ST-segment Elevation Myocardial Infarction Network Research Articles

Advancements in reperfusion rates and quality of care for ST-segment elevation myocardial infarction: a ten-year evaluation of Salvador's STEMI network.

Continuous investment and systematic evaluation of program accomplishments are required to achieve excellence in ST-segment elevation myocardial infarction (STEMI) care, especially in resource-limited settings. Therefore, this study evaluates the impact of problem-driven interventions on reperfusion use rate in a long-term operating STEMI network from a low- to middle-income country. This is a healthcare improvement evaluation study of Salvador's public STEMI network in a quasi-experimental design, comparing data from 2009 to 2010 (pre-intervention) and 2019-2020 (post-intervention). There were evaluated all confirmed STEMI cases assisted in both periods. The interventions, implemented since 2017, included: expanding the support team, defining criteria to be a spoke, and initiating continuous education activities. The primary outcome was the rate of patients undergoing reperfusion, with secondary outcomes being time from door-to-ECG (D2E) and ECG-to-STEMI-team trigger (E2T). Over ten years, the network's coverage increased by 300,000 individuals, and expanded by 1,800 km2. A total of 885 records were analyzed, 287 in the pre-intervention group (182 men [63·4%]; mean [SD] age 62·1 [12·5] years) and 598 in the post-intervention group (356 men [59·5%]; mean [SD] age 61.9 [11·8] years). It was noticed a substantial increase in reperfusion delivery rate (90 [31%] vs. 431 [73%]; P = 001) and reductions in time from D2E (159 [83-340] vs. 29 [15-63], P = 001), and E2T (31 [21-44] vs. 16 [6-40], P = 001). The strategies adopted by Salvador's STEMI network were associated with significant improvements in the rate of patients undergoing reperfusion and in D2E and E2T. However, the mortality rate remains high.

Timing of P2Y12 Inhibitor Administration in Patients With STEMI Undergoing Primary PCI

BackgroundThe optimal timing of P2Y12 inhibitor administration in patients with ST-segment elevation myocardial infarction (STEMI) has not been completely elucidating. ObjectivesThis analysis from a prospective multicenter registry sought to assess the safety and effectiveness of P2Y12 inhibitor pretreatment in patients transferred for primary percutaneous coronary intervention (PCI) within a regional STEMI network. MethodsPretreatment was defined as P2Y12 inhibitor administration before coronary angiography. Endpoints were major adverse cardiac events (MACE), major bleeding, and net adverse clinical events, a composite of MACE or major bleeding, within 30 days of index admission. Association of P2Y12 inhibitor pretreatment with outcomes was modeled using doubly robust weighted estimators based on propensity score analysis. ResultsOf 1,624 patients included, 1,033 received P2Y12 inhibitors before angiography and 591 in the catheterization laboratory (cath lab). The non-pretreated cohort more often had history of coronary artery disease and were more likely to receive antiplatelet therapy before the index admission. After adjustment for confounding and dependent censoring, pretreatment with P2Y12 inhibitors predicted lower risk of MACE (adjusted HR: 0.53; 95% CI: 0.37-0.76), without increasing bleeding risk (adjusted HR: 0.62; 95% CI: 0.36-1.05), resulting in superior net clinical benefit (adjusted HR: 0.47; 95% CI: 0.26-0.86) compared with in-cath lab administration of P2Y12 inhibitors. There was a significant treatment-by-time interaction for MACE risk, whereby the observed benefits of pretreatment only became apparent when time between P2Y12 inhibitor administration and PCI was longer than 80 minutes. ConclusionsIn contemporary patients with STEMI transferred for primary PCI, pretreatment with P2Y12 inhibitors was associated with a significant time-dependent reduction of 30-day MACE without increasing bleeding risk.

Current status of emergency medical service use in ST-segment elevation myocardial infarction in China: Findings from China Acute Myocardial Infarction (CAMI) Registry

BackgroundThe mortality rate of myocardial infarction in China has increased dramatically in the past three decades. Although emergency medical service (EMS) played a pivotal role for the management of patients with ST-segment elevation myocardial infarction (STEMI), the corresponding data in China are limited. MethodsAn observational analysis was performed in 26,305 STEMI patients, who were documented in China acute myocardial infarction (CAMI) Registry and treated in 162 hospitals from January 1st, 2013 to January 31th, 2016. We compared the differences such as demographic factors, social factors, medical history, risk factors, socioeconomic distribution and treatment strategies between EMS transport group and self-transport group. ResultsOnly 4336 patients (16.5%) were transported by EMS. Patients with symptom onset outside, out-of-hospital cardiac arrest and presented to province-level hospital were more likely to use EMS. Besides those factors, low systolic blood pressure, severe dyspnea or syncope, and high Killip class were also positively related to EMS activation. Notably, compared to self-transport, use of EMS was associated with a shorter prehospital delay (median, 180 vs. 245 min, P < 0.0001) but similar door-to-needle time (median, 45 min vs. 52 min, P = 0.1400) and door-to-balloon time (median, 105 min vs. 103 min, P = 0.1834). ConclusionsEMS care for STEMI is greatly underused in China. EMS transport is associated with shorter onset-to-door time and higher rate of reperfusion, but not substantial reduction in treatment delays or mortality rate. Targeted efforts are needed to promote EMS use when chest pain occurs and to set up a unique regionalized STEMI network focusing on integration of prehospital care procedures in China.Trial registration:ClinicalTrials.gov (NCT01874691), retrospectively registered June 11, 2013.

Safety of early discharge after primary percutaneous coronary intervention in low risk ST-segment elevation myocardial infarction presented in a tertiary center without an established STEMI network

Abstract Introduction The application of ST-segment elevation myocardial infarction (STEMI) networks, is a key factor for improvements in outcomes of STEMI patients, leading to earlier treatment, better outcomes and shorter hospital stay. Current guidelines support an early discharge (48-72 h) in selected low risk patients. Yet, this strategy is not routinely applied, especially in centers without an established STEMI network. Purpose To evaluate safety of early discharge in low risk STEMI patients treated with primary PCI by analyzing 30 days outcomes, in a unique tertiary center without an established STEMI network and serving a large area of population. Methods We prospectively collected data from 220 consecutive patients admitted to our center with diagnosis of STEMI, in two different time periods, categorized as low risk according to Zwolle risk score.175 patients were discharged within 72 hours and 45 patients after 72 hours. Follow-up was done by phone call at 30 days. Primary endpoint was occurrence of a major adverse event - a composite of death from cardiac cause, nonfatal myocardial re-infarction, and repeat intervention. Secondary endpoints were death from any cause, residual angina and re-hospitalization. Results The mean age was 58.12 +/-10.32 years. 193 (87%) of patients were male. 118 (53.6%) of them had inferior MI. Mean ejection fraction was 50% +/- 6.04%. Median symptom to hospital arrival time was 5.17 +/- 0.2 hours. Median length of hospital stay was 69.8 +/-17.09 hours. Primary endpoint occurred in 6 (3.4%) patients, all of them in the &amp;lt;72 hours discharge group. 3 patients had cardiac death, 3 had nonfatal MI and eventually 2 of them had repeat intervention. Secondary endpoint occurred in 8 (4.6%) patients in the &amp;lt;72 hours discharge group and 1 (2.2%) patient in the &amp;gt;72 hours discharge group, all of them having residual angina. Conclusion In low risk STEMI patients treated with successful primary PCI, data from our study suggest that an early discharge strategy within 72 hours is associated with comparable outcomes regarding major adverse events compared to late discharge strategy.

Early outcome of on- versus off-hours admission in ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI) during COVID-19 pandemic

Abstract Funding Acknowledgements Type of funding sources: None. Background Most of studies have found no relevant impact of admission time on STEMI outcome among patients treated with primary PCI. Whether this observation has been affected by coronavirus disease (COVID-19) pandemic, in particular during the curfew application, has not been evaluated. Purpose To study the influence of admission time on the outcome of STEMI patients treated with primary PCI during COVID-19 pandemic in a large volume University Hospital Center, the only center capable of primary PCI serving a large area without an established STEMI network Methods Characteristics and outcomes of 308 consecutive STEMI patients admitted to our center between May 28 to December 2020, were collected. On-hours were defined as admission from Monday through Friday from 8:00 to 15:30 and off-hours admission from 15:30 to 8:00, weekends and non-working holidays. Clinical characteristics, key time delays and in-hospital and 3-month mortality were evaluated. Results 75 (24%) patients were admitted on-hours and 233 (76%) patients were admitted off-hours. There were no differences between groups regarding baseline clinical characteristics, laboratory data and STEMI clinical presentation. Median time from pain onset to coronary care unit admission was 4.0 hours in the on-hours group versus 6.0 hours in the off-hours group (p=0.11). Median time from coronary care unit to cathlab was 1.5 hours in the on-hours group versus 1.0 hour in the off-hour group (p=0.14). There was no difference between on-hours versus off- groups regarding in-hospital mortality (4% versus 6%, p=0.77) and 3-month mortality (10% versus 10%, p=0.76), as well as recurrent infarction (p=0.56) and stent thrombosis (p=0.64). Conclusion(s) Despite the lack of an organized STEMI network, patients admitted to a large-volume primary PCI tertiary center during COVID-19 pandemic, had similar outcome regardless their admission during on-hours or off-hours. Althgouh the specific impact of curfew on out of hospital time delays could not be assessed, it did not appear to influence patient outcomes.

Leveraging Existing STEMI Networks to Regionalize Cardiogenic Shock Systems of Care: Efforts to Expand the Scope Could Improve Shock Outcomes.

Brief Summary Cardiogenic shock (CS) is a high-acuity and time-sensitive condition associated with significant morbidity and mortality that may be best served with centralized care by an experienced multi-disciplinary team. We propose that existing Canadian "hub-and-spoke" systems for timely revascularization in ST-elevation myocardial infarction can be leveraged to expand, and ultimately improve timely referral, transfer, and survival of CS patients.

Implementation of a Regional STEMI Network in North Cairo (Egypt): Impact on The Management and Outcome of STEMI Patients.

Regional ST-segment-elevation myocardial infarction (STEMI) networks facilitate timely performance of primary percutaneous coronary intervention (PPCI), reduce mortality and improve outcomes. Few data exist on the feasibility and impact of regional STEMI networks in developing countries. The aim of this study was to examine the feasibility and impact of establishing a regional STEMI network on the management and outcomes of STEMI patients in north Cairo. A prospective observational study conducted on 352 patients presenting in North Cairo with confirmed diagnosis of STEMI within 48 hours of symptoms. Patients were divided into group I (n = 140) before and group II (n = 212) after establishment of the STEMI network. Both groups were compared as regards patients' demographics, presentation, management and short-term outcomes. The north Cairo regional STEMI network was established among four governmental hospitals and the governmental ambulance was used for interhospital transfer. WhatsApp® was used for trans-network team communication. Mean age of the study population was 55.4 ± 11.02 years and 286 (81.3%) were males. Mean time from chest pain to first medical contact did not change between the two groups (240 minutes; P = 0.36) while door to balloon mean time was reduced (from 54.3 to 44.1 minutes: P = 0.01). Use of thrombolytic therapy declined from 51 (36.4%) to 16 (7.5%) (P < 0.001) while primary PCI increased from 59.8% to 77.1% (p < 0.001). Left ventricular ejection fraction improved from 51.3 ± 10.7 to 55.4 ± 9.1 (P < 0.001), the mean time of CCU stay was reduced from a mean of 3.0 to 2.0 days (P < 0.001) and in-hospital mortality improved from 6.4% to 2.8% (P = 0.10). The establishment of the STEMI network in north Cairo was feasible and improved patients' outcomes. Use of primary PCI increased and in-hospital mortality improved from after establishment of STEMI network.

The role of process mining tools in STEMI networks: where should we build a new primary PCI centre?

Abstract Background In ST-segment elevation myocardial infarction (STEMI), time delay between symptom onset and treatment is critical to improve outcome. The expected transport delay between patient location and percutaneous coronary intervention (PCI) centre is paramount for choosing the adequate reperfusion therapy. The “Centre” region of Portugal has heterogeneity in PCI assess due to geographical reasons. Purpose We aimed to explore time delays between regions using process mining (PM) tools. Methods We retrospectively assessed the Portuguese Registry of Acute Coronary Syndromes for patients with STEMI from October 2010 to September 2019, collecting information on geographical area of symptom onset, reperfusion option, and in-hospital mortality. We used a PM toolkit (PM4H – PMApp Version) to build two models (one national and one regional) that represent the flow of patients in a healthcare system, enhancing time differences between groups. One-way analysis of variance was employed for the global comparison of study variables between groups and post hoc analysis with Bonferroni correction was used for multiple comparisons. Results Overall, 8956 patients (75% male, 48% from 51 to 70 years) were included in the national model (Fig. 1A), in which primary PCI was the treatment of choice (73%), with the median time between admission and primary PCI &amp;lt;120 minutes in every region; “Lisboa” and “Centro” had the longest delays, (orange arrows). Fibrinolysis was performed in 4.5%, with a median time delay &amp;lt;1 hour in every region. In-hospital mortality was 5%, significantly higher for those without reperfusion therapy compared to PCI and fibrinolysis (10% vs. 4% vs. 4%, P&amp;lt;0.001). In the regional model (Fig. 1B) corresponding to the “Centre” region of Portugal divided by districts (n=773, 74% male, 47% from 51 to 70 years), only 61% had primary PCI, with “Guarda” (05:04) and “Castelo Branco” (06:50) showing significant longer delays between diagnosis and reperfusion treatment (orange and red arrows, respectively) than “Coimbra” (01:19) (green arrow); only 15% of patients from “Castelo Branco” had primary PCI. Fibrinolysis was chosen in 10% of patients, mostly in “Castelo Branco” (53%), followed by “Guarda” (30%), with a median time delay of 39 and 48 minutes, respectively. Regarding mortality, PCI and fibrinolysis groups had similar death rates while those patients without reperfusion had higher mortality (5% vs. 3% vs. 13%, P=0.001). Conclusion Process mining tools help to understand referencing networks visually, easily highlighting inefficiencies and potential needs for improvement. The “Centre” region of Portugal has lower rates and longer delay to primary PCI partially due to the geographical reasons, with worse outcomes in remote regions. The implementation of a new PCI centre in one of these districts, is critical to offer timely first-line treatment to their population. Funding Acknowledgement Type of funding sources: None. Figure 1

Barriers to the Implementation of Primary PCI in the Management of STEMI in Egypt

Introduction: Evidence-based guidelines recommend primary percutaneous coronary intervention (PPCI) be the mainstay reperfusion strategy for the treatment of ST-segment elevation myocardial infarction (STEMI) if it is performed in the proper time window. However, the Egyptian health care system is still struggling to provide such an important service. The aim of the present study, through a quantitative questionnaire, is to explore the current practice of STEMI management in Egypt, and to identify the barriers, opportunities, and potential areas for improvement. Methods and Results: The questionnaire was conducted in Egypt via face-to-face qualitative in-depth interviews with cardiologists from 14 PPCI-capable hospitals and 26 non-PPCI-capable hospitals. Participants were selected in view of their experience and knowledge. The study identified potential barriers to the implementation of PPCI among STEMI patients in Egypt. These barriers included the prehospital patient delay and emergency medical service delay, delay in the emergency department and delay in patient transfer to the CCU, unavailable equipment, catheterization laboratory activation delay, lack of trained interventional cardiologists, lack of regional STEMI networks and hospital policies, and insufficient ICU beds. Conclusion: Limited resources and health care system inadequacies have led to potential barriers that prevent suboptimal implementation of PPCI in Egypt. Efforts from all health care providers should be directed to overcome these identified barriers.

Reperfusion Therapy and Predictors of 30-Day Mortality after ST-Segment Elevation Myocardial Infarction in a University Medical Center in Western Iran.

Considerable variability in survival rate after ST-segment elevation myocardial infarction (STEMI) is present and outcomes remain suboptimal, especially in low- and middle-income contraries. This study aimed to investigate predictors of 30- day mortality after STEMI, including reperfusion therapy, in a tertiary hospital in western Iran. In this registry-based cohort study (2016-2019), we investigated reperfusion therapies - primary percutaneous coronary intervention (PPCI), pharmaco-invasive (thrombolysis followed by angiography/percutaneous coronary intervention), and thrombolysis alone - used in Imam-Ali hospital, the only hospital with a PPCI capability in the Kermanshah Province. We estimated hazard ratios (HRs) and 95% confidence intervals (CIs), using Cox proportional-hazard models, to investigate the potential predictors of 30-day mortality including reperfusion therapy, admission types (direct admission/referral from non-PPCI-capable hospitals), demographic variables, coronary risk factors, vital signs on admission, medical history, and laboratory tests. Data of 2428 STEMI patients (mean age: 60.73; 22.9% female) were available. Reperfusion therapy was performed in 84% of patients (58% PPCI, 10% pharmaco-invasive, 16% thrombolysis alone). Only 17% of the referred patients had received thrombolysis at non-PPCI-capable hospitals. Among patients with thrombolysis, only 38.2% underwent coronary angiography/ percutaneous coronary intervention. The independent predictors of mortality were: no reperfusion therapy (HR: 2.01, 95% CI: 1.36-2.97), referral from non-PPCI-capable hospitals (1.73, 1.22-2.46), age (1.03, 1.01-1.04), glomerular filtration rate (0.97, 0.96-0.97), heart rate>100 bpm (1.94, 1.22-3.08), and systolic blood pressure<100 mm Hg (4.92, 3.43-7.04). Mortality was lower with the pharmaco-invasive approach, although statistically non-significant, than other reperfusion therapies. Reperfusion therapy, admission types, age, glomerular filtration rate, heart rate, and blood pressure were independently associated with 30-day mortality. Using a comprehensive STEMI network to increase reperfusion therapy, especially pharmaco-invasive therapy, is recommended.

The role of process mining tools in STEMI networks: where should we build a new primary PCI centre?

Abstract Background In ST-segment elevation myocardial infarction (STEMI), time delay between symptom onset and treatment is critical to improve outcome. The expected transport delay between patient location and percutaneous coronary intervention (PCI) centre is paramount for choosing the adequate reperfusion therapy. The “Centre” region of Portugal has heterogeneity in PCI assess due to geographical reasons. Purpose We aimed to explore time delays between regions using process mining (PM) tools. Methods We retrospectively assessed the Portuguese Registry of Acute Coronary Syndromes for patients with STEMI from October 2010 to September 2019, collecting information on geographical area of symptom onset, reperfusion option, and in-hospital mortality. We used a PM toolkit (PM4H – PMApp Version) to build two models (one national and one regional) that represent the flow of patients in a healthcare system, enhancing time differences between groups. One-way analysis of variance was employed for the global comparison of study variables between groups and post hoc analysis with Bonferroni correction was used for multiple comparisons. Results Overall, 8956 patients (75% male, 48% from 51 to 70 years) were included in the national model (Fig. 1A), in which primary PCI was the treatment of choice (73%), with the median time between admission and primary PCI &amp;lt;120 minutes in every region; “Lisboa” and “Centro” had the longest delays, (orange arrows). Fibrinolysis was performed in 4.5%, with a median time delay &amp;lt;1 hour in every region. In-hospital mortality was 5%, significantly higher for those without reperfusion therapy compared to PCI and fibrinolysis (10% vs. 4% vs. 4%, P&amp;lt;0.001). In the regional model (Fig. 1B) corresponding to the “Centre” region of Portugal divided by districts (n=773, 74% male, 47% from 51 to 70 years), only 61% had primary PCI, with “Guarda” (05:04) and “Castelo Branco” (06:50) showing significant longer delays between diagnosis and reperfusion treatment (orange and red arrows, respectively) than “Coimbra” (01:19) (green arrow); only 15% of patients from “Castelo Branco” had primary PCI. Fibrinolysis was chosen in 10% of patients, mostly in “Castelo Branco” (53%), followed by “Guarda” (30%), with a median time delay of 39 and 48 minutes, respectively. Regarding mortality, PCI and fibrinolysis groups had similar death rates while those patients without reperfusion had higher mortality (5% vs. 3% vs. 13%, P=0.001). Conclusion Process mining tools help to understand referencing networks visually, easily highlighting inefficiencies and potential needs for improvement. The “Centre” region of Portugal has lower rates and longer delay to primary PCI partially due to the geographical reasons, with worse outcomes in remote regions. The implementation of a new PCI centre in one of these districts, is critical to offer timely first-line treatment to their population. Funding Acknowledgement Type of funding sources: None. Figure 1

STEMI around-the-clock: how off-hours admissions impact door-to-balloon time and the long-term prognosis of ST-segment Elevation Myocardial Infarction

Abstract Introduction The outcomes of reperfusion in ST-segment Elevation Myocardial Infarction (STEMI) are time-dependent, and percutaneous coronary intervention (PCI) should be performed within 60 minutes from hospital admission in PCI centers – door-to-balloon time (D2B). The association between Off-Hours Admission (OHA) and long-term outcomes is controversial when considering contemporary organized STEMI networks. Purpose This study aims to analyze how OHA influences D2B and long-term mortality. Methods Retrospective study of consecutive STEMI patients (pts), admitted in a PCI-centre with a local Emergency Department, between 2010 and 2015. Pts submitted to rescue-PCI were excluded. OHA was defined as admission at night (8p.m. to 8a.m), weekends and nonworking holidays. Predictors of OHA and D2B were studied by logistic regression analysis. Demographic, clinical, angiographic and procedural variables were evaluated using stepwise Cox regression analysis to determine independent predictors of 5-year all-cause mortality (5yM). The cumulative incidence of 5yM stratified by hours of admission was calculated according to the Kaplan-Meier method. Results Of 901 pts, 472pts (52.4%) were admitted during off-hours. These pts were younger (61±13 vs 64±12, p=0.002) and had a lower median patient-delay time (128min vs 157min, p=0.014). Clinical severity at presentation, defined by systolic arterial pressure and Killip-Kimball (KK) class, did not differ between groups. OHA did not impact D2B (89 min vs 88 min, p=0.550), which was in turn influenced by age ≥75y (OR 1.85, 95% CI 1.31–2.61, p&amp;lt;0.001). Mean clinical follow-up (FUP) was 68±37 months, with 75.1% of pts achieving a FUP &amp;gt;5 years. 5yM rate was 9.7%. After multivariate cox regression analysis, independent determinants of long-term mortality were age (HR 1.05, 95% CI 1.02–1.08, p&amp;lt;0.001), previous history of heart failure (HR 6.76, 95% CI 1.32–34.72, p=0.022) and pulmonary disease (HR 3.79, 95% CI 1.16–12.33, p=0.027), presentation with KK ≥2 (HR 2.82, 95% CI 1.32–6.01, p=0.007) and radial artery access in catheterization (HR 0.39, 95% CI 0.18–0.83, p=0.014) – figure 1. Although there was an association between a higher D2B time and 5yM (87min vs 101min, p=0.024), neither OHA nor D2B were independent predictors of long-term mortality – figure 2. Conclusion OHA did not seem to influence D2B and long-term STEMI outcomes in our PCI-centre. 5yM was mostly influenced by patient characteristics and clinical severity at presentation. Funding Acknowledgement Type of funding sources: None. Figure 1. Predictors of long-term mortalityFigure 2. 5-year survival stratified by OHA

Evaluation of Door-to-Balloon Times After Implementation of a ST-Segment Elevation Myocardial Infarction Network.

ST-segment elevation myocardial infarction (STEMI) requires prompt therapy. It is recommended for door-to-balloon (DTB) times to be less than 90 minutes. In the United States, some locations have difficulty meeting this goal. The objective of this study was to determine whether implementation of a STEMI network decreased DTB times at a large, STEMI-receiving, metropolitan academic hospital in the southeastern United States. Furthermore, differences among presentation types, including walk-in, emergency medical services, and transfers, were explored. A pre-post time series study of electronic medical record data was conducted to evaluate the efficacy of a STEMI network. The sample included 127 patients with a diagnosis of STEMI, collected during 3 periods (T1, T2, and T3). Patients were primarily White (78.0%) and male (67.7%), with a mean (SD) age of 58.9 (13.9) years. The 1-way analysis of variance revealed a significant difference in overall DTB times, F2 = 11.66, P < .001. Post hoc comparisons indicated longer mean DTB times for T1 compared with T3 ( P < .001) and T2 ( P < .001). When exploring presentation type, 1-way analysis of variance revealed a significant difference in mean DTB times in transfer patients between T1 and T2 ( P < .001) and T1 to T3 ( P < .001). No other statistical differences were noted; however, all DTB times with the exception of T2 for emergency medical services presentation decreased. Implementation of a STEMI network was effective at decreasing overall DTB times with patients who presented to the hospital with a diagnosis of STEMI.

Trends in reperfusion therapy for acute ST-segment elevation myocardial infarction in an academic PCI centre in the metropolitan area of a developing country

Abstract Background Long-term reports on reperfusion therapy for acute ST-segment elevation myocardial infarction (STEMI) in developing countries are scarce. Purpose We reported changes in acute reperfusion therapy for STEMI that have been observed over time in an academic tertiary care percutaneous coronary intervention (PCI) centre that hosting a STEMI network in the large metropolitan area of Jakarta, Indonesia since 2010 and covering around 11 million inhabitants. Methods A retrospective analysis was performed in 6336 patients with STEMI who admitted to the emergency department of a PCI centre in 2008 (before STEMI network introduction), and during 2011 to 2018. Results Among STEMI patients admitted during 2011–2018 (mean age: 56±10 years, 86% male), 57.6% had anterior wall myocardial infarction, and 71.3% presented with Killip classification I. Compared with the period 2011–2014 (N=2766), patients who were admitted in the period 2015–2018 (N=3250) were receiving more primary percutaneous coronary intervention (PCI) (61.6% vs. 44.2%, P&amp;lt;0.001) with shorter door-to-device time (median 72 min versus 97 min, P&amp;lt;0.001), and less in-hospital fibrinolytic therapy (2.7% vs. 4.8%, P&amp;lt;0.001). The percentage of STEMI patients who did not receive reperfusion treatment decreased from 51% to 35.5% (P&amp;lt;0.001). In-hospital mortality declined from 10% in 2008 (before the STEMI network was initiated) and 8% in 2011 to 6.4% in 2018 (P for trends = 0.05). Multivariable analysis showed that primary PCI was significantly associated with better in-hospital survival (adjusted odds ratio, 0.52; 95% confidence interval, 0.42 to 0.65, P&amp;lt;0.001). Conclusion The data indicate that the introduction of a STEMI network resulted in more patients receiving timely primary PCI and lower early mortality rates in recent years. Funding Acknowledgement Type of funding source: None

Impacto de las diferencias de sexo y los sistemas de red en la mortalidad hospitalaria de pacientes con infarto agudo de miocardio con elevación del segmento ST

Introduction and objectivesNetwork systems have achieved reductions in both time to reperfusion and in-hospital mortality in patients with ST-segment elevation myocardial infarction (STEMI). However, the data have not been disaggregated by sex. The aim of this study was to analyze the influence of network systems on sex differences in primary percutaneous coronary intervention (pPCI) and in-hospital mortality from 2005 to 2015. MethodsThe Minimum Data Set of the Spanish National Health System was used to identify patients with STEMI. Logistic multilevel regression models and Poisson regression analysis were used to calculate risk-standardized in-hospital mortality ratios and incidence rate ratios (IRRs). ResultsOf 324 998 STEMI patients, 277 281 were selected after exclusions (29% women). Even when STEMI networks were established, the use of reperfusion therapy (PCI, fibrinolysis, and CABG) was lower in women than in men from 2005 to 2015: 56.6% vs 75.6% in men and 36.4% vs 57.0% in women, respectively (both P<.001). pPCI use increased from 34.9% to 68.1% in men (IRR, 1.07) and from 21.7% to 51.7% in women (IRR, 1.08). The crude in-hospital mortality rate was higher in women (9.3% vs 18.7%; P<.001) but decreased from 2005 to 2015 (IRRs, 0.97 for men and 0.98 for women; both P < .001). Female sex was an independent risk factor for mortality (adjusted OR, 1.23; P<.001). The risk-standardized in-hospital mortality ratio was lower in women when STEMI networks were in place (16.9% vs 19.1%, P<.001). pPCI and the presence of STEMI networks were associated with lower in-hospital mortality in women (adjusted ORs, 0.30 and 0.75, respectively; both P<.001). ConclusionsWomen were less likely to receive pPCI and had higher in-hospital mortality than men throughout the 11-year study period, even with the presence of a network system for STEMI.

Impacto de la COVID-19 en el tratamiento del infarto agudo de miocardio con elevación del segmento ST. La experiencia española

Introduction and objectivesThe COVID-19 outbreak has had an unclear impact on the treatment and outcomes of patients with ST-segment elevation myocardial infarction (STEMI). The aim of this study was to assess changes in STEMI management during the COVID-19 outbreak. MethodsUsing a multicenter, nationwide, retrospective, observational registry of consecutive patients who were managed in 75 specific STEMI care centers in Spain, we compared patient and procedural characteristics and in-hospital outcomes in 2 different cohorts with 30-day follow-up according to whether the patients had been treated before or after COVID-19. ResultsSuspected STEMI patients treated in STEMI networks decreased by 27.6% and patients with confirmed STEMI fell from 1305 to 1009 (22.7%). There were no differences in reperfusion strategy (> 94% treated with primary percutaneous coronary intervention in both cohorts). Patients treated with primary percutaneous coronary intervention during the COVID-19 outbreak had a longer ischemic time (233 [150-375] vs 200 [140-332] minutes, P<.001) but showed no differences in the time from first medical contact to reperfusion. In-hospital mortality was higher during COVID-19 (7.5% vs 5.1%; unadjusted OR, 1.50; 95%CI, 1.07-2.11; P <.001); this association remained after adjustment for confounders (risk-adjusted OR, 1.88; 95%CI, 1.12-3.14; P=.017). In the 2020 cohort, there was a 6.3% incidence of confirmed SARS-CoV-2 infection during hospitalization. ConclusionsThe number of STEMI patients treated during the current COVID-19 outbreak fell vs the previous year and there was an increase in the median time from symptom onset to reperfusion and a significant 2-fold increase in the rate of in-hospital mortality. No changes in reperfusion strategy were detected, with primary percutaneous coronary intervention performed for the vast majority of patients. The co-existence of STEMI and SARS-CoV-2 infection was relatively infrequent.

Comparison of Real-Life Systems of Care for ST-Segment Elevation Myocardial Infarction.

The success of ST-segment elevation myocardial infarction (STEMI) networks application in Europe and the United States in delivering rapid reperfusion therapy in the community have become an inspiration to other developing countries to develop regional STEMI network in order to improve the STEMI care. Although barriers are found in the beginning phase of constructing the network, recent analysis from national or regional registries worldwide have shown improvement of the STEMI care in many countries over the years. To improve the overall care of patients with STEMI particularly in developing countries, improvements should be focusing on how to minimize the total ischemia time, and this includes care improvement at each step of care after the patient shows signs and symptoms of chest pain. Innovation in health technology to develop the electrocardiogram transmission and communication system, along with routine performance measures of the STEMI network may help bridging the disparities of STEMI system of care between guideline recommended therapy and the real world clinical practice.

BASELINE CHARACTERISTICS AND CLINICAL OUTCOMES OF HOMELESS ADULTS PRESENTING TO AN INNER CITY STEMI NETWORK HOSPITAL

Cardiovascular mortality is a major cause of death among adults who are homeless. The underlying reasons for this increased risk are likely multifactorial and affected by medical, social and health care delivery factors. In the present study, we sought to characterize initial presentation, hospital course and clinical outcomes of homeless individuals presenting with ST-segment elevation myocardial infarction (STEMI) to an inner city STEMI network hospital.

Advanced age, time to treatment and long-term mortality: single centre data from the FAST-STEMI network

Background. Optimization of the techniques and larger accessibility to mechanical reperfusion have significantly improved the outcomes of patients with ST-segment elevation myocardial infarction (STEMI). However, suboptimal results have been observed in certain higher-risk subsets of patients, as in advanced age, where the benefits of primary PCI are more debated. We evaluated the impact of systematic primary percutaneous coronary intervention (PCI) and an optimized STEMI network on the long-term prognosis from a single centre experience. Methods. We included STEMI patients included in the FAST-STEMI network between 2016 and 2019. Ischemia duration was defined as the time from symptoms onset to coronary reopening (pain-to-balloon, PTB). The primary study endpoint (PE) was a composite of mortality and recurrent MI at long-term follow-up. Indywidual outcome endpoints were also assessed. Results. We included 253 patients undergoing primary PCI and discharged alive. Mean age was 67.2 ± 12.5 years, 75.1% males and 19.8% diabetics. At a median follow-up of 581 [307–922] days, the primary endpoint occurred in 24 patients (7.9%), of whom 5.5% died. The occurrence of a cardiovascular event was significantly associated with advanced age (p < 0.001), renal failure (p = 0.03), lower ejection fraction at discharge (p = 0.04) and longer in-hospital stay (p = 0.01). The median PTB was 198 minutes [IQR: 125–340 min], that was significantly longer among patients experiencing the PE (p = 0.01). A linear relationship was observed between age and PTB (r = 0.13, p = 0.009). However, both age ≥ 75 years and PTB above the median emerged as independent predictors of the primary endpoint (age: HR [95%CI] = 5.56 [2.26–13.7], p < 0.001, PTB: HR [95%CI] = 3.59 [1.39–9.3], p = 0.01). Similar results were observed for overall mortality. Conclusion. The present study shows that among STEMI patients undergoing primary PCI in a single centre, the duration of ischemia and advance age are independently associated to long-term mortality and recurrent myocardial infarction. However, longer time to reperfusion was observed among elderly patients.

Impact of COVID-19 on ST-segment elevation myocardial infarction care. The Spanish experience

Introduction and objectivesThe COVID-19 outbreak has had an unclear impact on the treatment and outcomes of patients with ST-segment elevation myocardial infarction (STEMI). The aim of this study was to assess changes in STEMI management during the COVID-19 outbreak. MethodsUsing a multicenter, nationwide, retrospective, observational registry of consecutive patients who were managed in 75 specific STEMI care centers in Spain, we compared patient and procedural characteristics and in-hospital outcomes in 2 different cohorts with 30-day follow-up according to whether the patients had been treated before or after COVID-19. ResultsSuspected STEMI patients treated in STEMI networks decreased by 27.6% and patients with confirmed STEMI fell from 1305 to 1009 (22.7%). There were no differences in reperfusion strategy (> 94% treated with primary percutaneous coronary intervention in both cohorts). Patients treated with primary percutaneous coronary intervention during the COVID-19 outbreak had a longer ischemic time (233 [150-375] vs 200 [140-332] minutes, P<.001) but showed no differences in the time from first medical contact to reperfusion. In-hospital mortality was higher during COVID-19 (7.5% vs 5.1%; unadjusted OR, 1.50; 95%CI, 1.07-2.11; P <.001); this association remained after adjustment for confounders (risk-adjusted OR, 1.88; 95%CI, 1.12-3.14; P=.017). In the 2020 cohort, there was a 6.3% incidence of confirmed SARS-CoV-2 infection during hospitalization. ConclusionsThe number of STEMI patients treated during the current COVID-19 outbreak fell vs the previous year and there was an increase in the median time from symptom onset to reperfusion and a significant 2-fold increase in the rate of in-hospital mortality. No changes in reperfusion strategy were detected, with primary percutaneous coronary intervention performed for the vast majority of patients. The co-existence of STEMI and SARS-CoV-2 infection was relatively infrequent.