ST-elevation Myocardial Infarction Care Research Articles

Impact of SARS-CoV2 pandemic onto acute ST-elevation myocardial infarction care and patient outcomes in a large tertiary cardiac center

Abstract Funding Acknowledgements Type of funding sources: None. Background SARS-CoV2 pandemic has caused major impact on patient care worldwide. We experienced a surge of cases beginning March 2020 leading to the government imposing a movement control order, more commonly known as ‘lockdown’ starting 18th March 2020. As such, various changes were implemented by our center to the clinical pathway for STEMI patients including using thrombolysis as the preferred initial treatment modality. Purpose We aim to determine the impact of SARS-CoV2 pandemic on the clinical outcome of acute STEMI patients in our center which is a large regional tertiary hospital for cardiology. Methods and results: This is a single center retrospective cross-sectional study from 1st January 2020 until 31st May 2020. We compared clinical outcomes of patients admitted for acute STEMI before (group 1) and after (group 2) 15th March 2020 which is the date our center implemented changes to our STEMI care pathway. A total of 172 cases of acute STEMI was admitted to our center during this period. Admission for STEMI was noticeably lower after the lockdown implementation (group 1, n = 97 vs group 2, n = 75). The median time from symptom to presentation at our center did not differ between the two groups being 4.15h[2.78,7.28] vs 4.42h[2.97,8.01] p = 0.702, suggesting no out-of-hospital delays in management. Majority of the patients in group 1 (n = 75, 77.2%) received primary percutaneous coronary intervention (PCI) vs only 17 (22.7%) in group 2. Most in group 2 (n = 54, 72%) received thrombolytic therapy and subsequently underwent coronary intervention within the same admission. This shows a shift in the preferred initial treatment modality for STEMI at our center during this period. The door to balloon time for patients undergoing primary PCI during this period was also numerically higher in group 2 but the difference was not statistically significant at 46min [38,63] vs 59min [45,72], p = 0.063, most likely due to the additional preparation needed in terms of SARS-CoV2 testing and personal protective equipment (PPE) prior to the procedure. The primary composite endpoint of in-hospital mortality and cardiogenic shock between the two groups (17.5% vs 24.3%, p = 0.275) did not show any significant difference. The incidence of in-hospital mortality and cardiogenic shock were 4.1% vs 6.7% (p = 0.458) and 15.5% vs 21.9% (p = 0.281) respectively. Conclusions This study suggests that thrombolysis as the preferred initial treatment modality for STEMI could be a reasonable temporary measure during the initial phase of a global pandemic to reduce infection risk of healthcare providers without compromising patient outcomes until adequate PPE and testing modalities are available for primary PCI to be performed safely. A follow-up study is needed to determine the long-term outcome of these patients.

Abstract 12267: Impact of a Comprehensive ST-Elevation Myocardial Infarction Protocol on Key Process Metrics in African American STEMI Patients

Background: Optimizing STEMI care processes for African Americans is a critical matter with important public health implications. We aimed to study if a comprehensive ST-elevation myocardial infarction (STEMI) protocol (CSP) could improve key process metrics in the African American (AA) population. Methods: We developed a 4-step CSP which included, 1) Emergency Department catheterization lab activation; (2) STEMI Safe Handoff Checklist; (3) immediate catheterization lab transfer; (4) and radial-first percutaneous coronary intervention (PCI). Baseline characteristics and procedural characteristics were compared between all consecutive STEMI patients who underwent PCI at the Cleveland Clinic main campus between January 1, 2011, to July 14, 2014 (pre-CSP group) and July 15, 2014, to July 15, 2019 (post-CSP group). Results: There were a total of 208 AA patients in the pre-CSP group compared to 271 AA patients in the post-CSP group. Baseline characteristics were quite similar between the two groups except for a lower rate of MI in the post-CSP group (45% vs 30%, P=0.001). After implementation of our CSP, guideline-directed medical therapy increased from 71.6% to 81.9% (P=0.011), radial utilization went up from 14.4% to 73.8% (P<0.001), door to balloon time decreased from 90 minutes (median IQR 64-120) to 70 minutes (median IQR 45-95) (P<0.001), fluoro dose decreased from 1610 mGy (median IQR 980.25-2592.25) to 1147 mGy (median IQR 742-1844) (P<0.001), and contrast dose decreased from 197.07 ml to 152.98 ml (P<0.001). Conclusion: Implementing a CSP was able to significantly improve the key STEMI process metrics for African American patients. Optimizing key STEMI process metrics is an important initiative to ensure equitable STEMI care.

Clinical profile of ST-elevation myocardial infarction patients from a tertiary care hospital in Northern India

Background: Our aim was to the study clinical and epidemiological profile of patients presenting with ST-elevation myocardial infarction (STEMI).Methods: We did a single centre cross-sectional observational study of 200 patients presented with STEMI to a tertiary referral centre in Northern India from January 2016 to November 2017. All patients above 18 years of age admitted with diagnosis of STEMI were included in the study.Results: The mean age of study population was 55.75±12.5. The most common chief compliant was chest pain (95.1%). The anterior wall myocardial infarction (AWMI) accounted for 60.5% of all STEMI patients. The median duration from onset of symptoms to presentation to hospital was 7.93±6.58 hours. Cardiogenic shock was observed in 10.5% patients. Most common risk factor noted was smoking (63%). Mean left ventricular ejection fraction (LVEF) was less in AWMI (47±9.09) as compared to inferior wall myocardial infarction (IWMI) (50.72±7.14) (p<0.05). Among 200 cases studied, 11.5% cases developed post MI-Angina. Among arrhythmic complications, sinus bradycardia was most common (17.5%).Conclusions: Our study represents the predominance of AWMI as the initial acute coronary syndrome (ACS) presentation with a considerable delay in first medical contact. Complications like cardiogenic shock, arrhythmia were frequently observed. The biggest barrier to uniform STEMI care in developing nations is nonexistence of regional systems of care and this need to be improved.

Impact of COVID-19 pandemic on a developing STEMI care system from a low-middle income country- a prospective observational study

Abstract Background COVID-19 pandemic has produced a great impact in the STEMI (ST Elevation Myocardial Infarction) care systems across the world. Patient hesitancy to seek medical attention for suspected STEMI, necessity of the health care systems to prioritize COVID-19 care, safety concerns of health care workers etc., have brought in unprecedented times for both patients and health care workers. The impact of COVID-19 pandemic on the establishment of a STEMI care system is less known Purpose To identify the impact of COVID-19 pandemic on a developing public STEMI care system in a low-middle income country in Asia, with reference to the type of reperfusion offered and outcome. Methods Data on number of STEMI admissions, type of reperfusion therapy and outcome are being collected from 12 teaching hospitals as a part of a developing public regional STEMI care system based on a hub and spoke model in a low middle-income country from August 2018. These 12 “thrombolysis only” hospitals were being upgraded as “primary percutaneous coronary intervention (PPCI) capable hub hospitals” in 2019. Though the hassles of COVID-19 pandemic affected this process significantly, daily data collection in our STEMI care system continued. The maximal COVID impacted period in 2020 was identified from the online database (1) as from April to December 2020. The number, type of reperfusion and outcome of the STEMI patients treated during this period were compared to the same data collected during April-December 2019. Results A total of 13,137 STEMI patients were treated in our system during the two time periods “April to December 2019” and “April to December 2020”. There was a 13.3% drop in the number of STEMI treated in 2020, compared to the number treated in 2019 (6101 vs 8925; P<0.001). This drop was in proportion to the number of new cases of COVID-19 reported in our state (Fig. 1a) We also noted a significant drop in the rate of PPCI and Pharmaco-invasive therapy (PIT) offered for STEMI in 2020 compared to 2019 in the same period (PPCI: 0.13% vs 5.9%-P<0.001 and PIT 0.64% vs 11%- P<0.001). This decrease in PPCI and PIT for STEMI also corresponded to the increase in number of new cases of COVID-19 reported (Fig. 1b). More patients received thrombolytic therapy for STEMI in 2020 compared to 2019 (73.6 vs 61.2% P<0.001). There was no change in the mortality of STEMI during this period. (Fig. 2) Conclusion We found a significant drop in number of patients seeking medical care for STEMI during COVID-19 pandemic. There was significant drop in the rate of PPCI and PIT offered in our STEMI care system. Thrombolytic therapy remained the predominant mode of reperfusion as before, but with a significant increased rate of thrombolysis. There was no change in mortality rate in STEMI patients. Thrombolytic therapy is an acceptable mode of reperfusion, when the balance of a STEMI care system is disturbed by extraneous influences like the COVID-19 pandemic. Funding Acknowledgement Type of funding sources: Public hospital(s). Main funding source(s): Tamil Nadu Innovation Initiative- Department of Planning and development, Govt of Tamil NaduNational Health Mission, Government of India

Impact of COVID-19 lockdowns on STEMI percutaneous interventions

Abstract Background Measures taken to mitigate the spread of coronavirus disease 2019 (COVID-19) have been correlated to a decline in the number of patients seeking medical care for emergency cardiovascular illness. Here we evaluate the impact of a state-wide lockdown on ST-elevation myocardial infarction (STEMI) care. Purpose The purpose of this study is to help understand the impact of COVID-related lockdowns on STEMI interventions. Methods All consecutive adult patients admitted with an acute STEMI diagnosis and percutaneous intervention (PCI) performed between January 17, 2020, and July 14, 2020, at five sites across our health care network, were included in this study. Patient demographics, medical history and procedure details were collected retrospectively from electronic medical records. Data were segregated according to date into pre-lockdown, lockdown (March 17 to May 13, 2020) and post-lockdown groups. Results A total of 225 patients formed the study cohort. Median age was 62 (IQR: 53–71) years. Patients were predominantly male (n=154, 68%), white (n=208, 92%), hypertensive (n=139, 61%) and dyslipidemic (n=135, 60%). The average weekly rate of STEMI PCIs performed pre-lockdown decreased by 40% during the lockdown from 10.9 to 6.5 PCIs per week (p<0.05). Door-to-balloon (D2B) times increased from 42 (IQR: 28–68) min pre-lockdown to 53 (IQR: 40–72) min during the lockdown (p=0.01). No significant differences were observed in in-hospital mortality or cardiac troponin measurements within 24 h of procedure between the three groups. Conclusion Adverse effects of COVID-19-related lockdowns on acute STEMI care include a decrease in PCI volumes and prolonged D2B times. Our results provide valuable data-driven criteria to help inform patient decisions to seek care and to find ways to protect healthcare workers without compromising timely critical intervention. Funding Acknowledgement Type of funding sources: None.

Association between off-hours admission with acute myocardial infarction and in-hospital mortality

Abstract Background The effect of time of admission on clinical outcomes in patients with acute myocardial infarction (AMI) is still a matter of debate. Purpose To investigate the association between off-hours admission and in-hospital mortality in patients with ST-elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI). Methods We used a two-stage, random sampling method to create a nationally representative sample of patients with AMI in 167 Chinese hospitals in four years (2001, 2006, 2011, and 2015). Off-hours were defined as 20:00–07:59 and on-hours as 08:00–19:59. We used hierarchical logistic regression model to examine whether off-hour admissions were associated with in-hospital mortality and 7-day mortality. Inverse-probability weighting propensity score analysis was also conducted to assess the robustness of the results. Results We identified 25654 patients admitted with AMI (median age 67.0 years; 31.6% women), of whom 20133 (78.5%) were diagnosed as STEMI and 5521 (21.5%) as NSTEMI. There were 5368 (26.7%) admissions for STEMI, and 1356 (24.6%) for NSTEMI occurring during off-hours, respectively. After adjusting for case mix, year of admission, comorbidities, clinical presentation, and in-hospital treatments, a significant association was observed between off-hours admissions and in-hospital mortality among the patients with STEMI (adjusted OR 1.14; 95% CI 1.01 to 1.28). The magnitude of the association became greater in the secondary analysis with 7-day mortality as the outcome (adjusted OR 1.16; 95% CI 1.02 to 1.31). But among patients with NSTEMI, no significant association was observed for in-hospital and 7-day mortality. Propensity score analysis showed similar results to hierarchical logistic model for both outcomes in patients with STEMI and NSTEMI. Conclusion Off-hours admission with STEMI is associated with higher in-hospital mortality. Reducing the disparity of care of STEMI by the time of admission represents a potential opportunity for quality improvement in China. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): National Key Research and Development Program (2017YFC1310803, 2017YFC1310801) from the Ministry of Science and Technology of China

Challenges in management of ST elevation myocardial infarction during COVID-19 pandemic.

The coronavirus disease-2019 (COVID-19) pandemic has brought unprecedented changes to our world and health-care system. Its high virulence and infectiousness directly infect people's respiratory system and indirectly disrupt our health-care infrastructure. In particular, ST elevation myocardial infarction (STEMI) is a clinical emergency emphasizes on the establishment of care system to minimize delay to reperfusion. As such, the impact of COVID-19 on STEMI care, ranging from disease severity, patient delay, diagnostic difficulty, triage to selection of reperfusion strategy and postoperative care, is immense. Importantly, not only we have to save our patients, but we must also need to protect all health-care workers and prevent environmental contamination. Otherwise, in-hospital transmission can quickly evolve into nosocomial outbreak with staff infection and quarantine which lead to health-care system collapse. In this article, we will discuss the challenges in various aspects of STEMI management during COVID-19, as well as the mitigation measures we can take to optimize outcome and our future.

CLINICAL OUTCOMES OF EARLY REPATRIATION FOR PATIENTS WITH ST-ELEVATION MYOCARDIAL INFARCTION UNDERGOING PERCUTANEOUS CORONARY INTERVENTION FROM A SINGLE, REGIONAL CARDIAC CARE CENTRE

<h3>BACKGROUND</h3> Centres that perform percutaneous coronary intervention (PCI) have resources specialized in the care of ST-elevation myocardial infarction (STEMI) patients both during and after PCI. Due to limited hospital resources, many centres that perform PCI have adopted protocols where STEMI patients are transferred to a non-PCI capable centre following successful PCI. However, the safety of this practice is not well established. The study objective is to evaluate the clinical outcomes of the current practice of transferring patients to non-PCI capable centres following successful PCI in a single, tertiary care regional PCI centre. <h3>METHODS AND RESULTS</h3> A retrospective analysis was performed of all consecutive STEMI patients presenting to a single, regional cardiac care centre between January 2013 and December 2014. STEMI patients with high-risk features including cardiac arrest, cardiogenic shock, medical complication nof STEMI, requiring transvenous pacing, mechanical ventiliation, mechanical circulatory support or not reperfused by PCI were excluded. Patients who were unable to be linked to the Provincial Population Registry were also excluded. Patients were analyzed based on whether they were transferred to a non-PCI capable centre following PCI for ongoing post-STEMI care. Clinical presentation, comorbidities, angiographic findings, revascularization, and repatriation status data were collected from the electronic medical record and cath lab database. Study data was linked to the Research Repository at the Manitoba Centre for Health Policy for long-term clinical outcomes. Of the 1092 consecutive STEMI patients screened, 337 patients (31%) were excluded (Figure). The final study cohort (n=697) included 397 repatriated patients and 300 non-repatriated patients. The median age of the study cohort was 60 (53-70) years. Baseline characteristics are summarized in the Table. The median length of stay at the PCI-capable hospital was 139 minutes (IQR 97-235 minutes) with 84% of patients transferred within 6 hours. Inverse probability of treatment weighting (IPTW) was used to adjust for unbalanced characteristics between the two study groups. All-cause mortality (12.9% admitted vs 10.4% repatriated patients, adjusted HR 0.90, 95% CI 0.64-1.26, p=0.535) and repeat MI (11.0% admitted vs 5.4% repatriated, adjusted HR 0.71, 95% CI 0.49-1.02, p=0.06) at 5 years were not statistically significant after IPTW adjustment, respectively. <h3>CONCLUSION</h3> This analysis demonstrated that there is no increased risk of mortality or repeat MI at five years in STEMI patients who are transferred to a non-PCI capable centre following successful PCI. This suggests that early repatriation is safe and effective for low-risk STEMI patients.

1394Better Cardiac Care Data Linkage Project: utilising cross-jurisdictional data to improve patient-flow capture

Abstract Background For patients experiencing acute myocardial infarction (AMI), particularly ST-elevation myocardial infarction (STEMI), timely revascularisation is important to optimise prognosis. The AMI patient journey often involves presentation to the closest appropriate facility and transfers between hospitals, including across jurisdictions. The Better Cardiac Care (BCC) dataset consists of cross-jurisdictional linked ambulance, emergency, hospital, outpatient, deaths, Medicare and Pharmaceutical Benefits Scheme records for residents of New South Wales (NSW), Australia. This dataset will be updated annually. Methods The BCC dataset comprises 332 million records, from 18 datasets, across 6 jurisdictions. For NSW residents hospitalised for STEMI between 2013 to 2018, we compared the number of STEMI hospitalisations, the proportion of patients receiving revascularisation procedures, and the time to procedures using only NSW records versus records from all jurisdictions and Medicare Benefits Scheme. Results Compared with NSW hospital data, including data from other jurisdictions increased the ascertainment of STEMI hospitalisations by 8.0% and procedures by 11.2% for NSW residents. This increase was greatest for residents living near state borders, increasing the number of STEMI hospitalisations by up to 210% and the percentage receiving procedures by up to 70%. Conclusions Cross-jurisdictional data is essential to understand patient journeys of residents who live in border areas and to evaluate patient care for STEMI and AMI more broadly. Key messages The BCC dataset is a vital asset that enables a more comprehensive view of care for AMI than has been possible to date.

Use of Thrombolytic Agents for ST-Elevation Myocardial Infarction Care in India

In India, ST-elevation myocardial infarction (STEMI) is the predominant form of acute coronary syndrome. It is estimated to affect approximately 30 million people in India. The mainstay treatment approach for STEMI management is primary percutaneous coronary intervention (PCI) within 90 min after the first medical contact. However, due to existent clinical and practical barriers in performing timely PCI, optimal treatment is not offered on a timely basis. The challenges or barriers to timely PCI can be overcome by a pharmaco-invasive approach, in which thrombolysis is performed as soon as the patient is diagnosed with STEMI and transferred for PCI. Pharmaco-invasive approach is effective in shortening time to reperfusion therapy by allowing prompt initiation of thrombolysis followed by PCI as soon as possible. An experts' panel discussion was conducted involving 47 cardiologists all over India to review evidence-based concept of pharmaco-invasive treatment approach and to gain their expert opinion on emergency management of STEMI patients in the Indian setting. The experts highlighted that thrombolysis is the most implemented reperfusion strategy in India, especially when primary PCI is not available for STEMI patients. According to them, pharmaco-invasive approach would be appropriate to gain time to treatment in the event of expected treatment delays. Among thrombolytic agents, the experts recommended using third-generation thrombolytic agents because of their faster patency, more effectiveness, and ease of administration. They also emphasized on various clinical factors and practical considerations to be assessed before employing thrombolytic agents. In their opinion, bolus thrombolytic agents such as tenecteplase and reteplase offer effective, safer, easier, and faster administration for varied clinical profiles in all practical ways.

Review of Irish patients meeting ST elevation criteria during the COVID-19 pandemic

IntroductionThe COVID-19 pandemic has seen the introduction of important public health measures to minimise the spread of the virus. We aim to identify the impact government restrictions and hospital-based infection...

Impact of regionalizing ST-elevation myocardial infarction care on sex differences in reperfusion times and clinical outcomes.

BackgroundWomen with ST‐elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention historically experience worse in‐hospital outcomes compared to men.HypothesisImplementation of a regional STEMI system will reduce care gaps in reperfusion times and in‐hospital outcomes between women and men.Methods1928 patients (413 women, 21.4%) presented with an acute STEMI between June 2007 and March 2016. The population was divided into an early cohort (n = 728 patients, 2007‐May 2011), and a late cohort (n = 1200 patients, June 2011–2016). The primary endpoints evaluated were reperfusion times and in‐hospital outcomes.ResultsCompared to men, women experienced significant delays in first medical contact (FMC) to arrival at the emergency room (26.0 vs. 22.0 min, p < 0.001) and FMC‐to‐device (109 vs. 101 min p = 0.001). Women had higher incidences of post‐PCI heart failure and death compared to men (p < 0.05). Following multivariable adjustment, no mortality difference was observed for women versus men (adjusted OR; 0.82; 95% confidence interval [CI], 0.51–1.34; p = 0.433) or for early versus late cohorts (adjusted OR; 1.04; 95% CI, 0.68–1.60; p = 0.856).ConclusionFollowing STEMI regionalization, women continued to experience significantly longer reperfusion times, although there was no difference in adjusted mortality. These results highlight the ongoing disparity of STEMI care between women and men, and suggest that regionalization alone is insufficient to close sex‐based care gaps.

Health Inequalities of STEMI Care Before Implementation of a New Regional Network: A Prefecture-Level Analysis of Social Determinants of Healthcare in Yunnan, China.

As one of the most serious types of coronary heart disease, ST-elevation myocardial infarction (STEMI) faces huge challenges in the equal management and care of patients due to its life-threatening and time-critical condition. Health inequalities such as sex and age differences in STEMI care have been reported from developed countries. However, limited outcomes have been investigated and the major drivers of inequality are still unclear, especially in under-developed areas. This study aimed to explore the major drivers of health inequalities in STEMI care before implementation of a new regional network in the south-west of China. Prefecture-level data of STEMI patients before the implementation of a regional network were analysed retrospectively. Drivers of inequality were identified from six social determinants of health, namely area of residence, ethnicity, sex, age, education and occupation. Outcomes of STEMI care included timely presentation, reperfusion therapy, timely reperfusion therapy, heart failure, inpatient mortality, length of hospital stay, hospital costs, and various intervals of ischaemic time. A total of 376 STEMI patients in the research area before implementation of the STEMI network were included. Compared with urban residents, rural patients were significantly less likely to have timely presentation (odds ratio [OR]=0.47, 95% CI: 0.28-0.80, P=.004) and timely reperfusion therapy (OR=0.32, 95% CI: 0.14-0.70, P=.005). Rural residents were less likely to present to hospital promptly than urban residents (HR=0.65, 95% CI=0.52-0.82, P<.001). In the first 3 hours of percutaneous coronary intervention (PCI) reperfusion delay and first 6 hours of total ischaemic time, rural patients had a significantly lower probability to receive prompt PCI (hazard ratio [HR]=0.40, 95% CI: 0.29-0.54, P<.001) and reperfusion therapy (HR=0.37, 95% CI: 0.25-0.56, P<.001) compared to urban patients. Rural residents were a major vulnerable group before implementation of the regional STEMI network. No obvious inequalities in ethnicity, sex, age, education or occupation existed in STEMI care in Chuxiong Prefecture of China.

A stepped wedge cluster randomized control trial to evaluate the implementation and effectiveness of optimized initiatives in improving quality of care for ST segment elevation myocardial infarction in response to the COVID-19 outbreak

BackgroundThe National Chest Pain Center Accreditation Program (CHANGE) is the first hospital-based, multifaceted, nationwide quality improvement (QI) initiative, to monitor and improve the quality of the ST segment elevation myocardial infarction (STEMI) care in China. The QI initiatives, as implementation strategies, include a bundle of evidence-based interventions adapted for implementation in China. During the pandemic of coronavirus disease 2019 (COVID-19), fear of infection with severe acute respiratory syndrome coronavirus 2, national lockdowns, and altered health care priorities have highlighted the program’s importance in improving STEMI care quality. This study aims to minimize the adverse impact of the COVID-19 pandemic on the quality of STEMI care, by developing interventions that optimize the QI initiatives, implementing and evaluating the optimized QI initiatives, and developing scale-up activities of the optimized QI initiatives in response to COVID-19 and other public health emergencies.MethodsA stepped wedge cluster randomized control trial will be conducted in three selected cities of China: Wuhan, Suzhou, and Shenzhen. Two districts have been randomly selected in each city, yielding a total of 24 registered hospitals. This study will conduct a rollout in these hospitals every 3 months. The 24 hospitals will be randomly assigned to four clusters, and each cluster will commence the intervention (optimized QI initiatives) at one of the four steps. We will conduct hospital-based assessments, questionnaire surveys among health care providers, community-based household surveys, and key informant interviews during the trial. All outcome measures will be organized using the RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework, including implementation outcomes, service outcomes (e.g., treatment time), and patient outcomes (e.g., in-hospital mortality and 1-year complication). The Consolidated Framework for Implementation Research framework will be used to identify factors that influence implementation of the optimized QI interventions.DiscussionThe study findings could be translated into a systematic solution to implementing QI initiatives in response to COVID-19 and future potential major public health emergencies. Such actionable knowledge is critical for implementors of scale-up activities in low- and middle-income settings.Trial registrationChiCTR 2100043319. Registered on 10 February 2021

Differential benefits of cardiac care regionalization based on driving time to percutaneous coronary intervention.

Patients with ST-elevation myocardial infarction (STEMI) require timely reperfusion, and percutaneous coronary intervention (PCI) decreases morbidity and mortality. Regionalization of STEMI care has increased timeliness and use of PCI, but it is unknown whether benefits to regionalization depend on a community's distance from its nearest PCI center. We sought to determine whether STEMI regionalization benefits, measured by access to PCI centers, timeliness of treatment (same-day or in-hospital PCI), and mortality, differ by baseline distance to nearest PCI center. Using a difference-in-difference-in-differences model, we examined access to PCI-capable hospitals, receipt of PCI either on the day of admission or during the care episode, and health outcomes for patients hospitalized from January 1, 2006, to September 30, 2015. Of 139,408 patients (2006 to 2015), 51% could reach the nearest PCI center in <30minutes, and 49% required ≥30minutes driving time. For communities with baseline access ≥30minutes, regionalization increased the probability of admission to a PCI-capable hospital by 9.4% and also increased the likelihood of receiving same-day PCI (by 11.2%) and PCI during the hospitalization (by 7.4%). Patients living within 30 minutes did not accrue significant benefits (measured by admission to a PCI-capable hospital or receipt of PCI) from regionalization initiatives. Regionalization more than halved access disparities and completely eliminated treatment disparities between communities ≥30minutes and communities <30minutes from the nearest PCI hospital. Measured by likelihood of admission to a PCI-capable facility and receipt of PCI, benefits of STEMI regionalization in California accrued only to patients whose nearest PCI center was ≥30minutes away. We found no mortality benefits of regionalization based on distance from PCI center. Our results suggest that policymakers focus STEMI regionalization efforts in communities that are not already well serviced by PCI-capable hospitals.

COVID-19 and Primary Percutaneous Coronary Intervention (PCI): Delayed Presentations and Outcomes for STEMI care

Primary percutaneous coronary intervention (PPCI) is a non-surgical procedure that requires catheterization to improve blood flow to the heart and is the recommended therapy for Acute Myocardial Infarction (AMI). The Coronavirus 2019 (COVID-19) pandemic has altered the course of reperfusion therapy for patients with ST-elevation myocardial infarction (STEMI). It is imperative to emphasize the awareness of timely PCI and the effects it has on improving patient outcomes. Based on the consensus statement by the American College of Cardiology (ACC), American College for Emergency Physicians (ACEP), and the Society for Cardiovascular Angiography and Interventions (SCAI), it is critical to inform the public to call the emergency medical system for AMI symptoms and obtain the appropriate level of care. Ultimately, COVID-19 has posed unprecedented challenges to public health. The immediate threat is linked to morbidity and mortality related to the infection, and the masked threat is the waning attention and resources utilized for the care of other diseases. First medical contact is the main time target, and reducing treatment delays to improve patient outcomes in AMI patients with STEMI should be the next immediate objective in healthcare systems worldwide.

Experts’ consensus: pharmaco-invasive therapy for ST‐elevation myocardial infarction along with focus on secondary prevention and cardiac rehabilitation in India

In India, patients with acute coronary syndrome (ACS) tend to present with higher percentage of ST-elevation myocardial infarction (STEMI). Numerous existing challenges like patient unawareness, lack of structured STEMI care systems, inadequacy of promptly available facilities and unequipped ambulances for patient transport make it difficult to achieve optimal STEMI treatment. Also, due to socio-economic diversities prevailing in India, a large proportion of the entire population has access to only basic primary healthcare and are unable to afford proper medical facilities. Judicious and timely reperfusion strategy has been the mainstay of STEMI management. Even though, percutaneous coronary intervention (PCI) continues to be the gold standard for treating STEMI worldwide, it is not the ideal strategy in many Indian settings, especially in villages and smaller towns/cities. In such scenarios, pharmaco-invasive approach has proved to be a better reperfusion therapeutic strategy for improving treatment outcomes and subsequently reducing morbidity and mortality. The purpose of this consensus article is to highlight the clinical perspectives of Indian cardiologists at identifying and addressing the need gaps currently existing in India for optimization of STEMI treatment approaches. The experts shared their views on the rationale of pharmaco-invasive approach and highlighted the significance of commonly used thrombolytic agents, STEMI treatment protocols, secondary prevention and cardiac rehabilitation.

Impact of STEMI Diagnosis and Catheterization Laboratory Activation Systems on Sex- and Age-Based Differences in Treatment Delay

BackgroundWomen and the elderly with ST-elevation myocardial infarction (STEMI) experience longer treatment delays despite prehospital STEMI diagnosis and catheterization laboratory activation systems. It is not known what role specific STEMI referral systems might play in mediating this gap in care. We therefore examined sex- and age-based differences in STEMI treatment delay (TD) in different STEMI activation systems. MethodsThis observational comparative effectiveness study comprised 3 retrospective STEMI cohorts: a traditional hospital-based activation cohort (Cohort 1), an automated “physician-blind” prehospital activation cohort (Cohort 2), and a prehospital activation with real-time physician oversight cohort (Cohort 3). Outcomes of interest included sex and age group (< or ≥ 75 years) differences in suboptimal (> 90 minutes) first medical contact-to-device time (FMC-to-device) within each cohort, as well as independent predictors of suboptimal FMC-to-device and in-hospital mortality across cohorts. ResultsFive hundred-sixty STEMI activations were analyzed. In Cohort 1 (n = 179), women and those ≥ 75 were more likely to experience suboptimal FMC-to-device times (78.7% vs 36.4%, P = 0.02 and 85.0% vs 58.3%, < 0.01, respectively). Similar findings were observed in Cohort 3 (n = 109) (53.5% vs 32.9%, 56.5% vs 33.3%, respectively; P = 0.05, for both). In Cohort 2 (n = 272), however, there was no significant age-based difference (30.4% vs 21.7%, P = 0.18), and the gap was numerically lower but still significant for women (32.1% vs 20.1%, P = 0.04). When examining prehospital activation cohorts only, female sex (P = 0.03), off-hours presentation (P < 0.01), and physician oversight (P < 0.01) were independent predictors of longer FMC-to-device times. Age ≥ 75 (P < 0.01), Killip class (P < 0.01), and female sex (P = 0.04) were independently associated with in-hospital mortality. ConclusionsAutomated “physician-blind” STEMI activation was associated with a reduced TD gap in women and the elderly, suggesting possible systemic bias. Appropriately powered confirmatory studies are required, but incorporating automated diagnosis and catheterization laboratory activation may be a solution to treatment gaps in STEMI care.

Myocardial infarction rates overview during COVID-19 pandemic In France: Results of the MODIF registry

BackgroundThe emergence of Coronavirus disease 2019 (COVID-19) has evolved into a global pandemic. Systems of care have been reorganized worldwide in an effort to preserve hospital bed capacity. In France, from March 17 to May 11 2020, government imposed a complete lockdown on the whole population. Only urgent cardiac procedures have been ensured such as ST-elevation myocardial infarction (STEMI) revascularization. Some previously published studies suggest a reduction of admission for STEMI in many countries. Nevertheless, strong evidences and data across different French regions that have been affected variously by the outbreak are still lacking.PurposeWe aimed to describe the incidence rates and characteristics of patients presenting with STEMI in order to evaluate the impact of the COVID-19 outbreak on STEMI care in France covering the lockdown period compared to same period one year ago.MethodsWe performed a retrospective multicenter registry across 60 French interventional cardiology centers including all consecutive STEMI patients referred for urgent revascularization in the heart catheterization laboratory between two periods: March 1st to May 31th 2020 compared with March 1st to May 31th 2019. Comprehensive data, including clinical, biological, COVID status and angiographic variables including time taken for care were recorded at admission. The primary outcome was a composite of invasive mechanical ventilation support or in-hospital death. The secondary outcome was the occurrence of myocardial infarction related complications during hospitalization. Enrollement is not complete at the time of the abstract submission.ConclusionThis data collection between two periods with and without COVID19 will gave insights for a complete descriptive cartography of STEMI patients among different French regions which have been variously impacted by the outbreak.

Working Against the Clock: A Model for Rural STEMI Triage.

Residents in rural communities have a higher incidence of cardiac death and risk factors associated with cardiac disease. Living in a rural region can add precious time that amplifies cardiac death during an ST-elevated myocardial infarction (STEMI) episode. The consensus is that improved efficiencies can increase myocardial salvage and decrease STEMI mortality rates. This article identifies issues that may impact pre-hospital STEMI triage of patients in a rural region of the United States (U.S.). A qualitative research design was chosen to gain insight into emergency personnel perceptions of pre-hospital STEMI triage. The participants (n = 18) were obtained from a convenience sample in rural Northeast Texas, U.S. Data were gathered by individual and group semi-structured interviews. Themes were identified, synthesized, and oriented to offer a basis for understanding opportunities to improve the delivery of rural STEMI care. This study demonstrated that quality improvement initiatives aimed at achieving pre-hospital STEMI triage efficiencies have dependencies on teamwork, technology, and training in the context of 3 stages (a) pre-transport, (b) door-to-door, and (c) post-transport. A pre-hospital STEMI triage model is offered based on the findings. By incorporating this model, emergency medical coordinators in rural communities have a better opportunity to facilitate timely reperfusion therapy for this high-risk population.