Impact of delayed presentation on management and outcome of non-ST-elevation acute coronary syndromes

Factors associated with late presentation to the emergency department in patients complaining of chest pain

OBJECTIVE

We investigated which factors predict late presentation (LP) to the emergency department (ED) in patients with non-traumatic chest pain (CP).

METHODS

All CP cases attended at a single ED (2008-2017) were included. LP was considered if time from CP onset to ED arrival was>6 h. We analyzed associations between 42 patient/CP-related characteristics and LP in the whole cohort and in patients with CP due to acute coronary syndrome (ACS).

RESULTS

The cohort included 25,693 cases (LP=50.6%; ACS=19.0%). Twenty factors were associated with LP, and 8 were also found in patients with ACS: CP of short-duration, aggravated by exertion or breathing/movement, undulating or recurrent CP increased the risk of LP, whereas CP accompanied by diaphoresis, irradiated to the throat, and chronic treatment with nitrates decreased the risk of LP. Exertional and recurrent CP were associated with both, LP and ACS.

CONCLUSION

Some characteristics, mainly CP-related, may lead to LP to the ED. CP aggravated by exercise and recurrent CP were associated with both LP and a final diagnosis of ACS.

PRACTICE IMPLICATIONS

Patient educational initiatives should consider these two features as potential warnings for ACS and thereby encourage patients to seek early medical consultation.

Prevalence and Predictors of Delay in Seeking Emergency Care in Patients Who Call 9-1-1 for Chest Pain

BACKGROUND

Delay in seeking medical treatment for suspected acute coronary syndrome can lead to negative patient outcomes.

OBJECTIVE

Our aim was to evaluate the prevalence and predictors of delay in seeking care in high-risk chest pain patients with or without acute coronary syndrome (ACS).

METHODS

This was a secondary analysis of an observational cohort study of patients transported by Emergency Medical Services for a chief complaint of chest pain. Important demographic and clinical characteristics were extracted from electronic health records. Two independent reviewers adjudicated the presence of ACS. Logistic regression was used to model the predictors of delay in seeking care.

RESULTS

The final sample included 743 patients (99% non-Hispanic). Overall, 24% presented > 12 h from onset of symptoms. Among those with ACS (n = 115), 14% presented > 12 h after onset of symptoms. Race, smoking, diabetes, and related symptoms were associated with delayed seeking behavior. In multivariate analysis, non-Caucasian race (black or others) was the only independent predictor of > 12 h delay in seeking care (odds ratio 1.4; 95% confidence interval 1.0-1.9).

CONCLUSIONS

One in four patients with chest pain, including 14% of those with ACS, wait more than 12 h before seeking care. Compared to non-blacks, black patients are 40% more likely to delay seeking care > 12 h.

Pre-hospital and hospital delay in patients with non-ST elevation acute coronary syndromes in tertiary care

Background

Early presentation is desirable in all cases of acute prolonged chest pain. Causes of delayed presentation vary widely across geographic regions because of different patients' profile and different healthcare capabilities.

Objectives

To detect causes of delay of Non-ST elevation acute coronary syndrome (NSTE-ACS) patients in our country.

Methods

Patients admitted with NSTE-ACS were included. We recorded the time delay between the onsets of acute severe symptoms till their arrival to the hospital (Pre-hospital delay). We also recorded the time delay between the arrival to hospital and the institution of definitive therapy (hospital delay). Causes of pre-hospital delay are either patient- or transportation-related, while hospital delay causes are either staff- or system-related.

Results

We recruited 315 patients, 200 (63.5%) were males, 194 (61.6%) hypertensives, 180 (57.1%) diabetics, 106 (33.7%) current smokers and 196 (62.2%) patients had prior history of cardiac diseases. The mean pre-hospital delay time was 8.7 ± 9.7 h. Sixty-six percent of this time was due to patient-related causes and 34% of pre-hospital delay time was spent in transportation. The mean hospital delay time was 2.3 ± 0.95 h. In 89.8% of cases, the hospital delay was system-related while in 10.2% the reason was staff-related. The mean total delay time to definitive therapy was 11.0 ± 9.8 h.

Conclusion

Pre-hospital delay was mainly patient-related. Hospital delay was mainly related to healthcare resources. Governmental measures to promote ambulance emergency services may reduce the pre-hospital delay, while improving the utilization of healthcare resources may reduce hospital delay.

Outcomes of non-STEMI patients transported by emergency medical services vs private vehicle

BACKGROUND

Non-ST-segment elevation myocardial infarctions (NSTEMIs) are more common but less studied than ST-segment elevation myocardial infarctions (STEMIs) treated by emergency medical services (EMS).

OBJECTIVE

The purpose of this study was to evaluate the differences in baseline characteristics and outcomes of NSTEMI patients when arriving by EMS vs self-transport.

METHODS

We performed a retrospective medical record review of 96 EMS patients and 96 self-transport patients with the diagnosis of NSTEMI based on billing code.

RESULTS

The mean age of patients arriving by EMS was 75 vs 65 years for self-transport patients (P≤ .000). Patients arriving by self-transport received cardiac catheterization more often than patients arriving by EMS (84% vs 49%, P≤ .001). Emergency medical services patients had significantly longer average hospital length of stay and intensive care unit length of stay than did patients arriving by self-transport (6.5 vs 4 days [P≤ .001] and 4.1 vs 2.7 days [P= .019]). Significantly more EMS patients were discharged to a new extended care facility (25% vs 3.1%, P≤ .001). Finally, more EMS patients died in the hospital (18.8 vs 4.2%, P= .002).

CONCLUSIONS

Patients with NSTEMI who arrived by EMS are older, are more ill, and have worse outcomes compared with patients who arrived by self-transport. Further research into patient reasoning for mode of transportation to the ED may influence public health interventions, public policy development, and EMS and hospital protocols for management of NSTEMIs. The high mortality in prehospital cohort should prompt further investigation to develop evidence-based protocols.

Neutrophil activation precedes myocardial injury in patients with acute myocardial infarction

Myeloperoxidase (MPO), a heme protein abundantly expressed and secreted by polymorphonuclear neutrophils (PMN), has emerged as a critical mediator in coronary atherosclerosis. Retrospective analyses have suggested that free plasma levels of MPO predict adverse outcome in patients with low troponin T (TnT) levels who subsequently experience myocardial injury. The aim of this study was to evaluate the time course of MPO plasma levels in the early stages of acute myocardial infarction (AMI). Of 155 consecutive patients hospitalized for acute coronary syndromes, 38 presenting within 2 h of the onset of symptoms and subsequently diagnosed for AMI were included in the study. Serial blood samples taken between 1 and 24 h after the onset of chest pain were analyzed for MPO, TnT, creatine kinase MB, myoglobin, and high sensitive C-reactive protein. Fifty patients with angiographically proven but stable coronary artery disease (CAD) served as controls. In contrast to all other investigated markers, MPO was markedly elevated within 2 h of symptom onset in patients with AMI. Heparin, which is known to increase MPO plasma levels in patients with stable CAD, had no effect on MPO plasma levels in AMI patients. High levels of MPO plasma levels at the time of admission and the rapid peak of free plasma MPO levels after the onset of symptoms suggests that PMN activation is an early event in AMI and potentially precedes myocardial injury.