Management Of ST-segment Elevation Myocardial Infarction Research Articles

Provocative Strategies for Primary PCI in STEMI: Time to Rethink Guidelines

Background: The primary percutaneous coronary intervention (PCI) is now the reference treatment for ST-segment elevation myocardial infarction (STEMI). Findings from randomized controlled trials suggest that PCI is superior to thrombolytic therapy in preventing death and recurrent myocardial infarction. However, longer delays for PCI implementation and variability in outcomes among different operators and centers may affect its efficacy. The European guidelines recommend fibrinolytic therapy if PCI cannot be performed within 120 minutes of the first medical contact. Objective: The main objective of the study was to evaluate the efficacy of adjunctive provocative strategies in primary PCI for STEMI and their impact on procedural success and clinical outcomes. Methods: This retrospective observational study was conducted at Luqman International Hospital, Mingora Swat, from December 2022 to June 2023. Data were collected from 230 STEMI patients, including demographic information, clinical characteristics, procedural details, and outcomes. The primary outcome measure was the occurrence of major adverse cardiac events (MACE) within 30 days and one year after primary PCI. Secondary outcomes included procedural success rate, myocardial blush grade, and left ventricular ejection fraction (LVEF) during follow-up assessments. Statistical analyses were performed using SPSS version 25, with continuous variables expressed as means and standard deviations and categorical variables as frequencies and percentages. Comparisons between groups were conducted using chi-square tests for categorical variables and Student’s t-tests or Mann-Whitney U tests for continuous variables, with a p-value of less than 0.05 considered statistically significant. Results: Of the 230 patients, 120 (52%) received conventional strategies, while 110 (48%) received adjunctive provocative strategies. The provocative strategy group had higher rates of successful reperfusion (95.5% vs. 83.3%), improved myocardial blush grades (mean ± SD: 3.2 ± 0.6 vs. 2.7 ± 0.8), and lower rates of the no-reflow phenomenon (9.1% vs. 20.8%). At 30 days post-PCI, the incidence of MACE was lower in the provocative strategy group (9.1% vs. 12.5%). At one year, the provocative strategy group continued to show lower MACE rates (16.4% vs. 20.8%). Conclusion: Adjunctive provocative strategies in primary PCI for STEMI show promise in enhancing reperfusion efficacy and preserving myocardial function. While trends towards improved procedural success and short-term outcomes were observed, larger prospective studies are needed to validate these findings. The exploration of provocative strategies represents an important avenue for advancing STEMI management and improving patient outcomes in interventional cardiology.

Gender differences in ST-segment elevation myocardial infarction: an analysis on treatment, complications and acute-phase mortality

Abstract Funding Acknowledgements None. Background Primary angioplasty is the gold-standard treatment in ST-segment elevation myocardial infarction (STEMI). Previous studies have shown differences in the treatment of STEMI between men and women. Purpose To analyze the differences in the management of STEMI between both genders in a mediterranean settlement when it comes to angioplasty, timing of revascularization, complication rates and 30-day mortality. Methods A prospective, unicentric study of consecutive STEMI patients that were admitted to an Acute Cardiac Care Unit was performed from January 2010 to December 2022. We compared the differences between genders on timing of revascularization, complication rates and 30-day mortality. Results A total of 4616 patients were included between 01/01/2010 and 31/12/2022, 21.75% were women. Women were older than men (68.5 vs 61.4 years, p<0,001), but there were no differences on cardiovascular risk factors, infarct location or ejection fraction. Female sex was associated with higher Killip class (Killip ≥2 on admission 22.6% vs 17.9%, p=0.005), less angioplasty rates (88.4% vs 93.1%, p<0.001), longer timing of revascularization (median time 223 minutes vs 178 minutes, p<0.001), higher rates of heart failure during admission (16.2% vs 11.3%, p<0,001), mechanical complications (2.9% vs 1.4%, p=0.001) and higher 30-day mortality (8.8% vs 5.7%, p<0,001). Conclusions Women with STEMI are less likely to receive revascularization therapy, are admitted with a higher Killip class and have higher rates of post-STEMI complications and 30-day mortality than men.

Social and clinical vulnerability in stroke and STEMI management during the COVID-19 pandemic: a registry-based study

ObjectiveThis study aims to evaluate whether the first wave of the COVID-19 pandemic resulted in a deterioration in the quality of care for socially and/or clinically vulnerable stroke and ST-segment...

Assessment of knowledge gaps in STEMI management among intern doctors in moroccan emergency department: a descriptive analytical study

Abstract Introduction Acute coronary syndrome (ACS) remains a significant public health issue in Morocco despite progress in management and prevention. ACS includes ST-segment elevation myocardial infarction (STEMI), a life-threatening condition that requires prompt diagnosis and treatment. Intern doctors working in emergency department are critical in managing STEMI, but there is limited information on their knowledge and practice of this condition. Purpose This study aimed to assess the knowledge gaps in STEMI management among intern doctors working in emergency department in Morocco. Methods This study employed a descriptive analytical design to assess the knowledge gaps in STEMI management among 141 intern doctors working in emergency department in Morocco who were selected through convenience sampling. Data were collected using an online questionnaire consisting of 15 questions on diagnostic criteria, treatment options, and interpretation of three electrocardiograms (ECGs): one typical and two atypical. Descriptive statistical analysis was performed to summarize the data and calculate the percentages of correct answers for each question, and the data were analyzed using Microsoft Excel. Results 96.45% of the intern doctors had good theoretical knowledge of typical and atypical clinical presentation. However, only 52.48% knew the typical electrocardiographic presentation, and only 9.22% knew the revised atypical presentations. Regarding hospital management, 99.30% knew the superiority of angioplasty within 120 minutes, but only 29.08% knew the time limit for its implementation in symptomatic patients. In addition, 55.32% knew the contraindications of thrombolysis, 67.38% knew the essential elements of the loading dose, but only 18.44% knew the exact loading dose in elderly subjects and those with renal insufficiency. For complications, most physicians (85.82%) knew the complications of this pathology, 64.53% knew how to manage associated hypertensive emergencies, and 26.95% knew how to manage associated acute pulmonary edema. For clinical cases, 68.79% were able to identify the typical ECG of ST elevation in the extensive anterior territory. However, only 14.18% identified the two atypical electrocardiograms. Conclusion In conclusion, this study highlights the significant knowledge gaps in STEMI management among intern doctors working in emergency department in Morocco. While intern doctors had good theoretical knowledge of STEMI management, they struggled to apply this knowledge in practice, particularly when it came to interpreting ECGs and implementing time-sensitive treatments. These findings emphasize the urgent need for targeted training on STEMI management in emergency department, especially for young physicians who may lack experience in this area. By addressing these knowledge gaps, we can improve the management of STEMI and ultimately reduce the morbidity and mortality associated with ACS.

The Influence of Presentation Timing and Door to Balloon Timing on the Clinical Outcomes in Primary Percutaneous Coronary Intervention

For best clinical results, ST-segment elevation myocardial infarction (STEMI) must be treated quickly. This prospective observational study, conducted at Peshawar institute of cardiology (PIC), Pakistan, from November 23, 2022, to August 16, 2023, examines the connection between clinical outcomes in 120 primary Percutaneous Coronary Intervention (PCI) cases, presentation timing (the period of time from symptom onset to hospital arrival), and Door-to-Balloon (D2B) time. Objective: to pave the road for more efficient, patient-centered care by fostering a more thorough awareness of the complexities involved in the management of acute STEMI. Methods: Demographic data, presentation timing, D2B times, and clinical outcomes were collected. Correlation analysis and regression modeling were employed to investigate the impact of presentation timing on D2B time and clinical outcomes. Sub-group analyses were conducted based on age and gender. Results: The relevance of an early presentation was highlighted by the study's substantial negative association between presentation timing and D2B time (r = -0.62, p 0.001). Smaller myocardial infarct sizes and a decreased frequency of major adverse cardiac events (MACE) were seen in patients with D2B times under 90 minutes. Age and gender differences were seen in this connection, according to subgroup analysis. Conclusion: Timely patient presentation is crucial in achieving shorter D2B times, leading to improved clinical outcomes in primary PCI for STEMI. These findings underscore the need for public awareness campaigns and streamlined hospital protocols to optimize STEMI management.

Tenecteplase: A Review of Its Pharmacology and Uses.

Tenecteplase: A Review of Its Pharmacology and Uses.

Trends and Outcomes of ST-Segment-Elevation Myocardial Infarction Among Young Women in the United States.

Background Although there has been a decrease in the incidence of ST-segment-elevation myocardial infarction (STEMI) in the United States, this trend might be stagnant or increasing in young women. We assessed the trends, characteristics, and outcomes of STEMI in women aged 18 to 55 years. Methods and Results We identified 177 602 women aged 18 to 55 with the primary diagnosis of STEMI from the National Inpatient Sample during years 2008 to 2019. We performed trend analyses to assess hospitalization rates, cardiovascular disease (CVD) risk factor profile, and in-hospital outcomes stratified by three age subgroups (18-34, 35-44, and 45-55 years). We found STEMI hospitalization rates were decreased in the overall study cohort from 52 per 100 000 hospitalizations in 2008 to 36 per 100 000 in 2019. This was driven by decreased proportion of hospitalizations in women aged 45 to 55 years (74.2% to-71.7%; P<0.001). Proportion of STEMI hospitalizationincreased in women aged 18-34 (4.7%-5.5%; P<0.001) and 35-44 years (21.2%-22.7%; P<0.001). The prevalence of traditional and non-traditional female-specific or female-predominant CVD risk factors increased in all age subgroups. The adjusted odds of in-hospital mortality in the overall study cohort and age subgroups were unchanged throughout the study period. Additionally, we observed an increase in the adjusted odds of cardiogenic shock, acute stroke, and acute kidney injury in the overall cohort over the study period. Conclusions STEMI hospitalizations are increasing among women aged <45 years, and in-hospital mortality has not changed over the past 12 years in women aged <55 years. Future studies on the optimization of risk assessment and management of STEMI in young women are urgently needed.

Coronary Microcirculation: The Next Frontier in the Management of STEMI

Although the widespread adoption of timely invasive reperfusion strategies over the last two decades has significantly improved the prognosis of patients with ST-segment elevation myocardial infarction (STEMI), up to half of patients after angiographically successful primary percutaneous coronary intervention (PCI) still have signs of inadequate reperfusion at the level of coronary microcirculation. This phenomenon, termed coronary microvascular dysfunction (CMD), has been associated with impaired prognosis. The aim of the present review is to describe the collected evidence on the occurrence of CMD following primary PCI, means of assessment and its association with the infarct size and clinical outcomes. Therefore, the practical role of invasive assessment of CMD in the catheterization laboratory, at the end of primary PCI, is emphasized, with an overview of available technologies including thermodilution- and Doppler-based methods, as well as recently developing functional coronary angiography. In this regard, we review the conceptual background and the prognostic value of coronary flow reserve (CFR), index of microcirculatory resistance (IMR), hyperemic microvascular resistance (HMR), pressure at zero flow (PzF) and angiography-derived IMR. Finally, the so-far investigated therapeutic strategies targeting coronary microcirculation after STEMI are revisited.

ST-Segment Elevation Myocardial Infarction (STEMI) Management in the Era of COVID-19: A Systematic and Critical Review of Published Guidance Reports

Background: Coronavirus disease 2019 (COVID-19) had a major impact on healthcare systems worldwide. During the early phase of the pandemic many elective procedures were postponed. At the same time, the safe and effective management of medical emergencies such as ST-segment elevation myocardial infarction (STEMI) has been a challenge. Methods: A systematic literature search was conducted aiming to identify published guidance reports by national or international societies regarding the management of patients suffering STEMI in the era of COVID-19. Results: Among 1681 articles initially retrieved, six fulfilled the inclusion criteria and were included in the systematic review. Two reports were international consensus documents, while four reports were national guidance statements from Asian countries (Taiwan, India, Iran, and China). Most documents were drafted during the early phase of the pandemic. According to the international consensus documents, percutaneous coronary intervention (PCI) should be regarded as the reperfusion method of choice. On the other hand, in three out of four national consensus statements (Taiwan, Iran and China) fibrinolysis was considered as the reperfusion method of choice for STEMI in suspected/confirmed patients with COVID-19, unless contraindicated or in the presence of high cardiovascular risk clinical features. Authors of all documents underlined the need for early COVID-19 testing in patients with STEMI to better determine the next therapeutical steps. Conclusions: National and international consensus statements for STEMI management in the era of COVID-19 have been published mainly during the early peak phase of the pandemic. Authors recognise that these recommendations are mainly based on expert opinions and observational data. As global immunization rates increase and methods for rapid COVID-19 detection are widely available, the implementation of traditional evidence-based practices used before the pandemic is becoming more feasible.

Long-term results of ST-segment elevation myocardial infarction management using recombinant prourokinase or primary percutaneous coronary intervention

Long-term results of ST-segment elevation myocardial infarction management using recombinant prourokinase or primary percutaneous coronary intervention

The Peripandemic Impact of the First Wave of the COVID-19 Pandemic on Management and Prognosis of ST-Segment Elevation Myocardial Infarction in China.

Rapid reperfusion of ST-segment elevation myocardial infarction (STEMI) has been challenging during the coronavirus disease 2019 (COVID-19) outbreak. Whether and to what degree there will be a residual impact when the COVID-19 pandemic has passed is unclear. This nationwide retrospective study was based on electronic records of STEMI patients registered in the Chinese Cardiovascular Association Database. We analyzed 141,375 STEMI patients (including 4871 patients in Hubei province, where 80% of COVID-19 cases in China occurred in 2019-2020) during the pre-outbreak (23 October 2019-22 January 2020), outbreak (23 January 2020-22 April 2020), and post-outbreak (23 April 2020-22 July 2020) periods. In the post-outbreak period in Hubei province, the increased in-hospital mortality dropped to become insignificant (adjusted odds ratio compared to the pre-outbreak level (aOR) 1.40, [95% confidential interval (CI): 0.97-2.03]) and was lower than that in the outbreak period (1.62 [1.09-2.41]). The decreased odds of primary percutaneous coronary intervention (PCI) (0.73 [0.55-0.96]) and timely reperfusion (0.74 [0.62-0.88]) persisted, although they were substantially improved compared to the outbreak period (aOR of primary PCI: 0.23 [0.18-0.30] and timely reperfusion: 0.43 [0.35-0.53]). The residual impact of COVID-19 on STEMI in the post-outbreak period in non-Hubei provinces was insignificant. Residual pandemic impacts on STEMI management persisted after the first wave of the COVID-19 outbreak in Hubei province, the earliest and hardest hit area in China.

Effects of healthcare system transformations spurred by the COVID-19 pandemic on management of stroke and STEMI: a registry-based cohort study in France

ObjectiveTo assess the impact of changes in use of care and implementation of hospital reorganisations spurred by the COVID-19 pandemic (first wave) on the acute management times of patients who...

North American COVID-19 Myocardial Infarction (NACMI) Risk Score for Prediction of In-Hospital Mortality.

BackgroundIn-hospital mortality in patients with ST-segment elevation myocardial infarction (STEMI) is higher in those with COVID-19 than in those without COVID-19. The factors that predispose to this mortality rate and their relative contribution are poorly understood. This study developed a risk score inclusive of clinical variables to predict in-hospital mortality in patients with COVID-19 and STEMI.MethodsBaseline demographic, clinical, and procedural data from patients in the North American COVID-19 Myocardial Infarction registry were extracted. Univariable logistic regression was performed using candidate predictor variables, and multivariable logistic regression was performed using backward stepwise selection to identify independent predictors of in-hospital mortality. Independent predictors were assigned a weighted integer, with the sum of the integers yielding the total risk score for each patient.ResultsIn-hospital mortality occurred in 118 of 425 (28%) patients. Eight variables present at the time of STEMI diagnosis (respiratory rate of >35 breaths/min, cardiogenic shock, oxygen saturation of <93%, age of >55 ​years, infiltrates on chest x-ray, kidney disease, diabetes, and dyspnea) were assigned a weighted integer. In-hospital mortality increased exponentially with increasing integer risk score (Cochran-Armitage χ2, P ​< ​.001), and the model demonstrated good discriminative power (c-statistic ​= ​0.81) and calibration (Hosmer-Lemeshow, P ​= ​.40). The increasing risk score was strongly associated with in-hospital mortality (3.6%-60% mortality for low-risk and very high–risk score categories, respectively).ConclusionsThe risk of in-hospital mortality in patients with COVID-19 and STEMI can be accurately predicted and discriminated using readily available clinical information.

Aortic Dissection Presenting as a STEMI.

This scenario was developed to educate emergency medicine residents on the presentation and management of a patient with a Stanford type A aortic dissection. Chest pain is one of the most common chief complaints seen in the emergency department with a deadly differential diagnosis list. A "can't miss" diagnosis, aortic dissection occurs when an intimal tear creates a false lumen in the aorta, with a variably reported incidence of approximately 2.5-5 per 100,000 person-years.1 This amounts to an estimated 8,000-16,000 cases per year in the United States with a mortality likely underestimated due to prehospital death ranging from 20-40% within 24 hours and 30-50% at 5 years.2,3,4 There is a reported increase in mortality by 1% for every hour the diagnosis is delayed, and half of diagnoses are made greater than 24 hours after presentation.5 The symptoms can range from chest pain to back pain, abdominal pain or extremity pain, to syncope or isolated neurologic deficits, even to shock or cardiac arrest.6 Aortic dissection is most commonly categorized into two groups: Stanford type A, involving the ascending aorta, and Stanford type B, involving only the descending aorta, and are generally managed surgically vs. medically respectively based on this paradigm.7,8 Stanford type A can be complicated by severe aortic regurgitation, pericardial tamponade or coronary artery occlusion mimicking ST-segment elevation myocardial infarction (STEMI). These potentials make it important to switch from heuristic to analytical thinking when developing a differential diagnosis.9 A high index of suspicion with early recognition and management is critical in this catastrophic disease state, especially given the propensity for complications and a wide variety of presentations. At the conclusion of the simulation session or during the debriefing session, learners will be able to: 1) Verbalize the anatomical differences and management of Stanford type A and type B aortic dissections, 2) Describe physical exam findings that may be found with ascending aortic dissections, 3) Describe the various clinical manifestations of the propagation of aortic dissections, 4) Discuss the management of aortic dissection, including treatment and disposition. This session was conducted using a simulation scenario with a high-fidelity manikin as the patient and confederate/actor in the nursing role, followed by a post-scenario debriefing session on the presentation, differential diagnosis, potential physical exam findings, and management of patients with aortic dissection. Debriefing methods may be left to the discretion of the educators, but the authors have utilized advocacy-inquiry techniques.10 This scenario may also be run as an oral board examination case. The residents are provided an electronic survey at the completion of the debriefing session to anonymously rate different aspects of the simulation, as well as provide qualitative feedback on the scenario. This survey is specific to the local institution's simulation center. Twenty learners completed a feedback form. This session received all 6 and 7 scores (consistently effective/very good and extremely effective/outstanding, respectively) other than one isolated 5 score. The lowest average score was 6.5 for, "Before the simulation, the instructor set the stage for an engaging learning experience," and the highest average score was 6.84 for, "The instructor identified what I did well or poorly - and why." Feedback from the residents was overwhelmingly positive (available upon request). All groups initially gave aspirin upon identification of the STEMI and several gave heparin. Debriefing topics included STEMI mimics, physical exam findings for aortic dissection, imaging and laboratory workup for aortic dissection, blood pressure and heart rate goals and pharmacologic management, uncomplicated STEMI management, and Type I versus Type II decision-making. This is an easily reproducible method for reviewing management of patients with aortic dissection. There are multiple potential presentations and complications of aortic dissections to further customize the experience for learners' needs. While it was discussed during debriefing that heparin administration was unlikely to cause immediate cardiopulmonary arrest, this state was included to reflect downstream hemorrhagic complications that may occur in the setting of antiplatelet administration for acute aortic dissection. Facilitators may choose to omit the arrest at their discretion. Medical simulation, emergency medicine, aortic dissection, ST-elevation myocardial infarction, cardiovascular emergencies, hypertensive emergencies, STEMI mimics, vascular surgery, cardiothoracic surgery.

EE478 Using Real World Evidence to Generate Cost-Effectiveness Analysis of Fibrinolytic Therapy in Patients with ST-Segment Elevation Myocardial Infarction in a Limited Resource Country

Due to limited access to primary percutaneous coronary intervention for treatment of ST-segment elevation myocardial infarction (STEMI) in low- and middle-income countries, fibrinolysis is the vital alternative treatment. We aimed to assess cost-effectiveness of tenecteplase (TNK) as compared to streptokinase (SK) for STEMI management using real world outcomes data obtained from a national electronic database.

Using real world evidence to generate cost-effectiveness analysis of fibrinolytic therapy in patients with ST-segment elevation myocardial infarction in Thailand

SummaryBackgroundDue to limited access to primary percutaneous coronary intervention for the management of ST-segment elevation myocardial infarction (STEMI) in low-to-middle-income countries (LMICs), fibrinolysis serves as a vital alternative reperfusion therapy. Among fibrinolytic agents, the cost-effectiveness of tenecteplase (TNK) in LMICs as compared to streptokinase (SK) for STEMI management remains unknown.MethodsCost-effectiveness was analyzed using a hybrid model consisting of short-term analysis (30-days decision tree model) and long-term analysis (Markov model). Both health care provider and societal perspectives over a lifetime horizon with 3% discount rate were considered. Input parameters were obtained from Thailand's national health database, a network meta-analysis and literature review. Outcome measure was an incremental cost-effectiveness ratio (ICER) determined by an incremental cost per quality-adjusted life years (QALY) gain. An ICER of less than $5,590 per QALY gain is considered cost-effective. Series of sensitivity analyses were also performed.FindingsFrom the societal perspective, TNK increases cost by $827 and increases QALY by 0·173. Thus, the ICER is $4,777 per QALY gained. Similarly, the ICER from health care provider perspective is $4,664 per QALY gained. In the probabilistic sensitivity analysis, using 5,590 USD per QALY as threshold, the probability of TNK being cost-effective was 83% from both perspectives. The most influential parameters were risk ratio of death for treatment with TNK compared to SK and drug cost of TNK.InterpretationIn a resource-limited country like Thailand, tenecteplase is a cost-effective fibrinolytic drug for treatment of STEMI compared to streptokinase.FundingNone.

Effects of the COVID-19 pandemic on the management of ST-Segment elevation myocardial infarction in Indonesia: a cohort study.

Background: ST-segment elevation myocardial infarction (STEMI) is a form of acute coronary syndrome with high mortality rate. Management of STEMI should be performed as soon as possible to prevent further damage. With the emergence of coronavirus disease 2019 (COVID-19), it may face obstacles. To overcome those problems, some changes in policy focusing on fibrinolytic therapy in STEMI patients have been applied. This study aimed to identify the effects of COVID-19 in management of STEMI patients in Indonesia. Methods: This retrospective study was conducted in Dr. Cipto Mangunkusumo Hospital (CMH), the national referral center in Indonesia. We compared data between 2018 to 2019 and 2020 to 2021 as before and during COVID-19 pandemic period, respectively. We analyzed the effects of COVID-19 on STEMI patients' visits to hospital i.e., monthly hospital admission and symptoms-to-hospital, management of STEMI i.e., the strategies and time of reperfusion, and clinical outcomes of STEMI patients i.e., major adverse coronary event and mortality. Results: There was a significant statistically reduced mean of monthly hospital admissions from 11 to 7 (p = 0.002) and prolonged duration of symptoms-to-hospital during COVID-19 from 8 to 12 hours (p = 0.005). There was also a decrease in primary percutaneous coronary intervention (PPCI) procedures during COVID-19 (65.2% vs. 27.8%, p<0.001), which was accompanied by an increased number of fibrinolytic (1.5% vs. 9.5%, p<0.001) and conservative therapy (28.5% vs. 55.6%, p <0.01). Moreover, there was also a prolonged duration of diagnosis-to-wire-crossing time (160 vs. 186 minutes, p = 0.005), meanwhile, percentage of urgent PCI, door-to-needle time, and clinical outcomes were not statistically significant. Conclusions: During COVID-19 pandemic, the number STEMI patients declined in monthly hospital admission, delays in symptoms-to-hospital time, changes in type of reperfusion strategy, and delays in PPCI procedures in CMH. Meanwhile, fibrinolytic time and clinical outcomes were not affected.

Management and Outcomes of ST-Segment Elevation Myocardial Infarction in Hospitalized Frail Patients in the United States

Cardiovascular diseases and frailty are common conditions of aging populations and often coexist. In this study, we examined the in-hospital management, outcomes, and resource use of frail patients hospitalized for ST-segment elevation myocardial infarction (STEMI). This was a retrospective analysis of the 2005-2014 data from the Nationwide Inpatient Sample. Patients were classified into to versus 'nonfrail' using the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnosis indicator. The primary outcome was STEMI management, whereas secondary outcomes were in-hospital mortality, length of stay, and cost. Outcomes were compared between frail and nonfrail patients using propensity score-matched analysis. There were 1,360,597 STEMI hospitalizations, of which 36,316 (2.7%) were frail. Propensity score-matched analysis showed that in in-hospital management options for STEMI, the odds of overall revascularization (odds ratio [OR], 0.60; 95% confidence interval [CI], 0.55 to 0.65), percutaneous coronary intervention (OR, 0.53; 95% CI, 0.49 to 0.57), and coronary angiography (OR, 0.59; 95% CI, 0.55 to 0.64) were significantly lower for frail patients. The odds of receiving coronary artery bypass grafting (OR, 1.66; 95% CI, 1.48 to 1.86) and overall hemodynamic support (OR, 1.26; 95% CI, 1.15 to 1.39) were significantly higher for frail patients. In-hospital mortality (18.7% vs 8.2%, p <0.001), length of stay (7.7 vs 3.7 days, p <0.001) and costs ($90,060 vs $63,507, p <0.001) were significantly higher in frail patients. Our findings suggest that collaborative efforts by cardiologists and cardiovascular surgeons for identifying frailty in patients with STEMI and incorporating frailty in risk estimation measures may improve management strategies, resource use and optimize patient outcomes.

Trends in Clinical Presentation, Management, and Outcomes of STEMI in Patients With COVID-19

BackgroundWe previously reported high in-hospital mortality for ST-segment elevation myocardial infarction (STEMI) patients with COVID-19 treated in the early phase of the pandemic. ObjectivesThe purpose of this study was to describe trends of COVID-19 patients with STEMI during the course of the pandemic. MethodsThe NACMI (North American COVID-19 STEMI) registry is a prospective, investigator-initiated, multicenter, observational registry of hospitalized STEMI patients with confirmed or suspected COVID-19 infection in North America. We compared trends in clinical characteristics, management, and outcomes of patients treated in the first year of the pandemic (January 2020 to December 2020) vs those treated in the second year (January 2021 to December 2021). ResultsA total of 586 COVID-19–positive patients with STEMI were included in the present analysis; 227 treated in Y2020 and 359 treated in Y2021. Patients’ characteristics changed over time. Relative to Y2020, the proportion of Caucasian patients was higher (58% vs 39%; P < 0.001), patients presented more frequently with typical ischemic symptoms (59% vs 51%; P = 0.04), and patients were less likely to have shock pre-PCI (13% vs 18%; P = 0.07) or pulmonary manifestations (33% vs. 47%; P = 0.001) in Y2021. In-hospital mortality decreased from 33% (Y2020) to 23% (Y2021) (P = 0.008). In Y2021, none of the 22 vaccinated patients expired in hospital, whereas in-hospital death was recorded in 37 (22%) unvaccinated patients (P = 0.009). ConclusionsSignificant changes have occurred in the clinical characteristics and outcomes of STEMI patients with COVID-19 infection during the course of the pandemic.

Performance of Management Strategies With Class I Recommendations Among Patients Hospitalized With ST-Segment Elevation Myocardial Infarction in China

Despite advances in the treatment of ST-segment elevation myocardial infarction (STEMI), little is known about how this evolving knowledge is applied in current clinical practice in China. To evaluate hospital performance and temporal trends in the management of STEMI. This study used data from the Improving Care for Cardiovascular Disease in China-Acute Coronary Syndrome Project, a nationwide quality improvement registry, in collaboration with the American Heart Association and the Chinese Society of Cardiology. Participants included patients with STEMI admitted to 143 tertiary hospitals across China from November 2014 to July 2019, and data were analyzed from November 2020 to December 2021. Levels, hospital-level variations, and trends for utilization rates of the 9 management strategies with Class I recommendations in Chinese and US guidelines. A total of 57 560 hospitalizations with STEMI were included. Overall, 20.0% of patients received all the care according to the 9 guideline-recommended strategies. The performance rate of quality measures was low for reperfusion therapy (61.0%, 35 115/57 560 patients), β-blocker at discharge (68.3%, 37 750/55 285 patients), angiotensin-converting enzyme inhibitor or angiotensin receptor blocker at discharge (55.1%, 2524/4578 patients), and smoking cessation counseling (36.5%, 9586/26 265 patients) among those who were eligible. Of 25 563 patients who underwent primary percutaneous coronary intervention (PCI), 66.8% underwent this procedure within 90 minutes of hospital arrival. Of 1128 patients who underwent fibrinolysis therapy, 253 (22.4%) underwent this treatment within 30 minutes of hospital arrival. Measures with high performance rates included receipt of dual antiplatelet therapy within 24 hours (95.5%, 54 263/56 848 patients) and at discharge (91.8%, 51 452/56 019 patients) and receipt of statin at discharge (93.0%, 52 214/56 141 patients) for those eligible. There was significant variation between hospitals in all-or-none score (ranging from 0 to 61.9%) and performance of individual measures. The quality of care improved during the study period, especially for reperfusion therapy, primary PCI within the first 90 minutes of hospital arrival, and smoking cessation counseling. The quality of care for patients hospitalized with STEMI does not meet guideline-recommended strategies in China, with only 1 in 5 patients receiving all the care according to the 9 guideline-recommended strategies. Large disparities in the quality of care exist across hospitals.