Performance Measures in STEMI after COVID-19 Pandemic: Results from the RECUIMA Registry

Abstract Background To offer proper medical care to patients with ST-segment Elevation Acute Myocardial Infarction (STEMI) in low- and middle-income settings (LMIS) is challenging. However, it is not known if performance indicators have changed back after the epidemiological recovery. Objective to describe performance measures (PM) in patients with STEMI during and after the COVID-19 pandemic. Methods Observational study of patients with STEMI, from an LMIS, with analysis of PM suggested in the 2017 AHA-ACC Performance Measures for Adults with STEMI. COVID-19 period was determined from January 2020 to October 2021, and from November 2021 to February 2022 as the post-COVID-19 period. Baseline characteristics, treatments and selected PM were compared using the χ2 test or Mann-Whitney U test. All tests were two-sided, and statistical significance was considered as p-value <0.05. Coronary interventionism-related PM were not reported. Results Administration of thrombolysis decreased (71.2% vs 51.6% (p: 0.001)), while the delay time for its administration (Median (Interquartile Range)) increased considerably (30 min (16-60) to 45 min (35- 60) (p: 0.003)). Aspirin at admission was administered in each period at 92.9% vs 94.2% (p: 0.62); and at discharge to 97.8% vs 98.9% (p: 0.48). Beta-blockers, P2Y12 inhibitors, statins, and angiotensin-converting enzyme inhibitors in patients with heart failure were administered to 67.1% vs 85.1% (p: 0.01), 96.4% vs 84% (p: 0.001), 96.2 % vs 95.7% (p: 1), and 81.2% vs 94.3% (p: 0.14), respectively. Conclusion Despite this being a current period of epidemiological recovery, the COVID-19 pandemic continues to negatively impact the care of patients with STEMI.

Monitoring quality of care in acute myocardial infarction complicated by acute heart failure using electronic medical record data: Experience of an underdeveloped country network

Background. Several improvements in performance measure (PM) have been described, in Cuba, in patients with ST Elevation Myocardial Infarction (STEMI). However, it still no clear if reported enhancement has an influence in management of STEMI complicated with Acute Heart Failure. The objective of this study is to determine if those changes in renewed protocol have improved PM of attention of this specific subgroup. Methods and material. Gathering data of patients after June 2014 is mandatory in a web-based tool, which allows, real time following of selected PM. After a first stage, updating in protocol was written, focusing in several gaps. The first stage closed with 81 patients admitted with heart failure after STEMI, meanwhile until late December 2019, other 126 patients were included. Data regarding PM was obtained from all registries, except for those PM related with coronary intervention. Results. Improvement in management was observed for 6 of presented PM for overall population; and in patients with cardiogenic shock, up to 6 PM were fully accomplished in both stages. Pharmacological treatments were administered fulfilling high standards, but no enhancement of in-hospital mortality was observed (19.4% vs. 18.5%; p: 0.86). Although not significant, thrombolytic decreased its prevalence in overall population (57.4 vs 48.1; p: 0.15), and in cardiogenic shock (29.4% vs 25%; p: 0.76). Conclusion. Performance measures were enhanced after an update in protocols of attention. However, most important ones didn’t suffer any changes. Efforts to maintain this increase in PM need to be taken.

Introdução. Diversas melhorias na medida de desempenho (MD) foram descritas, em Cuba, em pacientes com infarto do miocárdio com elevação do segmento ST (STEMI). No entanto, ainda não está claro se o realce relatado tem uma influência no tratamento do STEMI complicado com insuficiência cardíaca aguda. O objetivo deste estudo é determinarse essas mudanças no protocolo renovado melhoraram a atenção do MD deste subgrupo específico. Material e métodos. A coleta de dados dos pacientes após junho de 2014 é obrigatória em uma ferramenta baseada na web, que permite o acompanhamento em tempo real dos MD selecionados. Após uma primeira etapa, foi feita a atualização do protocolo, com foco em várias lacunas. A primeira fase encerrou com 81 pacientes internados com insuficiência cardíaca após IAMCSST, enquanto até o final de dezembro de 2019, outros 126 pacientes foram incluídos. Os dados sobre MD foram obtidos de todos os registros, exceto para MD relacionados com intervenção coronária. Resultados. Melhoria na gestão foi observada para 6 das MD apresentadas. Os tratamentos farmacológicos foram administrados de acordo com altos padrões, mas não foi observado aumento da mortalidade intra-hospitalar (21% vs. 24,6%; p: 0,54). Embora não seja significativo, o trombolítico aumenta sua prevalência fora do hospital (12/46 vs. 26/72; p: 0,256). Conclusão. As medidas de desempenho foram aprimoradas após uma atualização nos protocolos de atenção. No entanto, os mais importantes não sofreram alterações. Esforços para manter esse aumento na MD precisam ser feitos.

Antecedentes. Se han descrito varias mejoras en la medición del desempeño (MD), en Cuba, en pacientes con infarto de miocardio con elevación del ST (IAMCEST). Sin embargo, todavía no está claro si la mejora informada tiene influencia en el tratamiento del IAMCEST complicado con insuficiencia cardíaca aguda. El objetivo de este estudio es determinar si esos cambios en el protocolo renovado han mejorado la MD de atención de este subgrupo específico. Material y métodos. La recopilación de datos de pacientes después de junio de 2014 es obligatoria en una herramienta basada en web, que permite el seguimiento en tiempo real de los MD seleccionados. Luego de una primera etapa, se redactó la actualización en protocolo, enfocándose en varios aspectos de deficiente cumplimiento. La primera etapa cerró con 81 pacientes ingresados por insuficiencia cardíaca tras IAMCEST, mientras que hasta finales de diciembre de 2019 se incluyeron otros 126 pacientes. Los datos sobre MD se obtuvieron de todos los registros, excepto los relacionados con la intervención coronaria. Resultados. Se observó una mejora en el manejo para 6 MD presentados. Los tratamientos farmacológicos se administraron cumpliendo altos estándares, pero no se observó un aumento de la mortalidad hospitalaria (21% vs 24,6%; p=0,54). Aunque no es significativo, los trombolíticos aumentan la prevalencia extrahospitalaria (12/46 vs 26/72; p=0,256). Conclusión. Se mejoraron las medidas de desempeño luego de una actualización en los protocolos de atención. Sin embargo, los más importantes no sufrieron cambios. Es necesario realizar esfuerzos para mantener este aumento de MD.

Disección espontánea de arterias coronarias en el puerperio. Presentación de caso / Spontaneous dissection of coronary arteries in the puerperium. Case report

RESUMEN La disección espontánea de una arteria coronaria durante el embarazo es una causa poco común de infarto agudo de miocardio, con un alto riesgo de muerte materna. El diagnóstico se realiza mediante angiografía, aunque muchos casos son diagnosticados durante la autopsia. Se presenta el caso de una mujer blanca de 38 años de edad, fumadora, multípara, que al quinto día del puerperio presentó dolor centrotorácico, opresivo e intenso, y en el electrocardiograma se evidenció un infarto agudo de miocardio anterior extenso. La coronariografía demostró disección de la arteria coronaria izquierda incluido el tronco, la descendente anterior y la circunfleja. Se realizó angioplastia primaria y se produjo trombosis hiperaguda del stent implantado. La paciente falleció al quinto día en cuadro de shock cardiogénico refractario. No hay recomendaciones de tratamiento estándar, se considera que la angioplastia primaria es el tratamiento de elección. Es esencial la integración multidisciplinaria de cardiólogo, obstetra, cardiocirujano y anestesiólogo para decidir el mejor tratamiento.

ABSTRACT The spontaneous dissection of a coronary artery during pregnancy is a rare cause of acute myocardial infarction, with a high risk of maternal death. It can be diagnosed through coronary angiography, although many cases are diagnosed during autopsy. There is presented the case of a 38-year-old white woman, smoker, multiparous, that at the fifth day postpartum presented midthoracic, oppressive and intense pain, and the electrocardiogram evidenced an extensive acute anterior myocardial infarction. The coronary angiography showed dissection of the left coronary artery including the left main, the left anterior descending and the circumflex artery. A primary angioplasty was performed and there was a hyperacute thrombosis of the implanted stent. The patient died on the fifth day in refractory cardiogenic shock. There are no standard treatment recommendations, the primary angioplasty is considered the treatment of choice. The multidisciplinary integration of cardiologist, obstetrician, cardiac surgeon and anesthesiologist is essential to decide the best treatment.