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Sigal A, Isenberg DL, Kraus CK, Ackerman D, Herres J, Brandler ES, Kuc A, Nomura JT, Cooney DR, Mullen MT, Zhao H, Gentile NT. A Shorter Door-In-Door-Out Time Is Associated with Improved Outcome in Large Vessel Occlusion Stroke. West J Emerg Med 2023; 24:931-938. [PMID: 37788034 PMCID: PMC10527839 DOI: 10.5811/westjem.58946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 04/21/2023] [Accepted: 04/18/2023] [Indexed: 10/04/2023] Open
Abstract
Introduction: Endovascular thrombectomy (EVT) significantly improves outcomes in large vessel occlusion stroke (LVOS). When a patient with a LVOS arrives at a hospital that does not perform EVT, emergent transfer to an endovascular stroke center (ESC) is required. Our objective was to determine the association between door-in-door-out time (DIDO) and 90-day outcomes in patients undergoing EVT. Methods: We conducted an analysis of the Optimizing Prehospital Stroke Systems of Care-Reacting to Changing Paradigms (OPUS-REACH) registry of 2,400 LVOS patients treated at nine ESCs in the United States. We examined the association between DIDO times and 90-day outcomes as measured by the modified Rankin scale. Results: A total of 435 patients were included in the final analysis. The mean DIDO time for patients with good outcomes was 17 minute shorter than patients with poor outcomes (122 minutes [min] vs 139 min, P = 0.04). Absolute DIDO cutoff times of ≤60 min, ≤90 min, or ≤120 min were not associated with improved functional outcomes (46.4 vs 32.3%, P = 0.12; 38.6 vs 30.6%, P = 0.10; and 36.4 vs 28.9%, P = 0.10, respectively). This held true for patients with hyperacute strokes of less than four-hour onset. Lower baseline National Institutes of Health Stroke Scale (NIHSS) score (11.9 vs 18.2, P = <.001) and younger age (62.5 vs 74.9 years (P < .001) were associated with improved outcomes. On multiple regression analysis, age (odds ratio [OR] 1.71, 95% confidence interval [CI] 1.45-2.02) and baseline NIHSS score (OR 1.67, 95% CI 1.42-1.98) were associated with improved outcomes while DIDO time was not associated with better outcome (OR 1.13, 95% CI 0.99-1.30). Conclusion: Although the DIDO time was shorter for patients with a good outcome, this was non-significant in multiple regression analysis. Receipt of intravenous thrombolysis and time to EVT were not associated with better outcomes, while male gender, lower age, arrival by private vehicle, and lower NIHSS score portended better outcomes. No absolute DIDO-time cutoff or modifiable factor was associated with improved outcomes for LVOS. This study underscores the need to streamline DIDO times but not to set an artificial DIDO time benchmark to meet.
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Affiliation(s)
- Adam Sigal
- Reading Hospital, Department of Emergency Medicine, West Reading, Pennsylvania
| | - Derek L Isenberg
- Lewis Katz School of Medicine at Temple University, Department of Emergency Medicine, Philadelphia, Pennsylvania,
| | - Chadd K Kraus
- Geisinger Health, Department of Emergency Medicine, Danville, Pennsylvania
| | - Daniel Ackerman
- St. Luke's Health System, Department of Neurology, Bethlehem, Pennsylvania
| | - Joseph Herres
- Einstein Health System, Department of Emergency Medicine, Philadelphia, Pennsylvania
| | - Ethan S Brandler
- State University of New York-Stony Brook, Department of Emergency Medicine, Stony Brook, New York
| | - Alexander Kuc
- Cooper University Healthcare, Department of Emergency Medicine, Camden, New Jersey
| | - Jason T Nomura
- Christiana Care, Department of Emergency, Newark, Delaware
| | - Derek R Cooney
- State University of New York-Upstate, Department of Emergency Medicine, Syracuse, New York
| | - Michael T Mullen
- Lewis Katz School of Medicine at Temple University, Department of Neurology, Philadelphia, Pennsylvania
| | - Huaqing Zhao
- Lewis Katz School of Medicine at Temple University, Center for Biostatistics and Epidemiology, Philadelphia, Pennsylvania
| | - Nina T Gentile
- Lewis Katz School of Medicine at Temple University, Department of Emergency Medicine, Philadelphia, Pennsylvania
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Solà-Muñoz S, Jorge M, Jiménez-Fàbrega X, Jiménez-Delgado S, Azeli Y, Marsal JR, Jordán S, Mauri J, Jacob J. Prehospital stratification and prioritisation of non-ST-segment elevation acute coronary syndrome patients (NSTEACS): the MARIACHI scale. Intern Emerg Med 2023; 18:1317-1327. [PMID: 37131092 DOI: 10.1007/s11739-023-03274-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 04/11/2023] [Indexed: 05/04/2023]
Abstract
OBJECTIVE The objective of this study was to develop and validate a risk scale (MARIACHI) for patients classified as non-ST-segment elevation acute coronary syndrome (NSTEACS) in a prehospital setting with the ability to identify patients at an increased risk of mortality at an early stage. METHODS A retrospective observational study conducted in Catalonia over two periods: 2015-2017 (development and internal validation cohort) and Aug 2018-Jan 2019 (external validation cohort). We included patients classified as prehospital NSTEACS, assisted by an advanced life support unit and requiring hospital admission. The primary outcome was in-hospital mortality. Cohorts were compared using logistic regression and a predictive model was created using bootstrapping techniques. RESULTS The development and internal validation cohort included 519 patients. The model is composed of five variables associated with hospital mortality: age, systolic blood pressure, heart rate > 95 bpm, Killip-Kimball III-IV and ST depression ≥ 0.5 mm. The model showed good overall performance (Brier = 0.043) and consistency in discrimination (AUC 0.88, 95% CI 0.83-0.92) and calibration (slope = 0.91; 95% CI 0.89-0.93). We included 1316 patients for the external validation sample. There was no difference in discrimination (AUC 0.83, 95% CI 0.78-0.87; DeLong Test p = 0.071), but there was in calibration (p < 0.001), so it was recalibrated. The finally model obtained was stratified and scored into three groups according to the predicted risk of patient in-hospital mortality: low risk: < 1% (-8 to 0 points), moderate risk: 1-5% (+ 1 to + 5 points) and high risk: > 5% (6-12 points). CONCLUSION The MARIACHI scale showed correct discrimination and calibration to predict high-risk NSTEACS. Identification of high-risk patients may help with treatment and low referral decisions at the prehospital level.
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Affiliation(s)
| | - Morales Jorge
- Sistema d'Emergències Mèdiques de Catalunya, Catalonia, Spain
| | - Xavier Jiménez-Fàbrega
- Sistema d'Emergències Mèdiques de Catalunya, Catalonia, Spain
- Universitat de Barcelona, Barcelona, Spain
| | | | - Youcef Azeli
- Sistema d'Emergències Mèdiques de Catalunya, Catalonia, Spain
- Emergency Department, Hospital Universitari Sant Joan de Reus, Tarragona, Spain
- Institut d'Investigació Sanitària Pere i Virgili (IISPV), Tarragona, Spain
| | - J Ramon Marsal
- RTI Health Solutions, Research Triangle Park, Spain
- Epidemiology Unit of the Cardiology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Sara Jordán
- Sistema d'Emergències Mèdiques de Catalunya, Catalonia, Spain
| | - Josepa Mauri
- Cardiology Department, Hospital Universitari Germans Trias I Pujol, Badalona, Spain
- Pla Director de Malalties Cardiovasculars (PDMCV), Health Department of the Government of Catalonia, Catalonia, Spain
| | - Javier Jacob
- Universitat de Barcelona, Barcelona, Spain
- Emergency Department, Hospital Universitari de Bellvitge, Barcelona, Spain
- IDIBELL, L'Hospitalet de Llobregat, Spain
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3
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Lin YT, Chen HA, Wu HY, Fan CM, Hsu JC, Chen KC. Influence of the Door-to-ECG Time on the Prognosis of Patients with Acute Coronary Syndrome. ACTA CARDIOLOGICA SINICA 2023; 39:127-134. [PMID: 36685158 PMCID: PMC9829846 DOI: 10.6515/acs.202301_39(1).20220602b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 06/02/2022] [Indexed: 01/24/2023]
Abstract
Background The rapid acquisition of an electrocardiogram (ECG) plays a crucial role in the diagnosis and management decisions in patients with acute coronary syndrome (ACS). Objectives We determined the time-to-ECG acquisition, identified factors associated with timely acquisition, and evaluated the influence of time-to-ECG on in-hospital mortality. Methods We measured the door-to-ECG time for 903 of 2140 patients in the emergency department of Far Eastern Memorial Hospital with a diagnosis of ACS from January 1, 2016 to December 31, 2018, via a retrospective chart review. The primary outcome was in-hospital mortality. Outcome analysis of mortality was conducted using multivariable logistic regression. The secondary outcome was to determine which factors influenced whether or not a patient received an ECG within 10 min. The analysis was conducted using multiple logistic regression. Results The median time-to-ECG was 5 min (interquartile range: 4-11 min) in all patients. In multivariable logistic regression analysis, we found that older age and more severe heart-broken index were significantly related to timely ECG acquisition. In-hospital mortality was higher in those in whom ECG was performed after more than 10 min. However, in the multivariable logistic regression analysis, it did not have a significant positive correlation with ECG acquisition time. Conclusions Timely ECG acquisition owing to the triage protocol at our institution, the heart-broken index, led to early PCI and thus better outcomes for the ACS patients in this study. The implementation of a protocol-driven timely evaluation of patients with ACS and prompt PCI are important.
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Affiliation(s)
| | | | | | | | - Jung-Cheng Hsu
- Department of Cardiology, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Kuan-Chang Chen
- Department of Cardiology, Far Eastern Memorial Hospital, New Taipei City, Taiwan
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4
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Mackay MH, Chruscicki A, Christenson J, Cairns JA, Lee T, Turgeon R, Tallon JM, Helmer J, Singer J, Wong GC, Fordyce CB. Association of pre‐hospital time intervals and clinical outcomes in ST‐elevation myocardial infarction patients. J Am Coll Emerg Physicians Open 2022; 3:e12764. [PMID: 35702143 PMCID: PMC9174874 DOI: 10.1002/emp2.12764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 05/07/2022] [Accepted: 05/20/2022] [Indexed: 11/30/2022] Open
Abstract
Study Objectives Timely coronary reperfusion is critical for favorable outcomes after ST‐elevation myocardial infarction (STEMI). A substantial proportion of the total ischemic time is patient related, occurring before first medical contact (FMC). We aimed to expand the limited current understanding of the associations between prehospital intervals and clinical outcomes. Methods We conducted a retrospective analysis of consecutive STEMI patients who underwent primary percutaneous coronary intervention (pPCI) (January 2009–March 2016) and assessed the associations between prehospital intervals and the incidence of new heart failure, cardiogenic shock, and hospital length of stay (LOS), adjusting for important clinical variables. Results A total of 773 patients (77% men, median age 65 years) met eligibility criteria. The median pre‐911 activation interval was 29 minutes (interquartile range: 11, 89); the median 911 call to FMC interval was 12 minutes (interquartile range: 9, 15). In multivariable analysis, there was a V‐shaped relationship between the pre‐911 activation interval and outcomes: a lower likelihood of new heart failure (odds ratio [OR] 0.51; 95% confidence interval [CI]: 0.30, 0.87), cardiogenic shock (OR 0.40; 95% CI: 0.21, 0.75) and prolonged LOS (OR 0.24; 95% CI: 0.14, 0.42) for midrange intervals (11–88 minutes) when compared to the early (< 11‐minute) interval. There was no statistically significant relationship between total pre‐FMC time and FMC to device activation time. Conclusions Among ambulance‐transported STEMI patients receiving pPCI, the shortest and longest pre‐911 activation time intervals were associated with poorer outcomes. However, variation in post‐FMC interval alone was not associated with outcomes, suggesting that interventions to reduce pre‐FMC intervals must be prioritized.
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Affiliation(s)
- Martha H. Mackay
- School of Nursing University of British Columbia Vancouver British Columbia Canada
- Centre for Health Evaluation and Outcome Sciences University of British Columbia, St. Paul's Hospital Vancouver British Columbia Canada
- Providence Research Vancouver British Columbia Canada
| | - Adam Chruscicki
- Division of Internal Medicine Vancouver Coastal Health Diamond Health Care Centre Vancouver British Columbia Canada
| | - Jim Christenson
- Department of Emergency Medicine University of British Columbia Diamond Health Care Centre Vancouver British Columbia Canada
- Centre for Health Evaluation and Outcome Sciences University of British Columbia, St. Paul's Hospital Vancouver British Columbia Canada
- Providence Research Vancouver British Columbia Canada
- British Columbia Resuscitation Research Collaborative Vancouver British Columbia Canada
| | - John A. Cairns
- Division of Cardiology University of British Columbia Diamond Health Care Centre Vancouver British Columbia Canada
| | - Terry Lee
- Centre for Health Evaluation and Outcome Sciences University of British Columbia, St. Paul's Hospital Vancouver British Columbia Canada
| | - Ricky Turgeon
- St. Paul's Hospital Vancouver British Columbia Canada
| | - John M. Tallon
- Department of Emergency Medicine University of British Columbia Diamond Health Care Centre Vancouver British Columbia Canada
- British Columbia Emergency Health Services Vancouver British Columbia Canada
| | - Jennifer Helmer
- British Columbia Emergency Health Services Vancouver British Columbia Canada
| | - Joel Singer
- Centre for Health Evaluation and Outcome Sciences University of British Columbia, St. Paul's Hospital Vancouver British Columbia Canada
- School of Population and Public Health Faculty of Medicine University of British Columbia Vancouver British Columbia Canada
| | - Graham C. Wong
- Division of Cardiology University of British Columbia Diamond Health Care Centre Vancouver British Columbia Canada
| | - Christopher B. Fordyce
- Division of Cardiology University of British Columbia Diamond Health Care Centre Vancouver British Columbia Canada
- Centre for Health Evaluation and Outcome Sciences University of British Columbia, St. Paul's Hospital Vancouver British Columbia Canada
- British Columbia Resuscitation Research Collaborative Vancouver British Columbia Canada
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Yamaguchi J, Matoba T, Kikuchi M, Minami Y, Kojima S, Hanada H, Mano T, Nakashima T, Hashiba K, Yamamoto T, Tanaka A, Matsuo K, Nakayama N, Nomura O, Tahara Y, Nonogi H. Effects of Door-In to Door-Out Time on Mortality Among ST-Segment Elevation Myocardial Infarction Patients Transferred for Primary Percutaneous Coronary Intervention ― Systematic Review and Meta-Analysis ―. Circ Rep 2022; 4:109-115. [PMID: 35342837 PMCID: PMC8901244 DOI: 10.1253/circrep.cr-21-0160] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 01/31/2022] [Accepted: 02/08/2022] [Indexed: 12/24/2022] Open
Abstract
Background:
Primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) is now widely accepted. Recent guidelines have focused on total ischemic time, because shorter total ischemic time is associated with a more favorable prognosis. The door-in to door-out (DIDO) time, defined as time from arrival at a non-PCI-capable hospital to leaving for a PCI-capable hospital, may affect STEMI patient prognosis. However, a relevant meta-analysis is lacking. Methods and Results:
We searched PubMed for clinical studies comparing short-term (30-day and in-hospital) mortality rates of STEMI patients undergoing primary PCI with DIDO times of ≤30 vs. >30 min. Two investigators independently screened the search results and extracted the data. Random effects estimators with weights calculated by the inverse variance method were used to determine pooled risk ratios. The search retrieved 1,260 studies; of these, 2 retrospective cohort studies (15,596 patients) were analyzed. In the DIDO time ≤30 and >30 min groups, the primary endpoint (i.e., in-hospital or 30-day mortality) occurred for 51 of 1,794 (2.8%) and 831 of 13,802 (6.0%) patients, respectively. The incidence of the primary endpoint was significantly lower in the DIDO time ≤30 min group (odds ratio 0.45; 95% confidence interval 0.34–0.60). Conclusions:
Our findings suggest that a DIDO time ≤30 min is associated with a lower short-term mortality rate. However, further larger systematic reviews and meta-analyses are needed to validate our findings.
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Affiliation(s)
| | - Tetsuya Matoba
- Department of Cardiovascular Medicine, Kyushu University Faculty of Medical Sciences
| | - Migaku Kikuchi
- Department of Cardiovascular Medicine, Emergency and Critical Care Center, Dokkyo Medical University
| | | | - Sunao Kojima
- Department of Internal Medicine, Sakurajyuji Yatsushiro Rehabilitation Hospital
| | - Hiroyuki Hanada
- Department of Emergency and Disaster Medicine, Hirosaki University
| | | | - Takahiro Nakashima
- Department of Emergency Medicine and Michigan Center for Integrative Research in Critical Care, University of Michigan
| | | | - Takeshi Yamamoto
- Division of Cardiovascular Intensive Care, Nippon Medical School Hospital
| | - Akihito Tanaka
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Kunihiro Matsuo
- Department of Acute Care Medicine, Fukuoka University Chikushi Hospital
| | - Naoki Nakayama
- Department of Cardiology, Kanagawa Cardiovascular and Respiratory Center
| | - Osamu Nomura
- Department of Emergency and Disaster Medicine, Hirosaki University
| | - Yoshio Tahara
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
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6
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Yu AY, Lee DS, Vyas MV, Porter J, Rashid M, Fang J, Austin PC, Hill MD, Kapral MK. Emergency Department Visits, Care, and Outcome After Stroke and Myocardial Infarction During the COVID-19 Pandemic Phases. CJC Open 2021; 3:1230-1237. [PMID: 34723166 PMCID: PMC8548659 DOI: 10.1016/j.cjco.2021.06.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 06/02/2021] [Indexed: 12/11/2022] Open
Abstract
Background It is not known if initial reductions in hospitalization for stroke and myocardial infarction early during the coronavirus disease–2019 pandemic were followed by subsequent increases. We describe the rates of emergency department visits for stroke and myocardial infarction through the pandemic phases. Methods We used linked administrative data to compare the weekly age- and sex-standardized rates of visits for stroke and myocardial infarction in Ontario, Canada in the first 9 months of 2020 to the mean baseline rates (2015-2019) using rate ratios (RRs) and 95% confidence intervals (CIs). We compared care and outcomes by pandemic phases (pre-pandemic was January-March, lockdown was March-May, early reopening was May-July, and late reopening was July-September). Results We identified 15,682 visits in 2020 for ischemic stroke (59.2%; n = 9279), intracerebral hemorrhage (12.2%; n = 1912), or myocardial infarction (28.6%; n = 4491). The weekly rates for stroke visits in 2020 were lower during the lockdown and early reopening than at baseline (RR 0.76, 95% CI [0.66, 0.87] for the largest weekly decrease). The weekly rates for myocardial infarction visits were lower during the lockdown only (RR 0.61, 95% CI [0.46, 0.77] for the largest weekly decrease), and there was a compensatory increase in visits following reopening. Ischemic stroke 30-day mortality was increased during the lockdown phase (11.5% pre-coronavirus disease; 12.2% during lockdown; 9.2% during early reopening; and 10.6% during late reopening, P = 0.015). Conclusion After an initial reduction in visits for stroke and myocardial infarction, there was a compensatory increase in visits for myocardial infarction. The death rate after ischemic stroke was higher during the lockdown than in other phases.
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Affiliation(s)
- Amy Y.X. Yu
- Department of Medicine (Neurology), University of Toronto, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Corresponding author: Dr Amy Y.X. Yu, Neurologist, Department of Medicine (Neurology), University of Toronto, Sunnybrook Health Sciences Centre, Office A-455, 2075 Bayview Ave, Toronto, Ontario M4N 3M5, Canada. Tel.: +1-416-480-4866; fax: +1-416-480-5753.
| | - Douglas S. Lee
- ICES, Toronto, Ontario, Canada
- Department of Medicine (Cardiology), University of Toronto–University Health Network, Toronto, Ontario, Canada
| | - Manav V. Vyas
- Department of Medicine (Neurology), University of Toronto, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | | | | | | | | | - Michael D. Hill
- Department of Clinical Neurosciences, Community Health Sciences, and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Moira K. Kapral
- ICES, Toronto, Ontario, Canada
- Department of Medicine (General Internal Medicine), University of Toronto–University Health Network, Toronto, Ontario, Canada
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Nguyen DD, Doll JA. Quality Improvement and Public Reporting in STEMI Care. Interv Cardiol Clin 2021; 10:391-400. [PMID: 34053625 DOI: 10.1016/j.iccl.2021.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Mortality rates for patients with ST-segment elevation myocardial infarction (STEMI) remain high despite development of novel drugs and interventions over the past several decades. There is significant variability between hospitals in use of evidence-based treatments, and substantial opportunities exist to optimize care pathways and reduce disparities in care delivery. Quality improvement interventions implemented at local, regional, and national levels have improved care processes and patient outcomes. This article reviews evidence for quality improvement interventions along the spectrum of STEMI care, describes existing systems for quality measurement, and examines local and national policy interventions, with special attention to public reporting programs.
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Affiliation(s)
- Dan D Nguyen
- Division of Cardiology, Department of Medicine, University of Washington, 1959 NE Pacific Street, Seattle, WA 98195, USA
| | - Jacob A Doll
- Division of Cardiology, Department of Medicine, University of Washington, 1959 NE Pacific Street, Seattle, WA 98195, USA; VA Puget Sound Health Care System, 1660 S Columbian Way, Seattle, WA 98108, USA.
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8
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Govea A, Lipinksi J, Patel MP. Prehospital Evaluation, ED Management, Transfers, and Management of Inpatient STEMI. Interv Cardiol Clin 2021; 10:293-306. [PMID: 34053616 DOI: 10.1016/j.iccl.2021.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
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.
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Affiliation(s)
- Alayn Govea
- Division of Cardiovascular Medicine, UC San Diego, San Diego, CA, USA; UC San Diego Sulpizio Cardiovascular Center, 9452 Medical Center Drive #7411, La Jolla, CA 92037, USA
| | - Jerry Lipinksi
- UC San Diego Sulpizio Cardiovascular Center, 9452 Medical Center Drive #7411, La Jolla, CA 92037, USA; Department of Internal Medicine, UC San Diego, San Diego, CA, USA
| | - Mitul P Patel
- UC San Diego Sulpizio Cardiovascular Center, 9452 Medical Center Drive #7411, La Jolla, CA 92037, USA; Division of Cardiovascular Medicine, UC San Diego Cardiovascular Institute, San Diego, CA, USA.
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Clot S, Rocher T, Morvan C, Cardine M, Lotfi M, Turk J, Usseglio P, Descotes-Genon V, Vanzetto G, Savary D, Debaty G, Belle L. Door-in to door-out times in acute ST-segment elevation myocardial infarction in emergency departments of non-interventional hospitals: A cohort study. Medicine (Baltimore) 2020; 99:e20434. [PMID: 32501989 PMCID: PMC7306318 DOI: 10.1097/md.0000000000020434] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
In France, one in eight patients with acute ST-segment elevation myocardial infarction (STEMI) is admitted direct to an emergency department (ED) in a hospital without percutaneous coronary intervention (PCI) facilities. Guidelines recommend transfer to a PCI center, with a door-in to door-out (DI-DO) time of ≤30 min. We report DI-DO times and identify the main factors affecting them.RESURCOR is a French Northern Alps registry of patients with STEMI of <12 h duration. We focused on patients admitted direct, without prehospital medical care, to EDs in 19 non-PCI centers from 2012 to 2014. We divided DI-DO time into diagnostic time (ED admission to call for transfer) and logistical time (call for transfer to ED discharge).Among 2007 patients, 240 were admitted direct to EDs in non-PCI centers; 57.9% were treated with primary angioplasty and 32.9% received thrombolysis. Median (interquartile range) DI-DO time was 92.5 (67-143) min, with a diagnostic time of 41 (23-74) min and a logistical time of 47.5 (32-69) min. Five patients (2.1%) had a DI-DO time ≤30 min. Five variables were independently associated with a shorter DI-DO time: local transfer (mobile intensive care unit [MICU] team available at referring ED) (P = .017) or transfer by air ambulance (P = .004); shorter distance from referring ED to PCI center (P < .001); shorter time from symptom onset to ED admission (P = .002); thrombolysis (P = .006); and extended myocardial infarction (P = .007).In view of longer-than-recommended DI-DO times, efforts are required to promote urgent local transfer and use of thrombolysis.
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Affiliation(s)
- Sandrine Clot
- Emergency Department and Emergency Medical Service, Metropole Savoie Hospital, Chambery
| | - Thomas Rocher
- Emergency Department and Emergency Medical Service, Annecy Hospital, Annecy
| | - Claire Morvan
- Biostatistician, RENAU (Reseau Nord Alpin des Urgences), Annecy
| | - Mathieu Cardine
- Emergency Department and Emergency Medical Service, Grenoble University Hospital, Grenoble
| | | | - Julien Turk
- Emergency Department and Emergency Medical Service, Metropole Savoie Hospital, Chambery
| | - Pascal Usseglio
- Emergency Department and Emergency Medical Service, Metropole Savoie Hospital, Chambery
| | | | - Gerald Vanzetto
- Department of Cardiology, Grenoble University Hospital, Grenoble, France
| | - Dominique Savary
- Emergency Department and Emergency Medical Service, Annecy Hospital, Annecy
| | - Guillaume Debaty
- Emergency Department and Emergency Medical Service, Grenoble University Hospital, Grenoble
| | - Loic Belle
- Department of Cardiology, Annecy Hospital, Annecy
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10
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Yasaitis LC, Guan J, Ko DT, Chandra A, Stukel TA. Cardiac intervention rates for older patients with acute myocardial infarction in the United States and Ontario, 2003-2013: a retrospective cohort study. CMAJ Open 2020; 8:E437-E447. [PMID: 32527795 PMCID: PMC7850174 DOI: 10.9778/cmajo.20190190] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Previous work showed lower cardiac intervention rates for patients with acute myocardial infarction (AMI) in Ontario than in the United States. We assessed whether Ontario's efforts to improve access to rapid percutaneous coronary intervention (PCI) for AMI were associated with improved timeliness of care and whether this closed the gap between the 2 jurisdictions. METHODS In this retrospective cohort study, we followed adults aged 66-99 years in the US and Ontario for 30 days after admission for incident AMI between 2003 and 2013 using health administrative data from both countries. We calculated the proportion of patients who received cardiac catheterization, PCI and coronary artery bypass grafting on the day of and within 30 days of admission overall and according to AMI type (ST-segment elevation AMI [STEMI] v. non-STEMI) and risk group (low, medium or high predicted risk of 30-d mortality). RESULTS We followed 414 216 patients in the US and 112 484 in Ontario. The large disparities in cardiac intervention rates observed in 2003 mostly disappeared over time. By 2013, the proportion of patients who received same-day PCI was only slightly higher in the US than in Ontario (22.3% v. 19.2%), whereas the converse was true for 30-day PCI (44.0% v. 41.3%). In 2013, patients with STEMI in the US and Ontario received PCI at nearly identical rates on the day of admission (66.3% v. 63.8%); however, more patients at high risk with STEMI in the US than in Ontario received PCI, both on the day of admission (55.5% v. 44.7%) and by 30 days (60.5% v. 55.0%). INTERPRETATION Despite differences in resources and organization of delivery systems, by 2013, timely receipt of PCI by Ontario patients with AMI lagged only slightly behind that by US patients. A higher supply of PCI centres in the US may have facilitated earlier intervention among patients at high risk with STEMI.
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Affiliation(s)
- Laura C Yasaitis
- Leonard Davis Institute of Health Economics (Yasaitis), University of Pennsylvania, Philadelphia, Pa.; ICES Central (Guan, Ko, Stukel); Department of Medicine (Ko), Schulich Heart Centre, Sunnybrook Health Sciences Centre, and Institute of Health Policy, Management and Evaluation (Ko, Stukel), University of Toronto, Toronto, Ont.; John F. Kennedy School of Government (Chandra), Harvard University; Harvard Business School (Chandra); National Bureau of Economics Research (Chandra), Cambridge, Mass.; The Dartmouth Institute for Health Policy & Clinical Practice (Stukel), Geisel School of Medicine, Dartmouth College, Hanover, NH
| | - Jun Guan
- Leonard Davis Institute of Health Economics (Yasaitis), University of Pennsylvania, Philadelphia, Pa.; ICES Central (Guan, Ko, Stukel); Department of Medicine (Ko), Schulich Heart Centre, Sunnybrook Health Sciences Centre, and Institute of Health Policy, Management and Evaluation (Ko, Stukel), University of Toronto, Toronto, Ont.; John F. Kennedy School of Government (Chandra), Harvard University; Harvard Business School (Chandra); National Bureau of Economics Research (Chandra), Cambridge, Mass.; The Dartmouth Institute for Health Policy & Clinical Practice (Stukel), Geisel School of Medicine, Dartmouth College, Hanover, NH
| | - Dennis T Ko
- Leonard Davis Institute of Health Economics (Yasaitis), University of Pennsylvania, Philadelphia, Pa.; ICES Central (Guan, Ko, Stukel); Department of Medicine (Ko), Schulich Heart Centre, Sunnybrook Health Sciences Centre, and Institute of Health Policy, Management and Evaluation (Ko, Stukel), University of Toronto, Toronto, Ont.; John F. Kennedy School of Government (Chandra), Harvard University; Harvard Business School (Chandra); National Bureau of Economics Research (Chandra), Cambridge, Mass.; The Dartmouth Institute for Health Policy & Clinical Practice (Stukel), Geisel School of Medicine, Dartmouth College, Hanover, NH
| | - Amitabh Chandra
- Leonard Davis Institute of Health Economics (Yasaitis), University of Pennsylvania, Philadelphia, Pa.; ICES Central (Guan, Ko, Stukel); Department of Medicine (Ko), Schulich Heart Centre, Sunnybrook Health Sciences Centre, and Institute of Health Policy, Management and Evaluation (Ko, Stukel), University of Toronto, Toronto, Ont.; John F. Kennedy School of Government (Chandra), Harvard University; Harvard Business School (Chandra); National Bureau of Economics Research (Chandra), Cambridge, Mass.; The Dartmouth Institute for Health Policy & Clinical Practice (Stukel), Geisel School of Medicine, Dartmouth College, Hanover, NH
| | - Therese A Stukel
- Leonard Davis Institute of Health Economics (Yasaitis), University of Pennsylvania, Philadelphia, Pa.; ICES Central (Guan, Ko, Stukel); Department of Medicine (Ko), Schulich Heart Centre, Sunnybrook Health Sciences Centre, and Institute of Health Policy, Management and Evaluation (Ko, Stukel), University of Toronto, Toronto, Ont.; John F. Kennedy School of Government (Chandra), Harvard University; Harvard Business School (Chandra); National Bureau of Economics Research (Chandra), Cambridge, Mass.; The Dartmouth Institute for Health Policy & Clinical Practice (Stukel), Geisel School of Medicine, Dartmouth College, Hanover, NH
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