Real-world outcome from ST elevation myocardial infarction in the very elderly before and after the introduction of a 24/7 primary percutaneous coronary intervention service.

BACKGROUND: It remains unclear whether the superiority of primary percutaneous coronary intervention (PPCI) over thrombolysis for the treatment of ST elevation myocardial infarction (STEMI) extends to the very elderly. Furthermore, the deliverability and efficacy of PPCI in over the 80s has not been investigated in a real-world setting. The aim of this study was to compare outcome from STEMI in patients aged > or =80 before and after the introduction of routine 24/7 PPCI. METHODS: Retrospective observational analysis of all patients aged > or =80 presenting with STEMI to 2 neighboring hospitals in the 3-year period after the introduction of a 24/7 PPCI service and in the preceding 2 years when reperfusion therapy was by thrombolysis. RESULTS: Two hundred fifty-six STEMI patients aged > or =80 were included. After the introduction of PPCI, 84% (136/161) received reperfusion therapy, 73% PPCI, and 12% thrombolysis, compared to 77% ([73/95] 1% PPCI, 76% thrombolysis) previously. Mortality after inception of PPCI was reduced at 12 months (29% vs 41%, P = .04) and 3 years (43% vs 58%, P = .02). Improved outcome was attributable to treatment by PPCI, which was associated with numerically lower 12-month (26% vs 37%, P = .07) and significantly reduced 3-year (42% vs 55%, P = .05) mortality compared to thrombolysis. CONCLUSIONS: Primary PCI can be effectively delivered to very elderly patients presenting with ST elevation MI in a real-world setting and leads to a substantial reduction in mortality compared to patients treated by thrombolysis.

Primary angioplasty for heart attack: mismatch between expectations and reality?

AIM: This paper is a report of a study to explore patients' experiences of primary angioplasty and assess their illness perceptions during early recovery. BACKGROUND: Primary angioplasty is recognized as the gold standard treatment for patients with ST elevation myocardial infarction, yet little is known about patients' experiences of this treatment. Recent policy change has emphasized the need for clinical practice to be more patient-centred. One way to achieve this is to understand patients' experiences of treatment better. METHOD: A mixed methods exploratory study was carried out in 2006-2007 with a purposive sample of 29 patients. Data were collected 3-12 days after hospital discharge using (a) semi-structured interviews to explore participants' experiences and (b) The Illness Perception Questionnaire to evaluate illness perceptions. Interview data were analysed using the Framework approach. Questionnaire data were used to inform the qualitative findings. FINDINGS: Participants were very positive about their treatment but experienced considerable emotional shock, which was exacerbated by the speed with which events occurred. Patients' experiences were characterized by a mismatch between their expectations and reality. Questionnaire data supported the notion that they experienced difficulty in 'making sense' of their condition in a coherent way. They tended to see their condition as 'acute' rather than 'chronic' and their treatment as curative. CONCLUSION: Patient education should include focused discussions addressing the 'mismatches' that may occur between their expectations and reality. In this way, a more coherent understanding can be promoted, with greater awareness of heart disease as a long-term condition requiring ongoing self-management.

The information needs of patients treated with primary angioplasty for heart attack: an exploratory study.

OBJECTIVE: As early recovery is a challenging period for cardiac patients who frequently have 'unmet' health information needs, the objective of this study was to explore the information needs of patients treated with primary angioplasty for heart attack. METHODS: Qualitative methodology using semi-structured interviews with 29 patients recruited from a specialist English Cardiology centre, 3-12 days after discharge from hospital. Framework analysis techniques were used to synthesise findings. RESULTS: Participants were generally satisfied with the way in which health information was provided. The need for more specific information about the risk of recurrence, the level of heart muscle damage, discharge medications, appropriate levels of physical activity and diet was highlighted. There was no clear preference for informant and preferences for the timing of information delivery varied considerably. CONCLUSION: Health information provision was satisfactory for most but could be improved by the closer matching of patients' preferences with provision. The shortened hospital stay, rapid throughput and emotional shock experienced by patients influenced their ability to absorb information making the optimum timing for health information delivery variable. PRACTICE IMPLICATIONS: Current guidelines about the provision of health information for patients recovering from heart attack may need to be reviewed to reflect the recent technological advances in treatment. One approach may be to better 'stage' information to reflect patients' priorities. Home visits by specialist nurses may need to be scheduled earlier to improve continuity of care and address information 'gaps'.

Direct ambulance admission to the cardiac catheterization laboratory significantly reduces door-to-balloon times in primary percutaneous coronary intervention.

BACKGROUND: Primary percutaneous coronary intervention (PCI) is the preferred treatment for ST-segment elevation myocardial infarction (STEMI) provided it can be delivered within 90 minutes of hospital admission. In clinical practice this target is difficult to achieve. We aimed to determine the effect of direct ambulance admission to the cardiac catheterization laboratory on door-to-balloon and call-to-balloon times in primary PCI. METHODS: We performed a prospective evaluation of a new system of paramedic electrocardiogram diagnosis of STEMI and subsequent direct ambulance admission to the cardiac catheterization laboratory for primary PCI. Door-to-balloon and call-to-balloon times were recorded for all patients. Direct admissions were compared with admissions via the emergency room of the interventional center and of 2 referring hospitals. All times are quoted as medians. RESULTS: Five hundred and seventy-seven patients (70% male, age 63 +/- 13 years) underwent primary PCI between April 2005 and May 2007. After February 2006, 172 (44%) of 387 patients were admitted directly from the ambulance to the catheterization laboratory. Directly admitted patients had significantly reduced door-to-balloon (58 vs 105 minutes, P < .001) and call-to-balloon times (105 vs 143 minutes, P < .001). The 90-minute target for door-to-balloon time was achieved in 94% of direct admissions compared to 29% of patients referred from the emergency room. CONCLUSIONS: Direct admission of patients with suspected STEMI from the ambulance service to the catheterization laboratory significantly reduces time to treatment in primary PCI and allows the 90-minute door-to-balloon time target to be reliably achieved.