The effects of intravenous insulin infusions on early mortality for patients with acute coronary syndromes who present with hyperglycaemia: A matched propensity analysis using data from the MINAP database 2008-2012.

BACKGROUND: In acute coronary syndrome, the use of intravenous insulin infusions (IVII) to control hyperglycaemia is based on limited evidence of survival benefit. AIMS: To compare 7 day survival for patients receiving IVII compared with those receiving routine care to control admission hyperglycaemia (>=11 mmol/l) in acute coronary syndrome. METHODS AND RESULTS: We used matched propensity analysis to examine observational data from the MINAP database between 2008 and 2012. We matched 5974 pairs of patients. We separately examined outcomes for ST elevation (STEMI) and non ST segment elevation (NSTEMI) infarctions, and those without known diabetes and those with type 2 diabetes. Survival benefit from the use of IVII was seen only in patients with STEMI not known to have diabetes at admission (adjusted hazard ratio (HR) 0.77 (95% confidence interval (CI) 0.64-0.92), p=0.005). Those with STEMI and existing type 2 diabetes who received IVII showed similar outcomes to routine care (HR 0.99 (95% CI 0.80-1.23), p=0.931). In patients with NSTEMI IVII was associated with significantly worse adjusted 7 day survival outcome than routine care, regardless of diabetes status; for those without known diabetes, HR 1.50 (95% CI 1.04-2.16), p=0.029, and for those with type 2 diabetes, HR 1.35 (95% CI 1.08-1.70), p=0.010. CONCLUSION: As used in current clinical practice to treat hyperglycaemia in acute coronary syndromes, IVII appears to be of benefit only for patients with STEMI who are not known to have diabetes. IVII is associated with adverse early outcomes in patients with NSTEMI.

Resuscitated cardiac arrest and prognosis following myocardial infarction.

OBJECTIVES: To determine whether resuscitated cardiac arrest (CA) complicating ST elevation myocardial infarction (STEMI) impacts outcome, particularly in patients surviving to discharge. BACKGROUND: Resuscitated CA complicating STEMI is associated with increased inpatient mortality. The impact on later prognosis is unclear. METHODS: We analysed data from the UK Myocardial Ischaemia National Audit Project for STEMI patients admitted during January 2008-March 2010. We used survival analyses to assess the independent impact of resuscitated CA during the index episode on inhospital, 30 days, 1 year and medium term all-cause mortality. RESULTS: Of 48 749 STEMI patients, 5308 (10.9%) were recorded as having a CA. Of these, 1557 (29.3%) died on the day of CA. In survivors, after covariate adjustment, resuscitated CA was associated with increased risk of death during the index admission (HR 4.05 (3.69 to 4.45) p<0.001). In patients surviving to discharge, a history of resuscitated CA was associated with increased risk of death to 30 days (HR 1.53 (1.18 to 2.00), p<0.001). However, beyond 30 days, resuscitated CA was not associated with increased mortality risk (1-year HR 0.95 (0.79 to 1.14, p=0.596); 3.5 years HR 0.90 (0.78 to 1.04), p=0.144). The influence of resuscitated CA on inhospital or 30-day mortality was similar whether CA occurred before or after hospital admission. Where the resuscitated CA rhythm was asystole, inhospital mortality was higher compared with ventricular arrhythmia (p<0.001) or pulseless electrical activity (p=0.011). Late resuscitated CA (occurring after the day of index STEMI) was associated with higher 30-day postdischarge mortality compared with early resuscitated CA (p=0.023). CONCLUSIONS: STEMI complicated by resuscitated CA merits careful monitoring in the early period postevent. In contemporary practice, there is no impact of resuscitated CA on longer-term prognosis.

Euro Heart Survey 2009 Snapshot: regional variations in presentation and management of patients with AMI in 47 countries.

AIMS: Detailed data on patients admitted for acute myocardial infarction (AMI) on a European-wide basis are lacking. The Euro Heart Survey 2009 Snapshot was designed to assess characteristics, management, and hospital outcomes of AMI patients throughout European Society of Cardiology (ESC) member countries in a contemporary 'real-world' setting, using a methodology designed to improve the representativeness of the survey. METHODS: Member countries of the ESC were invited to participate in a 1-week survey of all patients admitted for documented AMI in December 2009. Data on baseline characteristics, type of AMI, management, and complications were recorded using a dedicated electronic form. In addition, we used data collected during the same time period in national registries in Sweden, England, and Wales. Data were centralized at the European Heart House. RESULTS: Overall, 4236 patients (mean age 66±13 years; 31% women) were included in the study in 47 countries. Sixty per cent of patients had ST-segment elevation myocardial infarction, with 50% having primary percutaneous coronary intervention and 21% fibrinolysis. Aspirin and thienopyridines were used in >90%. Unfractionated and low-molecular-weight heparins were the most commonly used anticoagulants. Statins, beta-blockers, and angiotensin-converting enzyme inhibitors were used in >80% of the patients. In-hospital mortality was 6.2%. Regional differences were observed, both in terms of population characteristics, management, and outcomes. CONCLUSIONS: In-hospital mortality of patients admitted for AMI in Europe is low. Although regional variations exist in their presentation and management, differences are limited and have only moderate impact on early outcomes.

The importance of audit to monitor applications of procedures and improve primary angioplasty results.

Although clinical trials have demonstrated that primary percutaneous coronary intervention (PPCI) provides better outcomes than thrombolysis for STEMI, it cannot be assumed that similar results can be obtained in day-to-day practice. To determine whether standards are being met, continuous audit of PPCI programmes is necessary, with appropriate feedback to participating centres and operators. Both the MINAP and BCIS national audit projects allow central electronic collection of data on consecutive patients presenting to every hospital involved in the acute management of these patients. Regular programmed feedback is provided to centres performing primary PCI that attempts to take account of statistical variation and differences in case mix between units by making use of funnel plots, statistical process control graphs and risk adjustment models. This reporting of "process" and "outcome" data, both confidentially and within the public domain, has been used to drive up clinical performance and has been associated with steady improvements and reduced inequalities of care.

Developing primary PCI as a national reperfusion strategy for patients with ST-elevation myocardial infarction: the UK experience.

In 2004 in the United Kingdom (UK), the infrastructural and organisational changes required for implementation of primary PCI for treatment of STEMI were unclear, and the cost-effectiveness and sustainability of a changed reperfusion strategy had not been tested. In addition, any proposed change was to be made against the background of a previously successful in-hospital thrombolysis strategy, with plans for greater use of pre-hospital administration. A prospective study (the "National Infarct Angioplasty Project - NIAP") was set up to collect information on all patients presenting with STEMI in selected regions in the UK over a one year period (April 2005 - March 2006). The key findings from the NIAP project included that PPCI could be delivered within acceptable treatment times in a variety of geographical settings and that the shortest treatment times were achieved with direct admission to a PPCI-capable cardiac catheter laboratory. The transformation from a dominant lytic strategy to one of PPCI across the UK was achieved both swiftly and consistently with the help of 28 cardiac networks. By the second quarter of 2011, 94% of those STEMI patients in England who received reperfusion treatment were being treated by PPCI compared with 46% during the third quarter of 2008.

The pre-hospital fibrinolysis experience in Europe and North America and implications for wider dissemination.

OBJECTIVES: The primary objective of this report was to describe the infrastructures and processes of selected European and North American pre-hospital fibrinolysis (PHL) programs. A secondary objective is to report the outcome data of the PHL programs surveyed. BACKGROUND: Despite its benefit in reducing mortality in patients with ST-segment elevation myocardial infarction, PHL remained underused in North America. Examination of existing programs may provide insights to help address barriers to the implementation of PHL. METHODS: The leading investigators of PHL research projects/national registries were invited to respond to a survey on the organization and outcomes of their affiliated PHL programs. RESULTS: PHL was successfully deployed in a wide range of geographic territories (Europe: France, Sweden, Vienna, England, and Wales; North America: Houston, Edmonton, and Nova Scotia) and was delivered by healthcare professionals of varying expertise. In-hospital major adverse outcomes were rare with mortality of 3% to 6%, reinfarction of 2% to 5%, and stroke of <2%. CONCLUSIONS: Combining formal protocols for PHL for some patients with direct transportation of others to a percutaneous coronary intervention hospital for primary percutaneous coronary intervention would allow for tailored reperfusion therapy for patients with ST-segment elevation myocardial infarction. Insights from a variety of international settings may promote widespread use of PHL and increase timely coronary reperfusion worldwide.

Impact of specialty of admitting physician and type of hospital on care and outcome for myocardial infarction in England and Wales during 2004-5: observational study.

OBJECTIVE: To examine process of care and outcome for patients admitted with acute myocardial infarction to hospitals in England and Wales in relation to type of consultant care and type of hospital. DESIGN: Observational study of 88,782 patients admitted with myocardial infarction during 2004-5, using records from the national audit of myocardial infarction project (MINAP) database. OUTCOME MEASURES: Use of reperfusion treatment and secondary prevention drugs, use of angiography, and 90 day mortality of patients admitted under the care of cardiologists and non-cardiologists in hospitals with and without facilities for coronary intervention. FINDINGS: 36% of patients were admitted under the care of a cardiologist and 20% to a hospital with coronary interventional facilities. Patients admitted under cardiologists had fewer comorbidities than other patients and were more likely to have reperfusion treatment (12,266/14,433 (85%) v 13,682/17,064 (80%)) and appropriate secondary prevention drugs. Overall, 27,431/79,374 (35%) of patients had angiography. Relatively more patients admitted to interventional hospitals (8167/14,661; 56%) than to other hospitals had angiography (19,264/64,713; 30%). The adjusted risk of death by 90 days for patients treated in interventional compared with non-interventional hospitals was 0.93 (95% confidence interval 0.82 to 1.06). The adjusted risk of death at 90 days for patients admitted under cardiologists compared with non-cardiologists was 0.86 (0.81 to 0.91). CONCLUSIONS: Patients cared for by cardiologists had less comorbidity than other patients. They were more likely to receive proved treatments and angiography, and they had a lower adjusted 90 day mortality. Large differences existed in the use of angiography between interventional and non-interventional hospitals. These findings show wide variations in the management and outcome of patients with myocardial infarction in England and Wales.

Developing a rapid access chest pain clinic: qualitative studies of patients' needs and experiences.

OBJECTIVE: The aims of this study are to understand the needs and experiences of rapid access chest pain clinic attenders and to determine the acceptability and effectiveness of simple procedural changes. METHODS: Two qualitative studies of clinic attenders before and after procedural changes which were guided by the first study. RESULTS: Study 1: Patients wanted to be reassured, by knowing what was causing their pain, understanding the cause, and feeling able to help themselves. Often, these needs were not met, and uncertainties left some patients feeling ill-equipped to help themselves. Communication problems were identified. Study 2: The changes were acceptable to patients, and almost all were reassured. Most valued receiving extra verbal and written advice and information. Many felt more aware of cardiac risk factors and intended to change their lifestyle. CONCLUSION: There were clear opportunities for improvements in care. Changes in procedures helped patients to understand their pain, to practice self-management, and to consider altering their lifestyle.

Impact of a region-wide approach to improving systems for heart attack care: the West Midlands thrombolysis project.

OBJECTIVE: To describe changes in delay to administration of thrombolytic therapy associated with a region-wide audit. DESIGN: Observational study of patients admitted with suspected myocardial infarction (MI) based on continuous audit. SUBJECTS: 18877 patients admitted to 23 hospitals with suspected MI between April 1995 and March 1998. RESULTS: Of 11232 patients with a discharge diagnosis of definite MI, 8802 (46.6%) received thrombolytic therapy during hospitalisation, with 5155 patients eligible for treatment on admission to hospital on the basis of established indications. Call-to-needle time for those eligible for treatment on admission fell from median 105 min in the first year of the project to 85 min in year 3 (P<0.001), and door-to-needle time fell from 45 to 35 min (P<0.001). Forty percent of eligible patients were treated within the then current national standard of 90 min from time of call for help, with nearly 49% in the final year and 20% being treated within the new national standard of 60 min, by the third year. CONCLUSION: The proportion of eligible patients receiving thrombolysis within 1 h of the call for help doubled during the 3-year project but the majority of patients still wait longer than 60-min 'call-to-needle'. New systems to reduce delays to administration of thrombolysis to within 60 min of call for help are required, including consideration of pre-hospital treatment.