On-site Primary Percutaneous Coronary Intervention Research Articles

Pharmaco-Invasive Therapy is a Critical Option in Nigerian Stemi Treatment: A Review

Primary percutaneous coronary intervention (PCI) is the recommended reperfusion approach in patients with ST-segment elevation myocardial infarction (STEMI), When conducted in a timely and by skilled operators. This technique, however, has proven to have limitations in areas without PCI facilities and with long wait times between the initial medical contact and balloon because to logistical issues and a lack of skilled operators. In STEMI patients, pre-treatment with a fibrinolytic prior to PCI has the potential to give early pharmacologic reperfusion before definitive PCI. According to current evidence, assisted PCI has no advantage over main PCI. The role for pharmaco-invasive reperfusion, defined as pharmacological re-perfusion followed by rapid transfer for routine delayed coronary angiography and PCI may still be considered in centers without on-site PCI capability.
 Patients presenting with STEMI in Nigeria have a lot of challenges which include delay in decision making, cost of revascularization, religious believes, ignorance and availability of cardiac catheterization and the skillful personnel for the operation. To meet with the demand and challenges of Myocardial infarction in Nigeria, we need the mode of treatment that is beneficial, cost effective and lifesaving. Hence, pharmaco-invasive is the way for Nigeria and other low-income countries of sub-Saharan Africa.

Symptom-to-door delay among patients with ST-segment elevation myocardial infarction in Singapore.

Symptom-to-door time (S2D) is one of the important components of ischaemic time, which might affect the infarct size and outcomes of acute myocardial infarction. The aim of the present study was to identify patients' characteristics associated with delayed symptom-onset-to-arrival at EDs in ST-segment elevation myocardial infarction (STEMI) patients in Singapore. Retrospective data of STEMI patients presenting to the ED of all public hospitals with onsite primary percutaneous coronary intervention facilities between 2010 and 2012 were obtained from the Singapore Myocardial Infarction Registry. Based on the S2D of 120 min, characteristics of patients were compared between short S2D (≤120 min) and long S2D (>120 min). Multivariate logistic and linear regression analyses were performed. Out of 3848 patients, 1682 patients had an S2D of ≤120 min, and 2166 had an S2D >120 min. In the multivariate analyses, older age, Malay ethnicity, diabetes mellitus, presenting symptoms of back and epigastric pain were independently associated with long S2D. Patients who utilised the emergency medical services, presented after office hours and with symptoms of chest pain, breathlessness, diaphoresis and past history of percutaneous transluminal coronary angioplasty/primary percutaneous coronary intervention, were independently associated with short S2D. Patients with long S2D had lower probability of receiving reperfusion treatment with delayed symptom-to-balloon and door-to-balloon time and higher probabilities of complications and mortality. The present study shows that longer S2D was associated with older age, ethnicity, diabetes mellitus, delay in receiving early reperfusion treatment and poorer prognosis.

KNOWLEDGE TRANSLATION TO REDUCE DELAYS OF PRIMARY PERCUTANEOUS CORONARY INTERVENTION IN PATIENTS IN QUÉBEC - INSIGHTS FROM THE AMI ON TIME STUDY

We previously showed prolonged delays of primary percutaneous coronary intervention (PCI) in patients with ST-segment elevation (STEMI) at 17 Québec hospitals in 2003 (median door-to-balloon (D2B) time: 102 minutes (mins)) for patients who presented directly to hospitals with on-site PCI facility (PCI-hospital). The primary objective of this study is to determine whether knowledge translation (KT) increases the adoption of AHA recommended strategies to reduce D2B time. The AMI-ONTIME study was a pre-post study evaluating the effectiveness of KT in increasing the adoption of the following strategies: (1) emergency physician (EP)’s direct activation of PCI-personnel, (2) single-number page system, (3) PCI personnel to be ready within 30 min of activation and (4) rapid feedback of D2B time. The primary endpoint was the proportion of PCI-hospitals which implemented all four strategies. We also evaluated the proportions of PCI-hospitals that accepted patients with STEMI at all times, maintain adequate volumes of PCI and dedicated personnel for quality control of primary PCI. We sent surveys to all 13 Québec PCI-hospitals in 2009 and in 2013. The response rates were 100% for both 2009 surveys. The KT interventions were networking between pre-hospital and in-hospital personnel, identification and resolution of obstacles to prompt primary PCI, use of opinion leaders, evaluation and feedback of STEMI care, hospital-based STEMI team and educational website. We also measured prospectively D2B times in patients who underwent primary PCI, without inter-hospital transfer, during 2010-2011. During the same time intervals, beside from the AMI-ON TIME study, there were several noteworthy provincial initiatives such as Ministry of Health’s mandated retrospective studies of D2B times, provincial guidelines of STEMI treatment and ongoing University of Montréal’s prospective registry of D2B times. The median D2B time was 74 mins in 2010-11 for patients who underwent primary PCI without inter-hospital transfer in Québec (68% of patients underwent primary PCI within 90 mins). Adoption rates of AHA recommended strategies are shown in the Table below. * denote statistically significant differences between values obtained before and after KT (p values <0.001) Increased adoption of AHA-recommended strategies was associated with reduction in D2B time in Québec. These improvements in STEMI care may have been partially due to KT interventions combined with the other province-wide initiatives mentioned above. However, a few strategies remained under-used such as single-number page system and rapid feedback of D2B time. Emphasis on these interventions should be made for timelier primary PCI in Québec.

Impact of ECG findings and process-of-care characteristics on the likelihood of not receiving reperfusion therapy in patients with ST-elevation myocardial infarction: results of a field evaluation.

BackgroundMany patients with ST-elevation myocardial infarction (STEMI) do not receive reperfusion therapy and are known to have poorer outcomes. We aimed to perform the first population-level, integrated analysis of clinical, ECG and hospital characteristics associated with non-receipt of reperfusion therapy in patients with STEMI.Methods and ResultsThis systematic evaluation of STEMI care in 82 hospitals in Quebec included all patients with a discharge diagnosis of myocardial infarction, presenting with characteristic symptoms and an ECG showing STEMI as attested by at least one of two study cardiologists or left bundle branch block (LBBB). Excluding LBBB, an ECG was considered a definite STEMI diagnosis if both cardiologists scored ‘certain STEMI’ and ambiguous if one scored ‘uncertain’ or ‘not STEMI’. Centers were classified according to accessibility to primary percutaneous coronary intervention (PPCI): 1) on-site PPCI; 2) routine transfer for PPCI; 3) varying mix of PPCI transfer and on-site fibrinolysis; and 4) routine on-site fibrinolysis. Of 3730 STEMI/LBBB patients, 812 (21.8%) did not receive reperfusion therapy. In multivariate analysis, likelihood of no reperfusion therapy was a function of PPCI accessibility (odds ratio [OR] for fibrinolysis versus PPCI centers = 3.1; 95% CI: 2.2–4.4), presence of LBBB (OR = 24.1; 95% CI: 17.8–32.9) and an ECG ambiguous for STEMI (OR = 4.1; 95% CI: 3.3–5.1). When the ECG was ambiguous, likelihood of no reperfusion therapy was highest in hospitals most distant from PPCI centers.ConclusionsECG diagnostic ambiguity, LBBB and PPCI accessibility are important predictors of not receiving reperfusion therapy, suggesting opportunities for improving outcomes.

Symptom-to-needle times in ST-segment elevation myocardial infarction: Shortest route to a primary coronary intervention facility

Primary percutaneous coronary intervention (PCI) is the preferred management for patients with acute ST-segment elevation myocardial infarction (STEMI) if performed in a timely manner by experienced providers. Patients can access a PCI facility by three routes: prehospital STEMI diagnosis by emergency medical services (EMS) and direct transport by EMS to a PCI facility (EMS-PCI); visit to a hospital emergency department (ED) followed by referral to an on-site PCI facility (ED-PCI); or transfer from the ED to a PCI facility in another hospital (ED-transfer-PCI). To assess the implementation rate in France of the guidelines recommending that STEMI patients be transported by EMS to a PCI facility and to compare the times between symptom onset and PCI for these three routes. We used the results of the pilot testing of a national quality indicator programme on STEMI in 64 hospitals, providing data on patient characteristics, referral route and symptom-onset-to-needle time. We compared delays for each route in a Cox proportional-hazard model. In a population of 1217 patients, median symptom-onset-to-needle time was 186minutes (Q1133; Q3 292) for the EMS-PCI route, 237minutes (Q1165; Q3 368) for the ED-PCI route and 305minutes (Q1230; Q3 570) for the ED-transfer-PCI route. A total of 70.8% of patients were transported by EMS as recommended. After adjustment for age, symptom onset period (weekends/nights) and history of cardiovascular disease, the EMS-PCI route was associated with the shortest symptom-onset-to-needle times. The hazard ratio was 0.71 [0.59-0.86] for the ED-PCI route and 0.67 [0.52-0.86] for the ED-transfer-PCI route. STEMI patients receive prompter care after prehospital diagnosis and direct transport to a PCI facility by EMS than by visiting a hospital ED. Use of this referral route should be further encouraged in France as approximately one-third of STEMI patients are still presenting directly to the ED.

Facilitated/Pharmaco-invasive Approaches in STEMI

Primary percutaneous coronary intervention (PCI) is the preferred reperfusion method in patients with ST-elevation myocardial infarction (STEMI), when performed in a timely manner and by skilled operators. However, this strategy has shown to be limited in environments with lack of PCI facilities and delay in the first medical contact-to-balloon time for logistic reasons. Pretreatment with fibrinolysis and/or glycoprotein IIb/IIIa inhibitors before PCI has the potential to provide early pharmacologic reperfusion before definitive PCI in STEMI patients. However, current data suggest that facilitated PCI does not offer any advantage over primary PCI. Conversely, a role for pharmacoinvasive recanalization, defined as pharmacological reperfusion followed by rapid transfer for routine delayed coronary angiography and PCI may still be considered in centers without on-site PCI capability.

Long-term Clinical Outcome and MIBI SPECT Parameters in Percutaneous Coronary Interventions

Background and AimPrimary percutaneous coronary intervention (PCI) is the preferred treatment option for acute myocardial infarction (MI). Off-site PCI reduces time-to-treatment, which could potentially lead to enhanced clinical outcomes. Therefore, we investigated whether off-site PCI improves 5-year clinical outcomes compared with on-site PCI and whether this is related to in-hospital 99mTc-sestamibi single photon emission computed tomography (MIBI SPECT) parameters.MethodsWe describe the 5-year follow-up for a combined endpoint of death or re-infarction in 128 patients with acute MI who were randomly assigned to undergo primary PCI at the off-site centre (n = 68) or to transferral to an on-site centre (n = 60). Three days after PCI, MIBI SPECT was performed to estimate infarct size. A multivariate Cox regression model was created to study the relation between MIBI SPECT parameters and long-term clinical outcomes.ResultsAfter a mean follow-up of 5.8 ± 1.1 years, 25 events occurred. Off-site PCI significantly reduced door-to-balloon time compared with on-site PCI (94 ± 54 versus 125 ± 59 min, p = 0.003). However, infarct size (17 ± 15 versus 14 ± 12%, p = 0.34) and 5-year death or infarct rate (21% versus 18%, p = 0.75) were comparable between treatment centres. With multivariate analysis, only Killip class ≥2 and Q wave MI, but not scintigraphic data, predicted long-term clinical outcomes.ConclusionOff-site PCI reduced door-to-balloon time with a comparable 5-year death or infarct rate. Parameters from resting MIBI SPECT on day 3 after MI did not predict long-term clinical outcomes.

Sustaining and Spreading Reduced Door-to-Balloon Times for ST-Segment Elevation Myocardial Infarction Patients

Prompt primary percutaneous coronary intervention (PCI) for patients with ST-segment elevation myocardial infarction (STEMI) significantly reduces mortality and morbidity. In 2004 the American College of Cardiology (ACC) and American Heart Association (AHA) set a goal to reduce door-to-balloon (D2B) time to < 90 minutes in 75% of STEMI cases. IMPLEMENTING THE STEMI INITIATIVE: In 2004, the STEMI/D2B leadership team broke down D2B time into four segments: door to data, data to diagnosis, diagnosis to decision, and decision to device. Each segment was examined for inefficiencies, duplication, and nonstandardization. In 2005, after the internal D2B processes and results showed improvement, the STEMI/D2B leadership team extended the project to prehospital emergency medical services. In 2006, UMass Memorial began to roll out a regional system for STEMI care to the 12 community hospitals in its service area without on-site PCI capabilities. In 2007, the STEMI program's first full year, D2B times averaged < or = 90 minutes in 94% of the 87 STEMI cases; 62% had a D2B of < or = 60 minutes. In 2008, 96% of the D2B times averaged < or = 90 minutes. Mortality rates following PCI for STEMI were 62% and 57% less than predicted in 2006 and 2007, respectively. In 2008 the D2B time for direct-admit STEMI patients averaged < 50 minutes. From December 2007 through April 2009 UMass Memorial achieved the new ACC/AHA metric of prehospital EKG to balloon in < or = 90 minutes for 64 (90%) of the 71 patients for whom a prehospital electrocardiogram was obtained. The D2B time process is being applied to other clinical venues; a vascular surgery project is underway to reduce "door-to-incision time" for patients with ruptured abdominal aortic aneurysms.

Infarct size in primary angioplasty without on-site cardiac surgical backup versus transferal to a tertiary center: a single photon emission computed tomography study

Primary percutaneous coronary intervention (PCI) performed in large community hospitals without cardiac surgery back-up facilities (off-site) reduces door-to-balloon time compared with emergency transferal to tertiary interventional centers (on-site). The present study was performed to explore whether off-site PCI for acute myocardial infarction results in reduced infarct size. One hundred twenty-eight patients with acute ST-segment elevation myocardial infarction were randomly assigned to undergo primary PCI at the off-site center (n = 68) or to transferal to an on-site center (n = 60). Three days after PCI, (99m)Tc-sestamibi SPECT was performed to estimate infarct size. Off-site PCI significantly reduced door-to-balloon time compared with on-site PCI (94 +/- 54 versus 125 +/- 59 min, respectively, p < 0.01), although symptoms-to-treatment time was only insignificantly reduced (257 +/- 211 versus 286 +/- 146 min, respectively, p = 0.39). Infarct size was comparable between treatment centers (16 +/- 15 versus 14 +/- 12%, respectively p = 0.35). Multivariate analysis revealed that TIMI 0/1 flow grade at initial coronary angiography (OR 3.125, 95% CI 1.17-8.33, p = 0.023), anterior wall localization of the myocardial infarction (OR 3.44, 95% CI 1.38-8.55, p < 0.01), and development of pathological Q-waves (OR 5.07, 95% CI 2.10-12.25, p < 0.01) were independent predictors of an infarct size > 12%. Off-site PCI reduces door-to-balloon time compared with transferal to a remote on-site interventional center but does not reduce infarct size. Instead, pre-PCI TIMI 0/1 flow, anterior wall infarct localization, and development of Q-waves are more important predictors of infarct size.