Systems of care for ST-segment elevation myocardial infarction: impact of different models on clinical outcomes

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

Background

Continuous investment and systematic evaluation of program accomplishments are required to achieve excellence in ST-segment elevation myocardial infarction (STEMI) care, especially in resource-limited settings. Therefore, this study evaluates the impact of problem-driven interventions on reperfusion use rate in a long-term operating STEMI network from a low- to middle-income country.

Methods

This is a healthcare improvement evaluation study of Salvador's public STEMI network in a quasi-experimental design, comparing data from 2009 to 2010 (pre-intervention) and 2019-2020 (post-intervention). There were evaluated all confirmed STEMI cases assisted in both periods. The interventions, implemented since 2017, included: expanding the support team, defining criteria to be a spoke, and initiating continuous education activities. The primary outcome was the rate of patients undergoing reperfusion, with secondary outcomes being time from door-to-ECG (D2E) and ECG-to-STEMI-team trigger (E2T).

Results

Over ten years, the network's coverage increased by 300,000 individuals, and expanded by 1,800 km2. A total of 885 records were analyzed, 287 in the pre-intervention group (182 men [63·4%]; mean [SD] age 62·1 [12·5] years) and 598 in the post-intervention group (356 men [59·5%]; mean [SD] age 61.9 [11·8] years). It was noticed a substantial increase in reperfusion delivery rate (90 [31%] vs. 431 [73%]; P = 001) and reductions in time from D2E (159 [83-340] vs. 29 [15-63], P = 001), and E2T (31 [21-44] vs. 16 [6-40], P = 001).

Conclusion

The strategies adopted by Salvador's STEMI network were associated with significant improvements in the rate of patients undergoing reperfusion and in D2E and E2T. However, the mortality rate remains high.

Acute dapagliflozin administration exerts cardioprotective effects in rats with cardiac ischemia/reperfusion injury

BACKGROUND

A sodium-glucose co-transporter 2 (SGLT-2) inhibitor had favorable impact on the attenuation of hyperglycemia together with the severity of heart failure. However, the effects of acute dapagliflozin administration at the time of cardiac ischemia/reperfusion (I/R) injury are not established.

METHODS

The effects of dapagliflozin on cardiac function were investigated by treating cardiac I/R injury at different time points. Cardiac I/R was instigated in forty-eight Wistar rats. These rats were then split into 4 interventional groups: control, dapagliflozin (SGLT2 inhibitor, 1 mg/kg) given pre-ischemia, at the time of ischemia and at the beginning of reperfusion. Left ventricular (LV) function and arrhythmia score were evaluated. The hearts were used to evaluate size of myocardial infarction, cardiomyocyte apoptosis, cardiac mitochondrial dynamics and function.

RESULTS

Dapagliflozin given pre-ischemia conferred the maximum level of cardioprotection quantified through the decrease in arrhythmia, attenuated infarct size, decreased cardiac apoptosis and improved cardiac mitochondrial function, biogenesis and dynamics, leading to LV function improvement during cardiac I/R injury. Dapagliflozin given during ischemia also showed cardioprotection, but at a lower level of efficacy.

CONCLUSIONS

Acute dapagliflozin administration during cardiac I/R injury exerted cardioprotective effects by attenuating cardiac infarct size, increasing LV function and reducing arrhythmias. These benefits indicate its potential clinical usefulness.

2019 Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology Guidelines on the Acute Management of ST-Elevation Myocardial Infarction: Focused Update on Regionalization and Reperfusion

Rapid reperfusion of the infarct-related artery is the cornerstone of therapy for the management of acute ST-elevation myocardial infarction (STEMI). Canada's geography presents unique challenges for timely delivery of reperfusion therapy for STEMI patients. The Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology STEMI guideline was developed to provide advice regarding the optimal acute management of STEMI patients irrespective of where they are initially identified: in the field, at a non-percutaneous coronary intervention-capable centre or at a percutaneous coronary intervention-capable centre. We had also planned to evaluate and incorporate sex and gender considerations in the development of our recommendations. Unfortunately, inadequate enrollment of women in randomized trials, lack of publication of main outcomes stratified according to sex, and lack of inclusion of gender as a study variable in the available literature limited the feasibility of such an approach. The Grading Recommendations, Assessment, Development, and Evaluation system was used to develop specific evidence-based recommendations for the early identification of STEMI patients, practical aspects of patient transport, regional reperfusion decision-making, adjunctive prehospital interventions (oxygen, opioids, antiplatelet therapy), and procedural aspects of mechanical reperfusion (access site, thrombectomy, antithrombotic therapy, extent of revascularization). Emphasis is placed on integrating these recommendations as part of an organized regional network of STEMI care and the development of appropriate reperfusion and transportation pathways for any given region. It is anticipated that these guidelines will serve as a practical template to develop systems of care capable of providing optimal treatment for a wide range of STEMI patients.

Five-year outcomes following timely primary percutaneous intervention, late primary percutaneous intervention, or a pharmaco-invasive strategy in ST-segment elevation myocardial infarction: the FAST-MI programme

Aims

ST-segment elevation myocardial infarction (STEMI) guidelines recommend primary percutaneous coronary intervention (pPCI) as the default reperfusion strategy when feasible ≤120 min of diagnostic ECG, and a pharmaco-invasive strategy otherwise. There is, however, a lack of direct evidence to support the guidelines, and in real-world situations, pPCI is often performed beyond recommended timelines. To assess 5-year outcomes according to timing of pPCI (timely vs. late) compared with a pharmaco-invasive strategy (fibrinolysis with referral to PCI centre).

Methods and results

The French registry of Acute ST-elevation and non-ST-elevation Myocardial Infarction (FAST-MI) programme consists of nationwide observational surveys consecutively recruiting patients admitted for acute myocardial infarction every 5 years. Among the 4250 STEMI patients in the 2005 and 2010 cohorts, those with reperfusion therapy and onset-to-first call time <12 h (n = 2942) were included. Outcomes at 5 years were compared according to type of reperfusion strategy and timing of pPCI, using Cox multivariable analyses and propensity score matching. Among those, 1288 (54%) patients had timely pPCI (≤120 min from ECG), 830 (28%) late pPCI (>120 min), and 824 (28%) intravenous fibrinolysis. Five-year survival was higher with a pharmaco-invasive strategy (89.8%) compared with late pPCI [79.5%; adjusted hazard ratio (HR) 1.51; 1.13–2.02] and similar to timely pPCI (88.2%, adjusted HR 1.02; 0.75–1.38). Concordant results were observed in propensity score-matched cohorts and for event-free survival.

Conclusion

A substantial proportion of patients have pPCI beyond recommended timelines. As foreseen by the guidelines, these patients have poorer 5-year outcomes, compared with a pharmaco-invasive strategy.

Reducing Health Inequalities: Comparison of Survival After Acute Myocardial Infarction According to Health Provider in Chile

Health inequalities are marked in Chile. To address this situation, a health reform was implemented in 2005 that guarantees acute myocardial infarction (AMI) health care for the entire population. We evaluated if the health reform changed AMI early and long-term survival rates by hospital provider (public/private) using a longitudinal population-based study of patients ≥15 years with a first AMI in Chile between 2002 and 2011. Time trends and early (within 28 days) and long-term (29-365 days) survival by age were assessed. We identified 59,557 patients: median age of 64 years; 68.9% men; 83.2% treated at public hospitals; 74.4% with public insurance. Early and long-term case-fatality was higher at public hospitals (14.6% vs 9.3%; P < .001 and 5.8% vs 3.3%; P < .001, respectively). There was a higher annual increase for early and long-term survival in public hospitals, 0.008 percentage points (95% CI: 0.006, 0.009; P < .0001) and 0.03 (0.002, 0.003; P < .0001), than in private hospitals, 0.0002 (95% CI: -0.0001, 0.005; P = .10) and 0.002 (95% CI: 0.0007, 0.003; P = .004), respectively. Being served at public hospitals affected early and long-term survival, especially in patients <70 years: hazard ratio was 2.01 (95% CI: 1.77, 2.28) and 3.11 (2.41, 4.01), respectively. Therefore, even if inequalities persist, there was a higher increase in early and long-term survival in public versus private hospitals.

Roles of mitochondrial dynamics modulators in cardiac ischaemia/reperfusion injury

The current therapeutic strategy for the management of acute myocardial infarction (AMI) is to return blood flow into the occluded coronary artery of the heart, a process defined as reperfusion. However, reperfusion itself can increase mortality rates in AMI patients because of cardiac tissue damage and dysfunction, which is termed ‘ischaemia/reperfusion (I/R) injury’. Mitochondria play an important role in myocardial I/R injury as disturbance of mitochondrial dynamics, especially excessive mitochondrial fission, is a predominant cause of cardiac dysfunction. Therefore, pharmacological intervention and therapeutic strategies which modulate the mitochondrial dynamics balance during I/R injury could exert great beneficial effects to the I/R heart. This review comprehensively summarizes and discusses the effects of mitochondrial fission inhibitors as well as mitochondrial fusion promoters on cardiac and mitochondrial function during myocardial I/R injury. The comparison of the effects of both compounds given at different time‐points during the course of I/R injury (i.e. prior to ischaemia, during ischaemia and at the reperfusion period) are also summarized and discussed. Finally, this review also details important information which may contribute to clinical practices using these drugs to improve the quality of life in AMI patients.

Population access to reperfusion services for ST-segment elevation myocardial infarction in Kerala, India

Background

Population access to timely reperfusion is a decisive factor in determining the success and acceptability of any regional system of ST-segment elevation myocardial infarction (STEMI) care. We sought to determine the proportion of population of the southern Indian state of Kerala having timely access to STEMI reperfusion.

Methods

We identified the STEMI reperfusion facilities available at all acute-care hospitals, in Kerala, by conducting a cross-sectional survey. We mapped the geographical catchment areas of these hospitals using historical travel speeds and appropriate Geospatial Information Systems (GIS) analyses. Subsequently, using block level population data, we estimated the proportion of the population residing within these geographies.

Results

We estimated that 23.33 million people, forming 69.84% of the state population, resided in the green zone (within half-hour travel distance of a percutaneous coronary intervention [PCI]-capable hospital), which covered 47.94% of the geographical area of the state. Outside this green zone, 21.87% of the state population resided within 1 hr travel distance of a thrombolysis-capable hospital. Finally, 8.28% of the state population resided in the red zone, where access to any reperfusion-capable hospital took >1 hr, which covered 22.15% of the geographical area of the state.

Conclusions

A majority of the population of Kerala had timely access to PCI-capable hospitals. GIS-based mapping of Indian states, in terms of access to STEMI reperfusion, may help devise protocols to achieve seamless transfer of patients to reperfusion-capable hospitals. Such regionalization of STEMI care would enhance organizational synergies to achieve better access to reperfusion, especially in remote areas.

Impact of a Rural Regional Myocardial Infarction System of Care in Wyoming

Background

Primary percutaneous coronary intervention (PCI) is the preferred reperfusion strategy for patients presenting with ST‐segment elevation myocardial infarction; however, to be effective, PCI must be performed in a timely manner. Rural regions are at a severe disadvantage, given the relatively sparse number of PCI hospitals and long transport times.

Methods and Results

We developed a standardized treatment and transfer protocol for ST‐segment elevation myocardial infarction in the rural state of Wyoming. The study design compared the time‐to‐treatment outcomes during the pre‐ and postintervention periods. Details of the program, changes in reperfusion strategies over time, and outcome improvements in treatment times were reported. From January 1, 2013, to December 31, 2014, 889 patients were treated in 11 PCI‐capable hospitals (4 in Wyoming, 7 in adjoining states). Given the large geographic distance in the state (median of 47 miles between patient and PCI center), 52% of all patients were transfers, and 36% were administered fibrinolysis at the referral facility. Following the intervention, there was a significant shift toward greater use of primary PCI as the dominant reperfusion strategy (from 47% to 60%, P=0.002), and the median total ischemic time from symptom onset to arterial reperfusion was decreased by 92 minutes (P<0.001). There was a similar significant reduction in median time from receiving center door to balloon of 11 minutes less than the baseline time (P<0.01).

Conclusions

Rural systems of care for ST‐segment elevation myocardial infarction require increased levels of cooperation between emergency medical services agencies and hospitals. This study confirms that total ischemic times can be reduced through a coordinated rural statewide initiative.

Are reductions in emergency department length of stay associated with improvements in quality of care? A difference-in-differences analysis

Background

We sought to determine whether patients seen in hospitals who had reduced overall emergency department (ED) length of stay (LOS) in the 2 years following the introduction of the Ontario Emergency Room Wait Time Strategy were more likely to experience improvements in other measures of ED quality of care for three important conditions.

Methods

Retrospective medical record review using difference-in-differences analysis to compare changes in performance on quality indicators over the 3-year period between 11 Ontario hospitals where the median ED LOS had improved from fiscal year 2008 to 2010 and 13 matched sites where ED LOS was unchanged or worsened. Patients with acute myocardial infarction (AMI), asthma and paediatric and adult upper limb fractures in these hospitals in 2008 and 2010 were evaluated with respect to 18 quality indicators reflecting timeliness and safety/effectiveness of care in the ED. In a secondary analysis, we examined shift-level ED crowding at the time of the patient visit and performance on the quality indicators.

Results

Median ED LOS improved by up to 26% (63 min) from 2008 to 2010 in the improved hospitals, and worsened by up to 47% (91 min) in the unimproved sites. We abstracted 4319 and 4498 charts from improved and unimproved hospitals, respectively. Improvement in a hospital's overall median ED LOS from 2008 to 2010 was not associated with a change in any of the other ED quality indicators over the same time period. In our secondary analysis, shift-level crowding was associated only with indicators that reflected timeliness of care. During less crowded shifts, patients with AMI were more likely to be reperfused within target intervals (rate ratio 1.59, 95% CI 1.03 to 2.45), patients with asthma more often received timely administration of steroids (rate ratio 1.88, 95% CI 1.59 to 2.24) and beta-agonists (rate ratio 1.47, 95% CI 1.25 to 1.74), and adult (but not paediatric) patients with fracture were more likely to receive analgesia or splinting within an hour (rate ratio 1.66, 95% CI 1.22 to 2.26).

Conclusions

These results suggest that a policy approach that targets only reductions in ED LOS is not associated with broader improvements in selected quality measures. At the same time, there is no evidence that efforts to address crowding have a detrimental effect on quality of care.

Huo Y, Thompson P, Buddhari W, Ge J, Harding S, Ramanathan L, Reyes E, Santoso A, Tam LW, Vijayaraghavan G, Yeh HI. Challenges and solutions in medically managed ACS in the Asia-Pacific region: expert recommendations from the Asia-Pacific ACS Medical Management Working Group

Acute coronary syndromes (ACS) remain a leading cause of mortality and morbidity in the Asia-Pacific (APAC) region. International guidelines advocate invasive procedures in all but low-risk ACS patients; however, a high proportion of ACS patients in the APAC region receive solely medical management due to a combination of unique geographical, socioeconomic, and population-specific barriers. The APAC ACS Medical Management Working Group recently convened to discuss the ACS medical management landscape in the APAC region. Local and international ACS guidelines and the global and APAC clinical evidence-base for medical management of ACS were reviewed. Challenges in the provision of optimal care for these patients were identified and broadly categorized into issues related to (1) accessibility/systems of care, (2) risk stratification, (3) education, (4) optimization of pharmacotherapy, and (5) cost/affordability. While ACS guidelines clearly represent a valuable standard of care, the group concluded that these challenges can be best met by establishing cardiac networks and individual hospital models/clinical pathways taking into account local risk factors (including socioeconomic status), affordability and availability of pharmacotherapies/invasive facilities, and the nature of local healthcare systems. Potential solutions central to the optimization of ACS medical management in the APAC region are outlined with specific recommendations.

Evaluation of a regional ST-elevation myocardial infarction primary percutaneous coronary intervention program at the Rouge Valley Health System

BACKGROUND

ST-elevation myocardial infarction (STEMI) remains the second leading cause of death in Canada. Primary percutaneous coronary intervention (PCI) has been recognized as an effective method for treating STEMI. Improved access to primary PCI can be achieved through the implementation of regional PCI centres, which was the impetus for implementing the PCI program in an east Toronto hospital in 2009. As such, the purpose of this study was to measure the efficacy of this program regional expansion.

METHODS

A retrospective review of 101 patients diagnosed with STEMI from May to Sept 2010 was conducted. The average door-to-balloon time for these STEMI patients was calculated and the door-to-balloon times using different methods of arrival were analyzed. Method of arrival was by one of three ways: paramedic initiated referral; patient walk-ins to PCI centre emergency department; or transfer after walk-in to community hospital emergency department.

RESULTS

The study found that mean door-to balloon time for PCI was 112.5 minutes. When the door-to-balloon times were compared across the three arrival methods, patients who presented by paramedic-initiated referral had significantly shorter door-to-balloon times, (89.5 minutes) relative to those transferred (120.9 minutes) and those who walked into a PCI centre (126.7 minutes) (p = 0.047).

CONCLUSIONS

The findings suggest that the partnership between the hospital and its EMS partners should be continued, and paramedic initiated referral should be expanded across Canada and EMS systems where feasible, as this level of coverage does not currently exist nationwide. Investments in regional centres of excellence and the creation of EMS partnerships are needed to enhance access to primary PCI.

Outcomes of a pharmacoinvasive strategy for successful versus failed fibrinolysis and primary percutaneous intervention in acute myocardial infarction (from the STrategic Reperfusion Early After Myocardial Infarction [STREAM] study)

Although a fibrinolytic pharmacoinvasive strategy is recommended for patients with ST elevation myocardial infarction (STEMI) unable to undergo timely primary percutaneous coronary intervention (PCI), there are limited data addressing outcomes specific to those with successful or unsuccessful pharmacologic reperfusions. Accordingly, we evaluated a contemporary pharmacoinvasive strategy for failed and successful reperfusions within the STrategic Reperfusion Early After Myocardial infarction study. Of 1,823 per-protocol-treated patients with STEMI, we examined clinical outcomes and angiographic and electrocardiographic metrics in 3 groups as follows: fibrinolysis requiring rescue (rescue, n = 348), fibrinolysis with scheduled angiography (scheduled, n = 516), and primary PCI (n = 927). Compared with pharmacoinvasive patients undergoing scheduled angiography, rescue patients were more likely to have anterior wall myocardial infarction, more baseline ST-segment elevation and deviation, as well as Q waves in the distribution of their ST elevation. Residual ST elevation ≥ 2 mm 30 minutes after angiography occurred in 27.9%, 7.9%, and 24.8% of patients who underwent rescue, scheduled, and primary PCI, respectively. Thirty-day composite event rates (all-cause death, cardiogenic shock, heart failure, and reinfarction) were 18.7%, 5.5%, and 13.9%; all-cause death: 6.1%, 2.1%, and 3.9%; cardiogenic shock: 7.5%, 2.0%, and 5.4%; heart failure: 11.8%, 2.3%, and 7.6%; and reinfarction: 1.5%, 1.4%, and 2.2%, for rescue, scheduled, and primary PCI, respectively. Compared with successfully reperfused patients undergoing scheduled angiography, the adjusted relative risk of the primary outcome was 2.92 (95% confidence interval 1.92 to 4.45) in rescue patients. In conclusion, pharmacoinvasive-treated patients requiring rescue angiography had greater baseline risk with more co-morbidities and worse 30-day outcomes compared with successful fibrinolytic-treated patients. Residual ST elevation after reperfusion assists in defining prognosis.

Impact of Timing of Eptifibatide Administration on Preprocedural Infarct-Related Artery Patency in Acute STEMI Patients Undergoing Primary PCI

The appropriate timing of eptifibatide initiation for acute ST segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI) remains unclear. This study aimed to analyze the impact of timing of eptifibatide administration on infarct-related artery (IRA) patency in STEMI patients undergoing primary PCI. Acute STEMI patients who underwent primary PCI (n = 324) were enrolled in this retrospective study; 164 patients received eptifibatide bolus ≤ 30 minutes after emergency department (ED) admission (group A) and 160 patients received eptifibatide bolus > 30 minutes after ED admission (group B). The primary endpoint was preprocedural IRA patency. Most patients in group A (90%) and group B (89%) were late presenters (> 2 hours after symptom onset). The two groups had similar preprocedural thrombolysis in myocardial infarction 2 or 3 flow of the IRA (26 vs. 24%, p = not significant [NS]), similar creatine kinase-MB (CK-MB) levels at 8 hours after admission (339 vs. 281 U/L, p = NS), similar left ventricular ejection fraction (LVEF) (52 vs. 50%, p = NS), and similar 30-day mortality (2 vs. 7%, p = NS). Compared with group B, patients in group A had shorter door-to-device time (p < 0.001) and shorter procedural time (p = 0.004), without increased bleeding risk (13 vs. 18%, p = NS). Earlier intravenous administration of eptifibatide before primary PCI did not improve preprocedural IRA patency, CK-MB level at 8 hours after admission, LVEF and 30-day mortality compared with patients who received intravenous eptifibatide that was administered later.

Does public reporting improve the quality of hospital care for acute myocardial infarction? Results from a regional outcome evaluation program in Italy

OBJECTIVE

To evaluate whether public reporting of performance data was associated with a change over time in quality indicators for acute myocardial infarction (AMI) in Italian hospitals.

DESIGN

Pre-post evaluation of AMI indicators in the Lazio region, before and after disclosure of the Regional Outcome Evaluation Program, and a comparative evaluation versus other Italian regions not participating in the program.

SETTING/DATA SOURCES

Nationwide Hospital Information System and vital status records.

PARTICIPANTS

24 800 patients treated for AMI in Lazio and 39 350 in the other regions.

INTERVENTION

Public reporting of the Regional Outcome Evaluation Program in the Lazio region.

MAIN OUTCOME MEASURE

Risk-adjusted indicators for AMI.

RESULTS

The proportion of ST-segment elevation myocardial infarction (STEMI) patients treated with percutaneous coronary interventions (PCI) within 48 h in Lazio changed from 31.3 to 48.7%, before and after public reporting, respectively (relative increase 56%; P < 0.001). In the other regions, the proportion increased from 51.5 to 58.4% (relative increase 13%; P < 0.001). Overall 30-day mortality and 30-day mortality for patients treated with PCI did not improve during the study period. The 30-day mortality for STEMI patients not treated with PCI in Lazio was significantly higher in 2009 (29.0%) versus 2006/07 (24.0%) (P = .002).

CONCLUSIONS

Public reporting may have contributed to increasing the proportion of STEMI patients treated with timely PCI. The mortality outcomes should be interpreted with caution. Changes in AMI diagnostic and coding systems should also be considered. Risk-adjusted quality indicators represent a fundamental instrument for monitoring and potentially enhancing quality of care.

Temporal trends of system of care for STEMI: insights from the Jakarta Cardiovascular Care Unit Network System

AIM

Guideline implementation programs are of paramount importance in optimizing acute ST-elevation myocardial infarction (STEMI) care. Assessment of performance indicators from a local STEMI network will provide knowledge of how to improve the system of care.

METHODS AND RESULTS

Between 2008-2011, 1505 STEMI patients were enrolled. We compared the performance indicators before (n = 869) and after implementation (n = 636) of a local STEMI network. In 2011 (after introduction of STEMI networking) compared to 2008-2010, there were more inter-hospital referrals for STEMI patients (61% vs 56%, p<0.001), more primary percutaneous coronary intervention (PCI) procedures (83% vs 73%, p = 0.005), and more patients reaching door-to-needle time ≤ 30 minutes (84.5% vs 80.2%, p<0.001). However, numbers of patients who presented very late (>12 hours after symptom onset) were similar (53% vs 51%, NS). Moreover, the numbers of patients with door-to-balloon time ≤ 90 minutes were similar (49.1% vs 51.3%, NS), and in-hospital mortality rates were similar (8.3% vs 6.9%, NS) in 2011 compared to 2008-2010.

CONCLUSION

After a local network implementation for patients with STEMI, there were significantly more inter-hospital referral cases, primary PCI procedures, and patients with a door-to-needle time ≤ 30 minutes, compared to the period before implementation of this network. However, numbers of patients who presented very late, the targeted door-to-balloon time and in-hospital mortality rate were similar in both periods. To improve STEMI networking based on recent guidelines, existing pre-hospital and in-hospital protocols should be improved and managed more carefully, and should be accommodated whenever possible.

Timely treatment for acute myocardial infarction and health outcomes: an integrative review of the literature

BACKGROUND

Coronary heart disease is the most common condition affecting Australians. The time sensitive nature of treating ST-segment elevation myocardial infarction (STEMI) has been the subject of extensive research for several years. Despite important advances in strategies to reduce time to treatment, time continues to represent a major determinant of mortality and morbidity. Door to balloon time (DTBT) is a key indicator of quality of care for STEMI. Nurses play a pivotal role in streamlining the care processes to influence timely management of STEMI.

PURPOSE

The aim of this paper is to review the evidence on the time to treat STEMI, the associated factors impacting upon health outcomes and explore systems of care that reduce time to treatment, using an integrative review approach.

METHOD

Established databases were searched from 2000 to 2012. The search terms 'myocardial infarction', 'emergency medicine', 'angioplasty balloon', 'time factors', 'treatment outcome', 'mortality', 'prognosis', 'female', 'age factors', and 'readmission', were used in various combinations. Research studies that addressed the aims of this paper were examined.

FINDINGS

Twenty-nine papers were included in this integrative review. The literature demonstrates a strong relationship between shorter DTBT and reduced in-hospital mortality. Factors such as age, gender, time of presentation and co-morbid condition were associated with increased in-hospital mortality. There is sparse literature examining the effect timely reperfusion has on longer-term mortality and other longer-term outcomes such as readmission rates and occurrence of heart failure. Additionally, strategies that effectively reduced DTBT were identified, yet little has been reported on the impact reduced DTBT has had upon health outcomes and whether these improvements were sustained.

CONCLUSION

Whilst the importance of timely reperfusion is now well recognised, additional efforts to streamline the process of care and demonstrate sustained improvement for STEMI patients is required. Nurses in the areas of emergency medicine and cardiac care, play an essential role in facilitating this.

Acute myocardial infarction system of care in the third world

BACKGROUND

We studied the characteristics of ST-elevation myocardial infarction (STEMI) patients from a local acute coronary syndrome (ACS) registry in order to find and build an appropriate acute myocardial infarction (AMI) system of care in Jakarta, Indonesia.

METHODS

Data were collected from the Jakarta Acute Coronary Syndrome (JAC) registry 2008-2009, which contained 2103 ACS patients, including 654 acute STEMI patients admitted to the National Cardiovascular Center Harapan Kita, Jakarta, Indonesia.

RESULTS

The proportion of patients who did not receive reperfusion therapy was 59% in all STEMI patients and the majority of them (52%) came from inter-hospital referral. The time from onset of infarction to hospital admission was more than 12 h in almost 80% cases and 60% had an anterior wall MI. In-hospital mortality was significantly higher in patients who did not receive reperfusion therapy compared with patients receiving acute reperfusion therapy, either with primary percutaneous coronary intervention (PPCI) or fibrinolytic therapy (13.3% vs 5.3% vs 6.2%, p < 0.001).

CONCLUSION

The Jakarta Cardiovascular Care Unit Network System was built to improve the care of AMI in Jakarta. This network will harmonise the activities of all hospitals in Jakarta and will provide the best cardiovascular services to the community by giving two reperfusion therapy options (PPCI or pharmaco-invasive strategy) depending on the time needed for the patient to reach the cath-lab.

The Use of Bivalirudin in ST-Segment Elevation Myocardial Infarction: Advantages and Limitations

The incidence of ST-segment elevation myocardial infarction (STEMI) is a common, albeit declining, manifestation of coronary heart disease. Significant improvements in cardiovascular outcomes and mortality in STEMI patients have occurred in recent years, reflecting evolution in the understanding of the pathophysiological mechanisms and therapeutic targets of this disease. Nonetheless, the risks of recurrent ischemia and bleeding complications in this population remain substantial. This review focuses on the adjunctive anticoagulant agents used in the management of STEMI. Major insights from the HORIZONS-AMI trial regarding the impact of bivalirudin on both hemorrhagic and ischemic outcomes in STEMI patients are discussed.

An Asian validation of the TIMI risk score for ST-segment elevation myocardial infarction

Background

Risk stratification in ST-elevation myocardial infarction (STEMI) is important, such that the most resource intensive strategy is used to achieve the greatest clinical benefit. This is essential in developing countries with wide variation in health care facilities, scarce resources and increasing burden of cardiovascular diseases. This study sought to validate the Thrombolysis In Myocardial Infarction (TIMI) risk score for STEMI in a multi-ethnic developing country.

Methods

Data from a national, prospective, observational registry of acute coronary syndromes was used. The TIMI risk score was evaluated in 4701 patients who presented with STEMI. Model discrimination and calibration was tested in the overall population and in subgroups of patients that were at higher risk of mortality; i.e., diabetics and those with renal impairment.

Results

Compared to the TIMI population, this study population was younger, had more chronic conditions, more severe index events and received treatment later. The TIMI risk score was strongly associated with 30-day mortality. Discrimination was good for the overall study population (c statistic 0.785) and in the high risk subgroups; diabetics (c statistic 0.764) and renal impairment (c statistic 0.761). Calibration was good for the overall study population and diabetics, with χ2 goodness of fit test p value of 0.936 and 0.983 respectively, but poor for those with renal impairment, χ2 goodness of fit test p value of 0.006.

Conclusions

The TIMI risk score is valid and can be used for risk stratification of STEMI patients for better targeted treatment.

Selection and validation of quality indicators for the Shorter Stays in Emergency Departments National Research Project

OBJECTIVE

Despite the spread of time targets for ED lengths of stay around the world, there have been few studies exploring the effects of such policies on quality of ED care. The Shorter Stays in Emergency Departments (SSED) National Research Project seeks to address this. The purpose of this paper was to describe how the indicators for the SSED study in New Zealand were selected and validated.

METHODS

A literature review was used to identify potential indicators. A reference group of 25 key stakeholders from across the health system was convened, with the aims of validating the suggested indicators and to ensure that other candidate indicators were not overlooked. A thematic analysis using a general inductive approach was used to analyse focus group discussions.

RESULTS

The major themes were communication, access, timeliness, appropriateness and satisfaction. The 12 indicators selected after literature review were confirmed and two further indicators added after the thematic analysis. The indicators are: hospital and ED length of stay; re-presentation within 48 h; mortality; times to reperfusion, antibiotics, asthma treatment, analgesia, CT for head injury and to theatre (appendicitis and fractured neck of femur); triage time compliance; proportion who left without being seen; quality of discharge information; and ED overcrowding/access block.

CONCLUSION

Through literature review and consultation with stakeholders, an evidence-based and clinically relevant set of indicators was compiled with which to measure the effect of the SSED target. This indicator set is consistent with recent international recommendations for measuring quality of care in EDs.

The Stent for Life project in Italy

In Italy, as in other European countries, public service healthcare presents some disparities that are related to geographical, economic, organizational and structural issues. Although some Italian regions have excellent networks for the treatment of ST-elevation myocardial infarction (STEMI), others still have to develop a model that allows each STEMI patient to receive the best reperfusion treatment. A recent nationwide registry from the Italian Society of Interventional Cardiology (SICI-GISE) showed that efficient STEMI networks cover approximately 50% of the Italian territory. For these reasons, Italy joined the Stent for Life initiative in August 2010 with the primary goal of implementing and defining tailored action programs in order to ensure that the majority of the Italian STEMI population have access to life-saving primary percutaneous coronary intervention.