Association between prehospital electrocardiogram use and patient home distance from the percutaneous coronary intervention center on total reperfusion time in ST-segment-elevation myocardial infarction patients: a retrospective analysis from the national cardiovascular data registry

Clinical Efficacy of Pre-Hospital Electrocardiogram Transmission in Patients Undergoing Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction

Rapid reperfusion by primary percutaneous coronary intervention (pPCI) is an established strategy for the treatment of patients with ST-segment elevation myocardial infarction (STEMI). Pre-hospital electrocardiogram (PH-ECG) transmission by the emergency medical services (EMS) facilitates timely reperfusion in these patients. However, evidence regarding the clinical benefits of PH-ECG in individual hospitals is limited.This retrospective, observational study investigated the clinical efficacy of PH-ECG in STEMI patients who underwent pPCI. Of a total of 382 consecutive STEMI patients, 237 were enrolled in the study and divided into 2 groups: a PH-ECG group (n = 77) and non-PH-ECG group (n = 160). Door-to-balloon time (D2BT) was significantly shorter in the PH-ECG group (66 [52-80] min), compared to the non-PH-ECG group (70 [57-88] minutes, P = 0.01). The 30-day all-cause mortality rate was 6% in the PH-ECG group, which was significantly lower than that in the non-PH-ECG group (16%) (P = 0.037, hazard ratio [HR]: 0.38, 95% CI: 0.15-0.98). This trend was particularly evident in severely ill patients when stratified by GRACE score.The use of PH-ECG improved the survival rate of STEMI patients undergoing pPCI due to the improved pre-arrival preparation based on the EMS information. Coordination between EMS and PCI-capable institutes is essential for the management of PH-ECG.

Development and outcomes of hyperkalemia in hospitalized patients: potential implications for care

INTRODUCTION

While severe hyperkalemia is commonly encountered, its manifestation in hospitalized patients and related outcomes are unclear. We aimed to examine development of hyperkalemia in hospitalized patients and associated outcomes.

METHODS

Data from a county hospital electronic health record were used to assess all inpatient admissions, 2012-2016, for non-dialysis-dependent patients with ≥1 K value for development of hyperkalemia. Unadjusted odds ratios (ORs) were calculated for associations of the maximum K value with in-hospital mortality and adjusted ORs were calculated for death associated with hyperkalemia.

RESULTS

In 47,018 individual patient hospitalizations, 1.3% had a maximum K ≥6.0 mEq/L and 4.2% <3.5 mEq/L. Fifth and 95th percentiles for maximum K values were 3.5 and 5.3 mEq/L. For high-K patients with a prior K value, the mean (SD) of the immediate pre-maximum K value was 5.0 ± 1.0 mEq/L, and the mean difference in K values (immediate pre-maximum to maximum) was 1.5 ± 1.1 mEq/L; mean duration between these two K tests was 10.7 ± 14.9 hours. Compared with maximum K values 3.5 to 4.0 mEq/L, ORs for death were 37.1 (95% confidence intervals, 25.8-53.3) for K 6.0 to <6.5, 88.6 (56.8-138.2) for K ≥7.0, and 18.9 (4.3-82.2) for K <3.0 mEq/L. In adjusted models, the OR for death for K ≥6.0 mEq/L was 4.9 (3.7-6.4).

DISCUSSION/CONCLUSIONS

Peak K values ≥6.0 mEq/L were associated with mortality. Values tended to increase rapidly, limiting opportunities for detection and treatment. Systems-based approaches to detect life-threatening hyperkalemia should be studied.

Factors affecting STEMI performance in six hospitals within one healthcare system

BACKGROUND

How quickly percutaneous coronary intervention is performed in patients with ST-elevation myocardial infarction (STEMI) is a quality measure, reported as door-to-balloon (D2B) time.

OBJECTIVES

To explore factors affecting STEMI performance in six hospitals in one healthcare system.

METHODS

This was a retrospective chart review of clinical features and D2B times. Predictors for D2B times were identified using multivariate linear regression.

RESULTS

The median D2B time for all six hospitals was 63 minutes and all hospitals surpassed the minimal recommended percentage of patients achieving D2B time ≤90 minutes (87.8%vs75%,p<0.001). Patient confounders adversely affect D2B times (+21.5 minutes, p<0.001). Field ECG/activation with emergency department (ED) transport (-22.0 minutes) or direct cardiac catheterization laboratory (CCL) transport (-27.3 minutes) was superior to ED ECG/activation (p<0.001).

CONCLUSION

Field ECG/STEMI activation significantly shortened D2B time. To improve D2B time, hospital and Emergency Medical Service collaboration should be advocated to increase field activation and direct patient transportation to CCL.

The impact of pre-hospital 12-lead electrocardiogram and first contact by cardiologist in patients with ST-elevation myocardial infarction in Kanagawa, Japan

Background pre-hospital 12-lead electrocardiogram (ECG) by emergency medical service (EMS) personnel at the site of first medical contact (FMC) and the physician of first contact both play important roles in managing patients with ST-elevation myocardial infarction (STEMI). However, in Japan, pre-hospital 12-lead ECG is not routinely performed by EMS personnel at the site of FMC and the physician of first contact is not always a cardiologist. Methods from October 2015 to October 2019, 2035 consecutive STEMI patients transported from the field by ambulance were analyzed from the K-ACTIVE registry. Based on the presence (+) or absence (-) of pre-hospital 12-lead ECG / first contact by cardiologist, patients were divided into 4 groups (+/+, +/-, -/+, -/-). Patient characteristics, FMC to door time, door to device time and in-hospital mortality were compared. Results the numbers of patients in each group were as follows (+/+, n = 987; +/-, n = 211; -/+, n = 610; -/-, n = 227). For patient characteristics, there were significant differences in the prevalence of dyslipidemia and the presence of chest pain. The FMC to door time was similar (median value, +/+, 24 min; +/-, 25 min; -/+, 24 min; -/-, 24 min; p = 0.23). The door to device time was the shortest in the +/+ group (median value, +/+, 65 min; +/-, 80 min; -/+, 69 min; -/-, 88 min; p < 0.0001). Crude in-hospital mortality was the highest in the -/- group (+/+, 3.9%; +/-, 2.4%; -/+, 5.8%; -/-, 11.9%; p < 0.0001). After adjustment for age and sex, the adjusted odds ratios for in-hospital mortality were as follows [odds ratio (with 95% confidence interval) +/+, 0.33 [0.19-0.57]; +/-, 0.19 [0.07-0.52]; -/+, 0.49 [0.29-0.86]; -/-, 1 [reference)]. Conclusion pre-hospital 12-lead ECG and the physician of first contact had a significant impact on the door to device time and in-hospital mortality. Continuous efforts should be made to improve acute management of STEMI.

Electrocardiogram Interpretation Competency Among Paramedic Students

BACKGROUND

Electrocardiography is an essential emergency tool used in the pre-hospital setting. However, no studies have yet assessed electrocardiogram (ECG) interpretation among emergency medical services (EMS) students in Saudi Arabia. This study aimed to determine the ECG interpretation competency of paramedic students.

METHODOLOGY

Cross-sectional, single-center study, a pre-validated, self-administered, two-part questionnaire first created by Coll-Badell et al was used to assess the ECG interpretation competency of paramedic students at Prince Sultan College for Emergency Medical Services (PSCEMS) in King Saud University. Participant data were collected and analyzed to identify factors associated with improved competency.

RESULTS

All students of PSCEMS were included, and 137 of 248 paramedic students completed the questionnaire (55% response rate); 88 students (64.2%) scored >7.5 points, indicating competency in (ECG) interpretation. Factors such as grade point average (GPA) (>3.5) and enrollment in cardiology and advanced cardiac life support courses were found to be significantly associated with competency (p<0.001).

CONCLUSION

The majority of paramedic students were found to be competent in ECG interpretation. GPA and enrollment in cardiology and advanced cardiac life support courses were significantly associated with improved competency.

Diurnal Variation in Outcomes of Percutaneous Coronary Intervention

Objectives

To determine whether the outcomes differ during regular hours as compared to off hours in patients with acute myocardial infarction who undergo primary percutaneous coronary intervention.

Methods

We conducted a prospective, interventional study of patients who presented to a specialized cardiac care center. Patients who satisfied the inclusion and exclusion criteria were included in the study. They were divided into two groups so that one group received intervention during regular working hours while the other group received intervention during 'off' hours. The data was collected through a self-constructed questionnaire. Cronbach's alpha was used to assess the internal consistency of the questionnaire, and it was found to be 0.75. The data obtained was analyzed on IBM's Statistical Package for the Social Sciences (SPSS) version 21.0 (IBM, Armonk, NY).

Results

Out of 100 participants, 64 (64%) were males and 36 (36%) were females. The mean age of the participants was 58.58 ± 13.21 years. Most (44%) of the patients were diabetic. Inferior wall myocardial infarcts were more common in our study. Percutaneous intervention during 'off' hours was associated with more adverse outcomes. The differences in gender and angina requiring revascularization were statistically significant (p-value<0.05).

Conclusion

No significant difference in outcomes was observed in both groups of patients. Metacentric data from different institutes should be gathered for a comprehensive insight on this topic where door-to-balloon times and initiation of catheterization lab procedures are practiced in different ways.

"Door-In to Door-Out" Delay in Patients with Acute ST-Segment Elevation Myocardial Infarction Transferred for Primary Percutaneous Coronary Intervention in a Metropolitan STEMI Network of a Developing Country

Background  Routine performance measures of primary percutaneous coronary intervention (PCI) within an ST-segment elevation myocardial infarction (STEMI) network are needed to improve care. Objective  We evaluated the door-in to door-out (DI-DO) delays at the initial hospitals in STEMI patients as a routine performance measure of the metropolitan STEMI network. Patients and Methods  We retrospectively analyzed the DI-DO time from 1,076 patients with acute STEMI who were transferred by ground ambulance to a primary PCI center for primary PCI between 4 October 2014 and 1 April 2019. Correlation analysis between DI-DO times and total ischemia time was performed using Spearman's test. Logistic regression analyses were used to find variables associated with a longer DI-DO time. Results  Median DI-DO time was 180 minutes (25th percentile to 75th percentile: 120-252 minutes). DI-DO time showed a positive correlation with total ischemia time ( r  = 0.4, p  < 0.001). The median door-to-device time at the PCI center was 70 minutes (25th percentile to 75th percentile: 58-88 minutes). Multivariate analysis showed that women patients were independently associated with DI-DO time > 120 minutes (odds ratio 1.55, 95% confidence interval 1.03 to 2.33, p  = 0.03). Conclusion  The DI-DO time reported in this study has not reached the guideline recommendation. To improve the overall performance of primary PCI in the region, interventions aimed at improving the DI-DO time at the initial hospitals and specific threat for women patients with STEMI are possibly the best efforts in improving the total ischemia time.

The effects of prehospital system delays on the treatment efficacy of STEMI patients

Background

Cardiovascular disease accounts for nearly half of all deaths in Poland. The aim of this study was to assess both the duration and the delays of prehospital treatment in ST-segment elevation myocardial infarction (STEMI) patients and how it impacts left ventricle ejection fraction (LVEF) measured at the time of discharge and the frequency of in-hospital patient mortality.

Methods

This study retrospectively analyzed medical records from January 2011 to December 2015 (excluding the year 2013) of 573 patients who were transported to a hospital with a diagnosis of STEMI.

Results

The mean time of prehospital system delays was 59 min with a maximum time of 152 min and a minimum time of 23 min. The relationship between reduced LVEF (< 55%) and in-hospital patient mortality and the relationship between length of time from first medical contact (FMC) to hospital admission was analysed in 515 respondents. Extending the time of FMC to hospital admission by 1 min increased the chances of lowering LVEF by 2% (95% CI: 1.004–1.041) and increased the chances of death by 2% (95% CI: 1.002–1.04) in STEMI patients.

Conclusions

This study emphasised how vital it is to minimise time spent with STEMI patients at the scene of their cardiovascular event by performing an ECG as quickly as possible and by immediately transporting the patient to the hospital with the targeted treatment. This may lead to the implementation of additional training in the field of ECG interpretation, increase the prevalence of teletransmission systems, and improve communication between Emergency Medical Services (EMS) and catheterization laboratories ultimately reducing patient mortality.

The effects of prearrival direct notification call to interventional cardiologist on door-to-balloon time in patients who required secondary diversion with ST-elevation myocardial infarction for primary percutaneous coronary intervention

Background:

Rapid door-to-balloon times in ST-elevation myocardial infarction patients undergoing primary percutaneous coronary intervention are associated with favorable outcomes.

Objectives:

We evaluated the effects of prearrival direct notification calls to interventional cardiologists on door-to-balloon time for ST-elevation myocardial infarction patients undergoing primary percutaneous coronary intervention.

Methods:

A 24-h hotline was created to allow prearrival direct notification calls to interventional cardiologists when transferring ST-elevation myocardial infarction patients. In an urban, tertiary referral center, patients who visited via inter-facility or the emergency department directly were included. Clinical parameters, time to reperfusion therapy, and in-hospital mortality were compared between patients with and without prearrival notifications.

Results:

Of 228 ST-elevation myocardial infarction patients, 95 (41.7%) were transferred with prearrival notifications. In these patients, door-to-balloon time was shorter (50.0 vs 60.0 min, p = 0.010) and the proportion of patients with door-to-balloon time < 90 min was higher (89.5% vs 75.9%, p = 0.034) than patients without notifications. These improvements were more pronounced during “off-duty” hours (52.0 vs 78.0 min, p = 0.001; 88.3% vs 72.3%, p = 0.047, respectively) than during “on-duty” hours (37.5 vs 43.5 min, p = 0.164; 94.4% vs 79.4%, p = 0.274, respectively). In addition, door-to-activation time (–39 vs 11 min, p < 0.001) and door-to-catheterization laboratory arrival time (33 vs 42 min, p = 0.007) were shorter in patients with prearrival notifications than those without. However, in-hospital mortality was similar between the two groups (6.3% vs 6.8%, p = 0.892).

Conclusion:

Prearrival direct notification calls to interventional cardiologists significantly improved the door-to-balloon time and the proportion of patients with door-to-balloon time < 90 min through rapid patient transport in primary percutaneous coronary intervention scheduled hospital and readiness of the catheterization laboratory.

Improvement in Care and Outcomes for Emergency Medical Service-Transported Patients With ST-Elevation Myocardial Infarction (STEMI) With and Without Prehospital Cardiac Arrest: A Mission: Lifeline STEMI Accelerator Study

Background

Patients with ST‐elevation myocardial infarction (STEMI) with out‐of‐hospital cardiac arrest (OHCA) may benefit from direct transport to a percutaneous cardiac intervention (PCI) hospital but have previously been less likely to bypass local non‐PCI hospitals to go to a PCI center.

Methods and Results

We reported time trends in emergency medical service transport and care of patients with STEMI with and without OHCA included from 171 PCI‐capable hospitals in 16 US regions with participation in the Mission: Lifeline STEMI Accelerator program between July 1, 2012, and March 31, 2014. Time trends by quarter were assessed using logistic regression with generalized estimating equations to account for hospital clustering. Of 13 189 emergency medical service–transported patients, 88.7% (N=11 703; 10.5% OHCA) were taken directly to PCI hospitals. Among 1486 transfer‐in patients, 21.7% had OHCA. Direct transport to a PCI center for OHCA increased from 74.7% (July 1, 2012) to 83.6% (March 31, 2014) (odds ratio per quarter, 1.07; 95% confidence interval, 1.02–1.14), versus 89.0% to 91.0% for patients without OHCA (odds ratio, 1.03; 95% confidence interval, 0.99–1.07; interaction P=0.23). The proportion with prehospital ECGs increased for patients taken directly to PCI centers (53.9%–61.9% for those with OHCA versus 73.9%–81.9% for those without OHCA; interaction P=0.12). Of 997 patients with OHCA taken directly to PCI hospitals and treated with primary PCI, first medical contact‐to‐device times within the guideline‐recommended goal of ≤90 minutes were met for 34.5% on July 1, 2012, versus 41.8% on March 31, 2014 (51.6% and 56.1%, respectively, for 9352 counterparts without OHCA; interaction P=0.72).

Conclusions

Direct transport to PCI hospitals increased for patients with STEMI with and without OHCA during the 2012 to 2014 Mission: Lifeline STEMI Accelerator program. Proportions with prehospital ECGs and timely reperfusion increased for patients taken directly to PCI hospitals.

Global Challenges and Solutions: Role of Telemedicine in ST-Elevation Myocardial Infarction Interventions

Major disparities exist between developed and developing countries in the management of acute myocardial infarction (AMI). These pronounced differences result in significantly increased morbidity and mortality from AMI in different regions of the world. Lack of infrastructure, insurance, facilities, and skilled personnel are the major constraints. Primary percutaneous coronary intervention has revolutionized the treatment of AMI; however, its global use is limited by the listed constraints. Telemedicine provides an efficient methodology that can hugely increase access and accuracy of AMI management.

Sex differences in the prehospital management of out-of-hospital cardiac arrest

BACKGROUND

Sex differences exist in the diagnosis and treatment of several cardiovascular diseases. Our objective was to determine whether sex differences exist in the use of guideline-recommended treatments in out-of-hospital cardiac arrest (OHCA).

METHODS

We included adult patients with non-traumatic OHCA treated by emergency medical services (EMS) in the Resuscitation Outcomes Consortium Prehospital Resuscitation using an IMpedance valve and Early versus Delayed (ROC PRIMED) database during 2007-2009. Outcomes included prehospital treatment intervals, procedures, and medications. Data were analysed using multivariable linear and logistic regression models that adjusted for sex, age, witnessed arrest, public location, bystander cardiopulmonary resuscitation (CPR), and first known rhythm of ventricular tachycardia/fibrillation.

RESULTS

We studied 15,584 patients; 64% were male and median age was 68 years (interquartile range 55-80). In multivariable analyses, intervals from EMS dispatch to first rhythm capture (p=0.001) and first EMS CPR (p=0.001) were longer in women than in men. Women were less likely to receive successful intravenous or intraosseous access (OR 0.78, 95% CI 0.71-0.86) but equally likely to receive a successful advanced airway (OR 0.94, 95% CI 0.86-1.02). Women were less likely to receive adrenaline (OR 0.81, 95% CI 0.74-0.88), atropine (OR 0.86, 95% CI 0.80-0.92), and lidocaine or amiodarone (OR 0.68, 95% CI 0.61-0.75).

CONCLUSION

Women were less likely than men to receive guideline-recommended treatments for OHCA. The reasons for these differences require further exploration, and EMS provider education and training should specifically address these sex differences in the treatment of OHCA.

Patient and System-Related Delays of Emergency Medical Services Use in Acute ST-Elevation Myocardial Infarction: Results from the Third Gulf Registry of Acute Coronary Events (Gulf RACE-3Ps)

Background

Little is known about Emergency Medical Services (EMS) use and pre-hospital triage of patients with acute ST-elevation myocardial infarction (STEMI) in Arabian Gulf countries.

Methods

Clinical arrival and acute care within 24 h of STEMI symptom onset were compared between patients transferred by EMS (Red Crescent and Inter-Hospital) and those transferred by non-EMS means. Data were retrieved from a prospective registry of 36 hospitals in 6 Arabian Gulf countries, from January 2014 to January 2015.

Results

We enrolled 2,928 patients; mean age, 52.7 (SD ±11.8) years; 90% men; and 61.7% non-Arabian Gulf citizens. Only 753 patients (25.7%) used EMS; which was mostly via Inter-Hospital EMS (22%) rather than direct transfer from the scene to the hospital by the Red Crescent (3.7%). Compared to the non-EMS group, the EMS group was more likely to arrive initially at a primary or secondary health care facility; thus, they had longer median symptom-onset-to-emergency department arrival times (218 vs. 158 min; p˂.001); they were more likely to receive primary percutaneous coronary interventions (62% vs. 40.5%, p = 0.02); they had shorter door-to-needle times (38 vs. 42 min; p = .04); and shorter door-to-balloon times (47 vs. 83 min; p˂.001). High EMS use was independently predicted mostly by primary/secondary school educational levels and low or moderate socioeconomic status. Low EMS use was predicted by a history of angina and history of percutaneous coronary intervention. The groups had similar in-hospital deaths and outcomes.

Conclusion

Most acute STEMI patients in the Arabian Gulf region did not use EMS services. Improving Red Crescent infrastructure, establishing integrated STEMI networks, and launching educational public campaigns are top health care system priorities.

First medical contact in patients with STEMI and its impact on time to diagnosis; an explorative cross-sectional study

OBJECTIVE

It is unknown into what extent patients with ST-elevation myocardial infarction (STEMI) utilise a joint service number (Swedish Healthcare Direct, SHD) as first medical contact (FMC) instead of Emergency Medical Services (EMS) and how this impact time to diagnosis. We aimed to (1) describe patients' FMC; (2) find explanatory factors influencing their FMC (ie, EMS and SHD) and (3) explore the time interval from symptom onset to diagnosis.

SETTING

Multicentred study, Sweden.

METHODS

Cross-sectional, enrolling patients with consecutive STEMI admitted within 24 h from admission.

RESULTS

We included 109 women and 336 men (mean age 66±11 years). Although 83% arrived by ambulance to the hospital, just half of the patients (51%) called EMS as their FMC. Other utilised SHD (21%), contacted their primary healthcare centre (14%), or went directly to the emergency room (14%). Reasons for not contacting EMS were predominantly; (1) my transport mode was faster (40%), (2) did not consider myself sick enough (30%), and (3) it was easier to be driven or taking a taxi (25%). Predictors associated with contacting SHD as FMC were female gender (OR 1.92), higher education (OR 2.40), history of diabetes (OR 2.10), pain in throat/neck (OR 2.24) and pain intensity (OR 0.85). Predictors associated with contacting EMS as FMC were history of MI (OR 2.18), atrial fibrillation (OR 3.81), abdominal pain (OR 0.35) and believing the symptoms originating from the heart (OR 1.60). Symptom onset to diagnosis time was significantly longer when turning to the SHD instead of the EMS as FMC (1:59 vs 1:21 h, p<0.001).

CONCLUSIONS

Using other forms of contacts than EMS, significantly prolong delay times, and could adversely affect patient prognosis. Nevertheless, having the opportunity to call the SHD might also, in some instances, lower the threshold for taking contact with the healthcare system, and thus lowers the number that would otherwise have delayed even longer.