Patient delay in patients with ST-elevation myocardial infarction: Time patterns and predictors for a prolonged delay.

BACKGROUND AND AIMS: To improve treatment success of ST-elevation myocardial infarction, a minimal delay from symptom onset to reperfusion therapy is crucial. The patient's response to initial symptoms (patient delay) substantially affects the delay. We investigated time patterns of patient delay during a seven-year time period, and aimed to identify key predictors that affect the length of the patient delay. METHODS: Data on 5848 patients hospitalized with ST-elevation myocardial infarction and treated with primary percutaneous intervention during the period 2003-2009 were obtained from Danish registry databases. The dependent variable was patient delay (<120 and ⩾120 min). Data were analysed for a possible time trend during the seven-year study period using Jonckheere-Terpstra analysis and we also performed multiple logistical regression to identify predictors of a prolonged patient delay. RESULTS: We observed a decrease in median patient delay from 101 min in 2003 to 85 min in 2009, p=0.018. We identified the age group 55-69 years (odds ratio (OR): 1.27 (95% confidence interval (CI): 1.09-1.47)) and age ⩾70 years (OR: 1.63 (95% CI: 1.40-1.90)), diabetes (OR: 1.26 (95% CI: 1.05-1.50)), female gender (OR: 1.17 (95% CI: 1.03-1.34)) and presentation during the night 22:00-05:59 (OR: 1.92 (95% CI: 1.68-2.20)), as independent risk factors of a patient delay ⩾120 min. Symptom onset between 14:00-21:59 was associated with a shorter patient delay (OR: 0.78 (95% CI 0.68-0.89)). CONCLUSION: A slight decrease in patient delay during the years from 2003-2009 was observed. High age, diabetes, female gender and symptoms presentation during the night were shown to be independent predictors of prolonged patient delay.

Comparative care and outcomes for acute coronary syndromes in Central and Eastern European Transitional countries: A review of the literature.

AIMS: The purpose of this review was to compare quality of care and outcomes following acute coronary syndrome (ACS) in Central and Eastern European Transitional (CEET) countries. METHODS: This was a review of original ACS articles in CEET countries from PubMed, ISI Web of Science, Medline and Embase databases published in English from November 2003 to February 2014. RESULTS: Seventeen manuscripts fulfilled the search criteria. Of 19 CEET countries studied, there were no published ACS management or outcome data for four countries. In-hospital mortality for patients with acute myocardial infarction (AMI) ranged from 6.3% in the Czech Republic to 15.3% in Latvia. In-hospital mortality for ST-elevation myocardial infarction (STEMI) ranged from 3.0% in Poland to 20.7% in Romania. For STEMI, primary percutaneous coronary intervention (PCI) ranged from 1.0% to over 92.0%, fibrinolytic therapy from 0.0% to 49.6%, and no reperfusion therapy from 7.0% to 63.0%. CONCLUSION: Many CEET countries do not have published ACS care and outcomes data. Of those that do, there is evidence for substantial geographical variation in early mortality. Wide variation in emergency reperfusion strategies for STEMI suggests that acute cardiac care is likely to be modifiable and if addressed could reduce mortality from ACS in CEET countries. The collection of ACS care and outcomes data across Europe must be prioritised.

Reperfusion therapy for ST elevation acute myocardial infarction 2010/2011: current status in 37 ESC countries.

AIMS: Primary percutaneous coronary intervention (PPCI) is the preferred reperfusion therapy in ST-elevation myocardial infarction (STEMI). We conducted this study to evaluate the contemporary status on the use and type of reperfusion therapy in patients admitted with STEMI in the European Society of Cardiology (ESC) member countries. METHODS AND RESULTS: A cross-sectional descriptive study based on aggregated country-level data on the use of reperfusion therapy in patients admitted with STEMI during 2010 or 2011. Thirty-seven ESC countries were able to provide data from existing national or regional registries. In countries where no such registries exist, data were based on best expert estimates. Data were collected on the use of STEMI reperfusion treatment and mortality, the numbers of cardiologists, and the availability of PPCI facilities in each country. Our survey provides a brief data summary of the degree of variation in reperfusion therapy across Europe. The number of PPCI procedures varied between countries, ranging from 23 to 884 per million inhabitants. Primary percutaneous coronary intervention and thrombolysis were the dominant reperfusion strategy in 33 and 4 countries, respectively. The mean population served by a single PPCI centre with a 24-h service 7 days a week ranged from 31 300 inhabitants per centre to 6 533 000 inhabitants per centre. Twenty-seven of the total 37 countries participated in a former survey from 2007, and major increases in PPCI utilization were observed in 13 of these countries. CONCLUSION: Large variations in reperfusion treatment are still present across Europe. Countries in Eastern and Southern Europe reported that a substantial number of STEMI patients are not receiving any reperfusion therapy. Implementation of the best reperfusion therapy as recommended in the guidelines should be encouraged.

Persistent geographical disparities in the use of primary percutaneous coronary intervention in 120 European regions: exploring the variation.

AIMS: Large inequalities in the use of primary percutaneous interventions (PPCI) for ST-elevation myocardial infarction (STEMI) are evident. In order to understand how we can help to implement best practice for STEMI patients, we investigated the variation in PPCI utilisation in 120 regions in 10 EU countries and the association with economic, organisational and demographic characteristics. METHODS AND RESULTS: We performed an ecological study using mixed effects regression models in the following 10 countries: Austria, Belgium, Denmark, England and Wales, Germany, Italy, Portugal, Spain, Sweden, and Northern Ireland. The main finding was the annual number of PPCI per million inhabitants from 2003 through 2008. Overall, the annual increase in PPCI utilisation was 1.15 (95% CI: 1.12, 1.19) per million per year. Regional-level rates varied from 0.74 (95% CI: 0.42, 1.30) to 1.90 (95 % CI: 1.01, 3.55) per million per year. At a regional level, significant positive associations with PPCI utilisation were the number of physicians per 100,000 inhabitants; the number of nurses and midwives per 100,000 inhabitants; and the proportion of the region's population aged 50 to <70 years. At a country level, significant positive associations with utilisation were the year of STEMI treatment, population density per km2; number of general hospital beds per 100,000 inhabitants; and the number of physicians per 100,000 inhabitants. CONCLUSIONS: Between 2003 and 2008, PPCI utilisation increased significantly in the ten European countries studied, but there was a great variation within country regions. Regional variation in PPCI rates were associated with both demographic and supply factors, revealing substantial opportunities to improve PPCI utilisation across Europe at national and regional levels.

Variable penetration of primary angioplasty in Europe--what determines the implementation rate?

Primary percutaneous coronary intervention (PPCI) is the recommended treatment for patients with acute ST-segment elevation myocardial infarction (STEMI). A survey conducted in 2008 in the European Society of Cardiology (ESC) countries reported that the annual incidence of hospital admissions for acute STEMI is around 800 patients per million inhabitants. The survey also showed that STEMI patients' access to reperfusion therapy and the use of PPCI or thrombolytic therapy (TT) vary considerably among countries. Northern, Western and Central Europe already had well-developed PPCI services, offering PPCI to 60-90% of all STEMI patients. Southern Europe and the Balkans were still predominantly using TT and had a higher proportion of patients who were left without any reperfusion treatment. The survey concluded that a nationwide PPCI strategy results in more patients being offered reperfusion therapy. To address the inequalities in STEMI patients' access to life-saving PPCI and to support the implementation of the ESC STEMI treatment guidelines in Europe, the Stent for Life (SFL) Initiative was launched jointly by the European Association of Percutaneous Cardiovascular Interventions (EAPCI) and EuroPCR in 2008. The aim of the SFL Initiative is to improve the delivery of life-saving PPCI for STEMI patients. Currently, 10 national cardiac societies support the SFL Initiative in their respective countries. SFL national action programmes have been developed and are being implemented in several countries. The formation of regional PPCI networks involving emergency medical services, non-PPCI hospitals and PPCI centres is considered to be a critical factor in implementing PPCI services effectively. Better monitoring of STEMI incidence and prospective registration of PPCI in all countries is required to document improvements in health care and to identify areas where further effort is required. Furthermore, studies on potential factors or characteristics that explain the national penetration of PPCI are needed. Such knowledge will be necessary to increase the effectiveness and efficiency of the implementation, and will be the first step in ensuring equal access to PPCI treatment for STEMI patients in Europe. Establishing the delivery of PPCI in an effective, high-quality and timely manner is a great challenge.

Status of Stent for Life Initiative across Europe.

Early revascularization with primary percutaneous coronary intervention (PPCI) in patients with ST-elevation myocardial infarction (STEMI) has been shown to reduce mortality, rates of nonfatal reinfarction and stroke, as compared to previous standard of care with thrombolytic therapy. Despite substantial evidence of its effectiveness, the use of PPCI varies considerably across Europe. The Stent for Life Initiative supports implementation of local STEMI treatment guidelines, helps to identify specific barriers to implementation of guidelines and defines actions to make sure that the majority of STEMI patients have access to PPCI. Launching a successful programme for PPCI requires the commitment and collaboration of a broad variety of members of the healthcare system. This narrative review is intended to describe some of the progress already seen in the 10 countries currently included in the Stent for Life Initiative and to report and discuss the engagement of the various stakeholders involved.