Usefulness of Prehospital 12-Lead Electrocardiography System in ST-Segment Elevation Myocardial Infarction Patients in Oita - Comparison Between Urban and Rural Areas, Weekday Daytime and Weekday Nighttime/Holidays

BACKGROUND

We have reported that a prehospital 12-lead electrocardiography system (P-ECG) contributed to transport of suspected acute coronary syndrome (ACS) patients to appropriate institutes and in this study, we compared its usefulness between urban and rural areas, and between weekday daytime and weekday nighttime/holiday.Methods and Results: Consecutive STEMI patients who underwent successful primary percutaneous coronary intervention after using P-ECG were assigned to the P-ECG group (n=123; 29 female, 70±13 years), and comparable STEMI patients without using P-ECG were assigned to the conventional group (n=117; 33 females, mean age 70±13 years). There was no significant difference in door-to-reperfusion times between the rural and urban cases (70±32 vs. 69±29 min, P=0.73). Door-to-reperfusion times in the urban P-ECG group were shorter than those in the urban conventional group for weekday nighttime/holiday (65±21 vs. 83±32 min, P=0.0005). However, there was no significance different between groups for weekday daytime. First medical contact to reperfusion time (90±22 vs. 105±37 min, P=0.0091) in the urban P-ECG group were significantly shorter than in the urban conventional groups for weekday nighttime/holiday, but were not significantly different between the groups for weekday daytime.

CONCLUSIONS

P-ECG is useful even in urban areas, especially for patients who develop STEMI during weekday nighttime or while on a holiday.

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

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

Comparison of STEMI Door-To-Device Time During the COVID-19 Crisis in a New Jersey Inner City Community Hospital

As the novel COVID-19 pandemic was on the rise, its impact on the healthcare system was devastating. Patients became more reluctant to present to the hospital and elective procedures were being postponed for patient safety. We wanted to assess the effects of the COVID-19 pandemic on the door-to-device time in our small community hospital in the heart of Trenton, New Jersey. We created a retrospective study that evaluated all STEMI cases that presented to our institute from January 2018 until the end of May, 2021. Our primary outcome was the door-to-device time. Secondary outcomes were the length of hospital stay, ICU admission, length of ICU stay, cardiac arrest, and death during the hospitalization. We studied 114 patients that presented with STEMI to our emergency department, 77 of these patients presented pre-COVID-19, and 37 presented during the pandemic. Our median door-to-device for STEMI cases pre-COVID-19, and during the pandemic were 70 min (IQR 84-57) and 70 min (IQR 88-59) respectively with no significant difference found (P-value 0.55, Mann Whitney Test). It is, however, interesting to note that the number of STEMI admissions significantly decreased during the pandemic era. There are limitations to our study, most noticeably the number of STEMI cases at our small community hospital which limits its generalizability. Moreover, we did not assess other comorbidities which might have confounded our outcomes and we were also unable to follow patients post-discharge to assess the long-term sequela of their STEMI admission. Therefore, more dedicated studies of this clinical conundrum are required to further assess and implement guidelines for the future.

Shorter door-to-balloon time, better long-term clinical outcomes in ST-segment elevation myocardial infarction patients: J-MINUET substudy

BACKGROUND

The impact of shorter door-to-balloon (DTB time on long-term outcomes in ST-segment elevation myocardial infarction (STEMI treated with primary percutaneous coronary intervention (PPCI has not been fully elucidated.

METHODS

We investigated 3283 consecutive patients with acute myocardial infarction selected from a prospective, nationwide, multicenter registry (J-MINUET database comprising 28 institutions in Japan between July 2012 and March 2014. Among the study population, we analyzed 1639 STEMI patients who had PPCI within 12 h of onset. Patients were stratified into four groups (DTB time < 45 min, 45-60 min, 61-90 min, >90 min. The primary endpoint was a composite of all-cause death, non-fatal MI, non-fatal stroke, cardiac failure, and urgent revascularization for unstable angina up to 3 years. We performed landmark analysis for incidence of the primary endpoint from 31 days to 3 years among the four groups.

RESULTS

The primary endpoint rate from 31 days to 3 years increased significantly and time-dependently with DTB time (10.2 % vs. 15.3 % vs. 16.2 % vs. 19.3 %, respectively; log-rank p = 0.0129. Higher logarithm-transformed DTB time was associated with greater risk of a primary endpoint from 31 days to 3 years, and the increased number of adverse long-term clinical outcomes persisted even after adjusting for other independent variables.

CONCLUSION

Shorter DTB time was associated with better long-term clinical outcomes in STEMI patients treated with PPCI in contemporary clinical practice. Further efforts to shorten DTB time are recommended to improve long-term clinical outcomes in STEMI patients.

TRIAL REGISTRATION

UMIN Unique trial Number: UMIN000010037.

Prehospital 12-Lead Electrocardiography System in Oita Assisted Transport of "True" Acute Coronary Syndrome Patients to Optimal Institutes

BACKGROUND

Mobile cloud electrocardiography (C-ECG) can reduce the door-to-balloon time of acute coronary syndrome (ACS) patients, so we hypothesized it would also assist in transporting ACS-suspected patients to the optimal institutes.Methods and Results: Initially, 10 fire departments in Oita had 10 ambulances equipped with C-ECG. Ambulance crews recorded a 12-lead ECG from the patient at the first point of contact and transmitted them to 18 hospitals (13 institutions (PCII) with 24-h availability for percutaneous coronary intervention (PCI) and 5 regional core hospitals (RCH) without 24-h PCI) for analysis by a cardiologist. During 41 months, 476 ECGs suspected to be ACS were transmitted and analyzed. Of these, 24 ECGs transmitted to PCII were judged as not requiring PCI, and the patients were directly transported to a RCH (PCII-RCH); 35 ECGs sent to a RCH were judged as requiring PCI, and the patients were directly transported to a PCII (RCH-PCII). The prevalence of cardiovascular disease was significantly higher in the RCH-PCII group than in the PCII-RCH group (P<0.01). There was no significant difference in the door-to-balloon time between the RCH-PCII and the group in which the C-ECG was sent to a PCII and the patients were transported directly to PCII (PCII-PCII) (49±14 vs. 59±20 min, P=0.14).

CONCLUSIONS

Prehospital 12-lead ECG can assist in transporting ACS-suspect patients to the optimal treatment facility.

Impact of Universal Health Insurance on Total Ischemia Time and Door-to-Balloon Time in STEMI: A Single-Center Study from a Geographical Adverse Region

INTRODUCTION

We studied the impact of a Universal Health Insurance (UHI) Scheme introduced in India on total ischemia time (an important determinant of ST-elevation myocardial infarction [STEMI] outcome).

MATERIALS AND METHODS

This is a retrospective hospital-based comparative study which evaluated the total ischemia time (min) of all the patients presenting with STEMI and undergoing primary angioplasty before (Group A) and after (Group B) implementation of this scheme.

RESULTS

A total of 221 patients (mean age: 54.18 ± 13.02 years in Group A and 57.59 ± 11.42 years in Group B) were included in the study. Median pain to first medical contact time was 300 and 360 min (P = 0.49), whereas the median first medical contact to percutaneous coronary intervention PCI center time was 330 and 210 min (P = 0.32), for Groups A and B, respectively. A statistically significant difference was noted in the mean door-to-device time between two groups (67.46 ± 33.10 min in Group A vs. 58.48 ± 12.99 min in Group B; P = 0.02).

CONCLUSIONS

A significant difference in door-to-balloon time was found after implementation of UHI, but total ischemia time was no different. It emphasizes the importance of establishing a system of STEMI care that can decentralize the benefits of early reperfusion like hub-and-spoke model.

COVID-19-mediated patient delay caused increased total ischaemic time in ST-segment elevation myocardial infarction

Background

The current study aimed to evaluate changes in treatment delay and outcome for ST-segment elevation myocardial infarction (STEMI) in the Netherlands during the first coronavirus disease 2019 (COVID-19) outbreak, thereby comparing regions with a high and low COVID-19 hospitalisation rate.

Methods

Clinical characteristics, STEMI timing variables, 30-day all-cause mortality and cardiovascular complications of all consecutive patients admitted for STEMI from 1 January to 30 June in 2020 and 2019 to six hospitals performing a high volume of percutaneous coronary interventions were collected retrospectively using data from the Netherlands Heart Registry, hospital records and ambulance report forms. Patient delay, pre-hospital delay and door-to-balloon time before and after the outbreak of COVID-19 were compared to the equivalent periods in 2019.

Results

A total of 2169 patients were included. During the outbreak median total treatment delay significantly increased (2 h 51 min vs 2 h 32 min; p = 0.043) due to an increased patient delay (1 h 20 min vs 1 h; p = 0.030) with more late presentations > 24 h (1.1% vs 0.3%) in 2020. This increase was particularly evident during the peak phase of COVID-19 in regions with a high COVID-19 hospitalisation rate. During the peak phase door-to-balloon time was shorter (38 min vs 43 min; p = 0.042) than in 2019. All-cause 30-day mortality was comparable in both time frames (7.8% vs 7.3%; p = 0.797).

Conclusions

During the outbreak of COVID-19 patient delay caused an increase in total ischaemic time for STEMI, with a more pronounced delay in high-endemic regions, stressing the importance of good patient education during comparable crisis situations.

Supplementary Information

The online version of this article (10.1007/s12471-021-01653-9) contains supplementary material, which is available to authorized users.

Comparison of door-to-balloon time and in-hospital outcomes in patients with ST-elevation myocardial infarction between before versus after COVID-19 pandemic

The situation around primary percutaneous coronary intervention (PCI) has dramatically changed since coronavirus disease 2019 (COVID-19) pandemic. The impact of COVID-19 pandemic on clinical outcomes as well as door-to-balloon time (DTBT), which is known as one of the indicators of early reperfusion, has not been fully investigated in patients with ST-elevation acute myocardial infarction (STEMI). The purpose of this study was to compare DTBT and in-hospital outcomes in patients with STEMI between before versus after COVID-19 pandemic. The primary interest was DTBT and the incidence of in-hospital outcomes including in-hospital death. We included 330 patients with STEMI who underwent primary PCI, and divided them into the pre COVID-19 group (n = 209) and the post COVID-19 group (n = 121). DTBT was significantly longer in the post COVID-19 group than in the pre COVID-19 group (p < 0.001), whereas the incidence of in-hospital death was comparable between the 2 groups (p = 0.238). In the multivariate logistic regression analysis, chest CT before primary PCI (OR 4.64, 95% CI 2.58-8.34, p < 0.001) was significantly associated with long DTBT, whereas chest CT before primary PCI (OR 0.76, 95% CI 0.29-1.97, p = 0.570) was not associated with in-hospital death after controlling confounding factors. In conclusion, although DTBT was significantly longer after COVID-19 pandemic than before COVID-19 pandemic, in-hospital outcomes were comparable between before versus after COVID-19 pandemic. This study suggests the validity of the screening tests including chest CT for COVID-19 in patients with STEMI who undergo primary PCI.

Impact of the SARS-CoV-2 Pandemic on Primary Percutaneous Coronary Intervention for Patients with ST-Elevation Myocardial Infarction

During the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, patients with ST-elevation myocardial infarction (STEMI) should be treated as possibly infected individuals. Therefore, more time is considered necessary to conduct primary percutaneous coronary intervention (PCI). In this study, we sought to evaluate the impact of the SARS-CoV-2 pandemic on primary PCI for STEMI. Between March 2019 and March 2021, 259 patients with STEMI underwent primary PCI. Patients were divided into 2 groups: the pre-pandemic group (March 2019-February 2020) and the pandemic group (March 2020-February 2021). The patient demographics, reperfusion time including onset-to-door time, door-to-balloon time (DTBT), computed tomography (CT), peak creatinine phosphokinase (CPK), and 30-day mortality rate were investigated. The mean age of the patients was 70.4 ± 12.9 years, and 71.6% were male. There were 117 patients before the pandemic and 142 during the pandemic. The median DTBT was 29 (21.25-41.25) minutes before the pandemic and 48 minutes (31-73 minutes) during the pandemic (P < 0.001). The median door-to-catheter-laboratory time was 13.5 (10-18.75) minutes before the pandemic and 29.5 (18-47.25) minutes during the pandemic (P < 0.001). CT evaluation was performed before PCI in 39 (33.3%) patients and 63 (44.4%) patients (P = 0.08); their peak CPK levels were 1480 (358-2737.5) IU and 1363 (621-2722.75) IU (P = 0.56), and the 30-day mortality rates were 4.3% and 2.1% (P = 0.48), respectively. The SARS-CoV-2 pandemic changed the diagnostic procedure in the emergency department and affected the DTBT in patients with STEMI. Nonetheless, no adverse effects on the 30-day mortality rate were observed.

Factors affecting STEMI performance in six hospitals within one healthcare system

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Door-to-balloon time and mortality in patients with ST-elevation myocardial infarction undergoing primary angioplasty

AIMS

The evidence are not conclusive that a small incremental increase in door-to-balloon (D2B) time leads to a significant increase in death of ST-elevation myocardial infarction (STEMI) patients. In a previous study, we described a quality improvement intervention that reduced D2B time in 333 patients with STEMI. The aim of the current study was to compare mortality rates of the patients, before and after the intervention.

METHODS AND RESULTS

We examined the survival of 133 consecutive patients with STEMI treated prior to an intervention to decrease D2B time and 200 treated after the intervention. The mortality rate was the same before and after the quality intervention. The median D2B time for the entire cohort was 55 min. The number of patients with D2B time >55 min prior to the intervention was 82/133 (61%) and after the intervention 74/200 (37%) P < 0.00001. Thirty-day mortality among the patients with D2B time ≤55 min was 5/178 (2.8%) and among those with D2B time >55 min was 15/155 (9.7%), P < 0.008. The hazard ratio for 30-day mortality when the D2B time was >55 min was 3.7 (1.3-10.4).

CONCLUSION

Mortality and non-fatal complications did not differ significantly between STEMI patients before and after a quality improvement intervention. However, the number of patients treated within 55 min from arrival was significantly higher after the intervention; and coronary intervention within this time was associated with a lower death rate.

The effect of sex on door-to-balloon time in patients presenting with ST-elevation myocardial infarction and referred for primary percutaneous coronary intervention: A systematic review

Timely reperfusion using primary percutaneous coronary intervention (pPCI) is the cornerstone of acute ST-elevation myocardial infarction (STEMI) management. We conducted a systematic review to examine the effect of sex on door-to-balloon (D2B) time and symptom-to-balloon (S2B) time. We observed longer D2B times and S2B times in female patients presenting with STEMI and referred for pPCI when compared to male patients. Future work is required to try and elucidate and mitigate sex-based front-line treatment delays for female STEMI patients.

Comparison of Door-to-Balloon Time and 30-Day Mortality According to Symptom Presentation in Patients With Acute Myocardial Infarction

Background: We hypothesized that symptom presentation in patients with acute myocardial infarction (AMI) may affect their management and subsequent outcome.

Methods and Results: Using Rural AMI Registry data, 1,337 consecutive patients with AMI who underwent percutaneous coronary intervention were analyzed. Typical symptoms were defined as any symptoms of chest pain or pressure due to myocardial ischemia. We considered the specific symptoms of dyspnea, nausea, or vomiting as atypical symptoms. The primary outcome was 30-day mortality. There were 150 (11.2%) and 1,187 (88.8%) patients who presented with atypical and typical symptoms, respectively. Those who presented with atypical symptoms were significantly older (mean [±SD] age 74±12 vs. 68±13 years; P<0.001) and had a higher Killip class (46.7% vs. 21.8%; P<0.001) than patients presenting with typical symptoms. The prevalence of door-to-balloon time of ≤90 min was significantly lower in patients with atypical than typical symptoms (40.0% vs. 66.3%; P<0.001). At 30 days, there were 55 incidents of all-cause death. Multivariate Cox proportional hazards regression analysis revealed that symptom presentation was associated with 30-day mortality (hazard ratio 2.33; 95% confidence interval 1.20–4.38; P<0.05).

Conclusions: Atypical symptoms in patients with AMI are less likely to lead to timely reperfusion and are associated with increased risk of 30-day mortality.

Mobile application to optimize care for ST-segment elevation myocardial infarction patients in a large healthcare system, STEMIcathAID: rationale and design

Aims

Technological advancements have transformed healthcare. System delays in transferring patients with ST-segment elevation myocardial infarction (STEMI) to a primary percutaneous coronary intervention (PCI) centre are associated with worse clinical outcomes. Our aim was to design and develop a secure mobile application, STEMIcathAID, streamlining communication, and coordination between the STEMI care teams to reduce ischaemia time and improve patient outcomes.

Methods and results

The app was designed for transfer of patients with STEMI to a cardiac catheterization laboratory (CCL) from an emergency department (ED) of either a PCI capable or a non-PCI capable hospital. When a suspected STEMI arrives to a non-PCI hospital ED, the ED physician uploads the electrocardiogram and relevant patient information. An instant notification is simultaneously sent to the on-call CCL attending and transfer centre. The attending reviews the information, makes a video call and decides to either accept or reject the transfer. If accepted, on-call CCL team members receive an immediate push notification and begin communicating with the ED team via a HIPAA compliant chat. The app provides live GPS tracking of the ambulance and frequent clinical status updates of the patient. In addition, it allows for screening of STEMI patients in cardiogenic shock. Prior to discharge, important data elements have to be entered to close the case.

Conclusion

We developed a novel mobile app to optimize care for STEMI patients and facilitate electronic extraction of relevant performance metrics to improve allocation of resources and reduction of costs.

The Impact of the COVID-19 Pandemic and the Importance of Telemedicine in Managing Acute ST Segment Elevation Myocardial Infarction Patients: Preliminary Experience and Literature Review

The coronavirus disease 2019 (COVID-19), which is caused by a novel coronavirus (SARS-COV-2), has compromised health care systems and normal management of patients with cardiovascular diseases [1-3]. Patients with non-communicable diseases, including acute myocardial infarction (AMI) are vulnerable to this stress [4, 5]. Acute ST segment elevation myocardial infarction (STEMI), the most critical type of AMI, is associated with high mortality even with modern medicine [6-8]. Timely reperfusion therapy is critical for STEMI patients because a short ischemia time is associated with better clinical outcomes and lower acute and long -term mortality [9-12]. The COVID-19 pandemic placed the management of STEMI patients in a difficult situation due to the need to balance timely reperfusion therapy and maintaining strict infection control practices [13, 14]. Telemedicine, which is used to deliver health care services using information or communication technology, provides an opportunity to carry out the evaluation, diagnosis, and even monitor the patients after discharge when social distancing is needed [15]. In this article, we reported our preliminary experience with the usefulness of telemedicine in managing STEMI patients during the COVID-19 pandemic. We also provided a review of this topic.

Impact of Mobile Cloud Electrocardiography System on Door-to-Balloon Time in Patients With Acute Coronary Syndrome in Oita Prefecture

Background: The mobile cloud electrocardiography (C-ECG) system is useful for reducing door-to-balloon (DTB) time in patients with acute coronary syndrome (ACS), but few studies have reported the usefulness of the C-ECG system across a wide provincial prefecture, such as Oita, in Japan.

Methods and Results: On 17 April 2017, the C-ECG system was integrated into the Oita remote image transmission system, in 10 ambulances of 10 respective fire departments in Oita Prefecture. During 6 months, 162 ECG indicating suspected ACS were transmitted to 18 hospitals using the C-ECG system. Of 162 patients, 17 who received emergency percutaneous coronary intervention (PCI) were assigned to the cloud group (mean age, 71±11 years). The control group consisted of 29 consecutive ACS patients who were transported to Oita University Hospital without using the C-ECG system (mean age, 66±12 years). Another 40 consecutive patients were diagnosed with ACS before transportation to Oita University Hospital, and were assigned to the diagnosed group (mean age, 70±14 years). DTB time (70±26 min vs. 96±24 min, P<0.005) and door-to-catheterization laboratory time (33±20 min vs. 53±22 min, P<0.0001) were shorter in the cloud group than in the control group, respectively.

Conclusions: C-ECG system integration in Oita Prefecture was useful to appropriately transfer ACS patients to hospital and to facilitate earlier PCI than in the conventional diagnostic system.

Door-to-balloon time and the determining factors in a tertiary cardiac center in Nepal

Background

Door-to-balloon (DTB) time of 90 min during primary angioplasty is considered as the benchmark duration. Shorter DTB time is preferable, and longer duration can have poor clinical outcomes.

Methods

A cross-sectional observational study of three months in Shahid Gangalal National Heart Center was conducted in which all patients undergoing primary angioplasty were included. The DTB time was calculated, and the different determining factors were studied.

Results

Seventy-nine patients undergoing primary percutaneous intervention were studied. The median DTB time was 79 minutes (Interquartile range [IQR] 59–115 min). Forty-six (58.2%) patients had a DTB time of less than 90 min. DTB time varied significantly with direct visit vs transfer (p = 0.029) and office time visit (9 am–5 pm) vs off time (5 pm–9 am) (p = 0.012). DTB time did not differ between any infarct-related vessels (p = 0.471), number of vessels involved (p = 0.638), and the added procedures (defibrillation, thrombosuction, and temporary pacemaker insertion) (p = 0.682) during angioplasty. No significant differences were recorded according to age (p = 0.330), gender (p = 0.254), hypertension (p = 0.073), diabetes (p = 0.487), heart failure (p = 0.316), and baseline left ventricular ejection fraction (LVEF) (p = 0.819).

Conclusion

The median DTB time in primary angioplasty was less than 90 minutes. The significant determining factors were timing of hospital visit (office vs off time) and type of visit (direct vs transfer). There can be improvement in factors determining DTB time to lower it further.

Impact of shorter door-to-balloon time on prognosis of patients with STEMI-single-center analysis with a large proportion of the patients treated within 30 min

Several recent studies suggested that the door-to-balloon time (DTBT) for patients with ST-segment elevation myocardial infarction (STEMI) should be as short as possible, despite the existing guideline for STEMI. This study aimed to evaluate the clinical outcomes of the STEMI patient cohort having the highest proportion of patients treated with a DTBT of ≤ 30 min ever reported. We evaluated 527 consecutive patients with STEMI who underwent percutaneous coronary intervention between 2007 and 2015. The mean age was 68.0 ± 12.7 years, and the mean DTBT was 44.4 ± 33.1 min. The patients were classified into four groups according to the DTBT, and the relationship between the DTBT and clinical outcome was investigated. DTBTs were ≤ 30 min in 146 patients (27.7%), 31-60 min in 297 patients (56.4%), 61-90 min in 60 patients (11.4%), and > 90 min in 24 patients (4.6%). In-hospital mortality rates were 0.7, 5.0, 11.7, and 12.5% for DTBTs of ≤ 30, 31-60, 61-90, and > 90 min, respectively. In multivariate analysis, a DTBT ≤ 30 min (odds ratio [OR] 0.11, 95% confidence interval [CI] 0.01-0.91, p = 0.041), shock on arrival (OR 2.74, 95% CI 1.02-7.37, p = 0.046), and blood transfusion (OR 49.60, 95% CI 13.90-177.00, p < 0.001) were the independent predictors of in-hospital mortality. Patients with STEMI treated with a DTBT ≤ 30 min showed significantly better clinical outcomes than those treated with a DTBT > 30 min.

Determinants of short and long door-to-balloon time in current primary percutaneous coronary interventions

Primary percutaneous coronary interventions (PCI) have been developed to improve clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI). In primary PCI, the door-to-balloon time (DTBT) is closely associated with mortality and morbidity. The purpose of this study was to find determinants of short and long DTBT. From our hospital record, we included 214 STEMI patients, and divided into the short DTBT group (DTBT < 60 min, n = 60), the intermediate DTBT group (60 min ≤ DTBT ≤ 120 min, n = 121) and the long DTBT group (DTBT > 120 min, n = 33). In-hospital mortality was highest in the long DTBT group (24.2%), followed by the intermediate DTBT group (5.8%), and lowest in the short DTBT group (0%) (< 0.001). Transfers from local clinics or hospitals (OR 3.43, 95% CI 1.72-6.83, P < 0.001) were significantly associated with short DTBT, whereas Killip class 3 or 4 (vs. Killip class 1 or 2: OR 0.20, 95% CI 0.06-0.64, P = 0.007) was inversely associated with short DTBT in multivariate analysis. In conclusion, transfer from local clinics/hospitals was associated with short DTBT. Our results may suggest the current limitation of ambulance system, which does not include pre-hospital ECG system, in Japan. The development of pre-hospital ECG system would be needed for better management in STEMI.

Effect of improved door-to-balloon time on clinical outcomes in patients with ST segment elevation myocardial infarction

OBJECTIVE

Few studies have focused on the effects of an improved door-to-balloon time on clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI). The aim of this study was to explore the effect of improving door-to-balloon time on prognosis and to identify major predictors of mortality.

METHODS

From January 2005 to December 2014, 1751 patients experienced STEMI and received primary percutaneous intervention in our hospital. During a 10-year period, the patients were divided into two groups according to the time period. Since mid-2009, shortening door-to-balloon time has been an important concern of health care. As a result of targeted efforts, as of January 2010, door-to-balloon time shortened significantly. In our study, a total 853 patients were in group 1 during January 2005 to December 2009, and a total 898 patients were in group 2 during January 2010 to December 2014.

RESULTS

The incidence of major adverse cardiac cerebral events (26.7% vs. 23.2%; p=0.120), the incidence of cardiovascular mortality (9.3% vs. 8.8%; p=0.741), and the incidence of all-cause mortality (12.6% vs. 12.2%; p=0.798) were similar between the two groups. The incidence of target vessel revascularization significantly decreased in group 2 (17.8% vs. 12.6%; p=0.008). However, the incidence of stroke increased in group 2 (1.8% vs. 3.6%; p=0.034).

CONCLUSION

Improving door-to-balloon time could not improve 1-year cardiovascular mortality whether low-risk or high-risk patients. The improvement in the door-balloon time does not improve outcomes studied, probably because it is not accompanied by a reduction in total reperfusion time, which means from onset of symptoms to reperfusion.

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

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

Time to Treatment: Focus on Transfer in ST-Elevation Myocardial Infarction

In the modern ST-elevation myocardial infarction (STEMI) system, the use of electrocardiogram by emergency medical services (EMS) personnel and the option to bypass emergency departments on route to a PCI-capable hospital is of particular importance. Through training and a standardized referral process, EMS personnel can now accurately diagnose and refer STEMI patients directly to the catheterization laboratory of a percutaneous coronary intervention-capable hospital. Regional STEMI models have been implemented successfully across North America, resulting in palpable reductions in door-to-balloon time, morbidity, and mortality.

Barriers Associated With Door-to-Balloon Delay in Contemporary Japanese Practice

BACKGROUND

Door-to-balloon (DTB) time ≤90 min is an important quality indicator in the management of ST-elevation myocardial infarction (STEMI), but a considerable number of patients still do not meet this goal, particularly in countries outside the USA and Europe.Methods and Results:We analyzed 2,428 STEMI patients who underwent primary PCI ≤12 h of symptom onset who were registered in an ongoing prospective multicenter database (JCD-KiCS registry), between 2008 and 2013. We analyzed both the time trend in DTB time within this cohort in the registry, and independent predictors of delayed DTB time >90 min. Median DTB time was 90 min (IQR, 68-115 min) during the study period and there were no significant changes with year. Predictors for delay in DTB time included peripheral artery disease, prior revascularization, off-hour arrival, age >75 years, heart failure at arrival, and use of IABP or VA-ECMO. Notably, high-volume PCI-capable institutions (PCI ≥200/year) were more adept at achieving shorter DTB time compared with low-volume institutions (PCI <200/year).

CONCLUSIONS

Half of the present STEMI patients did not achieve DTB time ≤90 min. Targeting the elderly and patients with multiple comorbidities, and PCI performed in off-hours may aid in its improvement.

Clinical outcomes of elderly South-East Asian patients in primary percutaneous coronary intervention for ST-elevation myocardial infarction

Objective

To evaluate the clinical characteristics and in-hospital outcomes of elderly South-East Asian patients undergoing primary percutaneous coronary intervention (PPCI).

Methods

From January 2009 to December 2012, 1268 patients (86.4% male, mean age of 58.4 ± 12.2 years) presented to our hospital for ST-elevation myocardial infarction (STEMI) and underwent PPCI. They were divided into two groups: elderly group defined as age ≥ 70 years and non-elderly group defined as age < 70 years. Data were collected retrospectively on baseline clinical characteristics, door-to-balloon (D2B) time, angiographic findings, therapeutic modality and hospital course.

Results

The elderly group constituted 19% of the study population with mean age 76.6 ± 5.0 years. There was a higher proportion of female gender and ethnic Chinese patients in the elderly group when compared with the non-elderly group. The former was less likely to be smokers and have a significantly higher prevalence of hypertension. The mean D2B time was significantly longer in the elderly group. They also had a significantly higher incidence of triple vessel disease and obstructive left main disease. The use of radial artery access, glycoprotein 2b/3a inhibitors and drug-eluting stents during PPCI were also significantly lower. In-hospital mortality was significantly higher in the elderly group. The rate of cardiogenic shock and inhospital complications were also significantly higher.

Conclusions

Our registry showed that in-hospital mortality rate in elderly South-East Asian patients undergoing PPCI for STEMI was high. Further studies into the optimal STEMI management strategy for these elderly patients are warranted.

Relationship between time to treatment and mortality among patients undergoing primary percutaneous coronary intervention according to Korea Acute Myocardial Infarction Registry

BACKGROUND

Despite large reductions in door-to-balloon times over the period, several studies from regional and national data showed that annual mortality rates were not decreased among patients who underwent primary percutaneous coronary intervention (PCI). However, these studies mostly focused on door-to-balloon time, and there was no consideration of total ischemic time in a trend of mortality. The aim of this study was to assess the annual trend between time to treatment and 1-month mortality among patients undergoing primary PCI.

METHODS AND RESULTS

The study population consisted of 8040 patients who underwent primary PCI at hospitals participating in the nationwide prospective Korea Acute Myocardial Infarction Registry (KAMIR) between January 2008 and December 2011. The primary end point of this study was 1-month all-cause mortality, and time to treatment (door-to-balloon time, symptom-to-balloon time). One-month death occurred in 452 patients (5.6%) from 2008 to 2011. Additional reductions in door-to-balloon time were not translated into parallel reductions in mortality rate and total ischemic time. After adjustment using clinical risk, shorter total ischemic time was an independent predictor of 1-month mortality [adjusted odds ratio (OR) 0.78, 95% confidential interval (CI) 0.62-0.99, p=0.04]. Total ischemic time could be reduced by using emergency medical services.

CONCLUSION

Despite improvements in door-to-balloon time, no parallel reductions in mortality rate and total ischemic time were observed. Total ischemic time was associated with mortality. The present study suggests that additional efforts are needed to shorten total ischemic time including patient and pre-hospital systemic delay for better prognosis after primary PCI.

The effect of door-to-balloon delay in primary percutaneous coronary intervention on clinical outcomes of STEMI: a systematic review and meta-analysis protocol

BACKGROUND

Acute myocardial infarction (AMI) is a medical emergency in which sudden occlusion of coronary artery(ies) results in ischemia and necrosis of the cardiac tissues. Reperfusion therapies that aim at reopening the occluded artery remain the mainstay of treatment for AMI. Primary percutaneous coronary intervention (PCI), which enables the restoration of blood flow by reopening the occluded artery(ies) via a catheter with an inflatable balloon, is currently the preferred treatment for AMI with ST segment elevation (STEMI). The door-to-balloon (D2B) delay refers to the time interval counting from the arrival of a patient with STEMI at a hospital to the time of the balloon inflation (or stent deployment) that reopens the occluded artery(ies). Reducing this delay in primary PCI is thought to be an important strategy toward achieving better patient outcomes. Unfortunately, significant reduction of D2B delay in the USA over the last decade has not been shown to be associated with improved STEMI mortality. It has been suggested that the lack of impact could be due to the expanding use of primary PCI in STEMI as well as the survival cohort effect, leading to a shift toward a higher risk population receiving the procedure. Others have suggested that reduction in D2B delay may not be as impactful as expected, given that it only represents a small fraction of the total ischemic time. Although most existing evidence have pointed to the presence of a beneficial effect of shorter D2B delay, some inconsistencies however exist. This study aims to synthesize available evidence in order to answer the following questions: (1) what is the overall effect of D2B delay on clinical outcomes in patients with STEMI treated with primary PCI? (2) What factors explain the differences of the effect estimates among the studies? (3) What are the important strength and limitation of the existing body of evidence?

METHOD

We will search PubMed/MEDLINE, EMBASE, ClinicalTrials.gov, WHO International Clinical Trials Registry, CINAHL Database, and the Cochrane Library using a predefined search strategy. Other sources of literature will include proceedings from the European Society of Cardiology, the American College of Cardiology, the American Heart Association, the EUROPCR, and the ProQuest Dissertations and Theses Database. We will include data from observational studies (case-control and cohort study design) and randomized control trials (that have investigated the relationship of D2B time and clinical outcome(s) in an adult (older than 18) STEMI population). Mortality (cardiac related and all-cause) and incidence heart failure (HF) have been prioritized as the primary outcomes. All eligible studies will be assessed for risk of bias using the Risk Of Bias in Non-randomized Studies - of Interventions tool. The Grading of Recommendations, Assessment, and Evaluation (GRADE) framework will be used to report the quality of evidence and strength of recommendations. We will proceed to analyze the data quantitatively if the pre-specified conditions are satisfied.

DISCUSSION

Recent discussion on the negative findings of improved D2B delay over time being unrelated to better STEMI outcomes at the population level has reminded us of an important knowledge gap we have on this domain. This systematic review will serve to address some of these key questions not previously examined. Answers to these questions could clarify the controversies and offer empirical support for or against the suggested hypotheses.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015026069.

[Evolution of the interventional reperfusion strategy and reperfusion times in acute ST-segment elevation myocardial infarction]

BACKGROUND

In patients with acute ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (pPCI), the recommended times (first medical contact-to-balloon (M2B) <120 or <90min, and door-to-balloon (D2B) <45min) are reached in less than 50% of patients.

PURPOSE

To compare the interventional reperfusion strategy and reperfusion times between two series of consecutive STEMI patients referred for pPCI within 12hours of symptom onset, in 2007 and 2012.

METHODS

Retrospective study of 182 patients, 87 admitted from January 2007 to March 2008 (period 1), and 95 admitted from January to December 2012 (period 2). The procedural characteristics and the different times between onset of pain and mechanical reperfusion were gathered and compared by non-parametric tests.

RESULTS

Radial access, thromboaspiration, and drug eluting stents were more frequent, and cardiogenic shock was less common during period 2, compared with the period 1. The median time from first medical contact to balloon (M2B) decreased by 26% (135min, [quartiles: 113-183] in 2007 versus 100 [76-137] in 2012, P<0.001), in relation to the reduction in both prehospital times and time in the catheterization laboratory (D2B: 51 [44-65] and 44min [37-55], respectively, P<0.01).

CONCLUSIONS

The D2B and M2B times significantly decreased in our centre between 2007 and 2012, and reached the recommended values in >60% of the cases. This may be explained by better coordination between emergency medical units and interventional cardiologists, and by the presence of two paramedics in the catheterization laboratory for 24/24 7/7 pPCI since 2010 in France, in accordance with recent national regulation.

Simultaneous computerised activation of the primary percutaneous coronary intervention pathway reduces out-of-hours door-to-balloon time but not mortality

BACKGROUND

In 2009 activation of out of hours (OOH) primary percutaneous coronary intervention (PPCI) in our institution changed from separate telephone calls to a simultaneous computerised alert. We assessed the impact of this protocol change on door-to-balloon (DTB) time, in hospital and 1 year mortality.

METHODS

Retrospective survey of our Myocardial Ischaemia National Audit Project (MINAP) database. OOH patients were categorized--pre- (Group 1) and post- (Group 2) introduction of the computerised alert protocol.

RESULTS

OOH PPCI was performed for 793 patients (mean age 61, 73.4% male)--295 in Group 1 and 498 in Group 2. Median DTB times were 92 min (interquartile range [IQR] 75-111) for Group 1 and 76 min (IQR 64-97) for Group 2 (p < 0.0001). Forty-eight percent achieved DTB in ≤ 90 min in Group 1 compared to 70% in Group 2 (p < 0.0001). Computerised alert was associated with a shorter DTB time on multivariate analysis (beta coefficient -0.09, p = 0.03 for linear regression and OR 2.8, 95% CI 1.6-5.0, p < 0.0001 for logistic regression). In hospital mortality was 4.1% in Group 1 and 5% in Group 2 (p = 0.60). All-cause mortality at 1 year was 6.1% in Group 1 and 9.9% in Group 2 (p = 0.09).

CONCLUSIONS

Simultaneous computerised activation for OOH PPCI reduced DTB times, increased the number of patients achieving target DTB times but did not affect mortality.

Real-time, two-way interaction during ST-segment elevation myocardial infarction management improves door-to-balloon times

OBJECTIVES

The study aimed to determine if utilization of the CodeHeart application (CHap) reduces door-to-balloon (DTB) times of ST-segment elevation myocardial infarction (STEMI) patients.

BACKGROUND

A pre-hospital electrocardiogram improves the management of patients with STEMI. Current telecommunication systems do not permit real-time interaction with the initial care providers. Our institution developed a novel telecommunications system based on a software application that permits real-time, two-way video and voice interaction over a secured network.

METHODS

All STEMI system activations after implementation of the CHap were prospectively entered into a database. Consecutive CHap activations were compared to routine activations as controls, during the same time period.

RESULTS

A total of 470 STEMI system activations occurred; CHap was used in 83 cases (17.7%). DTB time was reduced by the use of CHap when compared to controls (CHap 103 minutes, 95% CI [87.0-118.3] vs. standard 149 minutes, 95% CI [134.0-164.8], p<0.0001), as was first call-to-balloon time (CHap 70 minutes, 95% CI [60.8-79.5] vs. standard 92 minutes, 95% CI [85.8-98.9], p=0.0002). The percentage of 'true positive' catheterization laboratory activations was nominally higher with the use of CHap, although this did not reach statistical significance [CHap 47/83 (56.6%) vs. routine 178/387 (45.9%), p=0.103].

CONCLUSION

The implementation of a two-way telecommunications system allowing real-time interactions between interventional cardiologists and referring practitioners improves overall DTB time. In addition, it has the potential to decrease the frequency of false activations, thereby improving the cost efficiency of a network's STEMI system.

Use of emergency medical services expedites in-hospital care processes in patients presenting with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention

To determine whether door-to-balloon (DTB) times of patients presenting with ST-elevation myocardial infarction (STEMI) were reduced in patients transported by emergency medical services (EMS) compared to those who were self-transported. DTB time is an important measure of hospital care processes in STEMI. Use of EMS may expedite in-hospital processing and reduce DTB times. A total of 309 consecutive STEMI patients who underwent primary percutaneous coronary intervention in our institution were analyzed. Excluded were patients who received fibrinolytics, presented in cardiac arrest, were intubated, or were transferred from another hospital. EMS-transported patients (n=83) were compared to self-transported patients (n=226). The primary outcome measure was DTB time and its component time intervals. Secondary end points included symptom-to-door and symptom-to-balloon times, and correlates for DTB >90 minutes. A higher percentage of EMS-transported patients reached the time goal of DTB <90 minutes compared to self-transported patients (83.1 versus 54.3%; p<0.001). EMS-transported patients had shorter DTB times [median (IQR) minutes, 65 (50-86) versus 85 (61-126); p<0.001] due to a reduction of emergency department processing (door-to-call) time, whereas catheterization laboratory processing (call-to-balloon) times were similar in both groups. EMS-transported patients had shorter symptom-to-door [median (IQR) hours, 1.2 (0.8-3.5) versus 2.3 (1.2-7.5); p<0.001] and symptom-to-balloon [median (IQR) hours, 2.5 (1.9-4.7) versus 4.3 (2.6-9.1); p<0.001]. Independent correlates of DTB times >90 minutes were self-transport (odds ratio 5.32, 95% CI 2.65-10.70; p<0.001) and off-hours presentation (odds ratio 2.89, 95% CI 1.60-5.22; p<0.001). Use of EMS transport in STEMI patients significantly shortens time to reperfusion, primarily by expediting emergency department processes. Community education efforts should focus not only on the importance of recognizing symptoms of myocardial infarction, but also taking early action by calling the EMS.