Current acute coronary syndrome (ACS) protocols recommend against the administration of nitroglycerin to patients with inferior ST-elevation myocardial infarction (STEMI). Due to nitroglycerin's vasodilatory effects, which decrease preload and cardiac output, protocols warn of a possible critical drop in blood pressure with the drug's use that could be detrimental to patients with inferior STEMI. Research has shown, however, that nitroglycerin-induced hypotension occurs at similar rates in both inferior STEMI and non-inferior STEMI. Rather than the location of the culprit lesion, the development of hypotension depends on individual patient epidemiologic factors. An amendment to current ACS protocols for patients with inferior STEMI is warranted to reflect nitroglycerin's benefits in the preservation of myocardial function. Removing this barrier to the care of inferior STEMI would lead to therapeutic relief and improve patient survival overall.

Contemporary care of patients with ST-elevation myocardial infarction (STEMI) with primary percutaneous coronary intervention (PCI) is still dominated by “24/7 PCI-capable” hospital model, whereas a novel approach encompassing true “PCI now” capabilities could provide meaningful clinical benefits. Indeed, prehospital electrocardiogram (ECG) acquisition, early emergency medical service activation of the interventional team, direct transfer to the catheterization laboratory when appropriate, and continuous in-house staff coverage may reduce treatment delays, especially during off-hours, and may improve clinical outcomes. In this perspective, first-medical-contact-to-PCI and total ischemic time appear more meaningful quality indicators than door-to-balloon time alone, as also testified by regional data from Lazio and the experience from Santa Maria Goretti Hospital in Latina which show how delays frequently arise when patients first present to non-PCI hospitals, whereas organized direct-transfer pathways may streamline care. Development of centralized, sectorized STEMI networks, together with transparent auditing of performance and safeguards against false-positive activation, including ECG transmission, teleconsultation, standardized criteria, and validated artificial intelligence tools, may allow a safer and more effective management of STEMI. We hereby thus formally propose the universal adoption of such PCI now approach for STEMI care.

E-wave propagation index (EPI) could be a simple echocardiographic parameter to identify patients at increased risk of left ventricular (LV) thrombus following ST-elevation myocardial infarction (STEMI). We aimed to investigate the association between EPI and LV thrombus as assessed by cardiac magnetic resonance imaging (MRI). We included 665 STEMI patients treated with percutaneous coronary intervention from the MARINA-STEMI study. EPI was measured using transthoracic echocardiography at 3 (IQR 2-4) days post-STEMI and calculated as the ratio of the E-wave velocity-time integral to the LV end-diastolic length, measured in the apical four-chamber view. LV thrombus was evaluated with cardiac MRI at 4 (IQR 3-5) days post-STEMI. A total of 665 STEMI patients (17% female) with a median age of 58 [IQR 52-66] years were included. Patients with LV thrombus (n = 32, 5%) had a significantly lower EPI than those without (0.92 vs. 1.29, P < 0.001). EPI independently predicted LV thrombus with an adjusted odds ratio of 0.84 (95% CI 0.74-0.95; P = 0.007). The area under the curve for EPI in detecting LV thrombus was 0.73 (95% CI 0.64-0.82, P < 0.001). EPI of 0.95 emerged as best cut-off to identify patients at high risk of LV thrombus formation (15.9% thrombus rate in patients with EPI < 0.95 as compared to 2.5% in patients with EPI ≥ 0.95). EPI emerged as significant and independent predictor of LV thrombus formation in STEMI patients. These findings highlight the usefulness of EPI as simple echocardiographic parameter to optimize LV thrombus screening in routine STEMI care.

SummaryBackgroundRapid primary percutaneous coronary intervention (PPCI) in patients with ST-elevation myocardial infarction (STEMI) reduces in-hospital and long-term mortality. This study analyzes time intervals to PPCI in STEMI, risk factors for delay of PPCI, and in-hospital mortality from 2012 to 2023.MethodsThis is a retrospective population-based analysis of hospital billing data of adult STEMI patients receiving PPCI in Germany. The time for transport to hospital (TTH) was estimated using geographic routing. The in-hospital time to angiography (IHTA) was calculated using time coding of PPCI in patient records.FindingsA total of 575,247 patients were included. The median age was 64 years, 28.5% (164,016) were female. The population with IHTA ≤60 min increased from 44.5% (22,240/49,965) in 2012 to 57.7% (24,434/42,356) in 2023 with improved TTH + IHTA ≤120 min (56.6%, 28,280/49,965, in 2012–70.2%, 29,734/42,356, in 2023). IHTA improved from median 73.1 min (IQR 25.2–186.6) in 2012 to 46.4 min (IQR 17.5–111.6) in 2023 with a stable TTH (11.4–11.9 min). Risk factors for an IHTA >60 min included age, female sex, comorbidity, presentation out of regular hours, and low-volume hospitals. In-hospital mortality increased (8.8%, 4406/49,965, in 2012, 10.4%, 4822/46,203, in 2021, 10.1%, 4272/42,356, in 2023), paralleling a rise in patient age and comorbidity. Risk factors for in-hospital mortality included female sex, increased age, comorbidity, high-volume hospitals, intervention of multiple coronary arteries, weekend admission, and presentation out of regular hours. IHTA <40 min (90–120 min as reference) and TTH + IHTA <80 min (≥120 min as reference) reduced the risk of death.InterpretationCombining hospital billing records with geographic routing enables benchmarking of both pre- and in-hospital delays in STEMI care. In hospital delay decreased between 2012 and 2023. Important areas for improving time delays and STEMI-related mortality include the timeliness of care outside of regular hours and a focus on women, older patients, as well as individuals with comorbidities.FundingThere was no funding for this project or this publication.

This study aimed to evaluate the six-month major adverse cardiovascular and cerebrovascular events (MACCE) among ST-elevation myocardial infarction (STEMI) patients, and identify their predictors. This single-centre, prospective observational study involved STEMI patients who presented to the Makassar Cardiac Centre in Indonesia from July 2018 to June 2020. Consecutive sampling was employed. The primary endpoint was MACCE (including all-cause mortality, heart failure requiring hospitalization, reinfarction, and stroke) during hospitalization, at 30-day and 6-month follow-up. We recruited 365 patients with a mean age of 57.1 ± 10.3 years, and predominantly male (n = 294, 80.5%). Majority of the patients (n = 206, 56.4%) received reperfusion therapy, with 104 (28.5%) underwent primary percutaneous coronary intervention (PPCI) and 102 (27.9%) received fibrinolysis. Six-month mortality was higher without reperfusion than with PPCI or fibrinolysis (26.4% vs 17.3% vs 13.7%, p = 0.030). MACCE occurred in 23.6% at 30 days and 57.0% at 6 months. Most STEMI patients in East Indonesia were latecomers, with a median time from onset to hospitalization of 350 min. Independent predictors of 6-month MACCE were age ≥ 60 years (HR 1.45, p = 0.032), Killip class ≥ 2 (HR 2.06, p < 0.001), anterior MI (HR 1.47, p = 0.024), renal impairment (HR 1.57, p = 0.015), medication non-adherence (HR 1.70, p = 0.001), and hospital stay ≥ 8 days (HR 1.48, p = 0.018). The high incidence of MACCE at 6 months following STEMI in our region is worrisome. Identified MACCE predictors can guide better STEMI management. To reduce MACCE following STEMI, it is crucial to raise symptom awareness, expedite PPCI activation, and strengthen hospital infrastructure and resources for STEMI care.

The effectiveness of ST-elevation myocardial infarction (STEMI) treatment is highly time-dependent, and the information barrier between prehospital and in-hospital settings remains a key driver of treatment delays. Existing digital coordination tools either have a single function or lack long-term real-world evidence, making it difficult to meet clinical needs. This study adopts a prehospital chest pain alert app developed by the Fengxian District Medical Emergency Center. Mediated through a WeChat-based chest pain center group, the app enables prehospital information synchronization, real-time alerts, multidisciplinary coordination, and feedback on treatment outcomes to form a closed-loop model, overcoming the information barrier. This protocol aims to evaluate the impact of the app-mediated prehospital-in-hospital coordination model on treatment delays (eg, time from first electrocardiogram to catheterization laboratory preactivation and door-to-wire time) and clinical outcomes (eg, 30-day major adverse cardiovascular events, and 1-year and 4-year all-cause mortality) in patients with STEMI, and to assess its generalizability in high-risk subgroups. This is a single-center retrospective cohort study. Patients with STEMI admitted to Fengxian District Central Hospital from January 1, 2019, to December 31, 2024, will be enrolled and categorized into 3 groups: baseline group (January 1, 2019, to December 31, 2020, without app use), intervention group (January 1, 2021, to December 31, 2024, with app-mediated coordination), and concurrent control group (patients with STEMI who came to the hospital independently without calling an ambulance or were transported by ambulance but not reported via the app during the same period). The primary outcome is door-to-wire time. Secondary outcomes include other treatment delay indicators, clinical prognosis, and app operational efficiency. We will use propensity score matching to control for baseline confounding, segmented linear regression to analyze intervention trend effects, and subgroup analysis to assess generalizability in high-risk populations. This study is based on 4 years of real-world data from the Department of Cardiology and the STEMI database of Fengxian District Central Hospital. As of April 2026, all 2019-2021 data have been collected; a sample size of 944 or more is expected. Data cleaning and statistical analysis are scheduled from May 2026 to June 2026. Based on 4 years of real-world data, combined with propensity score matching and interrupted time series analysis, this study aims to provide high-quality observational evidence for the app-mediated prehospital-in-hospital coordination model. The findings are anticipated to offer preliminary references for optimizing regional STEMI care systems and to inform the potential application of digital health technologies in acute coronary syndrome management.

Rural and Remote Acute STEMI Diagnosis and Management: Current Status and Future Directions.

"Background: Globally, one of the leading causes of mortality and morbidity include cardiovascular diseases (CVD). Plaque disruption results in acute thrombotic coronary events, which leads to occlusion of blood flow to a portion of the myocardium. Acute anterior wall myocardial infarction (AWMI) is a critical condition among these presentations. This leads to high mortality and morbidity. The management of ST-elevation myocardial infarction (STEMI) is important. The standard care of STEMI is PPCI compared to thrombolytic therapy. It is because PPCI gives high clinical outcomes. Ostial LAD lesions have unique hemodynamic and anatomical characteristics which is why they represent a distinct subgroup of LAD lesions. The objective is to compare the clinical outcomes of non-ostial and ostial LAD lesions in patients having acute AWMI undergoing PPCI. Study design is Cross-sectional study. This study was conducted at People’s University of Medical and Health sciences for women Nawabshah from May 2024 to May 2025. Materials and Methods: This study is a cross-sectional analysis which was conducted on patients having acute AWMI and presented in the emergency department of the hospital. The diagnosis was confirmed based on their ECG and cardiac bio markers. All of the participants underwent primary percutaneous coronary intervention (PPCI) for a left anterior descending (LAD) artery culprit lesion. Participants were aged from 18 years and above. SPSS version 26 was used to analyse the data. Age, ejection fraction, BMI etc were the continuous variables while lesion type, gender, diabetes etc were the categorical variables. Chi-square test, Mann-Whitney U test, and t-test was conducted. Results: There were a total of 400 individuals involved in this research. Participants were aged from 18 years and above. The mean age was 54.9 years. The majority of the participants were male, representing 80% of the population (n=320). There were a total of 288 patients who had a non-ostial LAD culprit lesion. The remaining 112 patients had an ostial LAD artery culprit lesion. The most prevalent factor in all the patients was hypertension. Conclusion: Ostial LAD culprit lesions in patients with acute AWMI shows higher risk associated with increased procedural complexity, longer hospital stays, and increased mortality. Keywords: mortality, morbidity, acute thrombotic coronary events, on transient collateral circulation."

Abstract Background ST-elevation myocardial infarction (STEMI) remains a major cause of mortality in resource-limited countries. Initiation of appropriate therapy and timely reperfusion are often delayed due to a lack of ECG interpretation expertise, limited specialist availability, and geographic barriers, leading to a five-fold increase in mortality. Additional challenges include the absence of an organized STEMI care system, financial constraints, and fragmented referral pathways. Cardiovascular diseases impose a significant economic burden, with costs in low- and middle-income countries (LMICs) projected to reach $3.76 trillion by 2025. Digital health solutions, particularly telemedicine-driven ECG interpretation and triage systems, offer a promising approach to reducing diagnostic delays and optimizing referral strategies. However, their success depends on real-time specialist involvement to ensure adherence to guideline-directed care. Using a Triage-Treat-Transfer (T3) approach, the system could enable early STEMI and high-risk Acute Coronary Syndrome (ACS) recognition through rapid ECG interpretation, point-of-care ultrasound, and troponin assays. Purpose This study evaluated the feasibility of a digital platform in improving STEMI and high-risk ACS management by reducing referral delays and enhancing adherence to guideline-directed medical therapy. Methods The platform was deployed across community clinics and mobile heart camps, enabling real-time expert consultation for suspected STEMI cases. Local physicians transmitted ECGs securely for automated STEMI detection and cardiologist validation. Patients were triaged based on clinical risk and ECG findings, guiding decisions on urgent reperfusion therapy, a pharmaco-invasive strategy when percutaneous coronary intervention (PCI) was unavailable, or high-risk monitoring. High-risk patients were prioritized for transfer to PCI-capable centers. Results The digital platform significantly enhanced STEMI and high-risk ACS care delivery, streamlining diagnosis and treatment. A total of 211 patients were evaluated for suspected ACS, with 51 confirmed cases, all received guideline-directed therapy. Of the 12 transferred, 8 underwent PCI, 1 required coronary artery bypass surgery, and 3 continued on optimal medical therapy post-angiography. Interim results show improved STEMI recognition, structured triage, and faster intervention, reducing unnecessary admissions and transfers. Conclusions A digital platform–enhanced acute cardiac care model, with real-time cardiologist guidance, structured triage, and expedited transfers, is a scalable and cost-effective strategy for improving STEMI and high-risk ACS outcomes in resource-limited settings. By integrating real-time ECG interpretation and expert decision support, this model may optimize early reperfusion, reduce mortality, and lower healthcare costs. Future trials and broader network integration could enhance its impact.

Abstract Background Current guidelines recommend baseline Lipoprotein(a) (Lp(a)) measurement as part of risk stratification for future cardiovascular disease. However, the real-world implementation of these recommendations for the secondary prevention of atherosclerotic cardiovascular disease remains unclear. Purpose This study is the first to assess the practical use of Lp(a) measurement in the care of young ST-elevation myocardial infarction (STEMI) patients within a Canadian healthcare system. Methods We conducted a retrospective analysis of STEMI patients &amp;lt; 65 years old presenting to 13 regional hospitals between January 2016 and December 2022. The primary objective was to determine the proportion of patients who had baseline Lp(a) levels measured prior or within 1 year following their index STEMI hospitalization. The secondary objective was to identify predictors of Lp(a) measurement at any point in their lifetime in this population. Results Among 1,262 patients meeting the inclusion criteria, 1,106 (mean age 55.9±7 years, 88.1% male) were included in the final analysis. Two hundred and forty (21.7%) had an Lp(a) measurement prior or within 1 year of STEMI. Of these, 78(32.5%) had Lp(a) levels ≥100 nmol/L, while 162(67.5%) had levels &amp;lt;100 nmol/L. Based on univariable analysis, patients were less likely to have Lp(a) measured at any point in their lifetime if they were older (OR 0.71(95% CI:0.65, 0.78), p&amp;lt;0.001), had peripheral artery disease (OR 0.25(0.06, 1.09), p=0.064), had traditional coronary artery disease (CAD) risk factors (hypertension: OR 0.66(0.51,0.85), p=0.001; smoking: OR 0.64(0.48,0.85), p=0.003; stroke/TIA: OR 0.46(0.22,0.96), p=0.04) or a lower baseline LDL-C levels (OR 0.87(0.77, 0.98), p=0.027). Older age (OR 0.68(0.60, 0.75), p&amp;lt;0.001), smoking (0R 0.68(0.49,0.96), p=0.027), and higher BMI (OR 0.81(0.68,0.95), p=0.011) remained significantly associated with a lack of Lp(a) measurement after multivariate analysis. Among those with Lp(a) testing, approximately two-thirds had it measured before or within six months of hospitalization, while one-third had their first measurement more than 12 months post-discharge. Conclusions In the contemporary era, only 1 in 5 younger STEMI patients had LP(a) measurement within 1 year of their index event. Moreover, many patients had no Lp(a) measurement during their lifetime; this was associated with certain clinical factors such as increasing age and the presence of CAD risk factors. With the development of novel targeted therapeutics, additional studies to understand why Lp(a) is not being measured, and strategies to increase timely Lp(a) assessment in this high-risk population are warranted.

Background: ST elevation myocardial infarction (STEMI), characterized by complete coronary blockage, remains acutely lethal despite medical advances, with mortality rates unchanged over the past decade. Guidelines recommend electrocardiogram (ECG) within 10 minutes, fibrinolytics within 30 minutes when timely primary percutaneous coronary intervention (pPCI, 90-minute target) isn't feasible. Rural critical access hospitals face resource constraints potentially affecting adherence to these time-sensitive interventions. Hypothesis: CA hospitals demonstrate significantly lower adherence to STEMI guideline benchmarks compared to nCA hospitals, potentially contributing to persistent mortality rates despite medical advances. Aim: To evaluate disparities in guideline recommended times for STEMI care in CA and nCA hospitals. Methods: This retrospective cohort study analyzed 363,172 adult STEMI patients across the US from the American Heart Association Get With The Guidelines database. Multivariable logistic regression models assessed associations between hospital designation and guideline adherence (&lt;10 min for ECG, &lt;30 min for fibrinolysis, and &lt;90 min for pPCI), calculating odds ratios (OR) with 95% confidence intervals (95%CI). Regression models were adjusted for age and biological sex (p &lt;0.05 significance). Results: Analysis revealed no statistically significant difference in meeting ECG timing guidelines between CA and nCA hospitals. However, adjusted logistic regressions demonstrated that CA hospitals were 51% more likely to not meet fibrinolysis guideline recommendations compared to nCA hospitals (aOR:1.51, 95%CI: 1.10-2.05, p=0.009, Figure 1). Similarly, nCA hospitals were 7% more likely to not meet pPCI guideline recommendations (aOR: 1.07, 95%CI: 1.02-1.13, p=0.005) compared to nCA hospitals. Conclusions: CA hospitals meet diagnostic ECG timing guidelines but significantly underperform in treatment implementation compared to nCA facilities, with delays in both pPCI (standard care) and fibrinolysis (alternative strategy). These treatment disparities highlight specific targets for quality improvement initiatives in rural settings that could help reduce persistent STEMI mortality in underserved regions.

Prompt cardiac reperfusion reduces morbidity and mortality following an ST-elevation myocardial infarction (STEMI). Evidence demonstrates hospital-based treatment metrics for patients suffering STEMI such as door-to-balloon time can vary by patient race, gender, and socioeconomic status (SES). Approximately 2.5 million patients with chest pain call emergency medical services (EMS) every year in the United States to assess for the presence of a STEMI and provide immediate treatment prior to arriving at the hospital. It remains unclear if patient race, gender, or SES influence STEMI diagnosis and treatment in the prehospital environment. We analyzed 1,999 patients diagnosed with STEMI in the emergency department (ED) that received prehospital care in the United States in 2023 for two outcome variables. The primary outcome was if a 12-Lead ECG was acquired by EMS. The secondary outcome was if a STEMI was also diagnosed by EMS (concordance between ED and EMS STEMI diagnosis). Patients were stratified by gender, race, and the CDC’s Social Vulnerability Index at the census tract level of the EMS scene (SVI levels 1-4). For patients diagnosed in the ED with a STEMI, 82% (1,648) received a prehospital ECG. Overall, 43% (858) of patients diagnosed in the ED with a STEMI also had a prehospital diagnosis of STEMI. For patients diagnosed in the ED with a STEMI that received a 12-lead ECG by EMS providers, 75% (861) also had a prehospital STEMI diagnosis. Compared to White patients, Hispanic patients had higher odds of receiving a prehospital ECG (aOR, 2.5 [95% CI 1.23-5.08]). Patients of high social vulnerability (SVI 2-4) were found to have lower odds of receiving an ECG when compared to patients of lower social vulnerability (SVI 2 aOR, 0.58 [95% CI 0.37-0.90]; SVI 3 aOR, 0.47 [95% CI 0.32-0.70]; SVI 4 aOR, 0.34 [95% CI 0.23-0.49]). While we found no evidence of race-based difference in EMS to ED STEMI diagnostic concordance, the most vulnerable patients (SVI 4) had lower odds of an accurate EMS STEMI diagnosis (aOR 0.68 [95% CI 0.48-0.97]) when compared to the least vulnerable patient group. To our knowledge, this is the first evidence demonstrating that patients suffering STEMI located in the most vulnerable areas of the United States are less likely to receive a 12-lead ECG and less likely to be diagnosed accurately by EMS providers. Further research is needed to develop systems of care to mitigate racial and socioeconomic differences in prehospital STEMI care.

Background:ST-elevation myocardial infarction (STEMI) remains a significant global health concern, especially in low- and middle-income regions. This study aimed to identify long-term prognostic factors among STEMI patients, offering insights into improving patient outcomes.Materials and Methods:This study represents the 5-year follow-up of STEMI patients in the SEMI Cohort in Isfahan registry, a clinical-based registry of STEMI patients in Isfahan, Iran, from October 2015. All patients with STEMI within 24 h of symptom onset underwent a comprehensive evaluation. The dataset included demographic information, laboratory data, medical history, and clinical in-hospital data. Over 5 years, annual follow-ups were conducted to track hospitalization and patient all-cause mortality. Utilizing univariate and multivariate Cox regression proportional hazard modeling, we aimed to identify predictors of death.Results:In this study, involving 759 patients (621 men and 138 women) with a mean age of 58.92 ± 11.79 years, 158 deaths (21%) with a mean age of 70.33 ± 12.66 years occurred after STEMI. In the multiple model our analysis revealed that the following variables significantly increased all-cause mortality independently: Older age (hazard ratio [HR]: 1.070, P < 0.001), lower body mass index (HR: 0.890, P < 0.001), hypertension status (HR: 2.441, P < 0.001), lower systolic blood pressure at initial presentation (HR: 0.983, P < 0.001), number of affected epicardial territories (HR: 2.979, P < 0.001), lower last ejection fraction before discharge (HR: 0.951, P < 0.001), lower hemoglobin level (HR: 0.747, <0.001), higher plasma glucose level (HR: 1.005, P < 0.001), and in-hospital complications (HR: 7.646, P < 0.001).Conclusion:This study identified a range of factors that predict STEMI-related mortality. These findings are pivotal for future planning and decision-making regarding appropriate diagnostic and therapeutic strategies during patient follow-up, contributing to improved outcomes in STEMI care.

BackgroundAdvances in acute ST-elevation myocardial infarction (STEMI) care have substantially decreased in-hospital mortality; however, in absolute terms, in-hospital mortality still remains high. Reperfusion injury, particularly intramyocardial hemorrhage following primary percutaneous coronary intervention (PCI), is a major predictor of adverse cardiovascular outcomes in the long term, but whether it contributes to in-hospital mortality is not known.MethodsWe performed a multicenter study to investigate the use of post-PCI high-sensitivity cardiac troponin I (hs-cTn-I) as a diagnostic tool to identify hemorrhagic myocardial infarction (MI) by determining hourly hs-cTn-I thresholds (every hour up to 12 hours, and at 16, 20, 24, and 48 hours post-PCI). We then investigated the relationship between patients classified as having hemorrhagic MI based on post-PCI hs-cTn-I cutoff values and in-hospital mortality using STEMI registries containing information about 6180 patients across seven hospitals in a single large health system in the United States.ResultsWe enrolled 154 patients in a discovery cohort and 53 patients in a validation cohort. Hemorrhagic MI was diagnosed by cardiac magnetic resonance imaging. Post-PCI hs-cTn-I cutoff values for the determination of hemorrhagic MI were time dependent, with a sensitivity greater than 0.91, a specificity greater than 0.86, and an area under the curve (AUC) greater than 0.92 over the first 10 hours post-PCI, decreasing to a sensitivity greater than>0.84, a specificity greater than 0.80, and an AUC greater than 0.84 thereafter. The STEMI registry analysis demonstrated that patients classified as having hemorrhagic MI based on hs-cTn-I cutoff values had a 2.81-fold greater risk for in-hospital mortality than those classified as having had nonhemorrhagic MI (adjusted odds ratio, 2.81; 95% confidence interval, 2.17 to 3.64).ConclusionsPost-PCI troponin kinetics may have the potential to diagnose hemorrhagic MI, which was associated with in-hospital mortality. (Funded by the National Institutes of Health National Heart, Lung, and Blood Institute [grant numbers HL133407, HL136578, and HL147133] and others; ClinicalTrials.gov ID, NCT05872308.)

Patients with ST-elevation myocardial infarction (STEMI) cared for by rural emergency medical services (EMS) agencies commonly do not have first medical contact-to-percutaneous coronary intervention (PCI) time within the recommended goal of 90 minutes. In this study we identify factors associated with performance variation among rural EMS agencies in first medical contact-to-PCI time. In this explanatory, sequential, mixed-methods study, we ranked eight rural county EMS agencies by continuous first medical contact-to-PCI time, accounting for loaded mileage, using data from a regional STEMI registry (2016-2019). A qualitative researcher conducted 28, one-hour, semi-structured interviews from January- March 2021 with the EMS director, training officer, medical director, and four paramedics at the top two high- and bottom two low-performing rural EMS agencies. Key informants were blinded to agency STEMI performance. Interviews were structured to identify positive deviance by exploring agencies' clinical approach to patients with chest pain, their organizational culture, structure, and quality improvement (QI) activities regarding STEMI care, and recommendations for improving STEMI performance. Interviews were digitally recorded and transcribed verbatim by a professional transcription service. We established a codebook and performed a thematic analysis using an inductive approach. We summarized and compared data across agencies to identify commonalities and differences between high- and low-performing agencies. Findings were reviewed and validated by an expert panel. The top two highest-performing EMS agencies had a median first medical contact-to-PCI time of 79 minutes (interquartile range [IQR] 65-91) minutes vs 98 minutes (IQR 82-120) among the bottom two lowest-performing agencies, P<.001. Both high- and low-performing agencies identified issues with electrocardiogram (ECG) transmitting technology and cumbersome hospital activation communications. However, top-performing agencies shared a culture that encourages early EMS activation of the cardiac catheterization lab after STEMI recognition. Top-performing agencies also placed a higher value on QI and training. These agencies prioritized mission and chain of command over staff relationships/interpersonal bonds; have stable, strong leadership; provide opportunities for career advancement; and collaborate with community leaders. Top-performing rural EMS agencies for STEMI care promote early activation, have a strong chain of command, are mission focused, and have a greater focus on quality improvement and training.

The recent study by Shah and colleagues, "Association of Hemoglobin Level with In-Hospital Outcomes in Patients with STEMI Treated with Primary Percutaneous Coronary Intervention," brings renewed attention to the clinical impact of anemia in patients presenting with ST-elevation myocardial infarction (STEMI) [1]. Conducted at the Hayatabad Medical Complex in Pakistan, this retrospective study highlights a compelling association: lower hemoglobin levels at presentation correlate with higher rates of major adverse cardiac events (MACE) and in-hospital mortality. These findings underscore the need to reevaluate the role of hemoglobin as a prognostic marker—and potentially, a modifiable factor—in acute cardiac care. Despite significant advances in reperfusion strategies and emergency care, STEMI remains a leading cause of morbidity and mortality worldwide [2]. Among the modifiable risk factors that often go unrecognized in this context is anemia, typically defined as a hemoglobin level below 13 g/dL in men and 12 g/dL in women [3]. Anemia is prevalent in patients with acute coronary syndromes and may exacerbate myocardial ischemia by impairing oxygen delivery to already compromised tissue [4]. In Shah et al.'s cohort, mortality ranged from approximately 4% in patients with normal hemoglobin to nearly 20% in those with severe anemia. MACE—including heart failure, arrhythmias, and cardiogenic shock—was also significantly more common among anemic individuals. Notably, the statistical analysis demonstrated that severe anemia was an independent predictor of in-hospital mortality, with the risk of death more than doubling in this group. These findings have practical implications for clinical decision-making. While early reperfusion remains the cornerstone of STEMI management, the initial evaluation should not overlook hemoglobin levels, which may offer valuable prognostic information. Current transfusion guidelines advocate for a restrictive strategy, generally recommending transfusion only when hemoglobin drops below 7–8 g/dL or when symptoms of anemia emerge. Yet this study suggests that even moderate anemia may carry prognostic weight. This raises important questions about whether clinical thresholds for intervention should be reconsidered, or at least more individualized. Rather than defaulting to transfusion—which carries its own risks—clinicians might consider broader strategies: optimizing hemodynamics, minimizing procedural blood loss, and addressing reversible causes of anemia such as iron deficiency or chronic disease. Early detection of anemia could enable timely and targeted interventions, potentially improving outcomes without relying solely on transfusion-based strategies. Nevertheless, the study has important limitations. Its retrospective nature precludes causal inference, and its single-center setting in Pakistan may limit generalizability to other healthcare systems or populations. Larger prospective, multicenter trials are needed to validate these findings and guide evidence-based protocols. Future research should explore optimal hemoglobin thresholds for intervention, the timing and volume of transfusion when warranted, and the utility of adjunctive therapies such as iron supplementation or erythropoietin. An additional opportunity lies in better understanding how anemia interacts with common STEMI comorbidities like diabetes and chronic kidney disease. These interactions may demand a more personalized approach to risk stratification and management. Beyond the clinical sphere, this study also carries public health implications. In countries where nutritional deficiencies and chronic diseases are prevalent, population-level anemia screening and prevention strategies could play a pivotal role in reducing the burden of cardiovascular events. Integrating early hemoglobin assessment into STEMI protocols and educating frontline providers on its importance could enhance both patient care and system-level efficiency. The association between anemia and poor in-hospital outcomes in STEMI patients undergoing PCI, as demonstrated by Shah et al., invites renewed attention to a potentially modifiable risk factor in acute cardiac care. Their findings reinforce the need for routine hemoglobin evaluation at presentation and support the integration of anemia management into comprehensive STEMI care pathways. As the field moves toward increasingly personalized and precise cardiovascular medicine, even modest adjustments—like addressing anemia early—could make a significant difference in patient outcomes. References Shah SK, Danish N, Akhtar S, Khalil MSUD, Ali N, Amin QNU. Association of Hemoglobin Level with In-Hospital Outcomes in Patients with STEMI Treated with Primary Percutaneous Coronary Intervention. Pak Heart J. 2025;58(02):252-7. DOI: 10.47144/phj.v58i2.2786 Vernon ST, Coffey S, D'Souza M, Chow CK, Kilian J, Hyun K, et al. ST-Segment-Elevation Myocardial Infarction (STEMI) Patients Without Standard Modifiable Cardiovascular Risk Factors-How Common Are They, and What Are Their Outcomes? J Am Heart Assoc. 2019;8(21):e013296. DOI: 10.1161/JAHA.119.01329. Prabhakar SK, Abbott JD. Factors influencing the outcomes of percutaneous coronary intervention in the stent era. Interv Cardiol. 2012;4(5):557-68. DOI:10.2217/ica.12.59 Rhodes CE, Denault D, Varacallo MA. Physiology, oxygen transport [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan– [updated 2022 Nov 14; cited 2025 Jun 5]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK538336/

Percutaneous coronary intervention (PCI) is the criterion standard for acute ST-elevation myocardial infarction (STEMI). Achieving target first medical contact (FMC)-to-device time is a quality metric in STEMI care. To describe site-level variability in achieving target FMC-to-device time (≤90 minutes for primary presentations to PCI-capable hospitals and ≤120 minutes for transfers), compare treatment times according to hospital performance, location, and primary PCI volume, and assess whether these aspects are associated with clinical outcomes. This was a retrospective cross-sectional study from the American Heart Association Get With the Guidelines-Coronary Artery Disease registry from 2020 to 2022. Patients were recruited from a multicenter quality-improvement registry across 503 US hospitals. Patients with STEMI or STEMI equivalent who underwent primary PCI were included in this analysis. FMC-to-device time. Hospital performance was determined by the proportion of patients meeting target FMC-to-device time at each site. Treatment times and outcomes were compared by hospital performance, location, and primary PCI volume. A total of 73 826 patients were analyzed (median [IQR] age, 62 [54-71] years; 53 474 male [72.4%]). Of 60 109 patients who presented directly to PCI-capable hospitals (primary presentations), 35 783 (59.5%) achieved an FMC-to-device time of 90 minutes or less, whereas 6900 (50.3%) of 13 717 transfers had an FMC-to-device time of 120 minutes or less. There was substantial institutional variability in achieving target FMC-to-device time for both primary presentations (median [IQR], 60.8% [51.2%-68.8%]) and transfers (median [IQR], 50.0% [32.5%-66.9%]). High-performing centers met all target treatment times more frequently. Low-performing sites experienced prolonged emergency department stays, catheterization laboratory arrival-to-PCI times, and transfer delays, varying by mode of presentation. Compared with urban centers, presentation to rural hospitals did not affect the odds of meeting target FMC-to-device time for primary presentations (adjusted odds ratio [aOR], 1.20; 95% CI, 0.96-1.50) or transfers (aOR, 0.86; 95% CI, 0.50-1.47). Failure to achieve target FMC-to-device time was associated with increased in-hospital mortality risk for primary presentations (aOR, 2.21; 95% CI, 2.02-2.42) and transfers (aOR, 2.44; 95% CI, 1.90-3.12). Low hospital performance was associated with increased mortality risk compared with high performance in primary presentations (aOR, 1.16; 95% CI, 1.00-1.34). Outcomes were similar between rural vs urban and low vs high primary PCI volume centers. In this large cross-sectional study of patients with STEMI, there was substantial hospital-level variability in achieving target treatment times. Patients in whom target FMC-to-device time was not met and those presenting to low-performing hospitals had worse outcomes.

Rural vs metropolitan ST-elevation myocardial infarction (STEMI) patients experience delayed access to percutaneous coronary intervention (PCI). Existing New South Wales (NSW) Statewide Cardiac Reperfusion Strategy protocols provide thrombolysis and ambulance diversion for patients within 90 minutes of a PCI centre in regional and rural NSW. Rural patients presenting to non-PCI hospitals and those more than 90 minutes from PCI are not routinely, urgently, diverted under existing protocols. Western NSW Local Health District, covering 250,000 km2 and a population of 278,759, implemented a centralised management system (CMS) in 2019, in partnership with NSW Ambulance, utilising existing STEMI thrombolysis protocols and extending "drip and ship" protocols for "hot transfer" of all patients to the 24/7 PCI centre, by direct ambulance diversion up to 120 minutes by road, or via multi-stage transfer by road or air, or via interhospital transfer. Data for 2 years post-CMS was compared to historical controls. Time from first clinical contact (FCC) to reperfusion, FCC to PCI centre, major adverse clinical events and percentage of patients undergoing angiography within 24 hours were compared in "medium" (90-120 minutes) and "long" (>120 minutes) transfer zones, not covered by existing protocols. Outcomes were recorded for 274 patients before and 348 after CMS implementation (17% medium and 31% long transfer zones). Medium and long transfer zones had greater proportions of smokers and Indigenous patients than short transfer zones. There was significantly lower ambulance utilisation in the long (38%) compared with the short transfer zone (55%, p<0.001). In the long transfer zone, there were significant improvements in FCC to reperfusion (40 vs 48 minutes, p<0.05), FCC to PCI centre (296 vs 344 minutes, p<0.01), and angiography in 24 hours (77% vs 58%, p<0.01), with no significant differences in major adverse clinical events. A rural STEMI CMS, with "hot transfer", can deliver patients from a vast geographical area directly to a rural PCI centre. Patients furthest away, with the greatest risk profile, benefit the most. Extension of this program and development of 24/7 PCI in NSW rural cardiac hubs stands to improve timely, definitive treatment, including access to angiography within 24 hours.

Background: Cardiogenic shock (CS) is a life-threatening complication of ST-elevation myocardial infarction (STEMI) and remains the leading cause of in-hospital mortality, with rates ranging from 5 to 10% despite advances in reperfusion strategies. Early identification and timely intervention are critical for improving outcomes. This study investigates the utility of machine learning (ML) models for predicting the risk of CS during the early phases of care-prehospital, emergency department (ED), and cardiology-on-call-with a focus on accurate triage and prioritization for urgent angiography. Results: In the prehospital phase, the Extra Trees classifier demonstrated the highest overall performance. It achieved an accuracy (ACC) of 0.9062, precision of 0.9078, recall of 0.9062, F1-score of 0.9061, and Matthews correlation coefficient (MCC) of 0.8140, indicating both high predictive power and strong generalization. In the ED phase, the support vector machine model outperformed others with an ACC of 78.12%. During the cardiology-on-call phase, Random Forest showed the best performance with an ACC of 81.25% and consistent values across other metrics. Quadratic discriminant analysis showed consistent and generalizable performance across all early care stages. Key predictive features included the Killip class, ECG rhythm, creatinine, potassium, and markers of renal dysfunction-parameters readily available in routine emergency settings. The greatest clinical utility was observed in prehospital and ED phases, where ML models could support the early identification of critically ill patients and could prioritize coronary catheterization, especially important for centers with limited capacity for angiography. Conclusions: Machine learning-based predictive models offer a valuable tool for early risk stratification in STEMI patients at risk for cardiogenic shock. These findings support the implementation of ML-driven tools in early STEMI care pathways, potentially improving survival through faster and more accurate decision-making, especially in time-sensitive clinical environments.

IntroductionThe use of coronary artery bypass grafting (CABG) for primary revascularization during the acute care of ST-elevation myocardial infarction (STEMI) patients has declined significantly in the past decade; but there is little data to determine whether there has been a change in the use of CABG for STEMI patients treated by emergency medical services (EMS). In this study we described the incidence of urgent or emergent CABG for STEMI patients treated in a large, regionalized cardiac care system.MethodsWe obtained data obtained for patients transported by EMS between January 2011–December 2022 who were diagnosed with acute STEMI on prehospital or emergency department (ED) electrocardiogram and taken for primary diagnostic catheterization. All STEMI patients were transported by EMS to one of 34 STEMI receiving centers (SRC) in a regionalized cardiac care system, all of which are required to maintain onsite cardiac surgery as a condition of their SRC designation. Patients were considered to have undergone urgent or emergent CABG if it was performed within 72 hours of the primary diagnostic cardiac catheterization. We excluded patients if no diagnostic catheterization was performed or if CABG was performed >72 hours after diagnostic catheterization. The primary outcome was the incidence of urgent or emergent CABG. Patients were further stratified by time between diagnostic catheterization and CABG (<24 hours, 24–48 hours, 48–72 hours).ResultsA total of 28,349 patients were transported by EMS and diagnosed with an acute STEMI during the study period. Only 384 (1.35%) patients underwent CABG within 72 hours of diagnostic catheterization: 268 (0.95%) underwent CABG in <24 hours; 71 (0.25%) in 24–48 hours, and 45 (0.16%) in 48–72 hours. The median age of patients undergoing CABG was 64 years (interquartile range 58–72). Twenty-eight (7.3%) experienced prehospital cardiac arrest, and eight (2.1%) required vasopressors. Prior to undergoing CABG, 137 patients (36%) underwent primary percutaneous coronary intervention. The proportion of patients undergoing CABG within 72 hours remained relatively stable between 2011–2022 at 1.19% and 1.96%, respectively.ConclusionUrgent or emergent CABG remained infrequently performed for acute STEMI patients after primary diagnostic catheterization. There was little change in the percentage of STEMI patients who received CABG within 72 hours of diagnostic catheterization over the past decade. These findings suggest that regional or local policies requiring on-site cardiac surgery at SRCs may be reconsidered.