ST-elevation Myocardial Infarction Registry Research Articles

Clinical predictors of patient related delay in the VIENNA ST-elevation myocardial infarction network and impact on long-term mortality.

While contributors to system delay in ST-elevation myocardial infarction (STEMI) are well described, predictors of patient-related delays are less clear. The aim of this study was to identify predictors that cause delayed diagnosis of STEMI in a metropolitan system of care (VIENNA STEMI network) and to investigate a possible association with long-term mortality. The study population investigated consisted of 2366 patients treated for acute STEMI in the Vienna STEMI registry from 2003-2009. Multivariable regression modelling was performed for (a) onset of pain to first medical contact (FMC) as a categorical variable (pain-to-FMC⩽60 min versus >60 min: 'early presenters' versus 'late presenters'); and for (b) onset of pain-to-FMC (min) as a continuous variable. After multivariable adjustment, female sex (odds ratio (OR) 1.348; 95% confidence interval (CI) 1.013-1.792; p=0.04) and diabetes mellitus (OR 1.355; 95% CI 1.001-1.835; p=0.05) were independently associated with late presentation in STEMI patients, whereas cardiogenic shock (OR 0.582; 95% CI 0.368-0.921; p=0.021) was a predictor of early diagnosis. When onset of pain-to-FMC was treated as a continuous variable, female sex ( p=0.003), anterior infarction ( p=0.004) and diabetes mellitus ( p=0.035) were independently associated with longer delay, while hyperlipidaemia ( p=0.002) and cardiogenic shock ( p=0.017) were strong predictors of short pain-to-FMC times. Three-year-all cause mortality was 9.6% and 11.3% ( p=0.289) for early and late presenters, respectively. After adjustment for clinical factors (sex, age, diabetes, current smoking, hypertension, hyperlipidaemia, cardiogenic shock and location of myocardial infarction) only a trend for increased risk of all-cause death was observed for longer pain-to-FMC times in a cox regression model (hazard ratio (HR) 1.012; 95% CI 0.999-1.025 for every 10 min of delay; p=0.061). Interestingly, early presentation within one hour of symptom onset was not associated with three-year mortality survival (HR 1.031; 95% CI 0.676-1.573; p=0.886). In this all-comers study of STEMI patients in the VIENNA STEMI network, cardiogenic shock was the strongest predictor of short patient-related delays, whereas a history of diabetes and female sex were independent associated with late diagnosis in STEMI. After adjustment for clinical confounders, patient related delay did not significantly impact on long-term all-cause mortality.

Eligibility and utilization of implantable cardioverter-defibrillators in a regional STEMI system

Studies have shown mortality benefit for implantable cardioverter-defibrillators (ICDs) in ST-elevation myocardial infarction (STEMI) patients with reduced left ventricular ejection fraction (LVEF), but contemporary eligibility and appropriate utilization of ICDs is unknown. The purpose of this study was to determine the contemporary eligibility and appropriate utilization of ICDs post-STEMI. Using the prospective Minneapolis Heart Institute regional STEMI registry, LVEF before discharge and at follow-up were stratified into 3 groups: normal (LVEF ≥50%), mildly reduced (LVEF 35%-49%), and severely reduced (LVEF <35%). From March 2003 to June 2012, 3626 patients were treated. Patients with in-hospital death (n = 187), ICD in place (n = 21), negative cardiac biomarkers (n = 337), and undocumented in-hospital LVEF (n = 9) were excluded, leaving 3072 patients in the final analysis, including 1833 (59.7%) with LVEF ≥50%, 875 (28.5%) with LVEF between 35% and 49%, and 364 (11.8%) with LVEF <35% before hospital discharge. Overall, 1029 patients (33.5%) underwent follow-up echocardiography ≥40 days post-STEMI, including 140 of the 364 patients (38.5%) discharged with LVEF <35%. In total, 73 patients (7.1%) with follow-up echocardiography ≥40 days post-STEMI met criteria for an ICD (68 LVEF ≤30%, 5 LVEF 30%-35%, and New York Heart Association class II or greater). Only 26 of these patients (35.6%) underwent ICD placement within 1 year post-STEMI. Overall, only 10% to 15% of potentially eligible patients had an ICD implemented. Rates of ICD implantation in appropriate STEMI patients after 40 days are low. Strategies are needed to identify and expand access to these high-risk patients.

Safety and Efficacy of Staged Percutaneous Coronary Intervention During Index Admission for ST-Elevation Myocardial Infarction With Multivessel Coronary Disease (Insights from the University of Ottawa Heart Institute STEMI Registry)

The optimal management strategy for patients with ST-elevation myocardial infarction (STEMI) and multivessel disease has not been well established. In the present cohort study, we sought to examine the safety and efficacy of inhospital staged PCI for patients with STEMI and multivessel disease. We identified all patients with STEMI referred for primary PCI who were found to have multivessel disease (stenosis ≥50% in nonculprit vessel) and compared clinical outcomes in relation to the management strategy, staged versus culprit-only PCI, for nonculprit vessel disease. The primary outcome was mortality at 180days, and secondary outcomes included mortality during the index hospitalization and at 30days, myocardial infarction, stent thrombosis, stroke, and bleeding. Of the 1,038 patients with STEMI meeting inclusion criteria, 259 (25%) underwent staged PCI and 779 (75%) culprit-only PCI during the index admission. Mortality at 180days was 0.8% in patients with staged PCI and 5.0% in patients with culprit-only PCI (p= 0.003). The association between staged PCI and reduced mortality persisted after adjusting for baseline differences in patient characteristics and angiographic variables between the 2 cohorts (odds ratio 0.2, 95% confidence interval 0.04 to 0.77, p= 0.02). The rates of inhospital reinfarction in the staged and culprit-only PCI cohorts were 0.8% versus 1.3% (p= 0.50), respectively, stent thrombosis 0.8% versus 1.3% (p= 0.50), and stroke 0.4% versus 1.3% (p= 0.31). There were no inhospital adverse events related to acute occlusion of a nonculprit vessel in either cohort. Staged PCI during index admission is a safe and effective revascularization strategy for patients with STEMI and multivessel disease.

Prehospital Nitroglycerin Safety in Inferior ST Elevation Myocardial Infarction

Patients with inferior ST elevation myocardial infarction (STEMI), associated with right ventricular infarction, are thought to be at higher risk of developing hypotension when administered nitroglycerin (NTG). However, current basic life support (BLS) protocols do not differentiate location of STEMI prior to NTG administration. We sought to determine if NTG administration is more likely to be associated with hypotension (systolic blood pressure < 90 mmHg) in inferior STEMI compared to non-inferior STEMI. We conducted a retrospective chart review of prehospital patients with chest pain of suspected cardiac origin and computer-interpreted prehospital ECGs indicating “ACUTE MI.” We included all local STEMI cases identified as part of our STEMI registry. Univariate analysis was used to compare differences in proportions of hypotension and drop in systolic blood pressure ≥ 30 mmHg after nitroglycerin administration between patients with inferior wall STEMI and those with STEMI in another region (non-inferior). Multiple variable logistic regression analysis was also used to assess the study outcomes while controlling for various factors. Over a 29-month period, we identified 1,466 STEMI cases. Of those, 821 (56.0%) received NTG. We excluded 16 cases because of missing data. Hypotension occurred post NTG in 38/466 inferior STEMIs and 30/339 non-inferior STEMIs, 8.2% vs. 8.9%, p = 0.73. A drop in systolic blood pressure ≥ 30 mmHg post NTG occurred in 23.4% of inferior STEMIs and 23.9% of non-inferior STEMIs, p = 0.87. Interrater agreement for chart review of the primary outcome was excellent (κ = 0.94). NTG administration to patients with chest pain and inferior STEMI on their computer-interpreted electrocardiogram is not associated with a higher rate of hypotension compared to patients with STEMI in other territories. Computer interpretation of inferior STEMI cannot be used as the sole predictor for patients who may be at higher risk for hypotension following NTG administration.

SEX DIFFERENCES AND CHANGES IN HEALTH STATUS OF YOUNG ADULTS DURING THE FIRST YEAR FOLLOWING ACUTE MYOCARDIAL INFARCTION

Bivalirudin for primary percutaneous coronary interventions in patients with cardiogenic shock: Outcome Assessment in the CAPITAL STEMI registry. BACKGROUND: Data from randomized clinical trials have demonstrated superiority of bivalirudin to heparin with or without routine use of glycoprotein (GP) IIb/IIIa inhibitors in patients undergoing primary percutaneous coronary intervention (PPCI). However the performance of bivalirudin in PPCI without the use GPIIb/IIIa inhibitors, in patients with cardiogenic shock remains unknown. METHODS AND RESULTS: We screened 2536 patients who underwent PPCI for ST elevation myocardial infarction (STEMI) at the University of Ottawa Heart Institute between June 2004 to June 2011. From this cohort, we identified 91 patients who developed cardiogenic shock and who received either bivalirudin (n1⁄434) or Heparin (n1⁄457), with no GP IIb/IIIa inhibitors. The primary outcome was a composite of cardiovascular death, myocardial infarction and stroke. The secondary endpoints were the rate non-coronary artery bypass graft related TIMI major bleeding, any major bleeding, reinfarction and stent thrombosis and in-hospital mortality. The primary outcome was similar in both groups, occurring in 44% of patients receiving bivalirudin vs. 58% in patients treated with heparin alone (OR 0.76 CI 0.36 to 1.60, P1⁄40.47). Compared with the heparin group, a reduction in non-CABG related TIMI major bleeding (18% vs. 16%, P1⁄40.72), any major bleeding (18% vs. 19%, P1⁄40.87) or inhospital mortality (38% vs. 52%, P1⁄40.18) with bivalirudin could not be demonstrated. Notably, the use of bivalirudin was associated with a 6.8 fold increased risk of stent thrombosis and re-infarction (11.7% vs. 1.7%, P1⁄40.043). CONCLUSION: In patients with cardiogenic shock, undergoing PPCI with dual antiplatelet therapy with no GP IIb/IIIa inhibitors, the use of bivalirudin appears to be a safe anticoagulation strategy when compared to heparin. Bivalirudin was however associated with a potential risk of increased stent thrombosis and re-infarction in the setting of cardiogenic shock. Larger clinical studies are needed to either confirm or refute these findings.

BIVALIRUDIN FOR PRIMARY PERCUTANEOUS CORONARY INTERVENTIONS IN PATIENTS WITH CARDIOGENIC SHOCK: OUTCOME ASSESSMENT IN THE CAPITAL STEMI REGISTRY

Bivalirudin for primary percutaneous coronary interventions in patients with cardiogenic shock: Outcome Assessment in the CAPITAL STEMI registry. BACKGROUND: Data from randomized clinical trials have demonstrated superiority of bivalirudin to heparin with or without routine use of glycoprotein (GP) IIb/IIIa inhibitors in patients undergoing primary percutaneous coronary intervention (PPCI). However the performance of bivalirudin in PPCI without the use GPIIb/IIIa inhibitors, in patients with cardiogenic shock remains unknown. METHODS AND RESULTS: We screened 2536 patients who underwent PPCI for ST elevation myocardial infarction (STEMI) at the University of Ottawa Heart Institute between June 2004 to June 2011. From this cohort, we identified 91 patients who developed cardiogenic shock and who received either bivalirudin (n1⁄434) or Heparin (n1⁄457), with no GP IIb/IIIa inhibitors. The primary outcome was a composite of cardiovascular death, myocardial infarction and stroke. The secondary endpoints were the rate non-coronary artery bypass graft related TIMI major bleeding, any major bleeding, reinfarction and stent thrombosis and in-hospital mortality. The primary outcome was similar in both groups, occurring in 44% of patients receiving bivalirudin vs. 58% in patients treated with heparin alone (OR 0.76 CI 0.36 to 1.60, P1⁄40.47). Compared with the heparin group, a reduction in non-CABG related TIMI major bleeding (18% vs. 16%, P1⁄40.72), any major bleeding (18% vs. 19%, P1⁄40.87) or inhospital mortality (38% vs. 52%, P1⁄40.18) with bivalirudin could not be demonstrated. Notably, the use of bivalirudin was associated with a 6.8 fold increased risk of stent thrombosis and re-infarction (11.7% vs. 1.7%, P1⁄40.043). CONCLUSION: In patients with cardiogenic shock, undergoing PPCI with dual antiplatelet therapy with no GP IIb/IIIa inhibitors, the use of bivalirudin appears to be a safe anticoagulation strategy when compared to heparin. Bivalirudin was however associated with a potential risk of increased stent thrombosis and re-infarction in the setting of cardiogenic shock. Larger clinical studies are needed to either confirm or refute these findings.

The availability of prior ECGs improves paramedic accuracy in recognizing ST-segment elevation myocardial infarction

IntroductionEarly and accurate identification of ST-elevation myocardial infarction (STEMI) by prehospital providers has been shown to significantly improve door to balloon times and improve patient outcomes. Previous studies have shown that paramedic accuracy in reading 12 lead ECGs can range from 86% to 94%. However, recent studies have demonstrated that accuracy diminishes for the more uncommon STEMI presentations (e.g. lateral). Unlike hospital physicians, paramedics rarely have the ability to review previous ECGs for comparison. Whether or not a prior ECG can improve paramedic accuracy is not known. Study hypothesisThe availability of prior ECGs improves paramedic accuracy in ECG interpretation. Methods130 paramedics were given a single clinical scenario. Then they were randomly assigned 12 computerized prehospital ECGs, 6 with and 6 without an accompanying prior ECG. All ECGs were obtained from a local STEMI registry. For each ECG paramedics were asked to determine whether or not there was a STEMI and to rate their confidence in their interpretation. To determine if the old ECGs improved accuracy we used a mixed effects logistic regression model to calculate p-values between the control and intervention. ResultsThe addition of a previous ECG improved the accuracy of identifying STEMIs from 75.5% to 80.5% (p=0.015). A previous ECG also increased paramedic confidence in their interpretation (p=0.011). ConclusionsThe availability of previous ECGs improves paramedic accuracy and enhances their confidence in interpreting STEMIs. Further studies are needed to evaluate this impact in a clinical setting.

Impact of Reperfusion Strategy on Aborted Myocardial Infarction: Insights From a Large Canadian ST-Elevation Myocardial Infarction Clinical Registry

BackgroundReperfusion in ST-elevation myocardial infarction (STEMI) improves survival. Moreover, early reperfusion can abort the infarct and avoid significant myocardial necrosis. Yet, limited real world data exist and comparison between reperfusion strategies has not been established. MethodsUsing a comprehensive Canadian registry of consecutive STEMI patients, we prospectively collected serial electrocardiograms (ECGs) and clinical data from August 2006 to March 2011. Aborted myocardial infarction (AbMI) was defined as a maximal creatine kinase ≤ 2 times the upper limit of normal with evolutionary ECG changes of STEMI. ECG confounders and subjects with incomplete data were excluded. ResultsOf the 2235 STEMI patients reperfused within 12 hours, 16.0% were considered to have an AbMI. Numerically, higher rates of AbMI with fibrinolysis vs primary percutaneous coronary intervention were reported (17.0% vs 14.7%; P = 0.15) with a temporal pattern seen up to 4 hours from symptom onset in favour of fibrinolysis (P trend < 0.001). Most notably, the highest frequency of AbMI was observed within the first hour with fibrinolysis (31.1%). Improved in-hospital outcomes (death/shock/congestive heart failure) were seen with AbMI (5.6% vs 13.6%; P < 0.001; adjusted odds ratio, 0.22; 95% confidence interval, 0.08-0.57). ConclusionsIn a large contemporary Canadian STEMI registry, AbMI appears to be common and associated with improved clinical outcome. Early reperfusion seems to enhance AbMI particularly when fibrinolysis is administered within 1 hour of symptom onset.

Variable Impact of State Legislative Advocacy on Registry Participation and Regional Systems of Care Implementation

Regionalization, systems of care design, and quality improvement (QI) registry participation all promote the widespread dissemination of guideline-based evidence into actual practice. As a result, policy statements from the American Heart Association/American Stroke Association (AHA/ASA) advocate for the creation of regional systems of care for various time-critical diagnoses, including ST-elevation myocardial infarction (STEMI), out-of-hospital cardiac arrest resuscitation, and acute stroke.1–3 Creation of these regional networks requires multidisciplinary collaboration to implement 5 mutually reinforcing core elements4 that build each system: (1) Designation of certain hospitals with special treatment capabilities as Receiving Centers for STEMI, resuscitation, or stroke; (2) emergency medical services (EMS) destination protocols that allow for direct transport of certain patients identified by explicit triage criteria to a designated Receiving Center, thus allowing for bypass of closer hospitals if they lack the needed specialty service; (3) organized interhospital transfer and transport protocols to a Receiving Center for appropriate patients who initially self-present or are mistriaged to a Referral Hospital; (4) communication or telemedicine options to provide real-time expert consultation as needed from a Receiving Center to its associated Referral Hospitals or EMS providers; and (5) participation in a regional and/or national QI registry to track relevant process-of-care metrics and meaningful risk-adjusted clinical outcomes. Within each of the 50 states, unique challenges exist for stakeholders attempting to implement the 5 aforementioned core elements of regional or statewide systems of care. In particular, substantial variation exists with regard to the starting point for these initiatives. For example, some states already have sufficient regulatory authority within their EMS agency or state department of health (DOH) to regionalize care of time-critical diagnoses, whereas other states require new legislation to create coordinated systems. In October 2011, the Advocacy Coordinating Committee of the AHA convened a multispecialty task force to assess the …

Reperfusion therapy and mortality in octogenarian STEMI patients: results from the Belgian STEMI registry

Treatment strategies and outcome of ST-elevation myocardial infarction (STEMI) have been mainly studied in middle-aged patients. With increasing lifetime expectancy, the proportion of octogenarians will substantially increase. We aimed to evaluate whether the benefit of currently recommended reperfusion strategies is maintained in octogenarians. Reperfusion therapy and in-hospital mortality were evaluated in 1,092 octogenarians and compared with 7,984 STEMI patients <80 years old based on data from the prospective Belgian STEMI registry. The octogenarian STEMI group had more cardiovascular comorbidities, contained more female patients and presented more frequently with cardiac failure (Killip class >1, 40 vs. 20 %) compared with their younger counterparts (all p < 0.05). Although the rate of thrombolysis was similar (9.2 vs. 9.9 %) between both groups, a conservative approach was chosen more frequently (13.8 vs. 4.7 %), while PCI was performed less frequently (76.9 vs. 85.4 %) in octogenarians (p < 0.001). Moreover, ischemic time and door-to-needle/balloon time were longer for octogenarians. In-hospital mortality for octogenarians was 17.8 vs. 5.5 % in the younger group [adjusted OR 2.43(1.92-3.08)]. In haemodynamically stable octogenarians, PCI seemed to improve outcome compared with thrombolysis or conservative treatment (5.7 vs. 12.7 vs. 8.5 %, p = 0.09). In octogenarians with cardiac failure, in-hospital mortality was extremely high independent of the chosen reperfusion therapy (34.6 vs. 31.6 vs. 36.3 %, p = 0.88). In-hospital mortality in octogenarian STEMI patients was high and related to a high prevalence of cardiac failure. Less PCI was performed in the octogenarian group compared with the younger patients, although mortality benefit of PCI was maintained in haemodynamically stable octogenarians.

Predicting Readmission or Death After Acute ST‐Elevation Myocardial Infarction

Risk factors for emergent readmissions or death after acute myocardial infarction (AMI) are important in identifying patients at risk for major adverse events. However, there has been limited investigation conducted of prospective clinical registries to determine relevant risk factors. We hypothesize 30-day readmission or death could be predicted using patient, procedural, and process factors. Patients presenting with ST-elevation myocardial infarction (STEMI) from 2006 to 2011 were prospectively enrolled in a STEMI registry (1271 patients). Thirty-day readmission was ascertained by administrative claims data. Death was determined by linking to the Social Security Death Master File. Univariate and stepwise multivariate logistic regression was conducted with Hosmer-Lemeshow goodness-of-fit statistics for model calibration and receiver operating characteristic (ROC) curve for model discrimination. The combined end point of 30-day readmission or postdischarge death included 135 patients (10.6%), including 109 emergent readmissions and 26 deaths. Factors associated with an increase risk of 30-day readmission or postdischarge death included age ≥ 80 years, diabetes, chest pain or cardiac arrest at presentation, and 3-vessel disease found at initial angiography. Factors associated with a decreased risk of 30-day readmission or postdischarge death included transfer to the catheterization lab from another emergency department, clopidogrel given during the procedure hypercholesterolemia, and receiving aspirin, β-blockers, and angiotensin-converting enzyme or angiotensin receptor blocker inhibitors at discharge. Index admission outcomes indicative of readmission or death postdischarge only included a new diagnosis of congestive heart failure. The model discriminated well with an ROC of 0.71 (95% confidence interval: 0.66-0.76). Prehospitalization factors are overlooked and are important factors to incorporate in routine risk prediction models for readmission or death within 30 days following an AMI.

Inter-hospital variation in length of hospital stay after ST-elevation myocardial infarction: results from the Belgian STEMI registry

Objective The aim of this paper was to assess the determinants of and variations in length of hospital stay (LOS) in Belgium after ST-elevation myocardial infarction (STEMI).Methods and results Data on LOS were collected from 2079 STEMI patients who were discharged alive from 33 Belgian hospitals (21 with PCI facilities) during 2010-2011. Early discharge was defi ned as hospital discharge within 4 days after admission, and the hospitals were clustered according to their LOS for low-risk patients. Determinants of LOS were calculated by means of a negative binomial regression model. LOS was, on average, 6.5 days with a median of 5 days (IQR 4). Baseline risk profi les and reperfusion treatment explained only 13% of the LOS variation. Additional analysis revealed major in-hospital variations independent of the case mix of patients. For comparable baseline risk profi les, the average LOS in a cluster of 11 hospitals with short discharge policies was 5.3 ± 5.6 days, with an early discharge rate of 58%, while in the cluster of 11 hospitals with long discharge policies, the average LOS was 7.9 ± 8.5 days with an early discharge rate of 22% (P < 0.0001). Among the clustered hospitals, there were no differences with regard to logistics (PCI facility, academic affi liation) or volume of STEMI patients. The 1-month mortality rate was less than 0.5% in the different clusters of hospitals (p= NS).Conclusions Length of hospital stay is not only determined by baseline risk profi les of patients but is also highly dependent on hospital discharge policy, which seems to be unrelated to medical or logistical factors.

Risk is not flat. Comprehensive approach to multidimensional risk management in ST-elevation myocardial infarction treated with primary angioplasty (ANIN STEMI Registry)

IntroductionCurrent risk assessment concepts in ST-elevation myocardial infarction (STEMI) are suboptimal for guiding clinical management.AimTo elaborate a composite risk management concept for STEMI, enhancing clinical decision making.Material and methods1995 unselected, registry patients with STEMI treated with primary percutaneous coronary intervention (pPCI) (mean age 60.1 years, 72.1% men) were included in the study. The independent risk markers were grouped by means of factor analysis, and the appropriate hazards were identified.ResultsIn-hospital death was the primary outcome, observed in 95 (4.7%) patients. Independent predictors of mortality included age, leukocytosis, hyperglycemia, tachycardia, low blood pressure, impaired renal function, Killip > 1, anemia, and history of coronary disease. The factor analysis identified two significant clusters of risk markers: 1. age-anemia- impaired renal function, interpreted as the patient-related hazard; and 2. tachycardia-Killip > 1-hyperglycemia-leukocytosis, interpreted as the event-related (hemodynamic) hazard. The hazard levels (from low to high) were defined based on the number of respective risk markers. Patient-related hazard determined outcomes most significantly within the low hemodynamic hazard group.ConclusionsThe dissection of the global risk into the combination of patient- and event-related (hemodynamic) hazards allows comprehensive assessment and management of several, often contradictory sources of risk in STEMI. The cohort of high-risk STEMI patients despite hemodynamically trivial infarction face the most suboptimal outcomes under the current invasive management strategy.