Proportion Of ST-elevation Myocardial Infarction Patients Research Articles

P3605Lower benefit of women than men with ST-elevation myocardial infarction networks system in Spain: a study of 325,017 episodes over 10 years (2005–2015)

Abstract Background Sex differences are known to exist in the management of women presenting with ST elevation myocardial infarction (STEMI).Few studies have examined whether the clinical management and prognosis differs by sex when the STEMI network system is applied. Purpose To assess whether the STEMI network system improves management and prognosis both in men and women in Spain and to analyze possible differences according to sex. Methods We conducted a retrospective longitudinal study using information provided by the minimal database system (MDBS) of the Spanish National Health System (SNHS) to identify all hospitalizations in patients aged 35–94 years with the principal diagnosis of STEMI from 2005–2015. The risk-standardized in-hospital mortality ratio (RSMR) was defined as the ratio between predicted mortality and expected mortality, multiplied by the crude rate of mortality. The RSMR was calculated using multilevel risk adjustment models developed by the Medicare and Medicaid Services. The year of the development of organized systems of care for STEMI patients in the different Autonomous Communities was double-checked using data from the National Cardiac Catheterization and Interventional Cardiology Annual Registry. RSMR was used to compare outcomes related with gender and with the presence of regional AMI networks and the performance of PCI. Temporal trends for in-hospital mortality during the observed period were modeled using Poisson regression analysis with year as the only independent variable. In all models, incidence rate ratios (IRR) and their 95% confidence intervals (95% CI) were calculated. Results A total of 325,017 STEMI were identified among patients aged 35–94 years old. Of them 273,182 were selected after exclusions, and 106,277 (38.8%) were women. Women were on average 10 years older than men and had more comorbidities burden. The overall proportion of STEMI patients underwent to PCI increased, when a regional STEMI network was present from 2005–2015: (63.7% vs 48.2% in men; and 47.4% vs 32.9% in women; p<0.001). Differences in crude mortality between sexes was 15%, maintaining through 10 years, despite a higher increased of PCI (figure 1).However, women were less likely to be treated with PCI even though when STEMI network was stablished (63.7% vs 48.2% in men, 47.4% vs 32.9% in women, p<0.001) (figure 1).The mean crude in-hospital mortality rate for the whole study period was higher in women (9.3% vs 18.3%; unadjusted OR: 2.18, 95% CI: 2.12.-2.23, p<0.0001). RSMR was lower for women when STEMI network were working (17.7% vs. 19.7%; p<0.001).PCI and the presence of STEMI network were associated with a lower in-hospital mortality in STEMI women (adjusted OR, 0.48; 95% CI 0.41–0.52 and OR, 0.84; 95% CI 0.79–0.89, p<0.001, respectively). Conclusions Women were less likely to be treated with PCI and had higher in-hospital risk-adjusted mortality than men, despite the existence of STEMI network system.

Evolving Modifiable Risk Factor Patterns in STEMI Patients Without Known Cardiovascular Disease in a 21st Century Cohort

Background: Identification and management of the standard modifiable cardiovascular risk factors (SMuRFs) of hypercholesterolaemia, hypertension, diabetes and smoking has contributed to a substantial improvement in cardiovascular disease (CVD) mortality. However, CVD remains the leading cause of death globally. Methods: We performed a single centre retrospective study of patients presenting from January 2006 to December 2014 to a large tertiary hospital in Australia. All consecutive ST elevation myocardial infarction (STEMI) patients field-triaged directly to the cardiac catheterisation laboratory were assessed and included in analysis if they had confirmed diagnosis of STEMI and no previous history of CVD. Results: 536 patients were included in the analysis. The proportion of STEMI patients who were SMuRF-less increased in a linear manner from 11% in 2006 to 27% in 2014 (proportion increased by odds ratio 1.13 per year (95% confidence interval 1.04-1.22). The proportion of patients with hypercholesterolaemia decreased by an odds ratio 0.92 (95% confidence interval 0.86-0.98) and the proportion of current smokers decreased by an odds ratio 0.93 (95% confidence interval 0.86-0.99). The proportion of patients with diabetes and hypertension did not significantly change. In patients with 0 SMuRFs compared to patients with ≥ 1 SMuRF there was no significant difference in: the extent of coronary artery disease (single versus multi-vessel involvement); left ventricular ejection fraction (χ2 test, p = 0.25); peak creatinine kinase (χ2 test, p = 0.52); or in-hospital mortality. Conclusion: Our study suggests that the SMuRF profile of STEMI patients in the 21st century is evolving, with an increasing prevalence of SMuRF-less STEMI patients.

Impact of vascular access on acute kidney injury after percutaneous coronary intervention

We performed a systematic review of the literature and a meta-analysis to examine the role of access site in affecting the incidence of acute kidney injury (AKI) after percutaneous coronary intervention (PCI). The vascular access site may play a central role among procedure-related risk factors for AKI after PCI. Transradial access is associated with reduced vascular complications and major bleeding which, in turn, is an emerging risk factor for post-procedural AKI. Results of six observational studies, three out of six providing propensity matching adjustment, of patients undergoing PCI from the radial and the femoral access were pooled, including overall 26,185 patients. The endpoint was the incidence of study-defined AKI. A meta-regression analysis was performed to further assess the role of study-level covariates. Random-effects models were privileged. There was a significant difference in the incidence of AKI after PCI, favoring radial access (odds ratio [OR] 0.51, 95% CI 0.39-0.67, p<0.0001), and the effect size was larger in studies including only patients presenting with ST-elevation myocardial infarction (STEMI) (OR 0.42, 95% CI 0.24-0.72, p=0.001). The meta-regression showed a significant relationship between the benefit of radial access and the proportion of STEMI patients (p=0.031) in each of the included studies. Transradial intervention is associated with a reduction in the incidence of AKI after PCI, as compared to the femoral access, and this benefit is more evident in STEMI patients. These findings warrant further confirmation in randomized controlled trials.

Temporal and Provincial Variation in Ambulance Use Among Patients Who Present to Acute Care Hospitals With ST-Elevation Myocardial Infarction

BackgroundAt the first sign or symptoms consistent with an ST-elevation myocardial infarction (STEMI), patients are encouraged to call 9-1-1 and activate emergency medical services immediately. We examined: (1) temporal trends and provincial variations in the proportion of STEMI patients who arrive by ambulance; and (2) the association between patient demographic and clinical characteristics and ambulance use. MethodsHospital data for all patients 20 years or older who presented with a primary diagnosis of STEMI between April 1, 2007 and March 31, 2013 in all provinces, except Quebec, were examined to identify ambulance use rates according to year and province. ResultsAmong 67,232 STEMI hospitalizations (for 66,008 unique patients), the proportion of patients who presented by ambulance increased from 60% in fiscal year (FY) 2007 to 68% in FY 2012. In FY 2012, Alberta had the highest percentage of ambulance use (76%), followed by New Brunswick (73%) and Ontario (72%). At the province level, a higher rate of ambulance use was negatively correlated (r = −0.72; P = 0.04) with in-hospital mortality rate. Patients who presented by ambulance were older and more likely to be female. Self-presenters were more likely to be urban dwellers and present during work hours. Provincial differences in ambulance use remained after adjustment for patient characteristics, overall, and within specific patient subgroups. ConclusionsThe use of ambulance services among patients who presented with STEMI in Canada has increased significantly over the past 5 years, although significant interprovincial variation remains.

Abstract 9764: Clinical Characteristics and Temporal Trends Among Patients Presenting Late (>12 Hours After Symptom Onset) With ST-Elevation Myocardial Infarction - A Report From the NCDR®

Background: Late presentation after ST-elevation myocardial infarction (STEMI) is associated with poor outcomes. However, contemporary data regarding management and outcomes of such patients are lacking. Methods: Using data from the ACTION Registry-GWTG, we identified 170,247 patients who presented with STEMI to 688 US sites, between 7/08 and 12/13. Patients were stratified according to time from symptom onset to presentation as timely presenters (&lt;12 hours) and late presenters (≥12 hours). Baseline characteristics, management and in-hospital outcomes were compared between the groups. Among late presenters, temporal trends in reperfusion strategy were also examined. Results: A total of 9389 patients (5.5%) had late presentation and 160,858 (94.5%) had timely presentation. Late presenters were more frequently elderly, female and of non-White ethnicity (Table). Late presenters were less likely to have prior MI or prior revascularization, but more likely to have diabetes. Compared with timely presenters, late presenters had worse in-hospital outcomes including mortality (6.3% vs. 5.2%; p&lt;0.0001). Over the 6-year study period, the proportion of late presenters decreased slightly (5.8 vs. 5.4% respectively; p=0.03), while the proportion of late presenters undergoing primary PCI increased from 65% to 71% (p&lt;0.001). Over the same time-period, among late presenters, median time from symptom onset to presentation increased slightly, door to balloon time decreased, and in-hospital mortality remained unchanged (6.0% vs. 6.0%). Conclusions: In contemporary practice, a modest proportion of STEMI patients continue to present &gt;12 hours after symptom onset. Despite increased use of primary PCI and reduction in door-to-balloon times, the unadjusted mortality remains high among late presenters. Continued efforts to educate the public in order to reduce the proportion of late presenters remains warranted.

Abstract P149: Self versus Emergency Medical Service Transport for Patients With ST-Elevation Myocardial Infarction: Findings From the National Cardiovascular Data Registry ACTION - Get With the Guidelines

Background: Guidelines recommend expedited transport via emergency medical services (EMS) to facilitate early triage and reperfusion of patients with ST-elevation myocardial infarction (STEMI). Yet, a significant proportion of patients still present to the hospital via self-transportation. Methods: We examined rates of self- vs. EMS-transport for 33,678 STEMI patients treated at 348 hospitals in the ACTION Registry-GWTG between Jan 07 and Jun 09. Patients transferred in from outside hospitals to ACTION participating hospitals were excluded. Using generalized estimating equations (GEE) logistic regression model, we examined independent factors associated with patient self (vs. EMS) transportation. We further compared differences in reperfusion use and timing between these two groups. Results: A total of 13,479 STEMI patients (40%) self-transported to the hospital. Sociodemographic factors associated with self- (vs. EMS-) transportation include younger age, male sex, Hispanic ethnicity, and non-white race ( Table ). In contrast, the presence of cardiovascular risk factors were largely associated with EMS- rather than self-transport. Self-transport patients had longer delays from symptom onset to hospital arrival (median time 120 vs. 90 min, p&lt;0.0001), lower rates of reperfusion (93.0 vs. 94.5%, p&lt;0.0001), and longer delays to reperfusion (median door-to-balloon time 76 vs. 64 min, p&lt;0.0001, median door-to-needle time 30 vs. 23 min, p&lt;0.0001). Conclusion: A substantial proportion of STEMI patients in contemporary practice self-transport to the hospital and this mode of transport is associated with delays in reperfusion therapy compared with EMS transport. Since younger age, non-white race, and male sex are significantly associated with self-transport, community education efforts should target these groups and should be integrated with system-wide strategies designed to improve timely access to reperfusion care. Factors associated with self-transport versus EMS-transport Sociodemographic variables Adjusted χ2 OR 95% CI p-value Age ( per 5 yr. decrease) 187 1.06 1.05-1.08 &lt;0.0001 Male (vs. female) 46 1.19 1.13-1.26 &lt;0.0001 Hispanic ethnicity 32 1.37 1.23-1.52 &lt;0.0001 Race (vs. white) 12 0.0022 Black/African American 1.21 1.09-1.34 Asian/American Indian 1.12 0.95-1.34 Insurance status (vs. private) 22 &lt;0.0001 Medicare/Medicaid/Military/VA 0.89 0.84-0.94 Self/none 0.86 0.80-0.93 Clinical variables Heart failure symptoms on presentation 89 0.68 0.62-0.73 &lt;0.0001 Prior PCI 24 0.84 0.78-0.90 &lt;0.0001 Prior stroke 23 0.78 0.70-0.86 &lt;0.0001 Prior CABG 13 1.18 1.08-1.29 0.0003 * Other variables included in this model: prior CHF, DM, prior MI, BMI, dyslipidemia, currently on dialysis, and HTN

Effect of time to electrocardiogram on time from electrocardiogram to fibrinolysis in acute myocardial infarction patients

The American Heart Association (AHA) recommends a benchmark door-to-electrocardiogram (ECG) time of 10 minutes for acute myocardial infarction patients, but this is based on expert opinion (level of evidence C). We sought to establish an evidence-based benchmark door-to-ECG time. This retrospective cohort study used a population-based sample of patients who suffered an ST elevation myocardial infarction (STEMI) in Ontario between 1999 and 2001. Using cubic smoothing splines, we described (1) the relationship between door-to-ECG time and ECG-to-needle time and (2) the proportion of STEMI patients who met the benchmark door-to-needle time of 30 minutes based on their door-to-ECG time. We hypothesized nonlinear relationships and sought to identify an inflection point in the latter curve that would define the most efficient (benefit the greatest number of patients) door-to-ECG time. In 2,961 STEMI patients, the median door-to-ECG and ECG-to-needle times were 8.0 and 27.0 minutes, respectively. There was a linear increase in ECG-to-needle time as the door-to-ECG time increased, up to approximately 30 minutes, after which the ECG-to-needle time remained constant at 53 minutes. The inflection point in the probability of achieving the benchmark door-to-needle time occurred at 4 minutes, after which it decreased linearly, with every minute of door-to-ECG time decreasing the average probability of achievement by 2.2%. Hospitals that are not meeting benchmark reperfusion times may improve performance by decreasing door-to-ECG times, even if they are meeting the current AHA benchmark door-to-ECG time. The highest probability of meeting the reperfusion target time for fibrinolytic administration is associated with a door-to-ECG time of 4 minutes or less.