Primary Percutaneous Coronary Intervention Hospitals 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.

Comparing In-Hospital Outcomes for Acute Myocardial Infarction Patients in High-Volume Hospitals Performing Primary Percutaneous Coronary Intervention vs. Regional General Hospitals.

It has been reported that patients with acute myocardial infarction (AMI) transferred to low-volume primary percutaneous coronary intervention (PCI) hospitals (<115/year) in low population density areas experience higher in-hospital mortality rates. This study compared in-hospital outcomes of patients admitted to high-volume primary PCI hospitals (≥115/year) with those for other regional general hospitals. Retrospective analysis was conducted on data obtained from 2,453 patients with AMI admitted to hospitals in Iwate Prefecture (2014-2018). Multivariate analysis revealed that the in-hospital mortality rate of AMI among patients in regional general hospitals was significantly higher than among patients in high-volume hospitals. However, no significant difference in mortality rate was observed among patients with ST-elevation myocardial infarction (STEMI) undergoing primary PCI. Although no significant difference was found in the in-hospital mortality rate of patients with Killip class I STEMI, significantly lower in-hospital mortality rates were observed in patients admitted in high-volume hospitals for Killip classes II, III, and IV. Although in-hospital outcomes for patients with STEMI undergoing primary PCI were similar, patients with heart failure or cardiogenic shock exhibited better in-hospital outcomes in high-volume primary PCI hospitals than those in regional general hospitals.

Cardiac catheterization laboratory activation by social media reduces reperfusion time of patients transferred for primary percutaneous coronary intervention in community hospital

Objective: The objective of the study is to evaluate the impact of cardiac catheterization laboratory (CCL) activation by WeChat in community hospitals transfer for primary percutaneous coronary intervention (PCI) bypassing emergency department (ED) on time delay in ST-segment elevation myocardial infarction (STEMI) patients. Methods: This was a retrospective, cohort study of STEMI patients who were transferred from community hospitals to Luhe Hospital for primary PCI. Patients were divided into two groups: in CCL group, electrocardiogram (ECG) was transmitted through WeChat in the community hospital and the patients were transferred directly to CCL by emergency medical services (EMS) (n = 43); in control group, patients without ECG transmission were transferred by EMS to ED before CCL arrival (n = 57). The primary endpoint was median first medical contact (FMC)-to-device (FMC2D) times. The secondary endpoint was door-to-device (D2D) times. Results: The baseline clinical data and angiographic features among the two groups were similar (all P &gt; 0.05. There was no difference in the symptom onset-to-FMC time (median interquartile range [IQR] min, 100.00 [74.50–247.00] vs. 105.00 [70.00–180.00], P &gt; 0.05) between the two groups. Compared to control group, CCL group had shortened FMC2D times (median IQR min, 95.00 [72.60–160.58] vs. 160.79 [124.72–205.50], P &lt; 0.001) and shortened D2D time (median IQR min, 17.18 [13.77–21.15] vs. 49.27 [40.26–64.90], P &lt; 0.001). Achievement of the FMC2D time goal of &lt;120 min rose from 29.82% in the control group to 76.74% in the CCL group (P &lt; 0.001). Conclusion: CCL activated by WeChat can reduce reperfusion time of STEMI patients who are transferred for PCI from community hospitals.

Abstract 14040: Hospital Volume-Outcome Relationship After Primary Percutaneous Coronary Intervention: A Contemporary Nationwide Analysis

Introduction: There is paucity of data on the relationship between hospital procedural volume and outcomes of primary percutaneous coronary intervention (PCI) procedures in the past decade. Methods: We queried the National Inpatient Sample database (2010-2016) for hospitalizations undergoing primary PCI for STEMI. Hospitals were divided into 3 groups: low-volume (&lt;36 primary PCI/ year), moderate-volume (36-72 primary PCI/year) and high-volume (&gt;72 primary PCI/ year). The main outcome was in-hospital mortality. Results: The analysis included 694,505 hospitalizations for primary PCI. There were 329,878 (47.5%) primary PCI procedures performed at low-volume hospitals, 224,317 (32.3%) at moderate-volume, and 140,223 (20.2%) at high-volume hospitals. Compared with high-volume hospitals, low-volume hospitals were associated with higher in-hospital mortality in the unadjusted model (5.3% vs. 4.8%, odds ratio [OR] 1.10; 95% confidence interval-CI 1.02-1.18, p=0.01) and on multivariable analysis (adjusted-OR 1.15; 95%CI 1.04-1.27, p=0.01). There was no difference between moderate-volume and high-volume hospital in unadjusted analysis (5.1% vs. 4.8%, OR 1.07; 95%CI 0.99-1.15, p=0.11) and on multivariable analysis (adjusted-OR 1.08; 95%CI 0.97-1.20, p=0.17). Conclusions: This nationwide analysis showed that low-volume hospitals are associated with higher in-hospital mortality after primary PCI compared with high-volume hospitals even in recent years. The current threshold set by national guidelines for primary PCI hospitals remains valid in contemporary practice.

Survival after Resuscitated Out-of-Hospital Cardiac Arrest in Patients with Paramedic-Identified ST-Segment Elevation Myocardial Infarction Treated with Primary Percutaneous Coronary Intervention

Background: ST-segment elevation myocardial infarction (STEMI) is a common cause of out-of-hospital cardiac arrest (OHCA). For these patients, urgent angiography and revascularization is an important treatment goal. There is a lack of data on the prognosis of STEMI patients after OHCA, who are diagnosed and treated by paramedics prior to hospital transport for primary percutaneous coronary intervention (PCI). Methods: Included were adult STEMI patients identified and treated by paramedics in Queensland (Australia) from January 2016 to December 2019, transported to a hospital for primary PCI, and receiving primary PCI. Patients were grouped into those with resuscitated OHCA and those without OHCA. Clinically-important time intervals, angiographic and clinical profiles, and survival were described. Results: Patients with OHCA had longer time intervals from prehospital STEMI identification to reperfusion than those without OHCA (median 97 versus 87 mins, p = 0.001). The former had higher rates of cardiac arrhythmia history (50.5 versus 12.4%, p < 0.001), classified low left ventricular ejection fraction on admission (64.9 versus 50.1%, p = 0.006), and cardiogenic shock (5.2 versus 1.2%, p = 0.011) than the latter. A significantly higher proportion of patients with OHCA had multiple diseased vessels (16.9 versus 8.3%, p = 0.005). In-hospital, 30-day, and one-year mortality was low, being 4.1%, 4.1% and 5.2%, respectively, for STEMI patients with OHCA. The corresponding figures for those without OHCA were 1.6%, 1.8% and 3.3%, respectively. Conclusions: Survival in paramedic-identified STEMI patients treated with primary PCI following OHCA resuscitation was high. Rapid angiography and reperfusion are critical in these patients.

Chest Pain Severity Rating Is a Poor Predictive Tool in the Diagnosis of ST-Segment Elevation Myocardial Infarction.

Current ST-segment elevation myocardial infarction (STEMI) guidelines require persistent electrocardiogram ST-segment elevation, cardiac enzyme changes, and symptoms of myocardial ischemia. Chest pain is the determinant symptom, often measured using an 11-point scale (0-10). Greater severity of chest pain is presumed to be associated with a stronger likelihood of a true positive STEMI diagnosis. This retrospective observational cohort study considered consecutive STEMI patients from May 02, 2009 to December 31, 2018. Analysis of standard STEMI metrics included positive electrocardiogram-to-device and first medical contact-to-device times, presence of comorbidities, false-positive diagnosis, 30-day and 1-year mortality, and 30-day readmission. Chest pain severity was assessed upon admission to the primary percutaneous coronary intervention hospital. We analyzed 1409 STEMI activations (69% male, 66.3 years old ± 13.7 years). Of these, 251 (17.8%) had no obstructive lesion, consistent with false-positive STEMI. Four hundred sixty-six (33.1%) reported chest pain rating of 0 on admission, 378 (26.8%) reported mild pain (1-3), 300 (21.3%) moderate (4-6), and 265 (18.8%) severe (7-10). Patients presenting without chest pain had a significantly higher rate of false-positive STEMI diagnosis. Increasing chest pain severity was associated with decreased time from first medical contact to device, and decreased in-hospital, 30-day and 1-year mortality. Severity of chest pain on admission did not correlate to the likelihood of a true-positive STEMI diagnosis, although it was associated with improved patient prognosis, in the form of improved outcomes, and shorter times to reperfusion.

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.

A national registry to assess the value of cardiovascular magnetic resonance imaging after primary percutaneous coronary intervention pathway activation: a feasibility cohort study

Background Cardiovascular magnetic resonance (CMR) is increasingly used in patients who activate the primary percutaneous coronary intervention (PPCI) pathway to assess heart function. It is uncertain whether having CMR influences patient management or the risk of major adverse cardiovascular events in these patients. Objective To determine whether or not it is feasible to set up a national registry, linking routinely collected data from hospital information systems (HISs), to investigate the role of CMR in patients who activate the PPCI pathway. Design A feasibility prospective cohort study. Setting Four 24/7 PPCI hospitals in England and Wales (two with and two without a dedicated CMR facility). Participants Patients who activated the PPCI pathway and underwent an emergency coronary angiogram. Interventions CMR either performed or not performed within 10 weeks of the index event. Main outcome measures A. Feasibility parameters – (1) patient consent implemented at all hospitals, (2) data extracted from more than one HIS and successfully linked for &gt; 90% of consented patients at all four hospitals, (3) HIS data successfully linked with Hospital Episode Statistics (HES) and Patient Episode Database Wales (PEDW) for &gt; 90% of consented patients at all four hospitals and (4) CMR requested and carried out for ≥ 10% of patients activating the PPCI pathway in CMR hospitals. B. Key drivers of cost-effectiveness for CMR (identified from simple cost-effectiveness models) in patients with (1) multivessel disease and (2) unobstructed coronary arteries. C. A change in clinical management arising from having CMR (defined using formal consensus and identified using HES follow-up data in the 12 months after the index event). Results A. (1) Consent was implemented (for all hospitals, consent rates were 59–74%) and 1670 participants were recruited. (2) Data submission was variable – clinical data available for ≥ 82% of patients across all hospitals, biochemistry and echocardiography (ECHO) data available for ≥ 98%, 34% and 87% of patients in three hospitals and medications data available for 97% of patients in one hospital. (3) HIS data were linked with hospital episode data for 99% of all consented patients. (4) At the two CMR hospitals, 14% and 20% of patients received CMR. B. In both (1) multivessel disease and (2) unobstructed coronary arteries, the difference in quality-adjusted life-years (QALYs) between CMR and no CMR [‘current’ comparator, stress ECHO and standard ECHO, respectively] was very small [0.0012, 95% confidence interval (CI) –0.0076 to 0.0093 and 0.0005, 95% CI –0.0050 to 0.0077, respectively]. The diagnostic accuracy of the ischaemia tests was the key driver of cost-effectiveness in sensitivity analyses for both patient subgroups. C. There was consensus that CMR leads to clinically important changes in management in five patient subgroups. Some changes in management were successfully identified in hospital episode data (e.g. new diagnoses/procedures, frequency of outpatient episodes related to cardiac events), others were not (e.g. changes in medications, new diagnostic tests). Conclusions A national registry is not currently feasible. Patients were consented successfully but conventional consent could not be implemented nationally. Linking HIS and hospital episode data was feasible but HIS data were not uniformly available. It is feasible to identify some, but not all, changes in management in the five patient subgroups using hospital episode data. The delay in obtaining hospital episode data influenced the relevance of some of our study objectives. Future work To test the feasibility of conducting the study using national data sets (e.g. HES, British Cardiovascular Intervention Society audit database, Diagnostic Imaging Dataset, Clinical Practice Research Datalink). Funding The National Institute for Health Research (NIHR) Health Services and Delivery Research programme. This study was designed and delivered in collaboration with the Clinical Trials and Evaluation Unit, a UK Clinical Research Collaboration-registered clinical trials unit that, as part of the Bristol Trials Centre, is in receipt of NIHR clinical trials unit support funding.

Factors associated with door-in to door-out delays among ST-segment elevation myocardial infarction (STEMI) patients transferred for primary percutaneous coronary intervention: a population-based cohort study in Ontario, Canada

BackgroundCompared to ST-segment elevation myocardial infarction (STEMI) patients who present at centres with catheterization facilities, those transferred for primary percutaneous coronary intervention (PCI) have substantially longer door-in to door-out (DIDO) times, where DIDO is defined as the time interval from arrival at a non-PCI hospital, to transfer to a PCI hospital. We aimed to identify potentially modifiable factors to improve DIDO times in Ontario, Canada and to assess the impact of DIDO times on 30-day mortality.MethodsA population-based, retrospective cohort study of 966 STEMI patients transferred for primary PCI in Ontario in 2012 was conducted. Baseline factors were examined across timely DIDO status. Multivariate logistic regression was used to examine independent predictors of timely DIDO as well as the association between DIDO times and 30-day mortality.ResultsThe median DIDO time was 55 min, with 20.1% of patients achieving the recommended DIDO benchmark of ≤30 min. Age (OR> 75 vs 18–55 0.30, 95% CI: 0.16–0.56), symptom-to-first medical contact (FMC) time (OR61-120mins vs < 60mins 0.60, 95% CI: 0.39–0.90; OR>120mins vs < 60mins 0.53, 95% CI:0.35–0.81) and emergency medical services transport with a pre-hospital electrocardiogram (ECG) (OREMS transport + ECG vs self-transport 2.63, 95% CI:1.59–4.35) were the strongest predictors of timely DIDO. Patients with timely ECG were more likely to have recommended DIDO times (33.0% vs 12.3%; P < 0.001). A significantly higher proportion of those who met the DIDO benchmark had timely FMC-to-balloon times (78.7% vs 27.4%; P < 0.001). Compared to patients with DIDO time ≤ 30 min, those with DIDO times > 90 min had significantly higher adjusted 30-day mortality rates (OR 2.82, 95% CI:1.10–7.19).ConclusionsWhile benchmark DIDO times were still rarely achieved in the province, we identified several potentially modifiable factors in the STEMI system that might be targeted to improve DIDO times. Our findings that patients who received a pre-hospital ECG were still being transferred to non-PCI capable centres suggest strategies addressing this gap may improve patient outcomes.

E-Transmission of ECGs for expert consultation results in improved triage and treatment of patients with acute ischaemic chest pain by ambulance paramedics.

AimsIn pre-hospital settings handled by paramedics, identification of patients with myocardial infarction (MI) remains challenging when automated electrocardiogram (ECG) interpretation is inconclusive. We aimed to identify those patients and to get them on the right track to primary percutaneous coronary intervention (PCI).Methods and resultsIn the Rotterdam-Rijnmond region, automated ECG devices on all ambulances were supplemented with a modem, enabling transmission of ECGs for online expert interpretation. The diagnostic protocol for acute chest pain was modified and monitored for 1 year.Patients with an ECG that met the criteria for ST-elevation myocardial infarction (STEMI) were immediately transported to a PCI hospital. ECGs that did not meet the STEMI criteria, but showed total ST deviation ≥800 µv were transmitted for online interpretation by the ECG expert. Online supervision was offered as a service if ECGs showed conduction disorders, or had an otherwise ‘suspicious’ pattern according to the ambulance paramedics.We enrolled 1,076 patients with acute ischaemic chest pain who did not meet the automated STEMI criteria. Their mean age was 63 years; 64% were men. After online consultation, 735 (68%) patients were directly transported to a PCI hospital for further treatment. PCI within 90 min was performed in 115 patients.ConclusionDuring a 1-year evaluation of the modified pre-hospital triage protocol for patients with acute ischaemic chest pain, over 100 acute MI patients with an initially inconclusive ECG received primary PCI within 90 min. Because of these results, we decided to continue the operation of the modified protocol.

Abstract 213: Treatment Delays in Patients with ST-Elevation Myocardial Infarction Across All Hospitals Performing Primary Percutaneous Coronary Intervention in Quebec, Canada: Results of a Third Field Evaluation

Background: Our government-funded independent cardiology evaluation unit conducted a third systematic province-wide field evaluation of ST-elevation myocardial infarction (STEMI) in collaboration with an interdisciplinary committee of clinical experts. Primary percutaneous coronary intervention (PPCI) is the predominant reperfusion treatment for STEMI in Quebec and in 2 previous evaluations (2006-7; 2008-9), there were wide variations in treatment delays across the 13 PPCI hospitals. Initiatives to improve delays have included individualized hospital report cards, presentations and discussions of inter-regional analyses with clinicians and decision-makers and the province-wide implantation of an ambulance (prehospital) ECG program. Our objective was to describe the differences in STEMI processes of care over time that these initiatives may have produced. Methods: Medical charts of all patients with a final diagnosis of acute myocardial infarction who presented with characteristic symptoms to an emergency department (ED) during a 6-month period in 2013-2014 were reviewed. Trained medical record librarians collected data on clinical characteristics and time points of care. An automated algorithm was used to identify STEMI. All patients with STEMI who presented directly to the ED of one of the 13 PPCI centers (by ambulance or other means) and were treated with PPCI were included in this preliminary analysis. ECGs were reviewed at our core laboratory. Results: During the 6-month study period, 735 patients with STEMI presented directly to the ED of a PPCI hospital (including ambulance bypass of local non-PPCI hospitals) and were treated with PPCI. Center patient volume varied from 29 to 117. Over 80% (596/735) of the patients arrived by ambulance (up from 71% in 2009-9) and of these, 93% (552/596) had a prehospital ECG compared with 20% in 2008-9. The median ED door-in-door-out delay was 26 min (10-90th percentile: 8-72) compared with 49 min (17-126) in 2008-9 (p=0.001). The median door-to-device delay was 59 min (30-125), compared with 77 min (38-163) during 2008-9 (p=0.017), and varied from a median of 38 to 87 min across the 13 PPCI hospitals. For patients arriving by ambulance with documented first medical contact time, 48% (260/541) had a first medical contact-to-device time ≤ 90 min compared with 35% in 2008-9 (p=0.06). Conclusions: This third province-wide evaluation shows important improvements in Quebec’s system of STEMI care. Since 2008-9, ED door-in-door-out delay improved by 47% and door-to-device delay for direct admission PPCI improved by 23%. These improvements have occurred after local, regional and provincial efforts to monitor and reduce treatment delays and the implantation of a province-wide prehospital ECG program. However, the wide variation in delays across PPCI centers underlines the need for continued evaluation and improvement initiatives.

Nationwide Analysis of Patients With ST-Segment-Elevation Myocardial Infarction Transferred for Primary Percutaneous Intervention: Findings From the American Heart Association Mission: Lifeline Program.

Current American College of Cardiology/American Heart Association guidelines recommend transfer and primary percutaneous coronary intervention (PCI) for ST-segment-elevation myocardial infarction (STEMI) patients within the time limit of first contact to device ≤ 120 minutes. We determined the hospital-level, patient-level, and process characteristics of timely versus delayed primary PCI for a diverse national sample of transfer patients confined to a travel distance that facilitates the process. We studied 14,518 patients transferred from non-PCI-capable hospitals for primary PCI to 398 National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines hospitals between July 2008 and December 2012. Patients with estimated transfer times > 60 minutes (by Google Maps driving times) were excluded from the analysis. Patients achieving first door-to-device time ≤ 120 minutes were compared with patients with delayed treatment; independent predictors of timely treatment were determined using generalized estimating equations logistic regression models. The median estimated transfer distance was 26.5 miles. First door-to-device ≤ 120 minutes was achieved in 65% of patients (n = 9380); only 37% of the hospitals were high-performing hospitals (defined as risk-adjusted rate, ≥ 75% of transfer STEMI patients with ≤ 120-minute first door-to-device time). In addition to known predictors of delay (cardiogenic shock, cardiac arrest, and prolonged door-in door-out time), STEMI referral hospitals' rural location and longer estimated transfer time were identified as predictors of delay. In this diverse national sample, regional and racial variations in care were observed. Finally, lower PCI hospital annual STEMI volume was a potent predictor of delay. More than one third of US STEMI patients transferred for primary PCI fail to achieve first door-to-device time ≤ 120 minutes, despite estimated transfer times <60 minutes. Delays are related to process variables, comorbidities, and lower annual PCI hospital STEMI volumes.

The effect of interhospital transfers, emergency medical services, and distance on ischemic time in a rural ST-elevation myocardial infarction system of care

BackgroundRegional myocardial infarction systems of care have been shown to improve timely access to primary percutaneous coronary intervention (PCI). However, there is a relatively sparse research on rural “frontier” regions. Arrival mode, high rates of interhospital transfers, long transport times, low population density, and mostly volunteer emergency medical services (EMS) distinguish this region from metropolitan systems of care. We sought to assess the effect of interhospital transfers, distance, and arrival mode on total ischemic times for patients with ST-elevation myocardial infarctions undergoing primary PCI. MethodsWe assessed patient data from our observational cohort of 395 patients with ST-elevation myocardial infarction with PCI as their primary treatment strategy. Data came from the 10 PCI hospitals participating in the Wyoming Mission: Lifeline program from January 2013 to September 2014. We performed both regression and tests of differences. ResultsMedian total ischemic time was nearly 2.7 times greater in transferred patients than those presenting directly (379 vs 140 minutes). Distance in miles traveled between patient’s home and PCI facility was 2.5 times larger in transfer patients (51 vs 20 miles). Emergency medical services arrival was associated with 23% shorter total ischemic times than self-arrival. ConclusionsTransfer patients from referral hospitals had significantly greater total ischemic time, and use of EMS was associated with significantly lower times. Transport distance was mixed in its effect. These findings suggest a continued focus on improving transitions between referral and receiving centers and enhancing coordination in rural systems of care to reduce the multiplier effect of transfers on total ischemic time.

Clinical Outcomes of Early Repatriation for Patients With ST-Segment Elevation Myocardial Infarction: A Propensity-Matched Analysis

BackgroundBecause of limitations on hospital resources, patients with ST-elevation myocardial infarction (STEMI) who undergo successful primary percutaneous coronary intervention (PCI) are often repatriated to non-PCI centres. However, the safety of this practice is not clear. Our objective was to evaluate the safety of early repatriation of STEMI patients after PCI to a non-PCI centre, compared with ongoing treatment at the PCI centre. MethodsConsecutive STEMI patients, who received primary PCI at 1 of 4 PCI hospitals in Toronto, Canada between 2010 and 2012 were identified. Patients with shock or who died within 24 hours of presentation were excluded. Outcomes of interest were all-cause mortality and readmission for recurrent myocardial infarction (MI) at 1 year. To account for confounding because of the observational nature of our data, propensity score-matched pairs of patients who were repatriated vs nonrepatriated were identified. ResultsUsing the propensity score, 430 well matched pairs were identified, representing our cohort. There was no significant difference between repatriated and nonrepatriated groups in 1-year mortality (repatriated: 6.7%, nonrepatriated: 5.6%, hazard ratio, 1.18; 95% confidence interval, 0.69-2.03; P = 0.545). The 1-year readmission rates for MI were significantly greater for the repatriated group compared with the nonrepatriated group (repatriated: 12.1%; nonrepatriated: 5.8%; hazard ratio, 2.09; 95% confidence interval, 1.30-3.36; P = 0.002). ConclusionsA strategy of early repatriation of STEMI patients was associated with a greater rate of readmission for MI. Our study raises questions regarding the safety of an early repatriation strategy that merit further research.

Predictors of Ventricular Fibrillation at Reperfusion in Patients With Acute ST-Elevation Myocardial Infarction Treated by Primary Percutaneous Coronary Intervention

Ventricular fibrillation (VF) during reperfusion (rVF) in ST-segment elevation myocardial infarction (STEMI) is an infrequent but serious event that complicates coronary interventions. The aim of this study was to analyze clinical predictors of rVF in an unselected population of patients with STEMI treated with percutaneous coronary intervention (PCI). Consecutive patients with STEMI admitted to a tertiary care hospital for primary PCI from 2007 to 2012 were retrospectively assessed for the presence of rVF. Admission electrocardiograms, stored in a digital format, were analyzed for a maximal ST-segment elevation in a single lead and the sum of ST-segment deviations in all leads. Clinical, electrocardiographic, and angiographic characteristics were tested for associations with rVF using logistic regression analysis. Among 3,724 patients with STEMI admitted from 2007 to 2012, 71 (1.9%) had rVF. In univariate analysis, history of myocardial infarction, aspirin and β-blocker use, VF before PCI, left main coronary artery disease, inferior myocardial infarction localization, symptom-to-balloon time <360 minutes, maximal ST-segment elevation in a single lead >300 μV, and sum of ST-segment deviations in all leads >1,500 μV were associated with increased risk for rVF. In a multivariate analysis, sum of ST-segment deviations in all leads >1500 μV (odds ratio 3.7, 95% confidence interval 1.45 to 9.41, p = 0.006) before PCI remained an independent predictor of rVF. In-hospital mortality was 18.3% in the rVF group and 3.3% in the group without VF (p <0.001), but rVF was not an independent predictor of in-hospital death. In conclusion, the magnitude of ST-segment elevation before PCI for STEMI independently predicts rVF and should be considered in periprocedural arrhythmic risk assessment. Despite higher in-hospital mortality in patients with rVF, rVF itself has no independent prognostic value for prognosis.

CLINICAL OUTCOMES OF EARLY REPATRIATION FOR PATIENTS WITH ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION: A PROPENSITY-MATCHED ANALYSIS

Given limitations on hospitals resources, patients with ST elevation myocardial infarction (STEMI) who undergo successful primary percutaneous coronary intervention (PCI) are often repatriated to non-PCI centers. However, the safety of this practice is not clear, given the transfer of care. Our objective was to evaluate the safety of early repatriation of stable STEMI patients post primary PCI, compared to ongoing treatment at the PCI center. Consecutive STEMI patients who received primary PCI at four PCI hospitals in Toronto, Canada between 2010 and 2012 were identified. Patients in cardiogenic shock or who died within 24 hours of presentation were excluded. In order to account for potential confounders, propensity score matching of repatriated vs. non-repatriated patients was performed. The primary outcomes were 1-year all-cause mortality and re-admission for recurrent myocardial infarction (MI). Secondary outcomes were 30-day all-cause mortality, 30-day re-admission for MI, mean first medical contact to balloon time (minutes) and mean length of stay (days). The overall cohort consisted of 1445 patients, of whom 792 (55%) were repatriated. Patients were repatriated within 1.5 days on average (median 1 day, 95% confidence interval (CI) 1.37-1.63 days). Using the propensity score, 427 well-matched pairs were identified. There was no significant difference between repatriated and non-repatriated groups in 1-year mortality (repatriated 6.6%; non-repatriated 5.6%; Hazard ratio (HR) 1.14, 95% CI 0.66-1.97, p= 0.629). The 1-year re-admission rates for MI were significantly greater for the repatriated group (repatriated: 11.5 %, non-repatriated: 5.9%; HR 1.97, 95% CI 1.22-3.19, p= 0.006). These findings were consistent in the 30-day outcomes (30-day mortality: 2.6% and 4.9% for repatriated and non-repatriated, p-value=0.072; 30-day re-admission for MI 5.6% and 1.9% for repatriated and non-repatriated, p-value =0.004). The mean contact to balloon time was comparable in both groups (repatriated 138 minutes, 95% CI 121-156; non-repatriated 150 minutes, 95% CI 129-172, p= 0.405). Similarly, the mean length of total hospital stay was comparable in both groups (repatriated 6 days, 95% CI 5-6; non-repatriated 5.5 days, 95% CI 4-7, p= 0.947). A strategy of early repatriation of STEMI patients was associated with an increase in re-admission for MI. Our study revisits the safety associated with an early repatriation strategy. Further research is needed to address challenges involved with transfer of care between medical institutions in this population.

Circulation : Clinical Summaries

<i>Circulation</i> : Clinical Summaries

Rationale and design of a double-blind, multicenter, randomized, placebo-controlled clinical trial of early administration of intravenous β-blockers in patients with ST-elevation myocardial infarction before primary percutaneous coronary intervention: EARLY β-blocker Administration before primary PCI in patients with ST-elevation Myocardial Infarction trial

β-Blockers have a class 1a recommendation in the treatment of patients with ST-elevation myocardial infarctions (STEMIs), as they are associated with a reduced mortality, recurrent myocardial infarction, life-threatening arrhythmias, and with prevention of unfavorable left ventricular remodeling. Whether early administration before primary percutaneous coronary intervention (PCI) of intravenous β-blockers reduces the infarct size in the current era is unknown. We postulate that the early administration of β-blockers will reduce the myocardial infarcted area as assessed by magnetic resonance imaging (MRI) at 30 days. In a multinational, multicenter, double-blind, placebo-controlled, randomized trial, patients with symptoms and signs of STEMI and transferred to a hospital for primary PCI will be randomized in a 1:1 fashion to intravenous metoprolol (5 mg twice daily) administration or placebo. Before admission, study treatment will be started as soon as possible after the diagnosis of STEMI. After admission, primary PCI will be performed as per standard of care. After primary PCI, medical treatment will occur as per current guidelines in all patients, including the use of oral β-blockers. The primary end point is the myocardial infarct size as assessed by MRI at 30 days. Based on a superiority design and assuming an 18% relative infarct size reduction (from 28% to 23.5%), 408 patients are required to be enrolled, accounting for 20% drop-out (α = .05 and power = 80%). The EARLY-BAMI trial is a multinational, multicenter, double-blind, placebo-controlled, randomized clinical trial that will investigate the impact of intravenous metoprolol administration before primary PCI for STEMI on myocardial infarct size as measured with MRI at 30 days.

Current use and clinical benefit of intraaortic balloon support in patients with ST-elevation myocardial infarction complicated by cardiogenic shock

Background: European guideline recommendations for the use of intraaortic balloon support in patients with STEMI complicated by cardiogenic shock have just been revised. We sought to evaluate current use and clinical benefit of intraaortic balloon support in clinical practice. Methods: Between 2007 and 2012 a total of 4065 consecutive patients presenting with STEMI were enrolled in the FITT-STEMI feasibility-trial. 6 primary percutaneous coronary intervention hospitals in Germany and 29 associated nonpercutaneous coronary intervention hospitals participated. Data from patient contact to balloon inflation were collected and analyzed. For the present study we evaluated the FITT-STEMI-trial and included all patients with STEMI complicated by cardiogenic shock in our analysis. Results: STEMI was complicated by cardiogenic shock in 10% (406/4065) of the patients. Hospital mortality in those patients was 44% (179/406). 40.4% (164/406) of the patients with STEMI complicated by cardiogenic shock were treated with intraaortic balloon counterpulsation. Hospital mortality did not differ between patients receiving or not receiving intraaortic ballon support (43.3% vs. 44.6%). Conclusion: Hospital mortality in patients with STEMI complicated by cardiogenic shock is still high, despite high use of early reperfusion therapy. Almost half of the patients admitted with STEMI complicated by cardiogenic shock received intraaortic balloon support. However, the use of intraaortic ballon support was not associated with a lower hospital mortality which supports the findings of the randomized IABP-Shock II trial.

Circulation: Cardiovascular Quality and Outcomes Editors’ Picks

<i>Circulation: Cardiovascular Quality and Outcomes</i> Editors’ Picks