RESUMO
BACKGROUND: Reducing the door-to-balloon time (D2BT) in ST-elevation myocardial infarction (STEMI) patients maximizes myocardial salvage and mitigates morbidity/mortality. AIMS: To assess the D2BT in STEMI patients requiring inter-hospital transfer for revascularization and identify any potential causes of delay. METHODS: Consecutive patients presenting to the Connolly Hospital Blanchardstown (CHB) emergency department (ED) who were transferred to the Mater Misericordiae University Hospital in Dublin for primary percutaneous coronary intervention from January 2018 to October 2022 were identified in a regional database and their D2BTs calculated. D2BTs were further sub-categorized into key intervals to identify any potential causes of delay. RESULTS: A total of 90 patients were included for analysis, with a median D2BT of 117.5 min (interquartile range [IQR]: 99.3-170.8 min) and 52.5% of patients achieving the ≤ 120 min target. Despite being the shortest interval considered, the time from arrival at the CHB ED to diagnostic electrocardiogram (ECG) was a substantial contributor to the overall delay to revascularization given its wide variability (median: 18.0 min; IQR: 9.0-46.8 min), with only 28.8% of patients achieving the ≤ 10 min target. CONCLUSIONS: Nearly half of the patients studied failed to achieve the overall target D2BT for revascularization. The time from arrival at the CHB ED to diagnostic ECG was identified as a substantial contributor to this failure, with a median time almost twice that of the target and a quarter of all patients spending longer than 46.8 min. These findings highlight a need to improve the implementation of ECG triage and interpretation in the ED.
RESUMO
PURPOSE OF REVIEW: Dual antiplatelet therapy (DAPT)-aspirin in conjunction with a P2Y12 inhibitor-is the cornerstone of managing patients with acute coronary syndromes post-revascularization, but the clinical response is highly variable, with potentially devastating consequences. Herein, we review the mechanisms underpinning said variability and explore emerging approaches to normalizing therapeutic benefit. RECENT FINDINGS: The potent P2Y12 inhibitors, prasugrel and ticagrelor, exhibit minimal inter-individual variability, replacing clopidogrel in DAPT and achieving greater rates of therapeutic response. However, these benefits decline in later phases when bleeding risk begins to supersede that of ischemia. Guided de-escalation of P2Y12 inhibition as well as shortening DAPT duration have emerged as strategies that retain antithrombotic efficacy while reducing bleeding risk. Aspirin is the other component of DAPT but is also used in isolation for secondary prevention of thrombotic disease. In contrast to the P2Y12 inhibitors, genetic influences on aspirin non-response appear to be outweighed by a triad of clinical factors: non-adherence, enteric aspirin use, and inappropriate dosing according to bodyweight and BMI. Multiple de-escalation strategies for DAPT have been shown to mitigate bleeding risk, but it remains unclear which approach is ideal, necessitating head-to-head investigations to determine which exhibits the most favorable cost-to-benefit ratio. However, there is likely a role for more than one approach in clinical practice, depending on patient risk profile. Our approach to aspirin use is also in need of reassessment: strategies to improve adherence, avoidance of enteric aspirin in cardiac patients, and dose adjustment according to bodyweight and/or BMI are all likely to improve rates of therapeutic response. Moreover, platelet function testing may have a role in identifying patients expected to benefit from primary prophylactic aspirin.
