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Wrenn JO, Christensen MA, Ward MJ. Limitations in the use of automated mental status detection for clinical decision support. Int J Med Inform 2023; 180:105247. [PMID: 37864949 DOI: 10.1016/j.ijmedinf.2023.105247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 09/22/2023] [Accepted: 10/08/2023] [Indexed: 10/23/2023]
Abstract
BACKGROUND Clinical decision support (CDS) tools improve adherence to evidence-based practices but are dependent upon data quality in the electronic health record (EHR). Mental status is an integral component of many risk stratification scores, but it is not known whether EHR-measures of altered mental status are reliable. The Glasgow Coma Scale (GCS) is a measure of altered mentation that is widely adopted and entered in the EHR in structured format. We sought to determine the accuracy GCS < 15 as an EHR-measure of altered mentation compared to ED provider documentation. METHODS In patients presenting to an academic Emergency Department (ED) with pneumonia we abstracted GCS values entered by nurses during routine care and in a randomly selected subset manually reviewed provider documentation for evidence of altered mental status. We defined eConfusion as present if GCS < 15 at any point during the ED encounter. We then calculated the CURB-65 score and corresponding suggested disposition using each method. Performance of eConfusion and corresponding CURB-65 compared to manual versions was measured using agreement (Cohen's K), sensitivity, and specificity. RESULTS Among 300 randomly selected encounters, 47 (16 %) had eConfusion present and 46 (15 %) had evidence of altered mental status in provider documentation with Cohen's K 0.73. eConfusion had 78 % sensitivity and 96 % specificity for provider documented altered mental status. When input into CURB-65 to recommend inpatient disposition, eConfusion had 95 % sensitivity, and recommended discordant disposition for 3 %. CONCLUSIONS There was modest agreement between eConfusion and provider documentation of altered mental status. eConfusion had good specificity but low sensitivity which resulted in under-estimation of the CURB-65 score and occasional inappropriate disposition recommendations compared to provider documentation. These data do not support the use of GCS as a measure for altered mentation for use in CDS tools in the ED.
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Affiliation(s)
- Jesse O Wrenn
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, United States; Division of Emergency Medicine, Tennessee Valley Healthcare System VA, Nashville, TN, United States.
| | - Matthew A Christensen
- Division of Allergy, Pulmonary, & Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Michael J Ward
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, United States; Division of Emergency Medicine, Tennessee Valley Healthcare System VA, Nashville, TN, United States; Geriatric Research Education and Clinical Care Center, Tennessee Valley Healthcare System VA, Nashville, TN, United States
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Deng Q, Liu W. Utilization of clinical practice guideline on antimicrobial in China: an exploratory survey on multilevel determinants. BMC Health Serv Res 2020; 20:282. [PMID: 32252756 PMCID: PMC7137508 DOI: 10.1186/s12913-020-05171-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 03/30/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Nowadays, irrational use of antimicrobials has threatened public health. It's necessary to expand the use of clinical practice guideline (CPG) on antimicrobial for facilitating the proper use of antimicrobial. However, the utilization status of CPG on antimicrobial and the influencing factors, especially the ones at the organizational level, remain largely unknown. METHODS A cross-sectional questionnaire survey was conducted on a sample among physicians from 16 public hospitals in the eastern, central and western parts of China. A multilevel regression model was employed to examine factors associated with physicians' utilization of CPG on antimicrobial. RESULTS A total of 815 physicians were included in this study. About 80% of the surveyed physicians reported their adherence to the CPG on antimicrobial. Dimensions of "subjective norm", "perceived risk" and "behavioral intention" from the domain of physician belief, a dimension of "ease of use" from the domain of CPG traits, and dimensions of "top management support" and "organization & implementation" from the domain of hospital practice were significantly associated with physicians' utilization of CPG on antimicrobial. And except for working department, most demographics characteristics of the physician were not found to be significantly related to the CPG use. In addition, it also showed that region is a significant factor affecting physicians' CPG use. CONCLUSIONS This study depicted the current status of CPG on antimicrobial and comprehensively identified its potential determinants not only from the three domains at the individual level, such as physician belief, but also from the location region at the organizational level. The results will provide a direct reference for the implementation of CPG on antimicrobial.
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Affiliation(s)
- Qingwen Deng
- Department of Health Management, School of Public Health, Fujian Medical University, Room 108 in the Building for School of Public Health, 1 Xuefubei Road, Minhou District, Fuzhou, 350122, China
| | - Wenbin Liu
- Department of Health Management, School of Public Health, Fujian Medical University, Room 108 in the Building for School of Public Health, 1 Xuefubei Road, Minhou District, Fuzhou, 350122, China.
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Limotai C, Boonyapisit K, Suwanpakdee P, Jirasakuldej S, Wangponpattanasiri K, Wongwiangiunt S, Tumnark T, Noivong P, Pitipanyakul S, Tungkasereerak C, Tansuhaj P, Rattanachaisit W, Pleumpanupatand P, Kittipanprayoon S, Ekkachon P, Ingsathit A, Thakkinstian A. From international guidelines to real-world practice consensus on investigations and management of status epilepticus in adults: A modified Delphi approach. J Clin Neurosci 2020; 72:84-92. [PMID: 31983648 DOI: 10.1016/j.jocn.2020.01.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 01/06/2020] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To establish a consensus which is practical and ready-to-use on investigations (ISE) and for management of status epilepticus (MSE) in adults using a modified Delphi approach. PATIENTS AND METHODS A 4-round modified Delphi approach was used. First and second rounds were conducted using Google® survey with structured statements and 6-point Likert scale response. Threshold agreement was set to ≥80%. Third round was a face-to-face meeting aimed to facilitate the development of approach algorithms for ISE and MSE. Fourth round was a final review asking participants to rate the algorithms post completion. RESULTS The panel consisted of 8 board-certified epileptologists along with 6 neurologists from main regional hospitals across Thailand. Thirty-seven statements for ISE and 68 statements for MSE were used for the Round I survey, 17/37 (45.9%) and 49/68 (72.1%) reached threshold agreement (≥80%). The average absolute-agreement intraclass correlation coefficients for ISE and MSE were 0.82 (95% CI 0.71, 0.89) and 0.81 (95% CI 0.73, 0.87), respectively; indicating good extent of consensus among participants. Upon Round II, further 10/18 (55.6%) for ISE and 10/19 (52.6%) for MSE reached agreement. In Round III, face-to-face point-by-point discussion was performed to generate approach algorithms. All (100%) provided positive responses with the algorithms post completion in Round IV. CONCLUSION A practical and ready-to-use consensus using modified Delphi approach on ISE and MSE was developed in a Thai regional hospital context. In real practice, this approach is more suitable and feasible for a localized setting when compared with totally adopting international guidelines.
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Affiliation(s)
- Chusak Limotai
- Chulalongkorn Comprehensive Epilepsy Center of Excellence, The Thai Red Cross Society, King Chulalongkorn Memorial Hospital, Bangkok, Thailand; Division of Neurology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
| | - Kanokwan Boonyapisit
- Division of Neurology, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Piradee Suwanpakdee
- Division of Neurology, Department of Pediatrics, Phramongkutklao Hospital, Bangkok, Thailand
| | - Suda Jirasakuldej
- Chulalongkorn Comprehensive Epilepsy Center of Excellence, The Thai Red Cross Society, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | | | - Sattawut Wongwiangiunt
- Division of Neurology, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | | | - Panutchaya Noivong
- Chulalongkorn Comprehensive Epilepsy Center of Excellence, The Thai Red Cross Society, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Sirincha Pitipanyakul
- Chulalongkorn Comprehensive Epilepsy Center of Excellence, The Thai Red Cross Society, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Chaiwiwat Tungkasereerak
- Maharat Nakhon Ratchasima Hospital, Ministry of Public Health, Nakhon Ratchasima Province, Thailand
| | - Phopsuk Tansuhaj
- Chiangrai Prachanukroh Hospital, Ministry of Public Health, Chiangrai Province, Thailand
| | | | | | | | - Phattarawin Ekkachon
- Maharaj Nakhon Si Thammarat Hospital, Ministry of Public Health, Nakhon Si Thammarat Province, Thailand
| | - Atiporn Ingsathit
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Ammarin Thakkinstian
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Haugland H, Uleberg O, Klepstad P, Krüger A, Rehn M. Quality measurement in physician-staffed emergency medical services: a systematic literature review. Int J Qual Health Care 2019; 31:2-10. [PMID: 29767795 PMCID: PMC6387994 DOI: 10.1093/intqhc/mzy106] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Revised: 02/14/2018] [Accepted: 04/25/2018] [Indexed: 12/14/2022] Open
Abstract
Purpose Quality measurement of physician-staffed emergency medical services (P-EMS) is necessary to improve service quality. Knowledge and consensus on this topic are scarce, making quality measurement of P-EMS a high-priority research area. The aim of this review was to identify, describe and evaluate studies of quality measurement in P-EMS. Data sources The databases of MEDLINE and Embase were searched initially, followed by a search for included article citations in Scopus. Study selection The study eligibility criteria were: (1) articles describing the use of one quality indicator (QI) or more in P-EMS, (2) original manuscripts, (3) articles published from 1 January 1968 until 5 October 2016. The literature search identified 4699 records. 4543 were excluded after reviewing title and abstract. An additional 129 were excluded based on a full-text review. The remaining 27 papers were included in the analysis. Methodological quality was assessed using an adapted critical appraisal tool. Data extraction The description of used QIs and methods of quality measurement was extracted. Variables describing the involved P-EMSs were extracted as well. Results of data synthesis In the included papers, a common understanding of which QIs to use in P-EMS did not exist. Fifteen papers used only a single QI. The most widely used QIs were ‘Adherence to medical protocols’, ‘Provision of advanced interventions’, ‘Response time’ and ‘Adverse events’. Conclusion The review demonstrated a lack of shared understanding of which QIs to use in P-EMS. Moreover, papers using only one QI dominated the literature, thus increasing the risk of a narrow perspective in quality measurement. Future quality measurement in P-EMS should rely on a set of consensus-based QIs, ensuring a comprehensive approach to quality measurement.
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Affiliation(s)
- Helge Haugland
- Department of Research and Development, Norwegian Air Ambulance Foundation, Drøbak, Norway.,Department of Emergency Medicine and Pre-Hospital Services, St. Olavs Hospital, Trondheim, Norway.,Department of Circulation and Medical Imaging, Medical Faculty, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
| | - Oddvar Uleberg
- Department of Research and Development, Norwegian Air Ambulance Foundation, Drøbak, Norway.,Department of Emergency Medicine and Pre-Hospital Services, St. Olavs Hospital, Trondheim, Norway.,Department of Circulation and Medical Imaging, Medical Faculty, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
| | - Pål Klepstad
- Department of Circulation and Medical Imaging, Medical Faculty, NTNU, Norwegian University of Science and Technology, Trondheim, Norway.,Department of Anaesthesiology and Intensive Care, St. Olav University Hospital, Trondheim, Norway
| | - Andreas Krüger
- Department of Research and Development, Norwegian Air Ambulance Foundation, Drøbak, Norway.,Department of Emergency Medicine and Pre-Hospital Services, St. Olavs Hospital, Trondheim, Norway.,Department of Circulation and Medical Imaging, Medical Faculty, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
| | - Marius Rehn
- Department of Research and Development, Norwegian Air Ambulance Foundation, Drøbak, Norway.,Department of Health Studies, University of Stavanger, Stavanger, Norway.,Division of Emergencies and Critical Care, Department of Anaesthesia, Oslo University Hospital, Oslo, Norway
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Balen F, Lhermusier T, Grolleau S, Pélissier F, Dehours E, Charpentier S, Azema O, Lamy S. Identifying key factors leading to the optimal care pathway for patients with ST-segment elevation myocardial infarction: Results from the RESCAMIP registry. Arch Cardiovasc Dis 2019; 112:374-380. [PMID: 31160206 DOI: 10.1016/j.acvd.2019.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 09/27/2018] [Accepted: 01/24/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND In France, when someone presents with chest pain, it is recommended to call a health emergency number. The patient talks with an emergency doctor at a medical dispatch centre, who decides whether (or not) to send a Mobile Intensive Care Unit (MICU). Patients with an ST-segment elevation myocardial infarction (STEMI) should have an MICU as their first medical contact, to speed up confirmation of diagnosis and enable them to benefit from reperfusion therapy as quickly as possible. AIM To evaluate the proportion of patients with STEMI benefiting from an optimal care pathway, and to identify the key factors leading to this pathway. METHODS RESCAMIP was a multicentre registry conducted between May 2015 and May 2017 in Midi-Pyrénées. All patients treated for STEMI within 12hours of symptoms onset, without initially going into cardiac arrest, were included. RESULTS Data from 1371 patients with STEMI were analysed; 60% had an MICU as their first medical contact. In-hospital mortality was 4%. Factors associated with calling the medical dispatch centre when presenting chest pain were: age>65 years (odds ratio [OR] 1.37, 95% confidence interval [CI] 1.02-1.83), personal history of cardiovascular disease (OR 1.9, 95% CI 1.22-2.96) and having cardiovascular risk factors (OR 1.84, 95% CI 1.35-2.5). Factors associated with sending an MICU as first medical contact were: male sex (OR 2.11, 955 CI 1.49-2.99) and personal history of cardiovascular disease (OR 1.69, 95% CI 1.07-2.65). CONCLUSIONS The proportion of patients with STEMI going through non-optimal pathways was 40% in our area. We note that there are sex-based inequalities in accessing MICUs.
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Affiliation(s)
- Frederic Balen
- Emergency Department, Toulouse University Hospital, 31059 Toulouse, France; Laboratory of Epidemiology and Analyses in Public Health, UMR 1027 INSERM, 31000 Toulouse, France; Toulouse III-Paul Sabatier University, 31330 Toulouse, France.
| | | | - Sabrina Grolleau
- Regional Observatory of Emergency Medicine in Midi-Pyrénées, Toulouse University Hospital, 31059 Toulouse, France
| | - Fanny Pélissier
- Poison Control Centre, Toulouse University Hospital, 31059 Toulouse, France
| | - Emilie Dehours
- Emergency Department, Toulouse University Hospital, 31059 Toulouse, France
| | - Sandrine Charpentier
- Emergency Department, Toulouse University Hospital, 31059 Toulouse, France; Laboratory of Epidemiology and Analyses in Public Health, UMR 1027 INSERM, 31000 Toulouse, France; Toulouse III-Paul Sabatier University, 31330 Toulouse, France
| | - Olivier Azema
- Regional Observatory of Emergency Medicine in Midi-Pyrénées, Toulouse University Hospital, 31059 Toulouse, France
| | - Sebastien Lamy
- Laboratory of Epidemiology and Analyses in Public Health, UMR 1027 INSERM, 31000 Toulouse, France
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Ebben RHA, Siqeca F, Madsen UR, Vloet LCM, van Achterberg T. Effectiveness of implementation strategies for the improvement of guideline and protocol adherence in emergency care: a systematic review. BMJ Open 2018; 8:e017572. [PMID: 30478101 PMCID: PMC6254419 DOI: 10.1136/bmjopen-2017-017572] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 09/21/2018] [Accepted: 10/05/2018] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE Guideline and protocol adherence in prehospital and in-hospital emergency departments (EDs) is suboptimal. Therefore, the objective of this systematic review was to identify effective strategies for improving guideline and protocol adherence in prehospital and ED settings. DESIGN Systematic review. DATA SOURCES PubMed (including MEDLINE), CINAHL, EMBASE and Cochrane. METHODS We selected (quasi) experimental studies published between 2004 and 2018 that used strategies to increase guideline and protocol adherence in prehospital and in-hospital emergency care. Pairs of two independent reviewers performed the selection process, quality assessment and data extraction. RESULTS Eleven studies were included, nine of which were performed in the ED setting and two studies were performed in a combined prehospital and ED setting. For the ED setting, the studies indicated that educational strategies as sole intervention, and educational strategies in combination with audit and feedback, are probably effective in improving guideline adherence. Sole use of reminders in the ED setting also showed positive effects. The two studies in the combined prehospital and ED setting showed similar results for the sole use of educational interventions. CONCLUSIONS Our review does not allow firm conclusion on how to promote guideline and protocol adherence in prehospital emergency care, or the combination of prehospital and ED care. For ED settings, the sole use of reminders or educational interventions and the use of multifaceted strategies of education combined with audit and feedback are all likely to be effective in improving guideline adherence.
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Affiliation(s)
- Remco H A Ebben
- Faculty of Health and Social Studies, Research Department of Emergency and Critical Care, HAN University of Applied Sciences, Nijmegen, The Netherlands
| | - Flaka Siqeca
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, Erasmus Scholar from the University of Prishtina, Kosovo at the KU Leuven, Leuven, Belgium
| | | | - Lilian C M Vloet
- Faculty of Health and Social Studies, Research Department of Emergency and Critical Care, HAN University of Applied Sciences, Nijmegen, The Netherlands
- Radboud Institute for Health Sciences, IQ Healthcare, Radboud University Medical Center, Nijmegen, Netherlands
| | - Theo van Achterberg
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, Leuven, Belgium
- Department of Public Health and Primary Care, Uppsala University, Uppsala, Sweden
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Factors influencing ambulance nurses' adherence to a national protocol ambulance care: an implementation study in the Netherlands. Eur J Emerg Med 2016; 22:199-205. [PMID: 24595355 PMCID: PMC4410961 DOI: 10.1097/mej.0000000000000133] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Objectives Adherence to prehospital guidelines and protocols is suboptimal. Insight into influencing factors is necessary to improve adherence. The aim of this study was to identify factors that influence ambulance nurses’ adherence to a National Protocol Ambulance Care (NPAC). Methods A questionnaire was developed using the literature, a questionnaire and expert opinion. Ambulance nurses (n=452) from four geographically spread emergency medical services (EMSs) in the Netherlands were invited to fill out the questionnaire. The questionnaire included questions on influencing factors and self-reported adherence. Results Questionnaires were returned by 248 (55%) of the ambulance nurses. These ambulance nurses’ adherence to the NPAC was 83.4% (95% confidence interval 81.9–85.0). Bivariate correlations showed 23 influencing factors that could be related to the individual professional, organization, protocol characteristics and social context. Multilevel regression analysis showed that 21% of the variation in adherence (R2=0.208) was explained by protocol characteristics and social influences. Conclusion Ambulance nurses’ self-reported adherence to the NPAC seems high. To improve adherence, protocol characteristics (complexity, the degree of support for diagnosis and treatment, the relationship of the protocol with patient outcomes) and social influences (expectance of colleagues to work with the national protocol) should be addressed.
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Dasari TW, Hamilton S, Chen AY, Wang TY, Peterson ED, de Lemos JA, Saucedo JF. Non-eligibility for reperfusion therapy in patients presenting with ST-segment elevation myocardial infarction: Contemporary insights from the National Cardiovascular Data Registry (NCDR). Am Heart J 2016; 172:1-8. [PMID: 26856209 DOI: 10.1016/j.ahj.2015.10.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 10/17/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND Reperfusion therapy is lifesaving in patients presenting with ST-segment elevation myocardial infarction (STEMI). Contemporary data describing the characteristics and outcomes of patients presenting with STEMI not receiving reperfusion therapy are lacking. METHODS Using the ACTION Registry-GWTG database, we examined 219,726 STEMI patients (January 2007-December 2013) at 721 percutaneous coronary intervention (PCI)-capable hospitals in United States. Clinical characteristics and in-hospital outcomes were stratified by those who underwent reperfusion (n = 188,200; 86%), those who did not undergo reperfusion with a reason for ineligibility (n = 27,179; 12%), and those without reperfusion but had no reason for ineligibility (n = 4,347; 2%). RESULTS Compared with STEMI patients receiving reperfusion therapy, the nonreperfusion groups were older, were more often female, and had higher rates of hypertension, diabetes, prior myocardial infarction, prior stroke, atrial fibrillation, and left bundle-branch block and heart failure on presentation. The major reason for reperfusion noneligibility was coronary anatomy not suitable for PCI (33%). Presence of 3-vessel coronary disease was more common in the nonreperfusion groups (with or without a documented reason) compared with reperfusion group (38% and 36% vs 26%, P < .001, respectively). In-hospital mortality was higher in patients not receiving reperfusion therapy with or without a documented reason compared with the reperfusion group (adjusted odds ratio [95% CI] 1.88 [1.78-1.99] and 1.37 [1.21-1.57], respectively). CONCLUSION Most patients with STEMI not receiving reperfusion therapy had a documented reason. Coronary anatomy not suitable for PCI was the major contributor to ineligibility. In-hospital mortality was higher in patients not receiving reperfusion therapy.
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Affiliation(s)
- Tarun W Dasari
- University of Oklahoma Health Sciences Center, Oklahoma City, OK.
| | - Steve Hamilton
- University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Anita Y Chen
- Duke University Medical Center and Duke Cardiovascular Research Institute (DCRI), Durham, NC
| | - Tracy Y Wang
- Duke University Medical Center and Duke Cardiovascular Research Institute (DCRI), Durham, NC
| | - Eric D Peterson
- Duke University Medical Center and Duke Cardiovascular Research Institute (DCRI), Durham, NC
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Azzaz S, Charbonnel C, Ajlani B, Cherif G, Convers R, Blicq E, Augusto S, Gibault-Genty G, Baron N, Koukabi M, Almeida S, Vienet-Legué A, Da Costa S, Galuscan G, Schwob J, Livarek B, Georges JL. [Evolution of the interventional reperfusion strategy and reperfusion times in acute ST-segment elevation myocardial infarction]. Ann Cardiol Angeiol (Paris) 2015; 64:325-333. [PMID: 26442656 DOI: 10.1016/j.ancard.2015.09.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Accepted: 09/03/2015] [Indexed: 06/05/2023]
Abstract
BACKGROUND In patients with acute ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (pPCI), the recommended times (first medical contact-to-balloon (M2B) <120 or <90min, and door-to-balloon (D2B) <45min) are reached in less than 50% of patients. PURPOSE To compare the interventional reperfusion strategy and reperfusion times between two series of consecutive STEMI patients referred for pPCI within 12hours of symptom onset, in 2007 and 2012. METHODS Retrospective study of 182 patients, 87 admitted from January 2007 to March 2008 (period 1), and 95 admitted from January to December 2012 (period 2). The procedural characteristics and the different times between onset of pain and mechanical reperfusion were gathered and compared by non-parametric tests. RESULTS Radial access, thromboaspiration, and drug eluting stents were more frequent, and cardiogenic shock was less common during period 2, compared with the period 1. The median time from first medical contact to balloon (M2B) decreased by 26% (135min, [quartiles: 113-183] in 2007 versus 100 [76-137] in 2012, P<0.001), in relation to the reduction in both prehospital times and time in the catheterization laboratory (D2B: 51 [44-65] and 44min [37-55], respectively, P<0.01). CONCLUSIONS The D2B and M2B times significantly decreased in our centre between 2007 and 2012, and reached the recommended values in >60% of the cases. This may be explained by better coordination between emergency medical units and interventional cardiologists, and by the presence of two paramedics in the catheterization laboratory for 24/24 7/7 pPCI since 2010 in France, in accordance with recent national regulation.
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Affiliation(s)
- S Azzaz
- Unité de soins intensifs cardiologiques et cardiologie interventionnelle, service de cardiologie, hôpital André-Mignot, 177, rue de Versailles, 78157 Le Chesnay cedex, France
| | - C Charbonnel
- Unité de soins intensifs cardiologiques et cardiologie interventionnelle, service de cardiologie, hôpital André-Mignot, 177, rue de Versailles, 78157 Le Chesnay cedex, France
| | - B Ajlani
- Unité de soins intensifs cardiologiques et cardiologie interventionnelle, service de cardiologie, hôpital André-Mignot, 177, rue de Versailles, 78157 Le Chesnay cedex, France
| | - G Cherif
- Unité de soins intensifs cardiologiques et cardiologie interventionnelle, service de cardiologie, hôpital André-Mignot, 177, rue de Versailles, 78157 Le Chesnay cedex, France
| | - R Convers
- Unité de soins intensifs cardiologiques et cardiologie interventionnelle, service de cardiologie, hôpital André-Mignot, 177, rue de Versailles, 78157 Le Chesnay cedex, France
| | - E Blicq
- Unité de soins intensifs cardiologiques et cardiologie interventionnelle, service de cardiologie, hôpital André-Mignot, 177, rue de Versailles, 78157 Le Chesnay cedex, France
| | - S Augusto
- Unité de soins intensifs cardiologiques et cardiologie interventionnelle, service de cardiologie, hôpital André-Mignot, 177, rue de Versailles, 78157 Le Chesnay cedex, France
| | - G Gibault-Genty
- Unité de soins intensifs cardiologiques et cardiologie interventionnelle, service de cardiologie, hôpital André-Mignot, 177, rue de Versailles, 78157 Le Chesnay cedex, France
| | - N Baron
- Unité de soins intensifs cardiologiques et cardiologie interventionnelle, service de cardiologie, hôpital André-Mignot, 177, rue de Versailles, 78157 Le Chesnay cedex, France
| | - M Koukabi
- Service d'accueil des urgences, hôpital André-Mignot, 78157 Le Chesnay, France
| | - S Almeida
- Unité de soins intensifs cardiologiques et cardiologie interventionnelle, service de cardiologie, hôpital André-Mignot, 177, rue de Versailles, 78157 Le Chesnay cedex, France
| | - A Vienet-Legué
- Unité de soins intensifs cardiologiques et cardiologie interventionnelle, service de cardiologie, hôpital André-Mignot, 177, rue de Versailles, 78157 Le Chesnay cedex, France
| | - S Da Costa
- SAMU 78/SMUR, hôpital André-Mignot, centre hospitalier de Versailles, 78157 Le Chesnay, France
| | - G Galuscan
- Unité de soins intensifs cardiologiques et cardiologie interventionnelle, service de cardiologie, hôpital André-Mignot, 177, rue de Versailles, 78157 Le Chesnay cedex, France
| | - J Schwob
- Unité de soins intensifs cardiologiques et cardiologie interventionnelle, service de cardiologie, hôpital André-Mignot, 177, rue de Versailles, 78157 Le Chesnay cedex, France
| | - B Livarek
- Unité de soins intensifs cardiologiques et cardiologie interventionnelle, service de cardiologie, hôpital André-Mignot, 177, rue de Versailles, 78157 Le Chesnay cedex, France
| | - J-L Georges
- Unité de soins intensifs cardiologiques et cardiologie interventionnelle, service de cardiologie, hôpital André-Mignot, 177, rue de Versailles, 78157 Le Chesnay cedex, France.
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Wong KL, Wong YTA, Yung SYA, Tam CCF, Lam CCS, Hai SHJ, Chan KWK, Chan WSC, Lam YM, Lam L, Chan HWR, Lee WLS. A single centre retrospective cohort study to evaluate the association between implementation of an acute myocardial infarction clinical pathway and clinical outcomes. Int J Cardiol 2014; 182:82-4. [PMID: 25576728 DOI: 10.1016/j.ijcard.2014.12.105] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Accepted: 12/25/2014] [Indexed: 12/22/2022]
Affiliation(s)
- Ka Lam Wong
- Division of Cardiology, Department of Medicine, Queen Mary Hospital, Hong Kong.
| | | | - See Yue Arthur Yung
- Division of Cardiology, Department of Medicine, Queen Mary Hospital, Hong Kong
| | | | | | - Siu Han Jojo Hai
- Division of Cardiology, Department of Medicine, Queen Mary Hospital, Hong Kong
| | - Ki Wan Kelvin Chan
- Division of Cardiology, Department of Medicine, Queen Mary Hospital, Hong Kong
| | | | - Yui Ming Lam
- Division of Cardiology, Department of Medicine, Queen Mary Hospital, Hong Kong
| | - Linda Lam
- Division of Cardiology, Department of Medicine, Queen Mary Hospital, Hong Kong
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12
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Duraffourg A, Yayehd K, Fourny M, Turk J, Massoutier M, Ageron FX, Debaty G, Ricard C, Vanzetto G, Belle L, Labarere J. [Reperfusion in ST elevation myocardial infarction. From the guidelines to practice]. Ann Cardiol Angeiol (Paris) 2014; 63:312-320. [PMID: 25283574 DOI: 10.1016/j.ancard.2014.09.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND International guidelines have recommendations for selecting the type of reperfusion (fibrinolysis or angioplasty) in the setting of ST-segment elevation myocardial infarction (STEMI), and suggest that emergency-care networks adapt these recommendations according to the local environment. AIM To assess the proportions of STEMI patients treated with fibrinolysis or angioplasty in accordance with regional guidelines. METHOD Observational study based on a permanent registry of patients with STEMI of <12h duration in an emergency network in the French North Alps (Isère, Savoie, Haute-Savoie) from January 2009 to December 2012. RESULTS The registry included 2620 patients. Reperfusion was given in 2425/2620 (93%) of patients. Reperfusion type was in accordance with recommendations in 1567/2620 (60%) patients. Guideline-recommended fibrinolysis and angioplasty were performed in 47% (656/1385) and 79% (911/1149) respectively, of patients. In multivariable analysis, variables independently associated with guideline-recommended reperfusion were: an age < 65 years (OR 1.60; 95%CI 1.33-1.90), being managed in Haute-Savoie versus Isère or Savoie (OR 1.38; 95%CI 1.12-1.71), an arterial tension < 100mmHg (OR 1.73; 95%CI 1.27-2.35), a cardiogenic shock (OR 0.50; 95%CI 0.30-0.84), a pacemaker or left bundle branch block (OR 0.49; 95%CI 0.28-0.88), and an initial management outside the network (followed by treatment in an interventional centre in the network) (OR 0.62; 95%CI 0.40-0.94). Patients initially treated by mobile intensive care units were more often reperfused in accordance with recommendations when admitted < 3 (versus ≥ 3) h following symptom onset (adjusted OR 2.05; 95% CI 1.61-2.59), while those initially treated by in-hospital emergency units were less often reperfused in accordance with recommendation when treated < 3h following symptom onset (adjusted OR 0.67; 95% CI 0.46-0.97). In-hospital major adverse cardiac events (9.1% vs. 8.5%) and in-hospital mortality (6.4% vs. 5.1%) were not significantly different between patients reperfused in accordance with (versus not) recommendations. CONCLUSIONS Forty percent of patients with STEMI were not reperfused with fibrinolysis or angioplasty in accordance with regional guidelines. Characterization of this population should allow us to improve guideline adherence.
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Affiliation(s)
- A Duraffourg
- Médecins de Montagne Rhône-Alpes, 256, rue de la République, 73000 Chambery, France
| | - K Yayehd
- Service de cardiologie, CHU Campus, 03 BP 30284, Lomé, Togo
| | - M Fourny
- Unité d'évaluation médicale, CHU, 38000 Grenoble, France
| | - J Turk
- Service d'aide médicale urgente, centre hospitalier, 73000 Chambery, France
| | - M Massoutier
- Unité d'évaluation médicale, CHU, 38000 Grenoble, France
| | - F X Ageron
- Service d'aide médicale urgente, centre hospitalier, 74000 Annecy, France
| | - G Debaty
- Service d'aide médicale urgente, CHU, 38000 Grenoble, France
| | - C Ricard
- Réseau nord Alpin des urgences, centre hospitalier, 74000 Annecy, France
| | - G Vanzetto
- Service de cardiologie, CHU, 38000 Grenoble, France
| | - L Belle
- Service de cardiologie, centre hospitalier, 74000 Annecy, France.
| | - J Labarere
- Unité d'évaluation médicale, CHU, 38000 Grenoble, France
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An Exploration of Factors Influencing Ambulance and Emergency Nurses’ Protocol Adherence in the Netherlands. J Emerg Nurs 2014; 40:124-30. [DOI: 10.1016/j.jen.2012.09.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2012] [Revised: 09/25/2012] [Accepted: 09/25/2012] [Indexed: 11/20/2022]
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Ebben RHA, Vloet LCM, Verhofstad MHJ, Meijer S, Groot JAJMD, van Achterberg T. Adherence to guidelines and protocols in the prehospital and emergency care setting: a systematic review. Scand J Trauma Resusc Emerg Med 2013; 21:9. [PMID: 23422062 PMCID: PMC3599067 DOI: 10.1186/1757-7241-21-9] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2012] [Accepted: 01/29/2013] [Indexed: 12/15/2022] Open
Abstract
A gap between guidelines or protocols and clinical practice often exists, which may result in patients not receiving appropriate care. Therefore, the objectives of this systematic review were (1) to give an overview of professionals' adherence to (inter)national guidelines and protocols in the emergency medical dispatch, prehospital and emergency department (ED) settings, and (2) to explore which factors influencing adherence were described in studies reporting on adherence. PubMed (including MEDLINE), CINAHL, EMBASE and the Cochrane database for systematic reviews were systematically searched. Reference lists of included studies were also searched for eligible studies. Identified articles were screened on title, abstract and year of publication (≥1990) and were included when reporting on adherence in the eligible settings. Following the initial selection, articles were screened full text and included if they concerned adherence to a (inter)national guideline or protocol, and if the time interval between data collection and publication date was <10 years. Finally, articles were assessed on reporting quality. Each step was undertaken by two independent researchers. Thirty-five articles met the criteria, none of these addressed the emergency medical dispatch setting or protocols. Median adherence ranged from 7.8-95% in the prehospital setting, and from 0-98% in the ED setting. In the prehospital setting, recommendations on monitoring came with higher median adherence percentages than treatment recommendations. For both settings, cardiology treatment recommendations came with relatively low median adherence percentages. Eight studies identified patient and organisational factors influencing adherence. The results showed that professionals' adherence to (inter)national prehospital and emergency department guidelines shows a wide variation, while adherence in the emergency medical dispatch setting is not reported. As insight in influencing factors for adherence in the emergency care settings is minimal, future research should identify such factors to allow the development of strategies to improve adherence and thus improve quality of care.
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Affiliation(s)
- Remco HA Ebben
- Research group for Acute Care, Faculty of Health and Social Studies, HAN University of Applied Sciences, Verlengde Groenestraat 75, 6525 EJ, Nijmegen, The Netherlands
- Research group for Acute Care, Faculty of Health and Social Studies, HAN University of Applied Sciences, PO Box 6960, 6503 GL, Nijmegen, The Netherlands
| | - Lilian CM Vloet
- Research group for Acute Care, Faculty of Health and Social Studies, HAN University of Applied Sciences, Verlengde Groenestraat 75, 6525 EJ, Nijmegen, The Netherlands
- Canisius Wilhelmina Hospital, Weg door Jonkerbos 100, 6532 SZ, Nijmegen, The Netherlands
| | | | - Sanne Meijer
- Research group for Acute Care, Faculty of Health and Social Studies, HAN University of Applied Sciences, Verlengde Groenestraat 75, 6525 EJ, Nijmegen, The Netherlands
| | - Joke AJ Mintjes-de Groot
- Research group for Acute Care, Faculty of Health and Social Studies, HAN University of Applied Sciences, Verlengde Groenestraat 75, 6525 EJ, Nijmegen, The Netherlands
| | - Theo van Achterberg
- Scientific Institute for Quality of Healthcare, Radboud University Nijmegen Medical Centre, Geert Grooteplein 21, 6525 EZ, Nijmegen, The Netherlands
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Sandouk A, Ducassé JL, Grolleau S, Azéma O, Elbaz M, Farah B, Tidjane A, Kelly-Irving M, Charpentier S. Compliance with guidelines in patients with ST-segment elevation myocardial infarction after implementation of specific guidelines for emergency care: Results of RESCA+31 registry. Arch Cardiovasc Dis 2012; 105:262-70. [DOI: 10.1016/j.acvd.2012.03.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2012] [Revised: 03/04/2012] [Accepted: 03/06/2012] [Indexed: 11/26/2022]
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Georges JL, Ben-Hadj I, Gibault-Genty G, Blicq E, Aziza JP, Ben-Jemaa K, Moro J, Koukabi M, Livarek B. [Accuracy of the door-to-balloon time for assessing the result of the interventional reperfusion strategy in acute ST-segment elevation myocardial infarction]. Ann Cardiol Angeiol (Paris) 2011; 60:244-251. [PMID: 21978820 DOI: 10.1016/j.ancard.2011.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2011] [Accepted: 07/24/2011] [Indexed: 05/31/2023]
Abstract
BACKGROUND In patients with acute ST-segment elevation myocardial infarction (STEMI), recent clinical guidelines recommend that primary percutaneous coronary intervention (PCI) should be performed within 90min of first medical contact or 45min after admission in cathlab. The Door-to-Balloon time (D2B) is widely used to measure the performance of interventional centres. AIM OF THE STUDY To analyze the time to reperfusion in a consecutive series of STEMI patients referred for primary PCI, and to evaluate the clinical accuracy of D2B in primary PCI. METHODS From January 2007 to March 2008, 177 patients were admitted within 12hours of a STEMI in our institution, and 87 were referred for a direct coronary angiography for primary PCI (47 by mobile medical emergency unit, 40 by the emergency department of the institution). RESULTS The median time from first medical contact to balloon inflation (M2B) was 135min [IQR 112-183]. Recommended times were fulfilled in a minority of patients (M2B<90min: 9%,<120min: 34%). Median cathlab D2B was 51min [IQR 44-65], and was less than 45min in 34% of patients. No differences for times to reperfusion within cathlab were found between in- and off-time hours. M2B and D2B were unavailable in 23 patients (26%), because of a spontaneous TIMI 3 flow reperfusion without indication for immediate PCI in 20 patients, contra-indication for PCI in two (distal occlusion, culprit vessel diameter less than 2mm), and failure in occlusion crossing by the guide-wire in one patient. In contrast, first medical contact- or door-to-reperfusion times, assessed by a TIMI 3 flow without no-reflow in culprit artery, were available in 95% of patients, and were shorter than M2B or D2B, respectively. CONCLUSION Although it is a feasible and reproducible process performance measure, D2B time is weakly associated with the outcome of the interventional reperfusion strategy in acute STEMI. This measure should be associated with an outcome performance measure, such as the rate of TIMI 3 flow achieved by primary PCI, or replaced by the Door-to-TIMI 3 flow reperfusion time.
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Affiliation(s)
- J-L Georges
- Service de cardiologie, hôpital André-Mignot, Le-Chesnay cedex, France.
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Ferrières J, Sartral M, Tcherny-Lessenot S, Belger M. A prospective observational study of treatment practice patterns in acute coronary syndrome patients undergoing percutaneous coronary intervention in Europe. Arch Cardiovasc Dis 2011; 104:104-14. [PMID: 21402345 DOI: 10.1016/j.acvd.2010.12.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2010] [Revised: 11/18/2010] [Accepted: 12/07/2010] [Indexed: 11/19/2022]
Abstract
BACKGROUND The AntiPlatelet Therapy Observational Registry (APTOR) was a prospective observational study of acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI) in France, Spain, and the UK. AIMS To evaluate patterns of ACS healthcare use, focusing on APTOR results from France. METHODS Consecutive presenting ACS patients requiring PCI were recruited between January and August 2007. Treatments and outcomes were recorded from the qualifying ACS event to 12 months follow-up. RESULTS In France, qualifying diagnosis was unstable angina/non-ST-segment elevation myocardial infarction (UA/NSTEMI) in 255(53%) patients and ST-segment elevation myocardial infarction (STEMI) in 228(47%)patients. Ninety-six percent underwent PCI with stent implantation. Drug eluting stents were used less frequently in France(22%) than Spain (54%) or the UK (42%). In France, antiplatelets were more frequently received in the ambulance (21%); a 200-299mg aspirin-loading dose was most frequently received (50%) and more than a third of patients received a clopidogrel-loading dose of over 300mg (34%). At 12 months in France, 86% were still receiving aspirin, 75% clopidogrel, and 73% combination treatment. CONCLUSION There was considerable country-variation in ACS management. These results provide a benchmark of physician practice to compare with guidelines.
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Affiliation(s)
- Jean Ferrières
- Unité 02 (rez-de-chaussée), service de cardiologie B, bâtiment H1, CHU Rangueil, TSA 50032, 31059 Toulouse cedex 9, France.
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Cohen M, Boiangiu C, Abidi M. Therapy for ST-segment elevation myocardial infarction patients who present late or are ineligible for reperfusion therapy. J Am Coll Cardiol 2010; 55:1895-906. [PMID: 20430260 DOI: 10.1016/j.jacc.2009.11.087] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2009] [Revised: 11/18/2009] [Accepted: 11/19/2009] [Indexed: 10/19/2022]
Abstract
Despite the wide contemporary availability of pharmacological and mechanical means of reperfusion, a very significant proportion of ST-segment elevation myocardial infarction (STEMI) patients are still not offered any reperfusion therapy, and some of them are considered "ineligible for reperfusion." Spontaneous reperfusion and contraindications to the use of fibrinolytics and/or mechanical reperfusion methods account only for a small part of these clinical situations. The boundary between "timely" and "late" presentation in STEMI, the appropriateness of percutaneous intervention in patients presenting late after onset of symptoms, and the impact of sex and age on the eligibility and/or choice of reperfusion therapy continue to be challenged by the most recent published data. In the current invasive-driven reperfusion era, if scientific evidence and clinical guidelines are applied diligently, the vast majority of eligible STEMI patients should receive reperfusion therapy. Pharmacological nonlytic therapy of patients with STEMI, regardless of the choice of reperfusion strategy or the absence of it, is clearly defined by the current practice guidelines. Available data suggest that for patients who do not receive any form of reperfusion, anticoagulation therapy with low molecular weight heparin provides a clear additional mortality benefit versus placebo. Fondaparinux as compared with usual care (unfractionated heparin infusion or placebo) significantly reduces the composite of death or myocardial reinfarction without increasing severe bleeding or number of strokes. In the treatment of late-presenting patients with STEMI (beyond the first 12 h after onset of symptoms), clinical evaluation and risk stratification represent the crucial elements helping in decision making between therapeutic interventions.
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Affiliation(s)
- Marc Cohen
- Division of Cardiology, Newark Beth Israel Medical Center, Newark, New Jersey 07112, USA.
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Gao Y, Tong GX, Zhang XW, Leng JH, Jin JF, Wang NF, Yang JM. Interleukin-18 Levels on Admission Are Associated With Mid-Term Adverse Clinical Events in Patients With ST-Segment Elevation Acute Myocardial Infarction Undergoing Percutaneous Coronary Intervention. Int Heart J 2010; 51:75-81. [DOI: 10.1536/ihj.51.75] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Yan Gao
- Department of Cardiology, Hangzhou No.1 Municipal Hospital and Hangzhou Hospital, Nanjing Medical University
| | - Guo-xin Tong
- Department of Cardiology, Hangzhou No.1 Municipal Hospital and Hangzhou Hospital, Nanjing Medical University
| | - Xing-wei Zhang
- Department of Cardiology, The Affiliated Hospital of Hangzhou Normal University and The Second Municipal Hospital
| | - Jian-hang Leng
- Department of Clinical Laboratory Medicine, Hangzhou No.1 Municipal Hospital and Hangzhou Hospital, Nanjing Medical University
| | - Jian-fen Jin
- Department of Cardiology, Hangzhou No.1 Municipal Hospital and Hangzhou Hospital, Nanjing Medical University
| | - Ning-fu Wang
- Department of Cardiology, Hangzhou No.1 Municipal Hospital and Hangzhou Hospital, Nanjing Medical University
| | - Jian-min Yang
- Department of Cardiology, Hangzhou No.1 Municipal Hospital and Hangzhou Hospital, Nanjing Medical University
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