Percutaneous Coronary Intervention Capability Research Articles

Initial treatment of uninsured patients with ST-elevation myocardial infarction by facility percutaneous coronary intervention capabilities.

Timely reperfusion is necessary to reduce morbidity and mortality in patients with ST-elevation myocardial infarction (STEMI). Initial care by facilities with percutaneous coronary intervention (PCI) capabilities reduces time to reperfusion. We sought to examine whether insurance status was associated with initial care at emergency departments (EDs) with PCI capabilities among adult patients with STEMI. We conducted a retrospective cross-sectional study using Department of Healthcare Access and Information, a nonpublic statewide database reporting ED visits and hospitalizations in California. We included adults initially arriving at EDs with STEMI by diagnostic code (International Classification of Diseases Ninth Revision or 10th Revision) from 2011 to 2019. Multivariable logistic regression modeling included initial care by PCI capable facility as the primary outcome and insurance status (none vs. any) as the primary exposure. Covariates included patient, facility, and temporal factors and we conducted multiple robustness checks. We analyzed 135,358 eligible visits with STEMI included. In our multivariable model, the odds of uninsured patients being initially treated at a PCI-capable facility were significantly lower than those of insured patients (adjusted odds ratio 0.62, 95% CI 0.54-0.72, p < 0.001) and was unchanged in sensitivity analyses. Uninsured patients with STEMI had significantly lower odds of first receiving care at facilities with PCI capabilities. Our results suggest potential disparities in accessing high-quality and time-sensitive treatment for uninsured patients with STEMI.

Interfacility Transfer of Uninsured vs Insured Patients With ST-Segment Elevation Myocardial Infarction in California

Insurance status has been associated with whether patients with ST-segment elevation myocardial infarction (STEMI) presenting to emergency departments are transferred to other facilities, but whether the facility's percutaneous coronary intervention capabilities mediate this association is unknown. To examine whether uninsured patients with STEMI were more likely than patients with insurance to experience interfacility transfer. This observational cohort study compared patients with STEMI with and without insurance who presented to California emergency departments between January 1, 2010, and December 31, 2019, using the Patient Discharge Database and Emergency Department Discharge Database from the California Department of Health Care Access and Information. Statistical analyses were completed in April 2023. Primary exposures were lack of insurance and facility percutaneous coronary intervention capabilities. The primary outcome was transfer status from the presenting emergency department of a percutaneous coronary intervention-capable hospital, defined as a facility performing 36 percutaneous coronary interventions per year. Multivariable logistic regression models with multiple robustness checks were performed to determine the association of insurance status with the odds of transfer. This study included 135 358 patients with STEMI, of whom 32 841 patients (24.2%) were transferred (mean [SD] age, 64 [14] years; 10 100 women [30.8%]; 2542 Asian individuals [7.7%]; 2053 Black individuals [6.3%]; 8285 Hispanic individuals [25.2%]; 18 650 White individuals [56.8%]). After adjusting for time trends, patient factors, and transferring hospital characteristics (including percutaneous coronary intervention capabilities), patients who were uninsured had lower odds of experiencing interfacility transfer than those with insurance (adjusted odds ratio, 0.93; 95% CI, 0.88-0.98; P = .01). After accounting for a facility's percutaneous coronary intervention capabilities, lack of insurance was associated with lower odds of emergency department transfer for patients with STEMI. These findings warrant further investigation to understand the characteristics of facilities and outcomes for uninsured patients with STEMI.

Measuring Accessibility to Healthcare Using Taxi Trajectories Data: A Case Study of Acute Myocardial Infarction Cases in Beijing.

Several methods have been applied to measure healthcare accessibility, ie, the Euclidean distance, the network distance, and the transport time based on speed limits. However, these methods generally produce less accurate estimates than actual measurements. This research proposed a method to estimate historical healthcare accessibility more accurately by using taxi Global Positioning System (GPS) traces. The proposed method's advantages were evaluated vis a case study using acute myocardial infarction (AMI) cases in Beijing in 2008. Comparative analyses of the new measure and three conventionally used measures suggested that the median estimated transport time to the closest hospital with percutaneous coronary intervention (PCI) capability for AMI patients was 5.72 minutes by the taxi GPS trace-based measure, 2.42 minutes by the network distance-based measure, 2.28 minutes by the speed limit-based measure, 1.73 minutes by the Euclidean distance-based measure; and the estimated proportion of patients who lived within 5 minutes of a PCI-capable hospital was 38.17%, 89.20%, 92.52%, 95.05%, respectively. The three conventionally used measures underestimated the travel time cost and overestimated the percentage of patients with timely access to healthcare facilities. In addition, the new measure more accurately identifies the areas with low or high access to healthcare facilities. The taxi GPS trace-based accessibility measure provides a promising start for more accurately estimating accessibility to healthcare facilities, increasing the use of medical records in studying the effects of historical healthcare accessibility on health outcomes, and evaluating how accessibility to healthcare changes over time.

Cardiac arrest centres: what, who, when, and where?

Cardiac arrest centres (CACs) may play a key role in providing postresuscitation care, thereby improving outcomes in out-of-hospital cardiac arrest (OHCA). There is no consensus on CAC definitions or the optimal CAC transport strategy despite advances in research. This review provides an updated overview of CACs, highlighting evidence gaps and future research directions. CAC definitions vary worldwide but often feature 24/7 percutaneous coronary intervention capability, targeted temperature management, neuroprognostication, intensive care, education, and research within a centralized, high-volume hospital. Significant evidence exists for benefits of CACs related to regionalization. A recent meta-analysis demonstrated clearly improved survival with favourable neurological outcome and survival among patients transported to CACs with conclusions robust to sensitivity analyses. However, scarce data exists regarding 'who', 'when', and 'where' for CAC transport strategies. Evidence for OHCA patients without ST elevation postresuscitation to be transported to CACs remains unclear. Preliminary evidence demonstrated greater benefit from CACs among patients with shockable rhythms. Randomized controlled trials should evaluate specific strategies, such as bypassing nearest hospitals and interhospital transfer. Real-world study designs evaluating CAC transport strategies are needed. OHCA patients with underlying culprit lesions, such as those with ST-elevation myocardial infarction (STEMI) or initial shockable rhythms, will likely benefit the most from CACs.

Short- and long-term outcomes of percutaneous coronary interventions of high-risk vs. low-risk lesions performed at a hospital without an on-site cardiac surgery unit.

Aim Widespread utilization of technology has led to the construction of a growing number of facilities with coronary angiography units and percutaneous coronary intervention (PCI) capability. Some of these centers do not have cardiovascular surgery (CVS) on site. Studies regarding the efficacy and safety of PCIs performed at these hospitals have been conducted. However, to date, high-risk procedures in this context have not been evaluated. The present study compares the outcomes of PCI procedures performed on high- and low-risk lesions groups in a center without CVS back-up.Material and methods A total of 999 patients treated with PCI with diagnoses other than ST elevation myocardial infarction were included in this study. Patients with SYNTAX scores 22 or higher, bifurcation lesions, chronic total occlusions, left main coronary artery lesions and saphenous graft lesions were classified as a high-risk group. In contrast, patients with SYNTAX scores lower than 22 were included in the low-risk group. Coronary lesions were classified as Type-A, B, and C. The 30‑day major adverse cardiac events (MACE) and 1‑year target vessel revascularization (TVR) rates were compared.Results There was no significant difference between the groups in terms of the rates of MACE (2 (0.9 %) vs 5 (0.6 %); p=0.64) and TVR (9 (4.2 %) vs 25 (3.2 %); p=0.52). Analysis regarding the lesion type also revealed no significant difference between the MACE and TVR rates (p=0.56 and p=0.43, respectively).Conclusions The findings in this study demonstrated that, similar to low-risk procedures, complex and high-risk coronary interventions can safely and effectively be conducted in hospitals without a CVS unit.

Left ventricular thrombus and anticoagulation: how long should we treat?

Abstract Background Left ventricular thrombus (LVT) is a potential complication of acute myocardial infarction and is associated with a high rate of thromboembolic events. With the advent of more potent antithrombotic medications and quicker reperfusion strategies, the incidence of LVT has been reduced. However, current guidelines recommendations are based on older evidence and some aspects of the treatment are being questioned, such as the optimal duration of anticoagulation. Purpose To determine how length of anticoagulation influences the risk of thromboembolic events and mortality in a tertiary-care cardiac center with primary percutaneous coronary intervention (PCI) capability. Methods A cohort of consecutive cases of patients with IVT diagnosed by transthoracic echocardiography between 2014 and 2020 was retrospectively analyzed. Results A total of 72 cases of LVT were identified. Etiology was ischemic cardiomyopathy in 60 (82.0%) patients and 13 (20.0%) were female. LVT was diagnosed in the setting of acute myocardial infarction in 23 (32.0%) of cases. Prolonged anticoagulation regimes were significantly associated with fewer systemic thromboembolic events (21.4% vs 6.1%; p=0.04), without a significant effect on mortality (Figure 1). Conclusion Clinical manifestations and epidemiology of LVT has recently changed after the advent of improved treatments. In our cohort, an indefinite anticoagulation strategy was significantly associated with fewer thromboembolic events, suggesting that future investigations should clarify these issues. Funding Acknowledgement Type of funding sources: None.

Impact of a telemedicine-guided, population-based, STEMI network on reperfusion strategy, efficiency, and outcomes: Impact of telemedicine on STEMI management.

A telemedicine-guided strategy increases the access to and efficiency of ST-elevation myocardial infarction (STEMI) networks resulting in increased access to, and reduced disparities in, acute myocardial infarction (AMI) care between rural and urban areas. The Latin America Telemedicine Infarct Network (LATIN) was developed for poor and remote regions in Brazil and Colombia that lacked coordinated AMI systems of care. It strategically connects small clinics and primary care health centres (spokes) to hubs with 24/7 percutaneous coronary intervention (PCI) capability. Experts at three remote sites provide urgent electrocardiogram (ECG) diagnosis and tele-consultation for the entire network. Data from the busiest LATIN site, the Santa Marcelina Hospital in Sao Paolo, Brazil, were compared with health statistics from Sistema Unico de Saude (Brazilian Public Health System - SUS). A total of 192 centres were networked using standardised and guideline-based protocols for AMI care. Overall, 313,897 patients were remotely screened, 3,572 AMI diagnosed (1.1%), and 1,636 AMI urgently reperfused (45.8%), mainly by primary PCI (n=1,351; 83%). In conclusion, a comparison between a pre-LATIN cohort from SUS (1,015) and a LATIN cohort from Santa Marcelina Hospital (1,247) revealed increased reperfusion with PCI (65.52% vs 75.2%), increased cost ($2,037.12 vs $2,246.40, p<0.005), a statistically significant reduction in PCI mortality (8.5% vs 4.3% p<0.01) and a non-significant reduction in mortality overall amongst all treatment pathways (9.69% vs 9.43%, p=0.931).

Association of Cardiac Care Regionalization With Access, Treatment, and Mortality Among Patients With ST-Segment Elevation Myocardial Infarction.

Regionalization of ST-segment elevation myocardial infarction (STEMI) systems of care has been championed over the past decade. Although timely access to percutaneous coronary intervention (PCI) has been shown to improve outcomes, no studies have determined how regionalization has affected the care and outcomes of patients. We sought to determine if STEMI regionalization is associated with changes in access, treatment, and outcomes. Using a difference-in-differences approach, we analyzed a statewide, administrative database of 139 494 patients with STEMI in California from 2006 to 2015 using regionalization data based on a survey of all local Emergency Medical Services agencies in the state. For patients with STEMI, the base rate of admission to a hospital with PCI capability was 72.7%, and regionalization was associated with an increase of 5.34 percentage points (95% CI, 1.58-9.10), representing a 7.1% increase. Regionalization was also associated with a statistically significant increase of 3.54 (95% CI, 0.61-6.48) percentage points in the probability of same-day PCI, representing an increase of 7.1% from the 49.7% base rate and a 4.6% relative increase (2.97 percentage points [95% CI, 0.1-5.85]) in the probability of receiving PCI at any time during the hospitalization. There was a 1.84 percentage point decrease (95% CI, -3.31 to -0.37) in the probability of receiving fibrinolytics. For 7-day mortality, regionalization was associated with a 0.53 (95% CI, -1 to -0.06) percentage point greater reduction (representing 5.8% off the base rate of 9.1%) and a 1.75 percentage point decrease in the likelihood of all-cause 30-day readmission (95% CI, -3.39 to -0.11; representing 6.4% off the base rate of 27.4%). No differences were found in longer-term mortality. Among patients with STEMI in California from 2006 to 2015, STEMI regionalization was associated with increased access to a PCI-capable hospital, greater use of PCI, lower 7-day mortality, and lower 30-day readmissions.

Qual o verdadeiro impacto da intervenção coronária percutânea on‐site? Análise de score de propensão de doentes admitidos por síndrome coronária aguda

IntroductionIn an era in which coronary heart disease is one of the leading causes of death worldwide, several studies report the persistence of obstacles to accessing revascularization, and percutaneous coronary intervention in particular, which may be associated with worse outcomes. ObjectivesTo compare cardiovascular outcomes in patients admitted to hospitals with and without on‐site percutaneous coronary intervention (PCI) capabilities. Material and MethodsA retrospective study based on the National Registry of Acute Coronary Syndromes (ACS) ‐ with data collection from 2010 to 2018. Division of the patients into two groups: with and without ST‐elevation. Two subgroups were subsequently created according to the presence/absence of on‐site PCI. A propensity score was performed to standardize the results. Patients without information about hospital admission (with/without PCI) were excluded. Results6008 patients were included after exclusion criteria and propensity score were applied. We found that patients admitted for ACS with ST‐elevation (STE‐ACS) had more episodes of sustained ventricular tachycardia (OR 2.14; CI (1.26‐3.61); p=0.004) in hospitals without on‐site PCI. Regarding ACS without ST elevation (NSTE‐ACS), there were more cases of congestive heart failure (OR 0.79; CI (0.65‐0.98)) in hospitals with on‐site PCI. ConclusionThe incidence of a greater number of major adverse events in hospitalizations without on‐site PCI, particularly in the case of STE‐ACS, is a consequence of the delay before revascularization. National and local strategies must be established to reduce the negative impact of the absence of on‐site PCI and the resulting time before revascularization.

Incidence of Stress Cardiomyopathy During the Coronavirus Disease 2019 Pandemic

The coronavirus disease 2019 (COVID-19) pandemic has resulted in severe psychological, social, and economic stress in people's lives. It is not known whether the stress of the pandemic is associated with an increase in the incidence of stress cardiomyopathy. To determine the incidence and outcomes of stress cardiomyopathy during the COVID-19 pandemic compared with before the pandemic. This retrospective cohort study at cardiac catheterization laboratories with primary percutaneous coronary intervention capability at 2 hospitals in the Cleveland Clinic health system in Northeast Ohio examined the incidence of stress cardiomyopathy (also known as Takotsubo syndrome) in patients presenting with acute coronary syndrome who underwent coronary arteriography. Patients presenting during the COVID-19 pandemic, between March 1 and April 30, 2020, were compared with 4 control groups of patients with acute coronary syndrome presenting prior to the pandemic across 4 distinct timelines: March to April 2018, January to February 2019, March to April 2019, and January to February 2020. Data were analyzed in May 2020. Patients were divided into 5 groups based on the date of their clinical presentation in relation to the COVID-19 pandemic. Incidence of stress cardiomyopathy. Among 1914 patient presenting with acute coronary syndrome, 1656 patients (median [interquartile range] age, 67 [59-74]; 1094 [66.1%] men) presented during the pre-COVID-19 period (390 patients in March-April 2018, 309 patients in January-February 2019, 679 patients in March-April 2019, and 278 patients in January-February 2020), and 258 patients (median [interquartile range] age, 67 [57-75]; 175 [67.8%] men) presented during the COVID-19 pandemic period (ie, March-April 2020). There was a significant increase in the incidence of stress cardiomyopathy during the COVID-19 period, with a total of 20 patients with stress cardiomyopathy (incidence proportion, 7.8%), compared with prepandemic timelines, which ranged from 5 to 12 patients with stress cardiomyopathy (incidence proportion range, 1.5%-1.8%). The rate ratio comparing the COVID-19 pandemic period to the combined prepandemic period was 4.58 (95% CI, 4.11-5.11; P < .001). All patients during the COVID-19 pandemic had negative reverse transcription-polymerase chain reaction test results for COVID-19. Patients with stress cardiomyopathy during the COVID-19 pandemic had a longer median (interquartile range) hospital length of stay compared with those hospitalized in the prepandemic period (COVID-19 period: 8 [6-9] days; March-April 2018: 4 [3-4] days; January-February 2019: 5 [3-6] days; March-April 2019: 4 [4-8] days; January-February: 5 [4-5] days; P = .006). There were no significant differences between the COVID-19 period and the overall pre-COVID-19 period in mortality (1 patient [5.0%] vs 1 patient [3.6%], respectively; P = .81) or 30-day rehospitalization (4 patients [22.2%] vs 6 patients [21.4%], respectively; P = .90). This study found that there was a significant increase in the incidence of stress cardiomyopathy during the COVID-19 pandemic when compared with prepandemic periods.

Study of primary angioplasty in hospital not having onsite cardiac catheterization facility

Objectives: The aim of this study is to evaluate the appropriateness of use and quality as well as outcomes of primary angioplasty for acute myocardial infarction (MI) in a single center without percutaneous coronary intervention (PCI) capability. Background: Primary percutaneous transluminal coronary angioplasty (PTCA) increases the rates of patency of the infarcted artery, improves survival rates, and reduces the rates of reinfarction and strokes as compared to thrombolysis. Methods: This is a hospital-based prospective study involving 77 patients. Primary PTCA was done by emergency transfer to PCI center at earliest. Results: Male patients outnumbered females (77% vs. 22%). Patients in the age group of 45–69 years constituted around 70.0% of the total ST-elevation MI patients. Majority of the patients (90%) presented with chest pain. During coronary angiography, it was found that the major culprit coronary was the right coronary (42.85%) followed by the left anterior descending artery (36.36%). A majority of the patients in the study group were found to have single-vessel disease (57.14%), and only five of the patients had triple-vessel disease (06.49%). Glycoprotein IIb/IIIa inhibitors were given to 41 patients (53.24%) as an adjuvant therapy. Conclusion: Primary angioplasty is very appropriate and feasible with a good outcome for the management of patients with acute ST-elevation MI even in a center where the facility of cardiac catheterization is not available. Our patients with acute ST-elevation myocardial infarction who were shifted to a center having cardiac catheterization laboratory and subsequently managed with primary angioplasty showed good response and outcome in terms of mortality and morbidity over a follow-up of 1 year.

Direct transport to PCI-capable hospitals after out-of-hospital cardiac arrest in New Zealand: Inequities and outcomes

BackgroundIt is widely accepted that survival from OHCA may be improved through direct transfer of patients to hospitals with percutaneous coronary intervention (PCI) capability. However, within the New Zealand healthcare system there is limited evidence available to support this. We aimed to compare patient characteristics and outcomes following an out-of-hospital cardiac arrest between those patients transported to hospitals with or without PCI-capability within New Zealand. MethodA retrospective cohort study was conducted using data from the St John New Zealand OHCA registry for adults treated for an out-of-hospital cardiac arrest of presumed cardiac aetiology between 1 October 2013 and 31 October 2018. Population characteristics were investigated using a Chi-Square analysis. Binary logistic regression modelling was used to investigate outcome differences in survival at 30 days post-event according to receiving hospital PCI-capability. ResultsThe study included 1750 patients who were transported to hospital following an OHCA. A significantly lower proportion of patients over 65 years (49.9%) were conveyed to hospitals with PCI-capability compared to younger aged patients (15–44 years (52.1%) and 45–64 years (59.7%) (p < 0.001). When ethnic groups were compared, Māori (32.9%) had the lowest proportion transported to PCI-capable hospitals, followed by European (55.6%) then Pacific Peoples (86.2%) (p < 0.001). A lower proportion of patients located rurally (34.7%) were transported to hospitals with PCI-capability compared to patients in an urban location (59.1%) (p < 0.001). Thirty-day survival was higher in patients transported to hospitals with PCI-capability (adjusted OR 1.285, 95%CI (1.01–1.63), p = 0.04). ConclusionsPatient characteristic differences indicate that inequities in healthcare may exist in New Zealand related to age, ethnic group, and rurality. Thirty-day survival was significantly increased in patients conveyed directly to a hospital with PCI-capability.

Iniciativa Stent-Save a Life! Argentina

The Stent-Save a Life! Initiative (SSL) is a European program that seeks to improve access of patients with acute myocardial infarction with ST-segment elevation (STEMI) to reperfusion therapies according to guideline recommendations, thus reducing morbidity and mortality. Objectives: To describe the results of the first three years of the SSL Initiative in Argentina. Methods: A mapping was carried out initially to analyze the local situation and a Door-to-Balloon Program (DBP) was developed for centers with primary percutaneous coronary intervention (pPCI) capability. Results: The lack of reperfusion culture with poor in-hospital organization was a common point in both public and private centers, triggering the development of the DBP. Since March-2016 to March-2018, 3041 patients with STEMI were included in 38 centers. Of these, 610 (20%) had their first medical contact (FMC) in emergency medical services. After excluding 184 (6%) patients without coronary lesions, reperfusion therapy was performed in 93% of the cases, mainly by pPCi. The total ischemic time was 117 minutes, with differences according to FMC. In-hospital mortality was 7%. Conclusions: Identification of barriers and the enhancement of in-hospital organization represent the first step to improve the care of STEMI patients. Integrated work is necessary to develop networks adapted to the local reality of each center and region.

Ethnic Differences in Direct Transport to PCI-Capable Hospitals Following OHCA

Background: Ethnic disparities exist in survival from out-of-hospital cardiac arrest (OHCA) in New Zealand. This study investigates how receiving-hospital impacts on outcomes, comparing hospitals with, or without, percutaneous coronary intervention (PCI) capability. Method: A retrospective observational study using St John New Zealand OHCA registry data for adult patients treated for OHCA of presumed cardiac aetiology between 1 October 2013 and 31 October 2018. Demographic characteristics were investigated using Chi-Squared analysis. Binary logistic regression modelling was used to investigate outcome differences in survival at thirty-days post-event, according to receiving-hospital PCI-capability. Results: Following an OHCA, 1750 patients were transported to hospital with sustained return-of-spontaneous-circulation (ROSC). Pacific Peoples (86.2%) had the highest proportion of transport to PCI-capable hospitals, followed by European (55.6%) then Māori (32.9%) (p < 0.001). Overall, a lower proportion of patients >65 years (49.9%) were conveyed to PCI-capable hospitals compared to younger age groups, 15–44 years (52.1%) and 45–64 years (59.7%) (p < 0.001). A lower proportion of patients located rurally (34.7%) were transported to PCI-capable hospitals compared to patients in urban locations (59.1%) (p < 0.001). Thirty-day survival was higher in patients transported to hospitals with PCI-capability (Adjusted OR 1.285, 95%CI (1.01 to 1.63), p = 0.04). Median ambulance transport time from OHCA scene to PCI-capable hospitals (13 minutes) was longer compared to non-PCI-capable hospitals (10 minutes) (p < 0.001). Conclusions: Inequities in healthcare may exist related to ethnicity, age, and rurality, associated with receiving-hospital capability. These warrant further investigation. Survival was significantly increased in patients conveyed to hospitals with PCI-capability compared to those who were not.

Factors Associated with the Transfer Decision in Resuscitated Patients with Out-of-Hospital Cardiac Arrest Presenting to a Hospital with Limited Targeted Temperature Management Capability in Korea.

This study aimed to identify factors associated with the decision to transfer resuscitated patients with out-of-hospital cardiac arrest (OHCA) who were initially examined at hospitals with limited targeted temperature management capability (HLTC) in Korea. We included adult patients with OHCA who were initially transported to HLTC from 2012 to 2015. We limited the study population with OHCA who were admitted or transferred. Potential factors associated with the transfer decision were categorized as patient- or hospital-level characteristics. The primary outcome was emergency department disposition: transfer out versus admission to HLTC. A stepwise multivariable logistic regression analysis was conducted to identify factors associated with the outcome. Of the 64,696 patients with OHCA, 37,705 (58.3%) were initially transported to HLTC. Approximately 44.7% of patients were transferred out. In terms of patient-level factors, age, socioeconomic status, and initial electrocardiogram rhythm were associated with the transfer decision. Hospital factors, such as percutaneous coronary intervention capability of HLTC (adjusted odds ratio = 0.16; 95% confidence interval = 0.14-0.19) and location of the metropolitan or urban hospital, were negatively associated with the transfer decision. Several hospital and patient factors were associated with the decision to transfer out patients with OHCA who were initially examined at HLTC.

Pre-hospital Transport Times and Outcomes After Different Reperfusion Strategies for ST-Elevation Myocardial Infarction

This study evaluated prehospital transport times and clinical outcomes after different reperfusion strategies for ST-elevation myocardial infarction in a real-world setting. We consecutively enrolled 27,205 patients who underwent percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction in Michigan from 2010 to 2016. Primary PCI was performed in 25,927 patients (95%), whereas 1,278 (5%) were treated with a pharmacoinvasive strategy. The overall use of a pharmacoinvasive strategy decreased during the study period (p <0.001). Prehospital transport times were estimated by using the Google Maps API from the centroid of each home zip code tabulation area to the zip code tabulation area for the nearest hospital with PCI capability. The estimated prehospital transport time predicted the choice of reperfusion strategy (p <0.001). Primary PCI was used in 97% of the patients living within 1 hour from a hospital with PCI capability compared with 48% with estimated transport times >1 hour. Bleeding and mortality rates were similar for patients treated with primary PCI or a pharmacoinvasive strategy (odds ratio 0.832, 95% confidence interval 0.649 to 1.067, p = 0.147). In conclusion, almost all patients in Michigan had timely access to a hospital with PCI capability and received treatment with primary PCI. The authors declare no conflicts of interests.

153EMF The Medicaid Expansion and Racial Disparities in Transfers to Hospitals Capable of Performing Percutaneous Coronary Intervention After Acute Myocardial Infarction

Racial disparities in rates of transfer to hospitals capable of performing invasive coronary reperfusion after acute myocardial infarction (AMI) have been previously documented. It is not known to what extent insurance coverage affects these disparities in rates of transfer. The Affordable Care Act (ACA) expanded insurance access to millions of Americans and has had a particular impact on rates of insurance for low-income populations and racial and ethnic minorities. Our objectives were to estimate the effect of the ACA’s Medicaid expansion on racial disparities in rates of transfer to percutaneous coronary intervention (PCI)-capable hospitals for patients admitted with AMI, both non-ST-segment elevation and ST-segment elevation myocardial infarction (NSTEMI and STEMI). We utilized a triple differences approach to compare racial disparities in rates of transfer to PCI-capable hospitals for patients with AMI who initially presented to hospitals without these capabilities in California, a state that expanded Medicaid (through the ACA, statewide, and pre-ACA expansion in certain counties) and Florida, a state that did not, before and after expansion. We used California non-public patient discharge data, hospital financial and utilization data from the California Office of Statewide Health Planning and Development, and Florida state inpatient and emergency department data from the Healthcare Cost and Utilization Project and included all Medicaid and uninsured patients ages 18-64 admitted with AMI from 2010 through 2015. We controlled for comorbidities, sex, age, date of admission, and urbanicity of patient’s home county. Standard errors were clustered at the hospital level. We did not find an association between the Medicaid expansion and changes in the likelihood of transferring to PCI-capable hospitals between white and nonwhite patients who initially presented to non-PCI-capable hospitals with AMI defined as both NSTEMI or STEMI. However, among patients with non-ST-segment myocardial infarction (NSTEMI) who initially presented to hospitals without PCI capabilities, there was a 14 percent increase (95% confidence interval 0.01, 0.28) in likelihood of transfer to a hospital capable of performing these procedures for nonwhite patients compared with white patients. The Medicaid expansion was associated with an increase in the likelihood of transferring to a PCI-capable hospital for nonwhite patients who initially presented to non-PCI-capable hospitals with NSTEMI, relative to white patients. We did not observe the same association when patients with ST-segment myocardial infarction (STEMI) were included in the analyses, potentially because there are clearer treatment guidelines for STEMI, and the treatment of NSTEMI may be more variable and subject to the influence of factors such as insurance coverage.

Unmet goals in the treatment of Acute Myocardial Infarction: Review.

Reperfusion therapy decreases myocardium damage during an acute coronary event and consequently mortality. However, there are unmet needs in the treatment of acute myocardial infarction, consequently mortality and heart failure continue to occur in about 10% and 20% of cases, respectively. Different strategies could improve reperfusion. These strategies, like generation of warning sign recognition and being initially assisted and transferred by an emergency service, could reduce the time to reperfusion. If the first electrocardiogram is performed en route, it can be transmitted and interpreted in a timely manner by a specialist at the receiving center, bypassing community hospitals without percutaneous coronary intervention capabilities. To administer thrombolytic therapy during transport to the catheterization laboratory could reduce time to reperfusion in cases with expected prolonged transport time to a percutaneous coronary intervention center or to a center without primary percutaneous coronary intervention capabilities with additional expected delay, known as pharmaco-invasive strategy. Myocardial reperfusion is known to produce damage and cell death, which defines the reperfusion injury. Lack of resolution of ST segment is used as a marker of reperfusion failure. In patients without ST segment resolution, mortality triples. It is important to note that, until recently, reperfusion injury and no-reflow were interpreted as a single entity and we should differentiate them as different entities; whereas no-reflow is the failure to obtain tissue flow, reperfusion injury is actually the damage produced by achieving flow. Therefore, treatment of no-reflow is obtained by tissue flow, whereas in reperfusion injury the treatment objective is protection of susceptible myocardium from reperfusion injury. Numerous trials for the treatment of reperfusion injury have been unsuccessful. Newer hypotheses such as “ controlled reperfusion”, in which the interventional cardiologist assumes not only the treatment of the culprit vessel but also the way to reperfuse the myocardium at risk, could reduce reperfusion injury.

Incidence, treatment strategies and outcomes of acute coronary syndrome with and without ongoing myocardial ischaemia: results from the CZECH-3 registry

Patients with acute coronary syndrome with signs of ongoing myocardial ischaemia at first medical contact should be indicated for immediate invasive treatment. To assess the incidence, treatment strategies and outcomes of acute coronary syndrome in a large unselected cohort of patients with respect to the signs of ongoing myocardial ischaemia. The CZECH-3 registry included 1754 consecutive patients admitted for suspected acute coronary syndrome to 43 hospitals during a 2-month period in the autumn of 2015. Acute coronary syndrome with ongoing myocardial ischaemia was defined by the presence of persistent/recurrent chest pain/dyspnoea and at least one of the following: persistent ST-segment elevation or depression, bundle branch block, haemodynamic or electric instability due to suspected ischaemia. Major adverse cardiac events (death, reinfarction, stroke, unexpected revascularisation, stent thrombosis) and severe bleeding according to Bleeding Academic Research Consortium criteria were evaluated at 30 days. Acute coronary syndrome was ruled out during the hospital stay in 434 (24.7%) patients. Out of 1280 patients with confirmed acute coronary syndrome, 732 (57%) had clinical signs of ongoing myocardial ischaemia at first medical contact. Coronary angiography was performed in 94.7% of patients with confirmed acute coronary syndrome with ongoing myocardial ischaemia and 89% of patients with confirmed acute coronary syndrome without ongoing myocardial ischaemia (P<0.001). The major adverse cardiac event rate was 9.8% for patients with confirmed acute coronary syndrome with ongoing myocardial ischaemia and 5.5% for patients without ongoing myocardial ischaemia (P=0.005), the 30-day severe bleeding rate was 1.6% and 1.5% (P=1.0). Patients with ongoing myocardial ischaemia admitted to regional hospitals had higher major adverse cardiac event rates compared with patients admitted directly to cardiocentres with percutaneous coronary intervention capability (13.3% vs. 8.2%, P=0.034). Ongoing myocardial ischaemia was present in more than half of patients hospitalised with acute coronary syndrome. These very high-risk patients may benefit from direct admission to percutaneous coronary intervention-capable centres.

LO08: Effect of an intact “chain of survival” sequence on survival to discharge from out-of-hospital cardiac arrest

Introduction: The “chain of survival” is a 5-link theoretical construct that has been central to cardiac arrest resuscitation for over 40 years. Although the role of each link has been extensively studied, little is known about the impact of performing the chain of survival in sequence. The purpose of this study was to estimate the proportion of out-of-hospital cardiac arrest (OHCA) responses by Emergency Medical Services (EMS) that had an intact chain of survival sequence response, and the effect of this on survival to hospital discharge. Methods: We conducted a prospective cohort study of adult (&amp;gt;age 20 years) OHCA patients using data collected between 2005-2007 by the Resuscitation Outcomes Consortium (ROC). ROC is a research network involving 10 research sites and 264 EMS agencies across North America. Using routinely collected data, we coded cases as receiving an intact or non-intact chain of survival sequence based on EMS cardio pulmonary resuscitation (CPR), rhythm analysis or defibrillation, epinephrine administration or endotracheal intubation, and transport to a hospital with an electrophysiology lab or percutaneous coronary intervention capability, contingent on the patient’s condition when EMS arrived. Multiple variable logistic regression was performed, adjusting for known (Utstein) survival predictors, to estimate the independent effect of intact chain of survival sequence on survival to hospital discharge. REB approval was obtained. Results: We enrolled12,821 OHCA cases, of which, 29.4% (n=3,773) had an intact chain of survival and 7.6% (n=972) survived to hospital discharge. Cases with an intact chain of survival were younger, and more likely to arrest in public, receive bystander CPR, occur in the USA and specific ROC sites, and had faster EMS response times. The adjusted odds ratio of survival to hospital discharge with an intact chain of survival sequence was 2.4 (95% CI: 2.1-2.8). A sensitivity analysis of 4,056 cases with known timing of endotracheal intubation found a similar adjusted odds ratio of 2.1 (95% CI: 1.6-2.8). Conclusion: Our results indicate that OCHA resuscitation with an intact chain of survival occurs in approximately 1/3 of cases, and results in over a two-fold increase in the odds of surviving to hospital discharge. Initiatives to improve EMS teamwork and increase the proportion of OHCA resuscitation with an intact chain of survival appear to be warranted.