Predictors of transportation delay in patients with suspected ST-elevation-myocardial infarction in the VIENNA-STEMI network.

OBJECTIVE: The emergency medical service (EMS) provides rapid pre-hospital diagnosis and transportation in ST-elevation myocardial infarction (STEMI) systems of care. Aim of the study was to assess temporal and regional characteristics of EMS-related delays in a metropolitan STEMI network. METHODS: Patient call-to-arrival of EMS at site (call-to-site), transportation time from site to hospital (site-to-door), call-to-door, patient's location, month, weekday, and hour of EMS activation were recorded in 4751 patients referred to a tertiary center with suspicion of STEMI. RESULTS: Median call-to-site, site-to-door, and call-to-door times were 9 (7-12), 39 (31-48), and 49 (41-59) minutes, respectively. The shortest transportation times were noted between 08:00 and 16:00 and in general on Sundays. They were significantly prolonged between midnight and 04:00, whereby the longest difference did not exceed 4 min in median. Patient's site of call had a major impact on transportation times, which were shorter in Central and Western districts as compared to Southern and Eastern districts of Vienna (p < 0.001 between-group difference for call-to-site, site-to-door, and call-to-door). After multivariable adjustment, patient's site of call was an independent predictor of call-to-site delay (p < 0.001). Moreover, age and hour of EMS activation were the strongest predictors of call-to-site, site-to-door, and call-to-door delays (p < 0.05). CONCLUSION: In our Viennese STEMI network, the strongest determinants of pre-hospital EMS-related transportation delays were patient's site of call, patient's age, and hour of EMS activation. Due to the significant but small median time delays, which are within the guideline-recommended time intervals, no impact on clinical outcome can be expected.

Impact of age on short- and long-term mortality of patients with ST-elevation myocardial infarction in the VIENNA STEMI network.

BACKGROUND AND AIM: Our senescent society includes a growing number of elderly people suffering from ST-elevation myocardial infarction (STEMI); however, exactly this population is often underrepresented in randomized trials. Hence, our aim was to investigate the influence of age on patient characteristics, as well as short- and long-term outcome in the Vienna STEMI registry. METHODS: We included all patients of the Vienna STEMI registry (2003-2009). Patients were stratified into age cohorts (≤45, 46-59, 60-79 and ≥80 years, respectively). Differences between cohorts were investigated by descriptive statistics and regression models. Crude and adjusted mortality rates were investigated using log rank test and Cox regression models, respectively. The influence of treatment on mortality was further investigated using propensity score matching. RESULTS: A total of 4579 patients fulfilled the criteria for further investigation. With rising age of cohorts, the number of females, diabetes mellitus (DM), hypertension (HTN), previous myocardial infarction (MI), shock, no reperfusion therapy and anterior wall infarction significantly increased. In contrast, the number of patients with a positive family history, smoking and hyperlipidemia (HLP) significantly declined. Log rank analysis showed significant differences between age cohorts for short- and long-term mortality. Cox regression analysis for short-term mortality revealed an independent association for age at the event, HTN and shock, while age, smoking, DM, HTN, HLP, previous MI and shock independently influenced long-term mortality after correction for confounders. Also, we found a significant association of age and total ischemic time (TIT), which however had no influence on long-term mortality (interaction term p = 0.236). Propensity score matching revealed reduced mortality rates for patients who received reperfusion therapy compared to conservative management, irrespective of age. CONCLUSIONS: Increasing age independently influenced short- and long-term mortality in patients with STEMI in the Vienna STEMI network. The TIT significantly increased with baseline age, but had no impact on mortality. Furthermore, reperfusion therapy exerted beneficial effects irrespective of the patients' age.

Impact of time of admission on short- and long-term mortality in the Vienna STEMI registry.

BACKGROUND: Several studies have shown contradictive findings regarding mortality and hospital admission time in patients presenting with ST-elevation myocardial infarction (STEMI). The aim of this study was to assess the impact of "on-" or "off-hour" admission on short- and long-term all-cause mortality of patients in the advanced Vienna STEMI network between 2003 and 2009. METHODS AND RESULTS: In total, 2829 patients were included into this analysis. Patients were stratified according to admission time into "on-hour" admission (07:30 until 15:00h on weekdays) and "off-hour" admission (15:00-7:30h on weekdays and 24h on weekends). As endpoint of interest, all-cause mortality was investigated after 30days and 3years of follow-up, the latter for all patients and as Landmark analysis for survivors of the index event. Mean age was 60.5±13.3years, 2048 (72.4%) patients were male and 1260 (44.5%) patients presented with anterior wall infarction. 683 (24.1%) patients were admitted "on-hours", 2146 (75.9%) patients were admitted "off-hours". All-cause death occurred in 176 (6.2%) patients after a follow-up of 30days and in 337 (11.9%) patients after 3years. For short- and long-term all-cause mortality no significant differences could be detected between "on-" and "off-hour" admission in univariate and multivariate Cox proportional hazard analyses as well as for propensity score adjusted outcome analysis. CONCLUSION: In the Vienna STEMI network, "on-" or "off-hour" admission had no impact on short- and long-term mortality for all-comers presenting with acute STEMI. Our findings confirm the imperative need for well-structured STEMI networks of care, as previous data repeatedly demonstrated increased adverse cardiovascular outcome for "off-hour" admission.

Gender differences in short- and long-term mortality in the Vienna STEMI registry.

BACKGROUND: Data obtained from registries have shown that women diagnosed with STEMI are older, have more co-morbidities and a worse clinical outcome than men. Aim of this study was to investigate potential gender differences in in-hospital and long-term mortality in patients from Vienna STEMI registry (2003-2009). PATIENTS AND METHODS: Data from 4593 patients who were enrolled from January 2003 until December 2009 into the Vienna STEMI registry were analyzed. Gender-related differences in patient characteristics, time delays, reperfusion therapy, as well as short- and long-term all-cause mortality were investigated. A landmark analysis was performed to assess long-term all-cause mortality in patients after discharge. Multivariate regression analysis was performed in order to correct for confounders. RESULTS: Mean age, history of hypertension, diabetes mellitus and shock at presentation were significantly higher in women compared to men, whereas men were more frequently smokers, had more frequently a positive family history, a history of previous myocardial infarction and received more often GbIIb/IIIa inhibitors and reperfusion therapy. Overall the only significant difference in time delays was found in the onset of pain-to first medical contact time, which was significantly prolonged in women. Unadjusted in-hospital mortality, long-term mortality and long-term mortality for in-hospital survivors were statistically higher for women. After adjustment for confounders, multivariate analysis revealed no differences in mortalities between males and females. CONCLUSION: The higher risk profile and the prolonged delay between onset of pain-to-first medical contact are responsible for the higher unadjusted mortality rates in women. Difference in short and long-term mortalities is no more existent after statistical correction for confounders such as age, co-morbidities and significantly different time delay.

Clinical predictors of patient related delay in the VIENNA ST-elevation myocardial infarction network and impact on long-term mortality.

BACKGROUND: While contributors to system delay in ST-elevation myocardial infarction (STEMI) are well described, predictors of patient-related delays are less clear. The aim of this study was to identify predictors that cause delayed diagnosis of STEMI in a metropolitan system of care (VIENNA STEMI network) and to investigate a possible association with long-term mortality. METHODS: The study population investigated consisted of 2366 patients treated for acute STEMI in the Vienna STEMI registry from 2003-2009. Multivariable regression modelling was performed for (a) onset of pain to first medical contact (FMC) as a categorical variable (pain-to-FMC⩽60 min versus >60 min: 'early presenters' versus 'late presenters'); and for (b) onset of pain-to-FMC (min) as a continuous variable. RESULTS: After multivariable adjustment, female sex (odds ratio (OR) 1.348; 95% confidence interval (CI) 1.013-1.792; p=0.04) and diabetes mellitus (OR 1.355; 95% CI 1.001-1.835; p=0.05) were independently associated with late presentation in STEMI patients, whereas cardiogenic shock (OR 0.582; 95% CI 0.368-0.921; p=0.021) was a predictor of early diagnosis. When onset of pain-to-FMC was treated as a continuous variable, female sex ( p=0.003), anterior infarction ( p=0.004) and diabetes mellitus ( p=0.035) were independently associated with longer delay, while hyperlipidaemia ( p=0.002) and cardiogenic shock ( p=0.017) were strong predictors of short pain-to-FMC times. Three-year-all cause mortality was 9.6% and 11.3% ( p=0.289) for early and late presenters, respectively. After adjustment for clinical factors (sex, age, diabetes, current smoking, hypertension, hyperlipidaemia, cardiogenic shock and location of myocardial infarction) only a trend for increased risk of all-cause death was observed for longer pain-to-FMC times in a cox regression model (hazard ratio (HR) 1.012; 95% CI 0.999-1.025 for every 10 min of delay; p=0.061). Interestingly, early presentation within one hour of symptom onset was not associated with three-year mortality survival (HR 1.031; 95% CI 0.676-1.573; p=0.886). CONCLUSION: In this all-comers study of STEMI patients in the VIENNA STEMI network, cardiogenic shock was the strongest predictor of short patient-related delays, whereas a history of diabetes and female sex were independent associated with late diagnosis in STEMI. After adjustment for clinical confounders, patient related delay did not significantly impact on long-term all-cause mortality.

One-year mortality in patients with acute ST-elevation myocardial infarction in the Vienna STEMI registry.

BACKGROUND AND AIM: Systems of care to treat acute ST-elevation myocardial infarction (STEMI) have been developed world wide in the past decade. Their effectiveness can only be proven by including and analyzing outcome data of consecutive patients in registries, which is not the case in the majority of STEMI networks. This study investigates 1-year mortality in STEMI patients in Vienna included over a 14 months time interval. The Vienna STEMI network is organized by a specific rotational system and offers both, primary percutaneous intervention (PPCI) and thrombolytic therapy (TT) as reperfusion strategies according to the recent guidelines. METHODS: At the time of investigation, the Vienna STEMI network consisted of the Viennese Ambulance Systems and five high-volume interventional cardiology departments. This network has been organized in order to increase the number of STEMI patients admitted for PPCI and to offer the fastest available reperfusion strategy, in the majority PPCI but in selected patients also TT (STEMI of short duration, mainly anterior wall MI and mainly patients younger than 75 years), followed by rescue PCI in non-responders and elective angiography with/without PCI in responders to TT during the index hospital stay. RESULTS: One-year all-cause mortality rates in the Vienna STEMI network by use of the fastest available reperfusion strategy were 13.4% in patients who received reperfusion therapy after 2 h of symptom onset and 7.4% in patients treated within 2 h; (p = 0.017). Whereas PPCI and TT demonstrated a nonsignificant difference in 1-year mortality rates when initiated within 2 h of symptom onset (10.0% vs 5.7%; p = 0.59), PPCI was more effective in acute STEMI of > 2 h duration as compared to TT but this difference did not reach statistical significance (12.1% vs 18.2%; p = 0.07). CONCLUSIONS: The reassuring long-term results of the Viennese STEMI network are another example of a specific regional system of care to offer timely diagnosis, transfer and reperfusion in patients with STEMI. In contrast to other metropolitan areas where TT has almost completely abandoned, we still use pharmacological reperfusion as a backup in case of expected and unacceptable time delays for PPCI in order to reduce myocardial damage especially in patients with larger infarctions of short duration with a low risk of bleeding complications.

Out of hospital cardiac arrest in Vienna: incidence and outcome.

AIM OF THE STUDY: To determine the incidence of out-of-hospital cardiac arrest and the survival rate of those patients who received CPR in the city of Vienna. METHODS: A cohort of patients with out-of-hospital cardiac arrests and who were treated by the Vienna Ambulance Service between January 1, 2009, and December 31, 2010, were followed up until either death or hospital discharge. The associations of survival and neurological outcome with their potential predictors were analysed using simple logistic regression models. Odds ratios were estimated for each factor. RESULTS: During the observation period, a total of 7030 (206.8/100,000 inhabitants/year) patients without signs of circulation were assessed by teams of the Vienna Ambulance Service, and 1448 adult patients were resuscitated by emergency medical service personnel. A sustained return of spontaneous circulation was reported in 361 (24.9%) of the treated patients, and in all 479 (33.0%) of the patients were taken to the emergency department. A total of 164 (11.3%) of the patients were discharged from the hospital alive, and 126 (8.7%) of the patients showed cerebral performance categories of 1 or 2 at the time of discharge. Younger age, an arrest in a public area, a witnessed arrest and a shockable rhythm were associated with a higher probability of survival to hospital discharge. CONCLUSION: Survival rates for out-of-hospital cardiac arrests remain low. Efforts should be focused on rapidly initiating basic life support, early defibrillation, and high-quality CPR by emergency medical services and state-of-the art post-resuscitation care.

Randomized placebo controlled trial of furosemide on subjective perception of dyspnoea in patients with pulmonary oedema because of hypertensive crisis.

BACKGROUND: To compare the administration of furosemide with placebo on the subjective perception of dyspnoea in patients with acute pulmonary oedema because of hypertensive crisis. Design Randomized, controlled and double-blinded clinical trial. SETTING: Municipal emergency medical service system and university-based emergency department. PARTICIPANTS: Fifty-nine patients with pulmonary oedema because of hypertensive crisis. INTERVENTIONS: Additional to administration of oxygen, morphine-hydrochloride and urapidil until the systolic blood pressure was below 160mmHg, the patients were randomized to receive furosemide 80mg IV bolus (furosemide group) or saline placebo (placebo group). MAIN OUTCOME MEASURES: The primary outcome was the subjective perception of dyspnoea as measured with a modified BORG scale at one hour after randomization. Secondary outcome parameters were the subjective perception of dyspnoea of patients as measured with a modified BORG scale and a visual analogue scale at 2, 3 and 6h after randomization of the patient; course of the systolic arterial pressure and peripheral oxygen saturation and lactate at admission and at 6h after admission. RESULTS: In 25 patients in the furosemide group and in 28 patients in the placebo group, a BORG score could be obtained. There was no statistically significant difference in the severity of dyspnoea at one hour after randomization (P=0·40). The median BORG score at 1h after randomization in the furosemide group was 3 (IQR 2 to 4) compared to 3 (IQR 2 to 7) in the placebo group (P=0·40). Those patients who were randomized to the placebo group needed higher doses of urapidil at 20min after randomization. There were no significant differences in the rate of adverse events, nonfatal cardiac arrests or death between the two groups. CONCLUSIONS: The subjective perception of dyspnoea in patients with hypertensive pulmonary oedema was not influenced by the application of a loop-diuretic. Therefore, additional furosemide therapy needs to be scrutinized in the therapy of these patients.

Cardiac arrest in public locations--an independent predictor for better outcome?

OBJECTIVE: Outcome after cardiac arrest is known to be influenced by immediate access to resuscitation. We aimed to analyse the location of arrest in relation to the prognostic value for outcome. DESIGN: Retrospective review from prospective databases (ambulance routine documentation database and emergency department database on patients treated for cardiac arrest). SETTING: Vienna (1.7 million inhabitants) ambulance service and tertiary care facility (university clinics). PATIENTS: Two independent cohorts: (1) a population-based cohort of patients who were treated for cardiac arrest by the municipal ambulance service outside the hospital. The endpoint in this group was survival to hospital admission with spontaneous circulation. (2) A cohort of patients who were admitted to the emergency department after successful out of hospital resuscitation. The endpoint in this group was survival to 6 months with good neurological status (best Cerebral Performance Category 1 or 2 within 6 months). MEASUREMENTS: We analysed whether the location of non-traumatic adult out-of-hospital cardiac arrest (public versus private place) was a predictor for good outcome. RESULTS: PATIENTS who had cardiac arrest in a public location were more likely to arrive in hospital alive (39% versus 31%, crude OR 1.4, 95% CI 1.001-1.975, p=0.049) and were more likely to have a good neurological outcome after 6 months (35% versus 25%, crude OR 1.65, adjusted OR 1.59, 95% CI 1.07-2.36, p=0.023), compared to patients who had cardiac arrest in a non-public location. CONCLUSION: Cardiac arrest in a public location is independently associated with a better outcome.

Implementation of guidelines improves the standard of care: the Viennese registry on reperfusion strategies in ST-elevation myocardial infarction (Vienna STEMI registry).

BACKGROUND: The purpose of this study was to determine whether implementation of recent guidelines improves in-hospital mortality from acute ST-elevation myocardial infarction (STEMI) in a metropolitan area. METHODS AND RESULTS: We organized a network that consisted of the Viennese Ambulance Systems, which is responsible for diagnosis and triage of patients with acute STEMI, and 5 high-volume interventional cardiology departments to expand the performance of primary percutaneous catheter intervention (PPCI) and to use the fastest available reperfusion strategy in STEMI of short duration (2 to 3 hours from onset of symptoms), either PPCI or thrombolytic therapy (TT; prehospital or in-hospital), respectively. Implementation of guidelines resulted in increased numbers of patients receiving 1 of the 2 reperfusion strategies (from 66% to 86.6%). Accordingly, the proportion of patients not receiving reperfusion therapy dropped from 34% to 13.4%, respectively. PPCI usage increased from 16% to almost 60%, whereas the use of TT decreased from 50.5% to 26.7% in the participating centers. As a consequence, in-hospital mortality decreased from 16% before establishment of the network to 9.5%, including patients not receiving reperfusion therapy. Whereas PPCI and TT demonstrated comparable in-hospital mortality rates when initiated within 2 to 3 hours from onset of symptoms, PPCI was more effective in acute STEMI of >3 but <12 hours' duration. CONCLUSIONS: Implementation of recent guidelines for the treatment of acute STEMI by the organization of a cooperating network within a large metropolitan area was associated with a significant improvement in clinical outcomes.

Increased occurrence of out-of-hospital cardiac arrest on Mondays in a community-based study.

Acute myocardial infarction and sudden cardiac death are more common on Mondays than other days of the week. The stress of returning to work at the beginning of the week has been postulated as a possible trigger factor. This project examined the weekly variation of out-of-hospital cardiac arrests of nontraumatic origin for the entire case series as well as for selected subgroups. A retrospective analysis of 1,498 incidences between January 1, 1995 and December 31, 1996 revealed a distinct Monday peak in occurrence irrespective of age, gender, presence of witnesses, primary survival, or primary ECG. This finding, however, was most pronounced in retired patients, subjects living alone, and persons found unconscious outside buildings or in public places. One important trigger of cardiac arrest is going to work after weekends; however, resumption of social and other activities on Mondays is another possible trigger. Other factors, such as endogenous biological rhythms, may contribute to an increased risk at this particular time even in elderly.

[First aid measures by bystanders at the place of accident. A prospective, epidemiologic study in the Vienna area]. / Massnahmen durch Ersthelfer am Unfallort. Eine prospektive, epidemiologische Studie im Raum Wien.

The object of this prospective, epidemiological study was to determine whether bystanders provided necessary first aid measures in the prehospital trauma setting, whether they performed these measures correctly, and whether the level of first aid training affected the quality of first aid measures performed. Data were collected by means of a questionnaire, which was filled out between March and July 2000 for all cases attended to by the Vienna Ambulance Service. A total of 2812 cases were documented. The most frequent causes of trauma were falls from heights less than 1 meter (50%) and traffic accidents (17%). The most frequent injuries were injuries to the extremities (59%) and head and traumatic brain injuries (42%). Most patients were "moderately" or "severely" injured (69% and 29%, respectively), but life-threatening injuries were rare (2%). Bystanders were present in 57% of the cases. The most frequently required first aid measures were "application of a dressing" and "positioning" of the patient. "Control of haemorrhage", "ensuring accident site safety" and "extrication" of the patient were less frequently required. "Clearing of the airway", "precautions against hypothermia" and cardio-pulmonary resuscitation were very rarely required. Bystanders were most frequently policemen, relatives or friends of the patient, and strangers. The vast majority of bystanders had no training in first aid or had only attended the first aid course required to attain a driving license. We found a clear relationship between the level of first aid training and the quality of first aid measures provided. It would be advisable to offer an increased amount of refresher courses in first aid to improve bystander trauma care.