The impact of systems-of-care on pharmacoinvasive management with streptokinase: The subgroup analysis of the TN-STEMI programme

Structure, Process, and Mortality Associated with Acute Coronary Syndrome Management in Guatemala's National Healthcare System: The ACS-GT Registry

Background

Acute coronary syndromes (ACS) include ST-segment elevation myocardial infarction (STEMI), non-ST-segment elevation myocardial infarction (NSTEMI), and unstable angina (UA). The leading cause of mortality in Guatemala is acute myocardial infarction (AMI) and there is no established national policy nor current standard of care.

Objective

Describe the factors that influence ACS outcome, evaluating the national healthcare system's quality of care based on the Donabedian health model.

Methods

The ACS-Gt study is an observational, multicentre, and prospective national registry. A total of 109 ACS adult patients admitted at six hospitals from Guatemala's National Healthcare System were included. These represent six out of the country's eight geographic regions. Data enrolment took place from February 2020 to January 2021. Data was assessed using chi-square test, Student's t-test, or Mann-Whitney U test, whichever applied. A p-value < 0.05 was considered statistically significant.

Results

One hundred and nine patients met inclusion criteria (80.7% STEMI, 19.3% NSTEMI/UA). The population was predominantly male, (68%) hypertensive (49.5%), and diabetic (45.9%). Fifty-nine percent of STEMI patients received fibrinolysis (alteplase 65.4%) and none for primary Percutaneous Coronary Intervention (pPCI). Reperfusion success rate was 65%, and none were taken to PCI afterwards in the recommended time period (2-24 hours). Prognostic delays in STEMI were significantly prolonged in comparison with European guidelines goals. Optimal in-hospital medical therapy was 8.3%, and in-hospital mortality was 20.4%.

Conclusions

There is poor access to ACS pharmacological treatment, low reperfusion rate, and no primary, urgent, or rescue PCI available. No patient fulfilled the recommended time period between successful fibrinolysis and PCI. Resources are limited and inefficiently used.

Fibrinolytic Strategy for ST-Segment–Elevation Myocardial Infarction

The ongoing coronavirus disease 2019 pandemic has resulted in additional challenges for systems designed to perform expeditious primary percutaneous coronary intervention for patients presenting with ST-segment–elevation myocardial infarction. There are 2 important considerations: the guideline-recommended time goals were difficult to achieve for many patients in high-income countries even before the pandemic, and there is a steep increase in mortality when primary percutaneous coronary intervention cannot be delivered in a timely fashion. Although the use of fibrinolytic therapy has progressively decreased over the last several decades in high-income countries, in circumstances when delays in timely delivery of primary percutaneous coronary intervention are expected, a modern fibrinolytic-based pharmacoinvasive strategy may need to be considered. The purpose of this review is to systematically discuss the contemporary role of an evidence-based fibrinolytic reperfusion strategy as part of a pharmacoinvasive approach, in the context of the emerging coronavirus disease 2019 pandemic.

Cognitive and Behavioral Impact on Children Exposed to Opioids During Pregnancy

The developmental impact of opioid use during pregnancy is a subject of ongoing debate. Short-term neonatal outcomes, such as lower birth weight and neonatal abstinence syndrome, are the most well-recognized outcomes. However, knowledge gaps exist regarding longer-term neurocognitive and mental health outcomes. In this article, we summarize an expert panel discussion that was held in April 2018 by the Substance Abuse and Mental Health Services Administration and attended by national experts in the field of perinatal opioid exposure and its impact on child development. Despite the challenges with research in this area, there is emerging literature revealing an association between neonates exposed to opioids in utero and longer-term adverse neurocognitive, behavioral, and developmental outcomes. Although adverse sequalae may not be apparent in the neonatal period, they may become more salient as children develop and reach preschool and school age. Multiple variables (genetic, environmental, and biological) result in a highly complex picture. The next steps and strategies to support families impacted by opioid use disorder are explored. Model programs are also considered, including integrated care for the child and mother, parenting supports, and augmentations to home visiting.

Predictors of short-term outcomes in patients undergoing percutaneous coronary intervention in cardiogenic shock complicating STEMI-A tertiary care center experience

BACKGROUND

Studying the outcomes in patients presenting with cardiogenic shock with ST-segment elevation myocardial infarction (CS-STEMI) and undergoing primary or rescue percutaneous coronary intervention (PCI) may give an insight to the unmet needs in STEMI-care in our region and may help in future recommendations in improving survival.

MATERIALS AND METHODOLGY

During the period from January 2001- June 2017, there were 114 patients included in the study. The demographic, clinical and angiographic characteristics were compared between the survivors and non-survivors. All these variables were also compared between two-time frames (Phase 1- January 2001 to June 2007; Phase 2- July 2007 to June 2017).

RESULTS

Among patients undergoing PCI for STEMI, 7.5% were in cardiogenic shock. In-hospital mortality for the patients included in the study was 53.5%. Total ischemic time (OR=0.99, 0.99-1; p=0.02), left ventricular ejection fraction (LVEF) (OR=0.90, 0.82-0.98; p=0.02), need for cardio-pulmonary resuscitation (OR=0.12, 0.24-0.66; p=0.01), and post PCI TIMI flows (OR=0.08, 0.02-0.29; p<0.001) were the significant determinants of in-hospital mortality in the regression analysis. There was no significant change in mortality between the two phases of the study, though there was a reduction in total ischemic and door-to-balloon times, transfer admissions, use of thrombolytics, glycoprotein IIb/IIIa inhibitors, intra-aortic balloon pump, and mechanical ventilation in phase 2.

CONCLUSION

Patients presenting in CS-STEMI and undergoing PCI continue to experience high mortality rates, despite improvements in total ischemic times. Further improvement in the systems-of-care are required to bring about reduction in mortality in this high-risk subset.

Low quality cardiovascular care is important coronary risk factor in India

Global Burden of Disease study has reported that cardiovascular and ischemic heart disease (IHD) mortality has increased by 34% in last 25 years in India. It has also been reported that despite having lower coronary risk factors compared to developed countries, incident cardiovascular mortality, cardiovascular events and case-fatality are greater in India. Reasons for the increasing trends and high mortality have not been studied. There is evidence that social determinants of IHD risk factors are widely prevalent and increasing. Epidemiological studies have reported low control rates of hypertension, hypercholesterolemia, diabetes and smoking/tobacco. Registries have reported greater mortality of acute coronary syndrome in India compared to developed countries. Secondary prevention therapies have significant gaps. Low quality cardiovascular care is an important risk factor in India. Package of interventions focusing on fiscal, intersectoral and public health measures, improvement of health services at community, primary and secondary healthcare levels and appropriate referral systems to specialized hospitals is urgently required.

Factors influencing prehospital delay in patients presenting with ST-elevation myocardial infarction and the impact of prehospital electrocardiogram

Background

In ST-elevation myocardial infarction (STEMI), prehospital delay is a significant factor, decreasing likelihood of revascularization and increasing mortality. Prehospital delays are substantive in Indian patients with STEMI. Our study aimed to investigate factors associated with prehospital delay in patients with STEMI.

Methods

A multicentric prospective analysis was conducted at five major cardiac care referral centers in Punjab including a tertiary care teaching hospital over a period of 1 year from January 2015 to December 2015. Patients presenting with STEMI were included in the study. A structured questionnaire was used to gather patient characteristics and factors responsible for prehospital delay.

Results

Of the 619 patients included in the study, 42% presented with more than 6 h of prehospital delay. On univariate analysis, delay was significantly higher among elderly (p = 0.01), illiterate patients (p = 0.02), and patients residing in rural areas (p = 0.04). Recognizing symptoms as cardiac in origin (p < 0.001), hospital as initial medical contact, and availability of prehospital electrocardiogram (ECG) (p = 0.001) were associated with shorter delays. On multivariate analysis, prehospital delay was significant in elderly patients, initial point of care as outpatient clinic, and patients without access to prehospital ECG.

Conclusion

Our study concludes that demographic and socioeconomic barriers exist that impede rapid care seeking and highlights the need for utilization of prehospital ECG to decrease prehospital delay. Possibilities include, educating the public on the importance of early emergency medical services contact or creating emergency stations in rural areas with ECG capabilities. Our study also invites further research, regarding role of telemedicine to triage patients derived from prehospital ECGs to decrease prehospital delay. Keywords: STEMI, Pre-hospital ECG, Pre-hospital delay, Factors, Telemedicine.