Impact of Regionalization of ST-Segment–Elevation Myocardial Infarction Care on Treatment Times and Outcomes for Emergency Medical Services–Transported Patients Presenting to Hospitals With Percutaneous Coronary Intervention

Effect of chest pain center accreditation on timely reperfusion and in-hospital mortality for STEMI in China

Existing studies in developing countries on the impact of chest pain center (CPC) accreditation on treatment quality have limited ability to demonstrate causal relationships. This retrospective study aims to utilize the data from national-level database and explore the impact of chest pain center certification on the treatment quality of ST-segment elevation myocardial infarction (STEMI) patients through a more appropriate method. At the hospital level, taking timely reperfusion and in-hospital mortality as outcomes, the impact was evaluated using the Counterfactual Synthetic Difference-in-Differences (CS-DID) method, a statistical technique that allows for the estimation of causal effects by comparing the differences over time between treated and non-treated groups. The results showed that CPC accreditation improved timely reperfusion of STEMI. Once a CPC was certified, without considering covariates, the timely reperfusion rate increased on average by 5.4%, the 90-min PCI rate by 7.1%, and the 30-min thrombolysis rate by 2.0% in comparison with non-accredited hospitals, and this effect shows a downward trend over time and varies between different regions. We found no evidence to confirm that CPC accreditation decreases in-hospital mortality in patients with STEMI. CPC accreditation in China has improved the timeliness of reperfusion therapy for STEMI patients. CPC accreditation and re-accreditation are crucial to maintaining high-quality care for STEMI patients.

2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes" incorporates new evidence since the "2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction" and the corresponding "2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes" and the "2015 ACC/AHA/SCAI Focused Update on Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial Infarction." The "2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes" and the "2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization" retire and replace, respectively, the "2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease."

METHODS

A comprehensive literature search was conducted from July 2023 to April 2024. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes" incorporates new evidence since the "2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction" and the corresponding "2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes" and the "2015 ACC/AHA/SCAI Focused Update on Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial Infarction." The "2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes" and the "2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization" retire and replace, respectively, the "2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease."

METHODS

A comprehensive literature search was conducted from July 2023 to April 2024. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

Expedited conveyance of out-of-hospital-cardiac arrest patients with STEMI and shockable rhythms to Cardiac Arrest Centres - A feasibility pilot study of the British Cardiovascular Intervention Society conveyance algorithm

BACKGROUND AND AIMS

Guidelines suggest non-traumatic out-of-hospital cardiac arrest (OHCA) be conveyed to cardiac arrest centres (CAC). We hypothesised that (a) a pre-hospital conveyance algorithm based on initial presenting rhythm following OHCA is feasible and (b) that would demonstrate survival advantage.

METHODS

This observational pilot study included all consecutive patients with OHCA from suspected cardiac aetiology from the county of Essex, United Kingdom from April 2022-April 2023. For the first 6 months, OHCA patients had conveyance as standard of care. For the next 6 months, consecutive OHCA patients with STEMI or initial shockable rhythm were directly conveyed to the CAC, initial non-shockable rhythm without STEMI continued to be taken to the nearest Emergency Department (BCIS protocol). Primary outcome was death from any cause at 30 days. Secondary outcome was survival with favourable neurological outcome.

RESULTS

Of 330 patients (mean age 67.5 ± 13.1, 66% male), 162 patients were in the standard care group and 168 in the BCIS conveyance group. Algorithm implementation was associated with numerically lower all cause 30-day mortality [(81% vs 73%, RR 1.10 (95% CI 0.98-1.24) p = 0.10] and numerically higher 30-day survival with favourable neurological outcome [15% vs 19%, RR 1.05 (0.95-1.15), p = 0.38]. Post hoc analysis showed that the BCIS conveyance algorithm was associated with lower 30 day mortality in those with an initial shockable rhythm [(61% vs 41%, RR 1.5 (95% CI 1.05-2.13) p = 0.02 and in those with a MIRACLE2 score ≤ 5 [(63%% vs 38%, RR 0.59 (95% CI 0.61-0.86) p = 0.005].

CONCLUSIONS

The BCIS algorithm is feasible and did not impact overall mortality, but there is signal that direct conveyance of OHCA patients with an initial shockable rhythm and low MIRACLE2 score, to a dedicated CAC may improve survival.

A proposed method for identifying Interfacility transfers in Medicare claims data

OBJECTIVE

To develop a method of consistently identifying interfacility transfers (IFTs) in Medicare Claims using patients with ST-Elevation Myocardial Infarction (STEMI) as an example.

DATA SOURCES/STUDY SETTING

100% Medicare inpatient and outpatient Standard Analytic Files and 5% Carrier Files, 2011-2020.

STUDY DESIGN

Observational, cross-sectional comparison of patient characteristics between proposed and existing methods.

DATA COLLECTION/EXTRACTION METHODS

We limited to patients aged 65+ with STEMI diagnosis using both proposed and existing methods.

PRINCIPAL FINDINGS

We identified 62,668 more IFTs using the proposed method (86,128 versus 23,460). A separately billable interfacility ambulance trip was found for more IFTs using the proposed than existing method (86% vs. 79%). Compared with the existing method, transferred patients under the proposed method were more likely to live in rural (p < 0.001) and lower income (p < 0.001) counties and were located farther away from emergency departments, trauma centers, and intensive care units (p < 0.001).

CONCLUSIONS

Identifying transferred patients based on two consecutive inpatient claims results in an undercount of IFTs and under-represents rural and low-income patients.

Improving STEMI Management Internationally: Initial Report of the American College of Cardiology-Global Heart Attack Treatment Initiative

Background

The burden of ST-segment elevation myocardial infarction (STEMI) worldwide is increasing as the leading cause of death; there are scant data on system-based initiatives and performance metrics relative to its management in low- and middle-income countries where resources are frequently limited.

Objectives

The Global Heart Attack Treatment Initiative (GHATI) ultimate aim is improving evidence-based STEMI care, adherence to guidelines, and tracking of clinical and institutional indicators in low- and middle-income countries. To achieve that goal, the process of care and outcomes of STEMI patients in those nations will be studied.

Methods

In this initial phase of GHATI (2019-2021), prospective analyses of selected STEMI metrics derived from the American College of Cardiology Chest Pain MI Registry were undertaken in 18 international hospitals, most located in developing countries unfamiliar with quality improvement metrics.

Results

Of 4,092 patients enrolled, complete data were available in 3,914 consecutive STEMIs included here: 80.5% male; 35.5% smokers; shock on arrival in 10%; and 5.1% with cardiac arrest before intervention. Overall, a 2% improvement on combined endpoints (shock; arrest before or after intervention; final ejection fraction <40%; survival at discharge) was observed over time, and survivorship also increased by 2% (P = 0.003). First medical contact to device time <90 minutes occurred in 74.8%; reperfusion therapy in 94.2%; and adherence to guidelines in 91.8%.

Conclusions

This global contemporary registry successfully enrolled STEMI patients in nations generally unfamiliar with quality improvement metrics; trends of improvement in their care were observed. GHATI may facilitate implementation of policies aimed at enhancing outcomes of cardiovascular disease worldwide, particularly in countries with evolving economies.

Defining the Cross-Volume Effect of Extracorporeal Life Support on Outcomes of Cardiogenic Shock

BACKGROUND

Cardiogenic shock (CS) remains a leading cause of mortality despite advancements in mechanical circulatory support and other management strategies. In particular, venoarterial extracorporeal membrane oxygenation (ECMO) requires expertise in cardiac surgery, cardiology, and critical care. The benefits of such expertise may extend beyond patients undergoing ECMO.

METHODS

Hospitalizations in adults (aged ≥18 years) with a primary diagnosis of CS who were not undergoing ECMO, cardiac operations, durable left ventricular assist device therapy, or heart transplantation were abstracted from the 2016-2020 Nationwide Readmissions Database. Multivariable regression models were developed to assess the association of cardiac surgical and ECMO institutional caseload with clinical and financial outcomes.

RESULTS

Of an estimated 70,339 patients with CS identified for study, 33,643 (47.8%) were treated at a high-volume hospital for ECMO (HVH-ECMO). HVH-ECMO was associated with decreased odds of in-hospital mortality (adjusted odds ratio [aOR], 0.85; 95% CI, 0.75-0.95), respiratory complications (aOR, 0.86; 95% CI, 0.79-0.94), and nonhome discharge (aOR, 0.86; 95% CI, 0.79-0.94). However, HVH-ECMO was associated with a longer length of stay by 1.7 days (95% CI, 1.3-2.1) and higher inpatient costs by $9170 (95% CI, $6,490-$12,060). Although ECMO volume was inversely associated with the predicted risk of in-hospital mortality, institutional volume of cardiac operations was not significantly associated with mortality.

CONCLUSIONS

Our findings suggest improved outcomes for patients with CS who were treated at an HVH-ECMO. Multidisciplinary care pathways, including those among surgery, cardiology, and critical care, may influence CS management. Further studies are needed to characterize long-term outcomes of regionalization and ensure equitable access for all populations.

A Pilot Rapid Triage Process for Prehospital ST-Segment Myocardial Infarction Patients Direct to the Catheterization Lab

Background Rapid treatment of ST-elevation myocardial infarction (STEMI) patients with primary percutaneous coronary intervention (PCI) significantly reduces morbidity and mortality rates. Recent studies emphasize the importance of reducing total ischemic time, making first-medical-contact-to-balloon (FMCTB) time a key performance indicator. To improve FMCTB times in patients brought to the Emergency Department (ED) by Emergency Medical Services (EMS), we implemented a "Direct to Lab" (DTL) workflow during the following conditions: weekday daytime hours, when the lab is fully staffed, and for hemodynamically stable STEMI patients presenting via EMS. Methods We performed a pre/post analysis following the implementation of a pilot workflow for EMS STEMI patients to be rapidly triaged to the cardiac catheterization lab as compared to those patients who underwent the standard workflow before program implementation at a 225-bed community hospital in a suburban setting in Maryland, USA. The hospital's STEMI database was queried from 2/1/2021 through 3/1/2024, including all EMS STEMI alert activations during the study period. Cases were excluded if the patient arrived after program operating hours, declined PCI, or if clinical circumstances (such as cardiac arrest or the need for other resuscitative or diagnostic interventions) necessitated additional ED stabilization before PCI. Results A total of 30 patients met the inclusion criteria. The analysis revealed significantly reduced ED, door-to-balloon (DTB), and FMCTB times for patients under the "Direct to Lab" workflow, including a total ED time of 8.4 minutes faster, an average DTB time of 19.6 minutes faster, and an average FMCTB time of 24.3 minutes faster than those triaged via the standard workflow. Complication rates were similar among both groups. The most common reason that stable patients were not taken directly to the lab was the need for further clinical evaluation before cardiac catheterization or the lab not being immediately available. Conclusion In this pilot single-center analysis, STEMI patients who were expeditiously triaged "Direct to Lab" experienced significantly lower total ED, DTB, and FMCTB times with no difference in procedural complications. This study highlights the patient-centered benefits of a robust collaboration between EMS, ED, and Interventional Cardiology teams.

SCAI Expert Consensus Statement on the Management of Patients With STEMI Referred for Primary PCI

ST-elevation myocardial infarction (STEMI) remains a leading cause of morbidity and mortality in the United States. Timely reperfusion with primary percutaneous coronary intervention is associated with improved outcomes. The Society for Cardiovascular Angiography & Interventions puts forth this expert consensus document regarding best practices for cardiac catheterization laboratory team readiness, arterial access with an algorithm to help determine proper arterial access in STEMI, and diagnostic angiography. This consensus statement highlights the strengths and limitations of various diagnostic and therapeutic interventions to access and treat a patient with STEMI in the catheterization laboratory, reviews different options to manage large thrombus burden during STEMI, and reviews the management of STEMI across the spectrum of various anatomical and clinical circumstances.

Sex differences in the presentation and outcomes of patients with acute myocardial infarction complicated by cardiogenic shock: a critical review of contemporary data and a look towards future directions

PURPOSE OF REVIEW

Cardiogenic shock (CS) is a devasting complicating of acute myocardial infarction (AMI), associated with significant mortality. Prior studies have reported sex differences in the presentation, management and outcomes of patients with AMI and CS. These differences are likely due to a variety of factors influencing therapeutic decision-making and impacting survival. This review highlights the more contemporary studies exploring differences in women and men with AMI-CS, providing a critical perspective towards understanding the factors that might lead to these differences and outlining potential opportunities to reduce disparities in treatment and improve survival for women with AMI-CS.

RECENT FINDINGS

Recent reports demonstrate that women with AMI-CS are older than men and have more cardiovascular comorbidities. When examining an unselected population of patients with AMI-CS, women receive less aggressive treatment compared to men and have poorer outcomes. However, when examining a selected population of patients with AMI-CS treated with mechanical circulatory support (MCS) and/or admitted to centers that implement CS protocols to manage AMI-CS, these sex-based differences in outcomes are largely mitigated.

SUMMARY

Standardizing protocols for the diagnosis and treatment of patients with AMI-CS, with an emphasis on early revascularization and appropriate invasive therapies, can improve outcomes in women and narrow the gender gap.

Current status of emergency medical service use in ST-segment elevation myocardial infarction in China: Findings from China Acute Myocardial Infarction (CAMI) Registry

BACKGROUND

The mortality rate of myocardial infarction in China has increased dramatically in the past three decades. Although emergency medical service (EMS) played a pivotal role for the management of patients with ST-segment elevation myocardial infarction (STEMI), the corresponding data in China are limited.

METHODS

An observational analysis was performed in 26,305 STEMI patients, who were documented in China acute myocardial infarction (CAMI) Registry and treated in 162 hospitals from January 1st, 2013 to January 31th, 2016. We compared the differences such as demographic factors, social factors, medical history, risk factors, socioeconomic distribution and treatment strategies between EMS transport group and self-transport group.

RESULTS

Only 4336 patients (16.5%) were transported by EMS. Patients with symptom onset outside, out-of-hospital cardiac arrest and presented to province-level hospital were more likely to use EMS. Besides those factors, low systolic blood pressure, severe dyspnea or syncope, and high Killip class were also positively related to EMS activation. Notably, compared to self-transport, use of EMS was associated with a shorter prehospital delay (median, 180 vs. 245 min, P < 0.0001) but similar door-to-needle time (median, 45 min vs. 52 min, P = 0.1400) and door-to-balloon time (median, 105 min vs. 103 min, P = 0.1834).

CONCLUSIONS

EMS care for STEMI is greatly underused in China. EMS transport is associated with shorter onset-to-door time and higher rate of reperfusion, but not substantial reduction in treatment delays or mortality rate. Targeted efforts are needed to promote EMS use when chest pain occurs and to set up a unique regionalized STEMI network focusing on integration of prehospital care procedures in China.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT01874691), retrospectively registered June 11, 2013.

Ventricular Arrhythmias After Primary Percutaneous Coronary Intervention for STEMI

Importance

Currently, mortality risk for patients with ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI) with an uncomplicated postprocedure course is low. Less is known regarding the risk of in-hospital ventricular tachycardia (VT) and ventricular fibrillation (VF).

Objective

To evaluate the risk of late VT and VF after primary PCI for STEMI.

Design, Setting, and Participants

This cohort study included adults aged 18 years or older with STEMI treated with primary PCI between January 1, 2015, and December 31, 2018, identified in the US National Cardiovascular Data Registry Chest Pain-MI Registry. Data were analyzed from April to December 2020.

Main Outcomes and Measures

Multivariable logistic regression was used to evaluate the risk of late VT (≥7 beat run of VT during STEMI hospitalization ≥1 day after PCI) or VF (any episode of VF≥1 day after PCI) associated with cardiac arrest and associations between late VT or VF and in-hospital mortality in the overall cohort and a cohort with uncomplicated STEMI without prior myocardial infarction or heart failure, systolic blood pressure less than 90 mm Hg, cardiogenic shock, cardiac arrest, reinfarction, or left ventricular ejection fraction (LVEF) less than 40%.

Results

A total of 174 126 eligible patients with STEMI were treated with primary PCI at 814 sites in the study; 15 460 (8.9%) had VT or VF after primary PCI, and 4156 (2.4%) had late VT or VF. Among the eligible patients, 99 905 (57.4%) at 807 sites had uncomplicated STEMI. The median age for patients with late VT or VF overall was 63 years (IQR, 55-73 years), and 75.5% were men; the median age for patients with late VT or VF with uncomplicated STEMI was 60 years (IQR, 53-69 years), and 77.7% were men. The median length of stay was 3 days (IQR, 2-7 days) for the overall cohort with late VT or VF and 3 days (IQR, 2-4 days) for the cohort with uncomplicated STEMI with late VT or VF. The risk of late VT or VF was 2.4% (overall) and 1.7% (uncomplicated STEMI). Late VT or VF with cardiac arrest occurred in 674 patients overall (0.4%) and in 117 with uncomplicated STEMI (0.1%). LVEF was the most significant factor associated with late VT or VF with cardiac arrest (adjusted odds ratio [AOR] for every 5-unit decrease ≤40%: 1.67; 95% CI, 1.54-1.85). Late VT or VF events were associated with increased odds of in-hospital mortality in the overall cohort (AOR, 6.40; 95% CI, 5.63-7.29) and the cohort with uncomplicated STEMI (AOR, 8.74; 95% CI, 6.53-11.70).

Conclusions and Relevance

In this study, a small proportion of patients with STEMI treated with primary PCI had late VT or VF. However, late VT or VF with cardiac arrest was rare, particularly in the cohort with uncomplicated STEMI. This information may be useful when determining the optimal timing for hospital discharge after STEMI.

Regionalization of stroke systems of care in the stroke belt states: The IMPROVE stroke care quality improvement program

BACKGROUND

Despite guidelines and strong evidence supporting intravenous thrombolysis and endovascular thrombectomy for acute stroke, access to these interventions remains a challenge. The objective of the IMPROVE stroke care program was to accelerate acute stroke care delivery by implementing best practices and improving the regional systems of care within comprehensive stroke networks.

METHODS

The IMPROVE Stroke Care program was a prospective quality improvement program based on established models used in acute coronary care. Nine hub hospitals (comprehensive stroke centers), 52 regional/community referral hospitals (spokes), and over 100 emergency medical service agencies participated. Through 6 regional meetings, 49 best practices were chosen for improvement by the participating sites. Over 2 years, progress was tracked and discussed weekly and performance reviews were disseminated quarterly.

RESULTS

Data were collected on 21,647 stroke code activations of which 8,502 (39.3%) activations had a final diagnosis of stroke. There were 7,226 (85.0%) ischemic strokes, and thrombolytic therapy was administered 2,814 times (38.9%). There was significant overall improvement in the proportion that received lytic therapy within 45 minutes (baseline of 44.6%-60.4%). The hubs were more frequently achieving this at baseline, but both site types improved. A total of 1,455 (17.1%) thrombectomies were included in the data of which 401 (27.6%) were transferred from a spoke. There was no clinically significant change in door-to-groin times for hub-presenting thrombectomy patients, however, significant improvement occurred for transferred cases, 46 minutes (interquartile range [IQR] 36, 115.5) at baseline to 27 minutes (IQR 10, 59).

CONCLUSIONS

The IMPROVE program approach was successful at improving the delivery of thrombolytic intervention across the consortium at both spoke and hub sites through collaborative efforts to operationalize guideline-based care through iterative sharing of performance and best practices for implementation. Our approach allowed identification of both opportunities for improvement and operational best practices providing guidance on how best to create a regional stroke care network and operationalize the published acute stroke care guidelines.

Reperfusion in Patients With ST-Segment-Elevation Myocardial Infarction With Cardiogenic Shock and Prolonged Interhospital Transport Times

BACKGROUND

In patients with ST-segment-elevation myocardial infarction complicated by cardiogenic shock, primary percutaneous coronary intervention (pPCI) is the preferred revascularization option. Little is known about the efficacy and safety of a pharmacoinvasive approach for patients with cardiogenic shock presenting to a non-PCI hospital with prolonged interhospital transport times.

METHODS

In a retrospective analysis of geographically extensive ST-segment-elevation myocardial infarction network (2006-2021), 426 patients with cardiogenic shock and ST-segment-elevation myocardial infarction presented to a non-PCI-capable hospital and underwent reperfusion therapy (53.8% pharmacoinvasive and 46.2% pPCI). The primary clinical outcome was a composite of in-hospital mortality, renal failure requiring dialysis, cardiac arrest, or mechanical circulatory support, and the primary safety outcome was major bleeding defined as an intracranial hemorrhage or bleeding that required transfusion was compared in an inverse probability weighted model. The electrocardiographic reperfusion outcome of interest was the worst residual ST-segment-elevation.

RESULTS

Patients with pharmacoinvasive treatment had longer median interhospital transport (3 hours versus 1 hour) and shorter median symptom-onset-to-reperfusion (125 minute-to-needle versus 419 minute-to-balloon) times. ST-segment resolution ≥50% on the postfibrinolysis ECG was 56.6%. Postcatheterization, worst lead residual ST-segment-elevation <1 mm (57.3% versus 46.3%; P=0.01) was higher in the pharmacoinvasive compared with the pPCI cohort, but no differences were observed in the worst lead ST-segment-elevation resolution ≥50% (77.4% versus 81.8%; P=0.57). The primary clinical end point was lower in the pharmacoinvasive cohort (35.2% versus 57.0%; inverse probability weighted odds ratio, 0.44 [95% CI, 0.26-0.72]; P<0.01) compared with patients who received pPCI. An interaction between interhospital transfer time and reperfusion strategy with all-cause mortality was observed, favoring a pharmacoinvasive approach with transfer times >60 minutes. The incidence of the primary safety outcome was 10.1% in the pharmacoinvasive arm versus 18.7% in pPCI (adjusted odds ratio, 0.41 [95% CI, 0.14-1.09]; P=0.08).

CONCLUSIONS

In patients with ST-segment-elevation myocardial infarction presenting with cardiogenic shock and prolonged interhospital transport times, a pharmacoinvasive approach was associated with improved electrocardiographic reperfusion and a lower rate of death, dialysis, or mechanical circulatory support without an increase in major bleeding.

Sex Disparities in Management and Outcomes Among Patients With Acute Coronary Syndrome

Importance

Sex disparities in the management and outcomes of acute coronary syndrome (ACS) have received increasing attention.

Objective

To evaluate the association of a quality improvement program with sex disparities among patients with ACS.

Design, Setting, and Participants

The National Chest Pain Centers Program (NCPCP) is an ongoing nationwide program for the improvement of quality of care in patients with ACS in China, with CPC accreditation as a core intervention. In this longitudinal analysis of annual (January 1, 2016, to December 31, 2020) cross-sectional data of 1 095 899 patients with ACS, the association of the NCPCP with sex-related disparities in the care of these patients was evaluated using generalized linear mixed models and interaction analysis. The robustness of the results was assessed by sensitivity analyses with inverse probability of treatment weighting. Data were analyzed from September 1, 2021, to June 30, 2022.

Exposure

Hospital participation in the NCPCP.

Main Outcomes and Measures

Differences in treatment and outcomes between men and women with ACS. Prehospital indicators included time from onset to first medical contact (onset-FMC), time from onset to calling an emergency medical service (onset-EMS), and length of hospital stay without receiving a percutaneous coronary intervention (non-PCI). In-hospital quality indicators included non-PCI, use of statin at arrival, discharge with statin, discharge with dual antiplatelet therapy, direct PCI for ST-segment elevation myocardial infarction (STEMI), PCI for higher-risk non-ST-segment elevation ACS, time from door to catheterization activation, and time from door to balloon. Patient outcome indicators included in-hospital mortality and in-hospital new-onset heart failure.

Results

Data for 1 095 899 patients with ACS (346 638 women [31.6%] and 749 261 men [68.4%]; mean [SD] age, 63.9 [12.4] years) from 989 hospitals were collected. Women had longer times for onset-FMC and onset-EMS; lower rates of PCI, statin use at arrival, and discharge with medication; longer in-hospital delays; and higher rates of in-hospital heart failure and mortality. The NCPCP was associated with less onset-FMC time, more direct PCI rate for STEMI, lower rate of in-hospital heart failure, more drug use, and fewer in-hospital delays for both men and women with ACS. Sex-related differences in the onset-FMC time (β = -0.03 [95% CI, -0.04 to -0.01), rate of direct PCI for STEMI (odds ratio, 1.11 [95% CI, 1.06-1.17]), time from hospital door to balloon (β = -1.38 [95% CI, -2.74 to -0.001]), and rate of in-hospital heart failure (odds ratio, 0.90 [95% CI, 0.86-0.94]) were significantly less after accreditation.

Conclusions and Relevance

In this longitudinal cross-sectional study of patients with ACS from hospitals participating in the NCPCP in China, sex-related disparities in management and outcomes were smaller in some aspects by regionalization between prehospital emergency and in-hospital treatment systems and standardized treatment procedures. The NCPCP should emphasize sex disparities to cardiologists; highlight compliance with clinical guidelines, particularly for female patients; and include the reduction of sex disparities as a performance appraisal indicator.

Comparing strategies for prehospital transport to specialty care after cardiac arrest

Outcomes are better when patients resuscitated from out-of-hospital cardiac arrest (OHCA) are treated at specialty centers. The best strategy to transport patients from the scene of resuscitation to specialty care is unknown.

METHODS

We performed a retrospective cohort study. We identified patients treated at a single specialty center after OHCA from 2010 to 2021 and used OHCA geolocations to develop a catchment area using a convex hull. Within this area, we identified short term acute care hospitals, OHCA receiving centers, adult population by census block group, and helicopter landing zones. We determined population-level times to specialty care via: (1) direct ground transport; (2) transport to the nearest hospital followed by air interfacility transfer; and (3) ground transport to air ambulance. We used an instrumental variable (IV) adjusted probit regression to estimate the causal effect of transport strategy on functionally favorable survival to hospital discharge.

RESULTS

Direct transport to specialty care by ground to air ambulance had the shortest population-level times from OHCA to specialty care (median 56 [IQR 47-66] minutes). There were 1,861 patients included in IV regression of whom 395 (21%) had functionally favorable survival. Most (n = 1,221, 66%) were transported to the nearest hospital by ground EMS then to specialty care by air. Patient outcomes did not differ across transport strategies in our IV analysis.

DISCUSSION

We did not find strong evidence in favor of a particular strategy for transport to specialty care after OHCA. Population level time to specialty care was shortest with ground ambulance transport to the nearest helicopter landing zone.

Identifying and Solving Gaps in Pre- and In-Hospital Acute Myocardial Infarction Care in Asia-Pacific Countries

Acute myocardial infarction (AMI) is a major cause of morbidity and mortality in the Asia-Pacific region, and mortality rates differ between countries in the region. Systems of care have been shown to play a major role in determining AMI outcomes, and this review aims to highlight pre-hospital and in-hospital system deficiencies and suggest possible improvements to enhance quality of care, focusing on Korea, Japan, Singapore and Malaysia as representative countries. Time to first medical contact can be shortened by improving patient awareness of AMI symptoms and the need to activate emergency medical services (EMS), as well as by developing robust, well-coordinated and centralized EMS systems. Additionally, performing and transmitting pre-hospital electrocardiograms, algorithmically identifying patients with high risk AMI and developing hospital networks that appropriately divert such patients to percutaneous coronary intervention-capable hospitals have been shown to be beneficial. Within the hospital environment, developing and following clinical practice guidelines ensures that treatment plans can be standardised, whilst integrated care pathways can aid in coordinating care within the healthcare institution and can guide care even after discharge. Prescription of guideline directed medical therapy for secondary prevention and patient compliance to medications can be further optimised. Finally, the authors advocate for the establishment of more regional, national and international AMI registries for the formal collection of data to facilitate audit and clinical improvement.

Race-Based Differences in ST-Segment-Elevation Myocardial Infarction Process Metrics and Mortality From 2015 Through 2021: An Analysis of 178 062 Patients From the American Heart Association Get With The Guidelines-Coronary Artery Disease Registry

BACKGROUND

Systems of care have been developed across the United States to standardize care processes and improve outcomes in patients with ST-segment-elevation myocardial infarction (STEMI). The effect of contemporary STEMI systems of care on racial and ethnic disparities in achievement of time-to-treatment goals and mortality in STEMI is uncertain.

METHODS

We analyzed 178 062 patients with STEMI (52 293 women and 125 769 men) enrolled in the American Heart Association Get With The Guidelines-Coronary Artery Disease registry between January 1, 2015, and December 31, 2021. Patients were stratified into and outcomes compared among 3 racial and ethnic groups: non-Hispanic White, Hispanic White, and Black. The primary outcomes were the proportions of patients achieving the following STEMI process metrics: prehospital ECG obtained by emergency medical services; hospital arrival to ECG obtained within 10 minutes for patients not transported by emergency medical services; arrival-to-percutaneous coronary intervention time within 90 minutes; and first medical contact-to-device time within 90 minutes. A secondary outcome was in-hospital mortality. Analyses were performed separately in women and men, and all outcomes were adjusted for age, comorbidities, acuity of presentation, insurance status, and socioeconomic status measured by social vulnerability index based on patients' county of residence.

RESULTS

Compared with non-Hispanic White patients with STEMI, Hispanic White patients and Black patients had lower odds of receiving a prehospital ECG and achieving targets for door-to-ECG, door-to-device, and first medical contact-to-device times. These racial disparities in treatment goals were observed in both women and men, and persisted in most cases after multivariable adjustment. Compared with non-Hispanic White women, Hispanic White women had higher adjusted in-hospital mortality (odds ratio, 1.39 [95% CI, 1.12-1.72]), whereas Black women did not (odds ratio, 0.88 [95% CI, 0.74-1.03]). Compared with non-Hispanic White men, adjusted in-hospital mortality was similar in Hispanic White men (odds ratio, 0.99 [95% CI, 0.82-1.18]) and Black men (odds ratio, 0.96 [95% CI, 0.85-1.09]).

CONCLUSIONS

Race- or ethnicity-based disparities persist in STEMI process metrics in both women and men, and mortality differences are observed in Hispanic White compared with non-Hispanic White women. Further research is essential to evolve systems of care to mitigate racial differences in STEMI outcomes.

Modeling the Association of Volume vs Composite Outcome Thresholds With Outcomes and Access to Transcatheter Aortic Valve Implantation in the US

Importance

Professional societies and the Centers for Medicare & Medicaid Services suggest volume thresholds to ensure quality in transcatheter aortic valve implantation (TAVI).

Objective

To model the association of volume thresholds vs spoke-and-hub implementation of outcome thresholds with TAVI outcomes and geographic access.

Design, Setting, and Participants

This cohort study included patients who enrolled in the US Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy registry. Site volume and outcomes were determined from a baseline cohort of adults undergoing TAVI between July 1, 2017, and June 30, 2020.

Exposures

Within each hospital referral region, TAVI sites were categorized by volume (<50 or ≥50 TAVIs per year) and separately by risk-adjusted outcome on the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy 30-day TAVI composite during the baseline period (July 2017 to June 2020). Outcomes of patients undergoing TAVIs from July 1, 2020, to March 31, 2022, were then modeled as though the patients had been treated at (1) the nearest higher volume (≥50 TAVIs per year) or (2) the best outcome site within the hospital referral region.

Main Outcomes and Measures

The primary outcome was the absolute difference in events between the adjusted observed and modeled 30-day composite of death, stroke, major bleeding, stage III acute kidney injury, and paravalvular leak. Data are presented as the number of events reduced under the above scenarios with 95% bayesian credible intervals (CrIs) and median (IQR) driving distance.

Results

The overall cohort included 166 248 patients with a mean (SD) age of 79.5 (8.6) years; 74 699 (47.3%) were female and 6657 (4.2%) were Black; 158 025 (95%) were treated in higher-volume sites (≥50 TAVIs) and 75 088 (45%) were treated in best-outcome sites. Modeling a volume threshold, there was no significant reduction in estimated adverse events (-34; 95% CrI, -75 to 8), while the median (IQR) driving time from the existing site to the alternate site was 22 (15-66) minutes. Transitioning care to the best outcome site in a hospital referral region resulted in an estimated 1261 fewer adverse outcomes (95% CrI, 1013-1500), while the median (IQR) driving time from the original site to the best site was 23 (15-41) minutes. Directionally similar findings were observed for Black individuals, Hispanic individuals, and individuals from rural areas.

Conclusions and Relevance

In this study, compared with the current system of care, a modeled outcome-based spoke-and-hub paradigm of TAVI care improved national outcomes to a greater extent than a simulated volume threshold, at the cost of increased driving time. To improve quality while maintaining geographic access, efforts should focus on reducing site variation in outcomes.

Mechanical Circulatory Support in COVID-19

Despite aggressive care, patients with cardiopulmonary failure and COVID-19 experience unacceptably high mortality rates. The use of mechanical circulatory support devices in this population offers potential benefits but confers significant morbidity and novel challenges for the clinician. Thoughtful application of this complex technology is of the utmost importance and should be done in a multidisciplinary fashion by teams familiar with mechanical support devices and aware of the particular challenges provided by this complex patient population.

Invasive Management and In-Hospital Outcomes of Myocardial Infarction Patients in Rural Versus Urban Hospitals in the United States

OBJECTIVES

The variation in the management and outcome of acute myocardial infarction (AMI) between rural and urban settings has been previously recognized, but there has previously been no nationwide data reported that is inclusive of the whole adult population.

METHODS

All discharge records between 2004 and 2018 with AMI diagnosis were extracted from the National Inpatient Sample (NIS) database and stratified by hospital location. The primary outcome was in-hospital mortality, and secondary outcomes included (a) major adverse cardiovascular and cerebrovascular events (MACCE), (b) major bleeding, (c) acute ischemic stroke, the utilization of invasive management in the form of (d) coronary angiography (CA), and (e) percutaneous coronary intervention (PCI). The adjusted odds ratios (aOR) and 95 % confidence interval (95 % CI) were determined using multivariable logistic regression.

RESULTS

9,728,878 records with AMI were identified, of which 1,011,637 (10.4 %) discharges were from rural hospitals. Rural patients were older (median of 71 years vs. 67 years, p < 0.001) and had lower prevalence of the highest risk presentations of AMI than their urban counterparts. After multivariable adjustment, patients from rural hospitals had increased aOR of all-cause mortality (aOR 1.15 95 % CI 1.13-1.16) and MACCE (aOR 1.04 95 % CI 1.04-1.05), as well as the decreased aOR of coronary angiography (aOR 0.29, 95 % CI 0.29-0.29, p < 0.001) and PCI (aOR 0.40, 95 % CI 0.39-0.40, p < 0.001), compared to their urban counterparts.

CONCLUSION

Between 2004 and 2018, the risk of in-hospital mortality and MACCE in AMI patients was significantly higher in rural hospitals, with considerably lower utilization of invasive angiography and revascularization.

Optimizing an Emergency Medical Dispatch System to Improve Prehospital Diagnosis and Treatment of Acute Coronary Syndrome: Nationwide Retrospective Study in China

Background

Acute coronary syndrome (ACS) is the most time-sensitive acute cardiac event that requires rapid dispatching and response. The medical priority dispatch system (MPDS), one of the most extensively used types of emergency dispatch systems, is hypothesized to provide better-quality prehospital emergency treatment. However, few studies have revealed the impact of MPDS use on the process of ACS care.

Objective

This study aimed to investigate whether the use of MPDS was associated with higher prehospital diagnosis accuracy and shorter prehospital delay for patients with ACS transferred by an emergency medical service (EMS), using a national database in China.

Methods

This retrospective analysis was based on an integrated database of China’s MPDS and hospital registry. From January 1, 2016, to December 31, 2020, EMS-treated ACS cases were divided into before MPDS and after MPDS groups in accordance with the MPDS launch time at each EMS center. The primary outcomes included diagnosis consistency between hospital admission and discharge, and prehospital delay. Multivariable logistic regression and propensity score–matching analysis were performed to compare outcomes between the 2 groups for total ACS and subtypes.

Results

A total of 9806 ACS cases (3561 before MPDS and 6245 after MPDS) treated by 43 EMS centers were included. The overall diagnosis consistency of the after MPDS group (Cohen κ=0.918, P<.001) was higher than that of the before MPDS group (Cohen κ=0.889, P<.001). After the use of the MPDS, the call-to-EMS arrival time was shortened in the matched ACS cases (20.0 vs 16.0 min, P<.001; adjusted difference: –1.67, 95% CI –2.33 to –1.02; P<.001) and in the subtype of ST-elevation myocardial infarction (adjusted difference: –3.81, 95% CI –4.63 to –2.98, P<.001), while the EMS arrival-to-door time (20.0 vs 20.0 min, P=.31) was not significantly different in all ACS cases and subtypes.

Conclusions

The optimized use of MPDS in China was associated with increased diagnosis consistency and a reduced call-to-EMS arrival time among EMS-treated patients with ACS. An emergency medical dispatch system should be designed specifically to fit into different prehospital modes in the EMS system on a regional basis.

Treatment Time and In-Hospital Mortality Among Patients With ST-Segment Elevation Myocardial Infarction, 2018-2021

IMPORTANCE

Recognizing the association between timely treatment and less myocardial injury for patients with ST-segment elevation myocardial infarction (STEMI), US national guidelines recommend specific treatment-time goals.

OBJECTIVE

To describe these process measures and outcomes for a recent cohort of patients.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional study of a diagnosis-based registry between the second quarter of 2018 and the third quarter of 2021 for 114 871 patients with STEMI treated at 648 hospitals in the Get With The Guidelines-Coronary Artery Disease registry.

EXPOSURES

STEMI or STEMI equivalent.

MAIN OUTCOMES AND MEASURES

Treatment times, in-hospital mortality, and adherence to system goals (75% treated ≤90 minutes of first medical contact if the first hospital is percutaneous coronary intervention [PCI]-capable and ≤120 minutes if patients require transfer to a PCI-capable hospital).

RESULTS

In the study population, median age was 63 (IQR, 54-72) years, 71% were men, and 29% were women. Median time from symptom onset to PCI was 148 minutes (IQR, 111-226) for patients presenting to PCI-capable hospitals by emergency medical service, 195 minutes (IQR, 127-349) for patients walking in, and 240 minutes (IQR, 166-402) for patients transferred from another hospital. Adjusted in-hospital mortality was lower for those treated within target times vs beyond time goals for patients transported via emergency medical services (first medical contact to laboratory activation ≤20 minutes [in-hospital mortality, 3.6 vs 9.2] adjusted OR, 0.54 [95% CI, 0.48-0.60], and first medical contact to device ≤90 minutes [in-hospital mortality, 3.3 vs 12.1] adjusted OR, 0.40 [95% CI, 0.36-0.44]), walk-in patients (hospital arrival to device ≤90 minutes [in-hospital mortality, 1.8 vs 4.7] adjusted OR, 0.47 [95% CI, 0.40-0.55]), and transferred patients (door-in to door-out time <30 minutes [in-hospital mortality, 2.9 vs 6.4] adjusted OR, 0.51 [95% CI, 0.32-0.78], and first hospital arrival to device ≤120 minutes [in-hospital mortality, 4.3 vs 14.2] adjusted OR, 0.44 [95% CI, 0.26-0.71]). Regardless of mode of presentation, system goals were not met in most quarters, with the most delayed system performance among patients requiring interhospital transfer (17% treated ≤120 minutes).

CONCLUSIONS AND RELEVANCE

This study of patients with STEMI included in a US national registry provides information on changes in process and outcomes between 2018 and 2021.

British Cardiovascular Interventional Society Consensus Position Statement on Out-of-Hospital Cardiac Arrest 1: Pathway of Care

Out-of-hospital cardiac arrest (OHCA) affects 80,000 patients per year in the UK; despite improvements in care, survival to discharge remains lower than 10%. NHS England and several societies recommend all resuscitated OHCA patients be directly transferred to a cardiac arrest centre (CAC). However, evidence is limited that all patients benefit from transfer to a CAC, and there are significant organisational, logistic and financial implications associated with such change in policies. Furthermore, there is significant variability in interventional cardiovascular practices for OHCA. Accordingly, the British Cardiovascular Interventional Society established a multidisciplinary group to address variability in practice and provide recommendations for the development of cardiac networks. In this position statement, we recommend: the formal establishment of dedicated CACs; a pathway of conveyance to CACs; and interventional practice to standardise our approach. Further research is needed to understand the role of CACs and which interventions benefit patients with OHCA to support wide-scale changes in networks of care across the UK.

Characteristics, Process Metrics, and Outcomes Among Patients With ST-Elevation Myocardial Infarction in Rural vs Urban Areas in the US: A Report From the US National Cardiovascular Data Registry

Importance

Patients with ST-segment elevation myocardial infarction (STEMI) living in rural settings often have worse clinical outcomes compared with their urban counterparts. Whether this discrepancy is due to clinical characteristics or delays in timely reperfusion with primary percutaneous coronary intervention (PPCI) or fibrinolysis is unclear.

Objective

To assess process metrics and outcomes among patients with STEMI in rural and urban settings across the US.

Design, Setting, and Participants

This cross-sectional multicenter study analyzed data for 70 424 adult patients with STEMI from the National Cardiovascular Data Registry Chest Pain-MI Registry in 686 participating US hospitals between January 1, 2019, and June 30, 2020. Patients without a valid zip code were excluded, and those transferred to a different hospital during the course of the study were excluded from outcome analysis.

Main Outcomes and Measures

In-hospital mortality and time-to-reperfusion metrics.

Results

This study included 70 424 patients with STEMI (median [IQR] age, 63 [54-73] years; 49 850 [70.8%] male and 20 574 [29.2%] female; patient self-reported race: 6753 [9.6%] Black, 60 114 [85.4%] White, and 2096 [3.0%] of another race [including American Indian, Alaskan Native, Native Hawaiian, and Pacific Islander]; 5281 [7.5%] individuals of Hispanic or Latino ethnicity) in 686 hospitals (50 702 [72.0%] living in urban zip codes and 19 722 [28.0%] in rural zip codes). Patients from rural settings were less likely to undergo PPCI compared with patients from urban settings (14 443 [73.2%] vs 43 142 [85.1%], respectively; P < .001) and more often received fibrinolytics (2848 [19.7%] vs 937 [2.7%]; P < .001). Compared with patients from urban settings, those in rural settings undergoing PPCI had longer median (IQR) time from first medical contact to catheterization laboratory activation (30 [12-42] minutes vs 22 [15-59] minutes; P < .001) and longer median (IQR) time from first medical contact to device (99 minutes [75-131] vs 81 [66-103] minutes; P < .001), including those who arrived directly at PPCI centers (83 [66-107] minutes vs 78 [64-97] minutes; P < .001) and those who transferred to PPCI centers from another treatment center (125 [102-163] minutes vs 103 [85-135] minutes; P < .001). Among those who transferred in, median (IQR) door-in-door-out time was longer in patients from rural settings (63 [41-100] minutes vs 50 [35-80] minutes; P < .001). Out-of-hospital cardiac arrest was more common in patients from urban vs rural settings (3099 [6.1%] vs 958 [4.9%]; P < .001), and patients from urban settings were more likely to present with heart failure (4112 [8.1%] vs 1314 [6.7%]; P < .001). After multivariable adjustment, there was no significant difference in in-hospital mortality between rural and urban groups (adjusted odds ratio, 0.97; 95% CI, 0.89-1.06).

Conclusions and Relevance

In this large cohort of patients with STEMI from US hospitals participating in the National Cardiovascular Data Registry Chest Pain-MI Registry, patients living in rural settings had longer times to reperfusion, were less likely to receive PPCI or meet guideline-recommended time to reperfusion, and more frequently received fibrinolytics than patients living in urban settings. However, there was no difference in adjusted in-hospital mortality between patients with STEMI from urban and rural settings.

A Standardized and Regionalized Network of Care for Cardiogenic Shock

BACKGROUND

The benefits of standardized care for cardiogenic shock (CS) across regional care networks are poorly understood.

OBJECTIVES

The authors compared the management and outcomes of CS patients initially presenting to hub versus spoke hospitals within a regional care network.

METHODS

The authors stratified consecutive patients enrolled in their CS registry (January 2017 to December 2019) by presentation to a spoke versus the hub hospital. The primary endpoint was 30-day mortality. Secondary endpoints included bleeding, stroke, or major adverse cardiovascular and cerebrovascular events.

RESULTS

Of 520 CS patients, 286 (55%) initially presented to 34 spoke hospitals. No difference in mean age (62 years vs 61 years; P = 0.38), sex (25% vs 32% women; P = 0.10), and race (54% vs 52% white; P = 0.82) between spoke and hub patients was noted. Spoke patients more often presented with acute myocardial infarction (50% vs 32%; P < 0.01), received vasopressors (74% vs 66%; P = 0.04), and intra-aortic balloon pumps (88% vs 37%; P < 0.01). Hub patients were more often supported with percutaneous ventricular assist devices (44% vs 11%; P < 0.01) and veno-arterial extracorporeal membrane oxygenation (13% vs 0%; P < 0.01). Initial presentation to a spoke was not associated with increased risk-adjusted 30-day mortality (adjusted OR: 0.87 [95% CI: 0.49-1.55]; P = 0.64), bleeding (adjusted OR: 0.89 [95% CI: 0.49-1.62]; P = 0.70), stroke (adjusted OR: 0.74 [95% CI: 0.31-1.75]; P = 0.49), or major adverse cardiovascular and cerebrovascular events (adjusted OR 0.83 [95% CI: 0.50-1.35]; P = 0.44).

CONCLUSIONS

Spoke and hub patients experienced similar short-term outcomes within a regionalized CS network. The optimal strategy to promote standardized care and improved outcomes across regional CS networks merits further investigation.

Primary Percutaneous Coronary Intervention and Application of the Pharmacoinvasive Approach Within ST-Elevation Myocardial Infarction Care Networks

The management of acute ST-elevation myocardial infarction (STEMI) has transitioned from observation and reactive treatment of hemodynamic and arrhythmic complications to accelerated reperfusion and application of evidence-based treatment to minimize morbidity and mortality. International research established the importance of timely reperfusion therapy and the application of fibrinolysis, primary percutaneous coronary intervention (PCI), and subsequent development of the pharmacoinvasive approach. Clinician thought leaders developed and investigated comprehensive systems of care to optimize the outcomes of patients with STEMI, with a key focus in Canada being the integration of prehospital paramedics in diagnosis, triage, and treatment. This article will review highlights of these interventions and identify future challenges and opportunities in STEMI patient care.

Incidence and Predictors of Adverse Events Among Initially Stable ST-Elevation Myocardial Infarction Patients Following Primary Percutaneous Coronary Intervention

Background

Cardiac intensive care units were originally created in the prerevascularization era for the early recognition of ventricular arrhythmias following a myocardial infarction. Many patients with stable ST‐segment–elevation myocardial infarction (STEMI) are still routinely triaged to cardiac intensive care units after a primary percutaneous coronary intervention (pPCI), independent of clinical risk or the provision of critical care therapies. The aim of this study was to determine factors associated with in‐hospital adverse events in a hemodynamically stable, postreperfusion population of patients with STEMI.

Methods and Results

Between April 2012 and November 2019, 2101 consecutive patients with STEMI who received pPCI in the Vancouver Coastal Health Authority were evaluated. Patients were stratified into those with and without subsequent adverse events, which were defined as cardiogenic shock, in‐hospital cardiac arrest, stroke, re‐infarction, and death. Multivariable logistic regression models were used to determine predictors of adverse events. After excluding patients presenting with cardiac arrest, cardiogenic shock, or heart failure, the final analysis cohort comprised 1770 stable patients with STEMI who had received pPCI. A total of 94 (5.3%) patients developed at least one adverse event: cardiogenic shock 55 (3.1%), in‐hospital cardiac arrest 42 (2.4%), death 28 (1.6%), stroke 21 (1.2%), and re‐infarction 5 (0.3%). Univariable predictors of adverse events were older age, female sex, prior stroke, chronic kidney disease, and atrial fibrillation. There was no significant difference in reperfusion times between those with and without adverse events. Following multivariable adjustment, moderate to severe chronic kidney disease (creatinine clearance <44 mL/min; 13% of cohort) was associated with adverse events (odds ratio 2.24 [95% CI, 1.12–4.48]) independent of reperfusion time, age, sex, smoking status, hypertension, diabetes, and prior myocardial infarction/PCI/coronary artery bypass grafting.

Conclusions

Only 1 in 20 initially stable patients with STEMI receiving pPCI developed an in‐hospital adverse event. Moderate to severe chronic kidney disease independently predicted the risk of future adverse events. These results indicate that the majority of patients with STEMI who receive pPCI may not require routine admission to a cardiac intensive care unit following reperfusion.

Overall and gender-specific associations between marital status and out-of-hospital coronary death during acute coronary events: a cross-sectional study based on data linkage in Beijing, China

OBJECTIVES

To assess overall and gender-specific associations between marital status and out-of-hospital coronary death (OHCD) compared with patients surviving to hospital admission.

DESIGN

A cross-sectional study based on linkage of administrative health databases.

SETTING

Beijing, China.

PARTICIPANTS

From 2007 to 2019, 378 883 patients with acute coronary event were identified in the Beijing Monitoring System for Cardiovascular Diseases, a validated city-wide registration system based on individual linkage of vital registration and hospital discharge data.

OUTCOME MEASURES

OHCD was defined as coronary death occurring before admission. Multilevel modified Poisson regression models were used to calculate the prevalence ratios (PR) and 95% CIs.

RESULTS

Among 378 883 acute coronary events, OHCD accounted for 33.8%, with a higher proportion in women compared with men (41.5% vs 28.7%, p<0.001). Not being married was associated with a higher proportion of OHCD in both genders, with a stronger association in women (PR 2.18, 95% CI 2.10 to 2.26) than in men (PR 1.97, 95% CI 1.91 to 2.02; p for interaction <0.001). The associations of OHCD with never being married (PR 1.98, 95% CI 1.88 to 2.08) and being divorced (PR 2.54, 95% CI 2.42 to 2.67) were stronger in men than in women (never married: PR 0.98, 95% CI 0.82 to 1.16; divorced: PR 1.47, 95% CI 1.34 to 1.61) (p for interaction <0.001 for both). Being widowed was associated with a higher proportion of OHCD in both genders, with a stronger association in women (PR 2.26, 95% CI 2.17 to 2.35) compared with men (PR 1.89, 95% CI 1.84 to 1.95) (p for interaction <0.001).

CONCLUSIONS

Not being married was independently associated with a higher proportion of OHCD and the associations differed by gender. Our study may aid the development of gender-specific public health interventions in high-risk populations characterised by marital status to reduce OHCD burden.

Comparison of the outcomes of EMS vs. Non-EMS transport of patients with ST-segment elevation myocardial infarction (STEMI) in Southern Iran: a population-based study

BACKGROUND

In the medical management of acute myocardial infarction, the transport of patients and primary care provided by emergency medical technicians (EMTs) and paramedics are effective in reducing the mortality and disabilities. Therefore, the present study aimed to compare the outcomes of emergency medical services (EMS) vs. non-EMS transport of patients with ST-segment elevation myocardial infarction (STEMI) in southern Iran.

METHODS

This is an analytical, cross-sectional study. The study population consisted of the individuals registered in Fasa Registry on Acute Myocardial Infarction (FaRMI) in the south of Iran. 2244 patients with STEMI were included in the study. Statistical analyses were performed using Chi-Square test and independent t-test at a significance level of P < 0.05 in SPSS 22.

RESULTS

Out of the 2244 patients with STEMI, 1552 (69.16%) were male and 672 patients (29.94%) were female. 934(41.62%) patients used EMS transport to the hospital, while 1310 (58.37%) patients used non-EMS transport to the hospital. A total of 169 patients with STEMI (7.26%) expired (out-of-hospital cardiac arrest); of them, 113 (66.86%) patients did not use EMS transport to the hospital. Successful cardiopulmonary resuscitation (CPR) was performed on 52 patients who used EMS transport. 27 patients also received an effective DC shock due to ventricular fibrillation (VF). Of the total number of patients, 49 had a stroke; among them, 37(75.51%) patients did not use EMS transport.

CONCLUSION

In the present study, the death rate in patients with acute myocardial infarction who used EMS transport was lower than those who used non-EMS transport. The health system managers and policymakers in the healthcare systems are recommended to take the necessary measures to increase public health awareness and knowledge about the use of EMS and consequently reduce the death rate and complications of acute myocardial infarction.

Quantity and Quality of Healthcare Professionals, Transfer Delay and In-hospital Mortality Among ST-Segment Elevation Myocardial Infarction: A Mixed-Method Cross-Sectional Study of 89 Emergency Medical Stations in China

Background

Transfer delay provokes prolongation of prehospital time, which contributes to treatment delay that endangers patients with ST-segment elevation myocardial infarction (STEMI). A key constraint in reducing transfer delay is the shortage of emergency healthcare workers. This study was to explore the influence of the quality and quantity of healthcare professionals at emergency medical stations on transfer delay and in-hospital mortality among STEMI patients.

Methods

A cross-sectional study using mixed methods was conducted at 89 emergency stations in 9 districts in China's Shenzhen province. Based on a sample of 31 hospitals, 1,255 healthcare professionals, and 3,131 patients with STEMI, a generalized linear model was used to explore the associations between the quality and quantity of healthcare professionals and transfer delay and in-hospital mortality among STEMI patients. Qualitative data were collected and analyzed to explore the reasons for the lack of qualified healthcare professionals at emergency medical stations.

Results

The analysis of the quantity of healthcare professionals showed that an increase of one physician per 100,000 individuals was associated with decreased transfer delay for patients with STEMI by 5.087 min (95% CI −6.722, −3.452; P &lt; 0.001). An increase of one nurse per 100,000 individuals was associated with decreased transfer delay by 1.471 min (95% CI −2.943, 0.002; P=0.050). Analysis of the quality of healthcare professionals showed that an increase of one physician with an undergraduate degree per 100,000 individuals was associated with decreased transfer delay for patients with STEMI by 8.508 min (95% CI −10.457, −6.558; P &lt; 0.001). An increase of one nurse with an undergraduate degree per 100,000 individuals was associated with decreased transfer delay by 6.645 min (95% CI −8.218, −5.072; P &lt; 0.001). Qualitative analysis illustrated that the main reasons for low satisfaction of healthcare professionals at emergency medical stations included low income, limited promotion opportunities, and poor working environment.

Conclusions

The quantity and quality of emergency healthcare professionals are key factors influencing transfer delay in STEMI patients. The government should increase the quantity of healthcare professionals at emergency medical stations, strengthen the training, and improve their performance by linking with clinical pathways to enhance job enthusiasm among emergency healthcare professionals.

Delays to Hospital Presentation in Women and Men with ST-Segment Elevation Myocardial Infarction: A Multi-Center Analysis of Patients Hospitalized in New York City

Purpose

Previous studies have shown longer delays from symptom onset to hospital presentation (S2P time) in women than men with acute myocardial infarction. The aim of this study is to understand the reasons for delays in seeking care among women and men presenting with an ST-Segment Elevation Myocardial Infarction (STEMI) through a detailed assessment of the thoughts, perceptions and patterns of behavior.

Patients/Methods and Results

A total of 218 patients with STEMI treated with primary angioplasty at four New York City Hospitals were interviewed (24% female; Women: 68.7 ± 13.1 years and men: 60.7 ± 13.8 years) between January 2009 and August 2012. A significantly larger percentage of women than men had no chest pain (62% vs 36%, p<0.01). Compared to men, a smaller proportion of women thought they were having a myocardial infarction (15% vs 34%, p=0.01). A larger proportion of women than men had S2P time >90 minutes (72% of women vs 54% of men, p= 0.03). Women were more likely than men to hesitate before seeking help, and more women than men hesitated because they did not think they were having an AMI (91% vs 83%, p=0.04). Multivariate regression analysis showed that female sex (Odds Ratio: 2.46, 95% CI 1.10–5.60 P=0.03), subjective opinion it was not an AMI (Odds Ratio 2.44, 95% CI 1.20–5.0, P=0.01) and level of education less than high school (Odds ratio 7.21 95% CI 1.59–32.75 P=0.01) were independent predictors for S2P >90 minutes.

Conclusion

Women with STEMI have longer pre-hospital delays than men, which are associated with a higher prevalence of atypical symptoms and a lack of belief in women that they are having an AMI. Greater focus should be made on educating women (and men) regarding the symptoms of STEMI, and the importance of a timely response to these symptoms.

Ten-Year Trends in Patient Characteristics, Treatments, and Outcomes in Myocardial Infarction From National Cardiovascular Data Registry Chest Pain-MI Registry

BACKGROUND

The Chest Pain-MI registry affords a 10-year perspective of the acute myocardial infarction (MI) patient characteristics, management, and clinical outcomes in the United States. We report the changes in the treatment and cardiovascular outcomes of acute MI patients over 10 years.

METHODS

Annual trends in patient characteristics, in-hospital treatment, and outcomes of 604 936 ST-segment-elevation MI (STEMI) and 933 755 non-ST-segment-elevation MI (NSTEMI) patients at 1230 hospitals from 2009 to 2018 were analyzed. Using the validated Acute Coronary Intervention and Outcomes Network mortality risk model, trends in in-hospital risk-adjusted mortality rates were tested between 2011 and 2018.

RESULTS

Over 10 years, the prevalence of diabetes (22.8%-28.3% [STEMI] and 35.7%-41.3% [NSTEMI]) and atrial fibrillation (4.1%-6.1% and 9.4%-11.7%) increased, whereas the prevalence of smoking decreased (43.5%-37.9% and 30.2%-27.5%, P<0.001 for all) in patients with STEMI and NSTEMI, respectively. Among eligible patients with STEMI, primary percutaneous coronary intervention use increased (82.3%-96.0%) with shorter median first medical contact to device time (90 to 82 minutes, P<0.001). Among patients with NSTEMI, percutaneous coronary intervention use increased significantly (43.9%-54.5%, P<0.001). Adherence to guideline-directed medical therapies improved in both groups. From 2011 to 2018, risk-adjusted mortality rate (2.8%-2.7%, P=0.46) was stable in STEMI and declined significantly in patients with NSTEMI (1.9%-1.3%, P=0.0001).

CONCLUSIONS

Risk factors of patients presenting with acute MI have changed modestly while treatment improved over time. Risk-adjusted mortality rates remained stable for patients with STEMI and declined significantly for patients with NSTEMI.

Safe Triage of STEMI Patients to General Telemetry Units After Successful Primary Percutaneous Coronary Intervention

Objective

To analyze outcomes of patients with ST-segment elevation myocardial infarction (STEMI) after successful primary percutaneous coronary intervention (PCI) triaged to the cardiac intensive care unit (CICU) vs a general telemetry unit by a Zwolle risk score–based algorithm.

Methods

We introduced a quality improvement protocol in 2014 encouraging admission of STEMI patients with Zwolle score of 3 or less to general telemetry units unless they were hemodynamically unstable. We subsequently conducted a retrospective single-center cohort study of consecutive STEMI patients who had undergone primary PCI from January 1, 2014, to December 31, 2018. Outcomes studied include immediate complications, need for urgent unplanned intervention, need for CICU care, length of hospitalization, and survival.

Results

We identified 547 patients, 406 with a Zwolle score of 3 or less. Of these, 192 (47.3%) were admitted to general telemetry and 214 (52.7%) to the CICU. Reasons for CICU admission included persistent chest pain, late presentation, and procedural complications. The average hospital length of stay was 2.1±1.4 days for non-CICU patients and 3.3±2.8 days for low-risk CICU patients (P<.001). Two patients initially admitted to general telemetry required transfer to the CICU. There were 26 patients who required unplanned cardiovascular intervention within 30 days, 5 from the general telemetry unit; 540 patients survived to discharge. One in-hospital death occurred among those initially triaged to the general telemetry unit, and this was due to a noncardiac cause.

Conclusion

A Zwolle score–based algorithm can be used to safely triage post-PCI STEMI patients to a general telemetry unit.

STEMI care 2021: Addressing the knowledge gaps

Tremendous progress has been made in the treatment of ST-segment elevation myocardial infarction (STEMI), the most severe and time-sensitive acute coronary syndrome. Primary percutaneous coronary intervention (PCI) is the preferred method of reperfusion, which has stimulated the development of regional STEMI systems of care with standardized protocols designed to optimize care. However, challenges remain for patients with cardiogenic shock, out-of-hospital cardiac arrest, an expected delay to reperfusion (>120 min), in-hospital STEMI, and more recently, those with Covid-19 infection. Ultimately, the goal is to provide timely reperfusion with primary PCI coupled with the optimal antiplatelet and anticoagulant therapies. We review the challenges and provide insights into the remaining knowledge gaps for contemporary STEMI care.

Can a Healthcare Quality Improvement Initiative Reduce Disparity in the Treatment Delay among ST-Segment Elevation Myocardial Infarction Patients with Different Arrival Modes? Evidence from 33 General Hospitals and Their Anticipated Impact on Healthcare during Disasters and Public Health Emergencies

(1) Background: Chest pain center accreditation has been associated with improved timelines of primary percutaneous coronary intervention (PCI) for ST-segment elevated myocardial infarction (STEMI). However, evidence from low- and middle-income regions was insufficient, and whether the sensitivity to improvements differs between walk-in and emergency medical service (EMS)-transported patients remained unclear. In this study, we aimed to examine the association of chest pain center accreditation status with door-to-balloon (D2B) time and the potential modification effect of arrival mode. (2) Methods: The associations were examined using generalized linear mixed models, and the effect modification of arrival mode was examined by incorporating an interaction term in the models. (3) Results: In 4186 STEMI patients, during and after accreditation were respectively associated with 65% (95% CI: 54%, 73%) and 71% (95% CI: 61%, 79%) reduced risk of D2B time being more than 90 min (using before accreditation as the reference). Decreases of 27.88 (95% CI: 19.57, 36.22) minutes and 26.55 (95% CI: 17.45, 35.70) minutes in D2B were also observed for the during and after accreditation groups, respectively. The impact of accreditation on timeline improvement was greater for EMS-transported patients than for walk-in patients. (4) Conclusions: EMS-transported patients were more sensitive to the shortened in-hospital delay associated with the initiative, which could exacerbate the existing disparity among patients with different arrival modes.

Temporal Trends in Post Myocardial Infarction Heart Failure and Outcomes Among Older Adults

BACKGROUND

We sought to determine national trends and long term outcomes of post myocardial infarction (MI) heart failure. An MI can be complicated by heart failure; there are limited data describing the contemporary patterns and clinical implications of post-MI heart failure.

METHODS AND RESULTS

We studied patients with an MI aged 65 years or older from 2000 to 2013 in a Medicare database. New-onset heart failure after an MI was defined as either heart failure during the index MI admission or a hospitalization for heart failure within 1 year of the index MI event. A trend analysis of the incidence of heart failure was performed, and differences were examined by Gray tests. The 5-year mortality rates were evaluated and differences among heart failure cohorts were ascertained by Gray tests. There were a total of 1,531,638 patients with an MI and 565,291 patients had heart failure (36.0%). The rate of heart failure during index admission was 32.3% and the frequency of heart failure hospitalization within 1 year was 10.4%. Patients with heart failure were older (81 years vs 77 years). The temporal trend from 2001 to 2012 suggested a decrease in the incidence of heart failure during index admission (2001: 34.7%, 2012: 31.2%, P_trend < .01), as well as heart failure hospitalization within 1 year (2001: 11.3%, 2012: 8.7%, P_trend < .01). The 5-year mortality rate among patients without heart failure was 38.4% and for patients with any heart failure it was 68.7%.

CONCLUSIONS

Post-MI heart failure in older adults occurs in 1 in 3 patients within 1 year; heart failure portends significantly higher long-term mortality.

Hydration for prevention of kidney injury after primary coronary intervention for acute myocardial infarction: a randomised clinical trial

OBJECTIVE

To evaluate the efficacy of aggressive hydration compared with general hydration for contrast-induced acute kidney injury (CI-AKI) prevention among patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (pPCI).

METHODS

The Aggressive hydraTion in patients with STEMI undergoing pPCI to prevenT Contrast-Induced Acute Kidney Injury study is an open-label, randomised controlled study at 15 teaching hospitals in China. A total of 560 adult patients were randomly assigned (1:1) to receive aggressive hydration or general hydration treatment. Aggressive hydration group received preprocedural loading dose of 125/250 mL normal saline within 30 min, followed by postprocedural hydration performed for 4 hours under left ventricular end-diastolic pressure guidance and additional hydration until 24 hours after pPCI. General hydration group received ≤500 mL 0.9% saline at 1 mL/kg/hour for 6 hours after randomisation. The primary end point is CI-AKI, defined as a >25% or 0.5 mg/dL increased in serum creatinine from baseline during the first 48-72 hours after primary angioplasty. The safety end point is acute heart failure.

RESULTS

From July 2014 to May 2018, 469 patients were enrolled in the final analysis. CI-AKI occurred less frequently in aggressive hydration group than in general hydration group (21.8% vs 31.1%; risk ratio (RR) 0.70, 95% CI 0.52 to 0.96). Acute heart failure did not significantly differ between the aggressive hydration group and the general hydration group (8.1% vs 6.4%, RR 1.13, 95% CI 0.66 to 2.44). Several subgroup analysis showed the better effect of aggressive hydration in CI-AKI prevention in male, renal insufficient and non-anterior myocardial infarction participants.

CONCLUSIONS

Comparing with general hydration, the peri-operative aggressive hydration seems to be safe and effective in preventing CI-AKI among patients with STEMI undergoing pPCI.

Evaluation of Door-to-Balloon Times After Implementation of a ST-Segment Elevation Myocardial Infarction Network

BACKGROUND

ST-segment elevation myocardial infarction (STEMI) requires prompt therapy. It is recommended for door-to-balloon (DTB) times to be less than 90 minutes. In the United States, some locations have difficulty meeting this goal.

OBJECTIVE

The objective of this study was to determine whether implementation of a STEMI network decreased DTB times at a large, STEMI-receiving, metropolitan academic hospital in the southeastern United States. Furthermore, differences among presentation types, including walk-in, emergency medical services, and transfers, were explored.

METHODS

A pre-post time series study of electronic medical record data was conducted to evaluate the efficacy of a STEMI network.

RESULTS

The sample included 127 patients with a diagnosis of STEMI, collected during 3 periods (T1, T2, and T3). Patients were primarily White (78.0%) and male (67.7%), with a mean (SD) age of 58.9 (13.9) years. The 1-way analysis of variance revealed a significant difference in overall DTB times, F2 = 11.66, P < .001. Post hoc comparisons indicated longer mean DTB times for T1 compared with T3 (P < .001) and T2 (P < .001). When exploring presentation type, 1-way analysis of variance revealed a significant difference in mean DTB times in transfer patients between T1 and T2 (P < .001) and T1 to T3 (P < .001). No other statistical differences were noted; however, all DTB times with the exception of T2 for emergency medical services presentation decreased.

CONCLUSIONS

Implementation of a STEMI network was effective at decreasing overall DTB times with patients who presented to the hospital with a diagnosis of STEMI.

Prehospital Evaluation, ED Management, Transfers, and Management of Inpatient STEMI

ST elevation myocardial infarction diagnoses have reduced in number over the past 10 years; however, associated morbidity and mortality remain high. Societal guidelines focus on early diagnosis and timely access to reperfusion, preferably percutaneous coronary intervention (PCI), with fibrinolytics reserved for those who cannot receive timely PCI. Proposed algorithms recommend emergency department bypass in stable patients with a clear diagnosis to reduced door-to-balloon time. Emergency providers should limit their evaluation, focusing on life-threatening comorbidities, unstable vitals, or contraindications to a catheterization laboratory. In-hospital patients prove diagnostically challenging because they may be unable to express symptoms, and reperfusion strategies can complicate other diagnoses.