necessary tranquilizers and oxygen (if peripheral saturation is below 90%). Monitored transport to the nearest clinic with percutaneous coronary intervention standby must be organized and this clinic must be informed about the arriving patient.

Abstract 147: ECG to Decision Time - Small Delays Deciding to Transfer a STEMI Patient Adds Much Larger Delays to Reperfusion Time

Background: Non-PCI capable facilities are faced with a time critical challenge to transfer a STEMI patient to a PCI capable hospital for Primary PCI within 120 minutes of first medical contact. Once a 12-Lead ECG is obtained and printed, a period of time elapses before STEMI is recognized, and a decision is made to transfer the patient for Primary PCI. It seems logical that the ECG-to-Decision time should not impact the subsequent Decision-to-PCI time. We evaluated the impact of the time spent from ECG-to-Decision time on the subsequent Decision-to-PCI time. Methods: Data was combined, and retrospectively analyzed on 157 consecutive STEMI cases first identified at 32 non-PCI capable facilities, and transferred to one of two different PCI capable hospitals located in either Duluth, Minnesota, or Fargo, North Dakota. There were 124 cases from September 2013 through February 2015 at one hospital, and 33 cases from May 2013 through February 2015 at the other. Decision time was defined by the call time for inter-facility transport for Primary PCI, or the call time to the PCI capable hospital to request activation of the Cath Lab. Findings: 30% of patients had an ECG-to-Decision time of less than 5 minutes, with mean &amp; median Decision-to-PCI times of 93 min. &amp; 86 min. (range 38-231; SD = 34.8). Another 30% of patients had an ECG to Decision time between 5 to 9 minutes, with mean &amp; median Decision-to-PCI times of 102 min. &amp; 103 min. (range 46 - 158; SD = 23.3). 40% of patients had an ECG-to-Decision time of 10 minutes or greater, with mean &amp; median Decision-to-PCI time of 131 &amp; 124 minutes (range 58 - 239; SD = 47.9). For a 5-9 minute delay in ECG-to-Decision time, an additional 17 minute delay was added to the median Decision-to-PCI time. If the ECG-to-Decision time was delayed 10 minutes or more, an additional 38 minute delay was added to the median Decision-to-PCI time. Conclusion: We observed an escalating impact of delay on Decision-to-PCI time as the result of smaller increases in delay of ECG-to-Decision time. Our data suggests that a realistic goal for ECG-to-Decision time of under 5 minutes should be considered for non-PCI capable facilities, to avoid escalating delays in Primary PCI time for STEMI patients.

Transport and treatment of patients with STEMI in rural Iceland--Only a few patients receive PPCI within 120 minutes

ST-segment Elevation Myocardial Infarction (STEMI) is a life-threatening disease and good outcome depends on early restoration of coronary blood flow. Primary percutaneous coronary intervention (PPCI) is the treatment of choice if performed within 120 minutes of first medical contact (FMC) but in case of anticipated long transport or delays, pre-hospital fibrinolysis is indicated. The aim was to study transport times and adherence to clinical guidelines in patients with STEMI transported from outside of the Reykjavik area to Landspitali University Hospital in Iceland. Retrospective chart review was conducted of all patients diagnosed with STEMI outside of the Reykjavik area and transported to Landspitali University Hospital in Reykjavik in 2011-2012. Descriptive statistical analysis and hypothesis testing was applied. Eighty-six patients had signs of STEMI on electrocardiogram (ECG) at FMC. In southern Iceland nine patients (21%) underwent PPCI within 120 minutes (median 157 minutes) and no patient received fibrinolysis. In northern Iceland and The Vestman Islands, where long transport times are expected, 96% of patients eligible for fibrinolysis (n=31) received appropriate therapy in a median time of 57 minutes. Significantly fewer patients received appropriate anticoagulation treatment with clopidogrel and enoxaparin in southern Iceland compared to the northern part. Mortality rate was 7% and median length of stay in hospital was 6 days. Time from FMC to PPCI is longer than 120 minutes in the majority of cases. Pre-hospital fibrinolysis should be considered as first line treatment in all parts of Iceland outside of the Reykjavik area. Directly electronically transmitted ECGs and contact with cardiologist could hasten diagnosis and decrease risk of unnecessary interhospital transfer. A STEMI database should be established in Iceland to facilitate quality control.

Approach to chest pain and acute myocardial infarction.

Patient history, physical examination, 12-lead electrocardiogram (ECG) and cardiac biomarkers are key components of an effective chest pain assessment. The first priority is excluding serious chest pain syndromes, namely acute coronary syndromes (ACSs), aortic dissection, pulmonary embolism, cardiac tamponade and tension pneumothorax. On history, the mnemonic SOCRATES (Site Onset Character Radiation Association Time Exacerbating/relieving factor and Severity) helps differentiate cardiac from non-cardiac pain. On examination, evaluation of vital signs, evidence of murmurs, rubs, heart failure, tension pneumothoraces and chest infections are important. A 12-lead ECG should be interpreted within 10 minutes of first medical contact, specifically to identify ST elevation myocardial infarction (STEMI). High-sensitivity troponins improve the rapid rule-out of myocardial infarction (MI) and confirmation of non-ST elevation MI (NSTEMI). ACS (STEMI and NSTEMI/unstable anginapectoris (UAP)) result from acute destabilisation of coronary atheroma with resultant complete (STEMI) or subtotal (NSTEMI/UAP) thrombotic coronary occlusion. The management of STEMI patients includes providing urgent reperfusion: primary percutaneous coronary intervention(PPCI) if available, deliverable within 60 - 120 minutes, and fibrinolysis if PPCI is not available. Essential adjunctive therapies include antiplatelet therapy (aspirin, P2Y12 inhibitors), anticoagulation (heparin or low-molecular-weight heparin) and cardiac monitoring.

SINGLE CENTRE REVIEW OF OUTCOMES WITH ALCOHOL SEPTAL ABLATION FOR DRUG-REFRACTORY HYPERTROPHIC OBSTRUCTIVE CARDIOMYOPATHY

chi-squared test. RESULTS: The rates of EKG within 10 minutes of first medical contact and DTNT less than 30 minutes showed significant improvement between the two time periods. The rate of cardiac catheterization, P-PCI and delayed PCI increased significantly between the two time periods. One year cardiac readmission and one year mortality were significantly lower during the post guideline period. Patients managed with PPCI had a significantly lower one year mortality than STEMI patients treated with fibrinolytic therapy. CONCLUSION: Although there have been significant improvements in STEMI management and outcomes in Nova Scotia, there are still considerable room for improvement. Further analysis is needed to understand more clearly the contribution of provincial guideline implementation to the improvements in STEMI treatment in Nova Scotia and the recent drop in readmissions and mortality. More detailed analysis of P-PCI and fibrinolytic treated patients is planned as well as comparison of treatment and outcome in other Canadian jurisdictions.

IMPACT OF PROVINCIAL ST ELEVATION MYOCARDIAL INFARCTION GUIDELINE IMPLEMENTATION ON TIMELINESS OF DIAGNOSIS, REPERFUSION THERAPY, SUBSEQUENT INVASIVE ASSESSMENT AND OUTCOMES - ANALYSIS FROM CARDIOVASCULAR HEALTH NOVA SCOTIA DATABASE

Provincial guidelines for the management of acute ST elevation myocardial infarction (STEMI) were implemented in Nova Scotia in 2008. These emphasized the importance of rapid diagnosis after first medical contact, timely reperfusion therapy (fibrinolysis or primary percutaneous coronary intervention (PPCI) as appropriate) and pre-discharge cardiac catheterization for most STEMI patients treated initially with fibrinolysis. Guideline adoption was accompanied by the development and implementation of multiple local and provincial protocols and quality improvement strategies across the province. The Cardiovascular Health Nova Scotia database was interrogated to determine the impact of guideline implementation on the timeliness of diagnosis, utilization of reperfusion therapy/cardiac catheterization and clinical outcomes in patients with acute STEMI. Data on EKG time, door to needle time (DTNT) for fibrinolytic treated patients, cardiac catheterization rates, PCI rates, one year cardiac readmission rate and one year mortality following admission with acute STEMI were obtained. These data were compared for a three year period prior to provincial guideline implementation (2004-6) against a three year period following guideline implementation (2010-12). The two time periods were compared using the chi-squared test. The rates of EKG within 10 minutes of first medical contact and DTNT less than 30 minutes showed significant improvement between the two time periods. The rate of cardiac catheterization, P-PCI and delayed PCI increased significantly between the two time periods. One year cardiac readmission and one year mortality were significantly lower during the post guideline period. Patients managed with P-PCI had a significantly lower one year mortality than STEMI patients treated with fibrinolytic therapy. Although there have been significant improvements in STEMI management and outcomes in Nova Scotia, there are still considerable room for improvement. Further analysis is needed to understand more clearly the contribution of provincial guideline implementation to the improvements in STEMI treatment in Nova Scotia and the recent drop in readmissions and mortality. More detailed analysis of P-PCI and fibrinolytic treated patients is planned as well as comparison of treatment and outcome in other Canadian jurisdictions.

FAVORABLE OUTCOMES AND 30 DAY READMISSION RATES ACHIEVED BY IMPLEMENTING A GUIDELINE BASED TRANSFER PROTOCOL IN A LARGE RURAL ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION SYSTEM OF CARE INCLUDING TRANSFERS UP TO 183 MILES

ACCF/AHA Guidelines for the Management of ST-Segment ElevationMyocardial Infarction (STEMI) recommend a mixed strategy approach, offering fibrinolytic therapy to eligible patients unable to receive Primary Percutaneous Coronary Intervention (PCI) within 120 minutes of first medical contact. Due to

Symptom Onset–to-Balloon Is More Important Than Door-to-Balloon Time

Current guidelines recommend percutaneous coronary intervention (PCI) be performed within 90 minutes of first medical contact (so-called

Combined reperfusion strategies in ST-segment elevation MI: Rationale and current role

Primary percutaneous coronary intervention (PCI) is the preferred reperfusion strategy for ST-elevation myocardial infarction (MI), but most patients do not arrive at a PCI facility within the recommended 90 minutes of first medical contact. If delay is expected, timely thrombolysis is recommended, followed by early transfer for PCI. The authors review the rationale behind three combined reperfusion strategies-facilitated PCI, pharmacoinvasive therapy, and rescue PCI-and data on their effectiveness.

The Strategic Reperfusion Early After Myocardial Infarction (STREAM) study

Primary percutaneous coronary intervention (PCI) has emerged as the preferred therapy for acute ST-elevation myocardial infarction (STEMI) provided it is performed in a timely fashion at an expert 24/7 facility. Fibrinolysis is a well-accepted alternative, especially in patients presenting early after symptom onset. The STREAM study will provide novel information on whether prompt fibrinolysis at first medical contact, followed by timely catheterization or rescue coronary intervention in STEMI patients presenting within 3 hours of symptom onset, represents an appropriate alternative strategy to primary PCI. Acute STEMI patients presenting early after symptom onset are eligible if PCI is not feasible within 60 minutes of first medical contact. This is an open-label, prospective, randomized, parallel, comparative, international multicenter trial. Patients are randomized to fibrinolysis combined with enoxaparin, clopidogrel, and aspirin, and cardiac catheterization within 6 to 24 hours or rescue coronary intervention if reperfusion fails within 90 minutes of fibrinolysis versus PCI performed according to local guidelines. Composite efficacy end points at 30 days include death, shock, heart failure, and reinfarction. Safety end points include ischemic stroke, intracranial hemorrhage, and major nonintracranial bleeding. Follow-up is extended to 1 year and includes all-cause mortality. Continuing delays in achieving timely PCI remain a difficult issue. Many patients fail to achieve the desired reperfusion times of 90 to 120 minutes after first medical contact. The STREAM results will provide useful additional data on which to base informed therapeutic decisions.