Patient and system delays in the treatment of acute coronary syndrome.

INTRODUCTION: Early reperfusion for patients with ST-segment elevation myocardial infarction (STEMI) is indicated by the European Society of Cardiology, while a timely invasive strategy is recommended for patients with high-risk and intermediate-risk non-ST-elevation acute coronary syndromes (NSTE-ACS). This study aims to assess patient and system delays according to diagnosis and risk profile, and to identify predictors of prolonged delay. METHODS: We assembled a cohort of patients (n=939) consecutively admitted to the cardiology department of two hospitals, one in the metropolitan area of Porto and one in the north-east region of Portugal, between August 2013 and December 2014. RESULTS: The proportion of patients with time from symptom onset to first medical contact (FMC) ≥120 min was highest among high-risk NSTE-ACS (57.7%), followed by intermediate-risk NSTE-ACS (52.1%) and STEMI (43.3%). Regardless of diagnosis and risk stratification, use of own transportation and inability to interpret cardiac symptoms correctly were associated with prolonged delays. Regarding system delays, we found that 78.0% of patients with STEMI and 65.8% of patients with high-risk NSTE-ACS were treated in a timeframe exceeding the recommended limits. Admission to a non-percutaneous coronary intervention-capable hospital, admission on weekends and complications at admission were associated with prolonged delays to treatment. CONCLUSIONS: Due to both patient and system delays, a large proportion of STEMI and high-risk NSTE-ACS patients still fail to have access to timely reperfusion.

Actualización del Código de Reperfusión Coronaria de Castilla-La Mancha (CORECAM). Medidas de actuación en Atención Primaria / Update of Code of Coronary Reperfusion of Castilla-La Mancha (CORECAM). Action measures in Primary Care

La cardiopatía isquémica es la causa más frecuente de muerte a nivel mundial. El infarto agudo de miocardio con elevación del segmento ST es una enfermedad tiempo-dependiente cuyo pronóstico se asocia, en gran medida, con el manejo óptimo inicial realizado en los Centros de Salud donde consultan un alto porcentaje de pacientes. Por ello, la labor del médico de familia es decisiva a la hora de tratar de forma inmediata y eficaz al paciente que acude con un infarto. Para mejorar la actuación entre el ámbito extrahospitalario y hospitalario, se creó un protocolo asistencial denominado Código de Reperfusión Coronaria de Castilla-La Mancha (CORECAM). Su objetivo es la atención urgente y coordinada que permita un acceso precoz a la estrategia de reperfusión, logrando disminuir la mortalidad y mejorar el pronóstico de los pacientes. En este artículo se realiza una revisión del código CORECAM con el propósito de resumir las medidas de actuación que deben ser llevadas a cabo en el abordaje de los pacientes con infarto agudo de miocardio en el ámbito de la Atención Primaria

Ischemic heart disease is the most common cause of death worldwide. Acute myocardial infarction with ST segment elevation is a time-dependent disease whose prognosis will depend, to a large extent, on the initial optimal management performed in health centers where a high percentage of patients seek medical care. Therefore, the work of the family doctor is decisive for an immediate and effective treatment of the patient who comes with a heart attack. In order to improve performance between out-of-hospital and hospital settings, a medical protocol called Code of Coronary Reperfusion of Castilla-La Mancha (CORECAM) was created. Its objective is to provide urgent and coordinated attention that allows early access to the reperfusion strategy, reducing mortality and improving prognosis. In this article, a revision of the CORECAM code is carried out with the purpose of summarizing the action measures that should be taken in the approach to patients with acute myocardial infarction in the field of Primary Care

Quality of Care and 30-day Mortality of Women and Men With Acute Myocardial Infarction.

INTRODUCTION AND OBJECTIVES: Despite increased awareness of sex disparities in care and outcomes of acute myocardial infarction (AMI), there appears to have been no consistent attenuation of these differences over the last decade. We investigated differences by sex in management and 30-day mortality using the European Society of Cardiology Acute Cardiovascular Care Association quality indicators (QIs) for AMI. METHODS: Proportions and standard errors of the 20 Acute Cardiovascular Care Association QIs were calculated for 771 patients with AMI who were admitted to the cardiology departments of 2 tertiary hospitals in Portugal between August 2013 and December 2014. The association between the composite QI and 30-day mortality was derived from logistic regression. RESULTS: Significantly fewer eligible women than men received timely reperfusion, were discharged on dual antiplatelet therapy and high-intensity statins, and were referred to cardiac rehabilitation. Women were less likely to receive recommended interventions (59.6% vs 65.2%; P <.001) and also had higher mean GRACE 2.0 risk score-adjusted 30-day mortality (3.0% vs 1.7%; P <.001). An inverse association between the composite QI and crude 30-day mortality was observed for both sexes (OR, 0.08; 95%CI, 0.01-0.64 for the highest performance tertile vs the lowest). CONCLUSIONS: Performance in AMI management is worse for women than men and is associated with higher 30-day mortality, which is also worse for women. Evidence-based QIs have the potential to improve health care delivery and patient prognosis in the overall AMI population and may also bridge the disparity gap between women and men.

Assessment of quality performance measures in patients with acute coronary syndromes: Data from the Portuguese Registry of Acute Coronary Syndromes (ProACS), a nationwide registry.

RATIONAL, AIMS, AND OBJECTIVES: Registries are a powerful tool to assess specific performance measurements and quality of care in acute coronary syndromes (ACSs). In Portugal, ProACS is a nationwide registry of ACS that has been active for the past 15 years, and our objective was to assess specific quality indicators for the treatment of ACS. METHODS: Descriptive analysis of data from ProACS registry in specific quality indicators previously defined by international scientific societies. RESULTS: A total of 45,141 patients were included since 2002, 43.5% with ST-segment elevation myocardial infarction. In ST-segment elevation myocardial infarction, reperfusion rates, particularly by primary angioplasty, have increased dramatically with 85% being submitted to any form of reperfusion presently. In-hospital time delays are, however, suboptimal, particularly in patients admitted first to hospitals without catheterization facilities. For non-ST elevation ACS, invasive strategy also showed important improvements, with more than 80% of patients being submitted to catheterization. Although there was also improvement in the use of guideline recommended medication, particularly statins, it is also suboptimal, requiring additional specific interventions. CONCLUSION: The quality of care of ACS improved dramatically in the last 15 years in Portugal, with major improvements in hospital mortality. It is, however, suboptimal in specific points that have been identified and that require additional measures.

Post-infarct cardiac injury, protection and repair: roles of non-cardiomyocyte multicellular and acellular components.

Following myocardial infarction (MI), cardiomyocytes and infarct size are the focus of our attention when evaluating the extent of cardiac injury, efficacy of therapies or success in repairing the damaged heart by stem cell therapy. Numerous interventions have been shown by pre-clinical studies to be effective in limiting infarct size, and yet clinical trials designed accordingly have yielded disappointing outcomes. The ultimate goal of cardiac protection is to limit the adverse cardiac remodeling. Accumulating studies have revealed that post-infarct remodeling can be attenuated without infarct size limitation. To reconcile this, one needs to appreciate the significance of various cellular and acellular myocardial components that, like cardiomyocytes, undergo significant damage and dysfunction, which impact the ultimate cardiac injury and remodelling. Microvascular injury following ischemia-reperfusion may influence infarct size and promote inflammation. Myocardial injury evokes innate immunity with massive inflammatory infiltration that, although essential for the healing process, exacerbates myocardial injury and damage to extracellular matrix leading to dilative remodeling. It is also important to consider the multiple non-cardiomyocyte components in evaluating therapeutic efficacy. Current research indicates the pivotal role of these components in achieving cardiac regeneration by cell therapy. This review summarizes findings in this field, highlights a broad consideration of therapeutic targets, and recommends cardiac remodeling as the ultimate target.

Temporal Trends of Reperfusion Strategies and Hospital Mortality for Patients With STEMI in Percutaneous Coronary Intervention-Capable Hospitals.

BACKGROUND: The aim of this study was to examine temporal trends and provincial variations in reperfusion strategies and in-hospital mortality among patients presenting with ST-segment elevation myocardial infarction (STEMI) at hospitals in Canada capable of performing percutaneous coronary intervention (PCI). METHODS: We included patients aged ≥ 20 years who were hospitalized between fiscal years 2009 and 2013 in all provinces except Quebec. We categorized patients as receiving fibrinolysis (lysis), primary PCI (pPCI), or no reperfusion. Patients undergoing lysis were further categorized as (1) lysis + PCI ≤ 90 minutes, (2) lysis + PCI > 90 minutes, and (3) lysis only. Patients undergoing pPCI were further categorized as (1) pPCI ≤ 90 minutes and (2) pPCI > 90 minutes. We used logistic regression to examine the baseline-adjusted association between reperfusion strategy and in-hospital mortality. RESULTS: Among 44,650 STEMI episodes in 44,373 patients, 66.3% received pPCI (annual increase of 7.8%; P < 0.001). British Columbia had the highest (81.4%) rates of pPCI and New Brunswick had the lowest rates (30.2%). In-hospital mortality ranged from a high of 16.3% among patients receiving no reperfusion to a low of 1.9% among patients receiving lysis + PCI > 90 minutes (adjusted odds ratio of 0.42; 95% confidence interval, 0.32-0.55 compared with pPCI ≤ 90 minutes). CONCLUSIONS: The use of pPCI in STEMI has increased significantly in Canada; however, significant interprovincial variation remains. Changes in reperfusion strategies do not appear to have had an impact on in-hospital mortality rates. Patients who underwent lysis followed by PCI in a systematic fashion had the lowest mortality.

Timely Reperfusion in Stroke and Myocardial Infarction Is Not Correlated: An Opportunity for Better Coordination of Acute Care.

BACKGROUND: Timely reperfusion is critical in acute ischemic stroke (AIS) and ST-segment-elevation myocardial infarction (STEMI). The degree to which hospital performance is correlated on emergent STEMI and AIS care is unknown. Primary objective of this study was to determine whether there was a positive correlation between hospital performance on door-to-balloon (D2B) time for STEMI and door-to-needle (DTN) time for AIS, with and without controlling for patient and hospital differences. METHODS AND RESULTS: Prospective study of all hospitals in both Get With The Guidelines-Stroke and Get With The Guidelines-Coronary Artery Disease from 2006 to 2009 and treating ≥10 patients. We compared hospital-level DTN time and D2B time using Spearman rank correlation coefficients and hierarchical linear regression modeling. There were 43 hospitals with 1976 AIS and 59 823 STEMI patients. Hospitals' DTN times for AIS did not correlate with D2B times for STEMI (ρ=-0.09; P=0.55). There was no correlation between hospitals' proportion of eligible patients treated within target time windows for AIS and STEMI (median DTN time <60 minutes: 21% [interquartile range, 11-30]; median D2B time <90 minutes: 68% [interquartile range, 62-79]; ρ=-0.14; P=0.36). The lack of correlation between hospitals' DTN and D2B times persisted after risk adjustment. We also correlated hospitals' DTN time and D2B time data from 2013 to 2014 using Get With The Guidelines (DTN time) and Hospital Compare (D2B time). From 2013 to 2014, hospitals' DTN time performance in Get With The Guidelines was not correlated with D2B time performance in Hospital Compare (n=546 hospitals). CONCLUSIONS: We found no correlation between hospitals' observed or risk-adjusted DTN and D2B times. Opportunities exist to improve hospitals' performance of time-critical care processes for AIS and STEMI in a coordinated approach.

Association of Rapid Care Process Implementation on Reperfusion Times Across Multiple ST-Segment-Elevation Myocardial Infarction Networks.

BACKGROUND: The Mission: Lifeline STEMI Systems Accelerator program, implemented in 16 US metropolitan regions, resulted in more patients receiving timely reperfusion. We assessed whether implementing key care processes was associated with system performance improvement. METHODS AND RESULTS: Hospitals (n=167 with 23 498 ST-segment-elevation myocardial infarction patients) were surveyed before (March 2012) and after (July 2014) program intervention. Data were merged with patient-level clinical data over the same period. For reperfusion, hospitals were grouped by whether a specific process of care was implemented, preexisting, or never implemented. Uptake of 4 key care processes increased after intervention: prehospital catheterization laboratory activation (62%-91%; P<0.001), single call transfer protocol from an outside facility (45%-70%; P<0.001), and emergency department bypass for emergency medical services direct presenters (48%-59%; P=0.002) and transfers (56%-79%; P=0.001). There were significant differences in median first medical contact-to-device times among groups implementing prehospital activation (88 minutes implementers versus 89 minutes preexisting versus 98 minutes nonimplementers; P<0.001 for comparisons). Similarly, patients treated at hospitals implementing single call transfer protocols had shorter median first medical contact-to-device times (112 versus 128 versus 152 minutes; P<0.001). Emergency department bypass was also associated with shorter median first medical contact-to-device times for emergency medical services direct presenters (84 versus 88 versus 94 minutes; P<0.001) and transfers (123 versus 127 versus 167 minutes; P<0.001). CONCLUSIONS: The Accelerator program increased uptake of key care processes, which were associated with improved system performance. These findings support efforts to implement regional ST-segment-elevation myocardial infarction networks focused on prehospital catheterization laboratory activation, single call transfer protocols, and emergency department bypass.

Effects of a change in entry-to-practice criteria for cardiovascular perfusion in Canada: results of a national survey.

INTRODUCTION: Years of experience and level of education are two important determinants of a clinician's expertise. While entry-to-practice criteria for admission to perfusion training in Canada changed from clinical experience-based criteria to education-based criteria in 2006, the effects of these changes have not been studied. OBJECTIVE: To determine the academic and clinical backgrounds of perfusionists in Canada, ascertain perceptions about the adequacy of training and evaluate the effects of the changes on the composition of the perfusion community of Canada. METHODS: An electronic questionnaire was distributed to all practicing perfusionists in Canada, addressing details regarding clinical experience, academic education and perceptions about the adequacy of training. RESULTS: Two hundred and twenty-eight questionnaires were completed, representing a 72% response rate. Perfusionists admitted under academic-based criteria have significantly higher levels of education (100% degree holders vs 69.1%, p<0.001), but less antecedent clinical training and experience (median, IQR: 0, 0 - 4.5 years vs 2, 2 - 8 years, p<0.0001), are younger (median age range 31-35 years vs 51-55 years, p<0.0001), more likely to be female (58.7% vs 41.3%, p=0.006) and are significantly more likely to enter perfusion because of attraction to the type of work (p=0.045). Many perfusionists (70, 32%) in Canada believe themselves inadequately trained for their clinical assignments outside the OR. In addition, 19% of perfusionists plan to retire over the next 10 years. CONCLUSIONS: The introduction of education-based entry criteria has changed the academic and clinical experience levels of perfusionists in Canada. Strategies designed to better prepare perfusionists for their clinical assignments outside the OR are merited.

Five-year evolution of reperfusion strategies and early mortality in patients with ST-segment elevation myocardial infarction in France.

AIM: To assess 5-year evolutions in reperfusion strategies and early mortality in patients with ST-segment elevation myocardial infarction. METHODS AND RESULTS: Using data from the French RESCUe network, we studied patients with ST-segment elevation myocardial infarction treated in mobile intensive care units between 2009 and 2013. Among 2418 patients (median age 62 years; 78.5% male), 2119 (87.6%) underwent primary percutaneous coronary intervention and 299 (12.4%) pre-hospital thrombolysis (94.0% of whom went on to undergo percutaneous coronary intervention). Use of primary percutaneous coronary intervention increased from 78.4% in 2009 to 95.9% in 2013 ( Ptrend<0.001). Median delays included: first medical contact to percutaneous coronary intervention centre 48 minutes; first medical contact to balloon inflation 94 minutes; and percutaneous coronary intervention centre to balloon inflation 43 minutes. Times from symptom onset to first medical contact and first medical contact to thrombolysis remained stable during 2009-2013, but times from symptom onset to first balloon inflation, and first medical contact to percutaneous coronary intervention centre to first balloon inflation decreased ( P<0.001). Among patients with known timings, 2146 (89.2%) had a first medical contact to percutaneous coronary intervention centre delay ⩽90 minutes, while 260 (10.8%) had a longer delay, with no significant variation over time. Primary percutaneous coronary intervention use increased over time in both delay groups, but was consistently higher in the ⩽90 versus >90 minutes delay group (83.0% in 2009 to 97.7% in 2013; Ptrend<0.001 versus 34.1% in 2009 to 79.2% in 2013; Ptrend<0.001). In-hospital (4-6%) and 30-day (6-8%) mortalities remained stable from 2009 to 2013. CONCLUSION: In the RESCUe network, the use of primary percutaneous coronary intervention increased from 2009 to 2013, in line with guidelines, but there was no evolution in early mortality.

The organization, function, and outcomes of ST-elevation myocardial infarction networks worldwide: current state, unmet needs and future directions.

The organization of networks in order to better coordinate and to faster offer reperfusion strategies for acute ST-elevation myocardial infarction (STEMI) is an important recommendation of recent versions of international guidelines. This article focusses on similarities and dissimilarities of world-wide networks, highlights essential network components, offers insights into still unmet needs and discusses potential measures to further improve quality of STEMI treatment.

The association between older age and receipt of care and outcomes in patients with acute coronary syndromes: a cohort study of the Myocardial Ischaemia National Audit Project (MINAP).

AIMS: Older people increasingly constitute a large proportion of the acute coronary syndrome (ACS) population. We examined the relationship of age with receipt of more intensive management and secondary prevention medicine. Then, the comparative association of intensive management (reperfusion/angiography) over a conservative strategy on time to death was investigated by age. METHODS AND RESULTS: Using data from 155 818 patients in the national registry for ACS in England and Wales [the Myocardial Ischaemia National Audit Project (MINAP)], we found that older patients were incrementally less likely to receive secondary prevention medicines and intensive management for both ST-elevation myocardial infarction (STEMI) and non-ST elevation myocardial infarction (NSTEMI). In STEMI patients ≥85 years, 55% received reperfusion compared with 84% in those aged 18 to <65 [odds ratio 0.22 (95% CI 0.21, 0.24)]. Not receiving intensive management was associated with worse survival [mean follow-up 2.29 years (SD 1.42)] in all age groups (adjusted for sex, cardiovascular risk factors, co-morbidities, healthcare factors, and case severity), but there was an incremental reduction in survival benefit from intensive management with increasing age. In STEMI patients aged 18-64, 65-74, 75-84, and ≥85, adjusted hazard ratios (HRs) for all-cause mortality comparing conservative treatment to intensive management were 1.98 (1.78, 2.19), 1.65 (1.51, 1.80), 1.62 (1.52, 1.72), and 1.36 (1.27, 1.47), respectively. In NSTEMI patients, the respective HRs were 4.37 (4.00, 4.78), 3.76 (3.54, 3.99), 2.79 (2.67, 2.91), and 1.90 (1.77, 2.04). CONCLUSION: We found an incremental reduction in the use of evidence-based therapies with increasing age using a national ACS registry cohort. While survival benefit from more intensive management reduced with older age, better survival was associated with intensive management at all ages highlighting the requirement to improve standard of care in older patients with ACS.

Predictors of reperfusion delay in patients with ST elevation myocardial infarction self-transported to the hospital (from the American Heart Association's Mission: Lifeline Program).

Primary percutaneous coronary intervention for ST elevation myocardial infarction (STEMI) is beneficial if performed in a timely manner. Self-transport patients with STEMI have prolonged treatment times compared with Emergency Medical Services-transported patients. This study evaluated self-transport patients with STEMI undergoing primary percutaneous coronary intervention to identify factors associated with prolonged door-to-balloon (D2B) times. From January 2007 to March 2011, data for 13,379 self-transport patients with STEMI treated at 432 hospitals in the Acute Coronary Treatment Intervention Outcomes Network Registry-Get With The Guidelines Registry were evaluated. Patients with a D2B time >90 minutes were compared with those with D2B time ≤90 minutes. Factors associated with prolonged D2B (>90 minutes) were explored using logistic generalized estimating equations. The median (twenty-fifth, seventy-fifth percentiles) D2B time for the entire cohort was 72 minutes (58, 86), and 19% had a D2B time of >90 minutes. Over the study period, there was a significant increase in the percentage of patients achieving D2B time ≤90 minutes. There were significant baseline differences between patients with D2B time ≤ versus >90 minutes. The main factors associated with prolonged treatment time were off-hour presentation (weekends and 7 p.m. to 7 a.m. weekdays), not obtaining an electrocardiogram within 10 minutes of hospital arrival, previous coronary artery bypass surgery, black race, older age, and female gender. In conclusion, although prolonged delay from arrival to electrocardiographic acquisition is a modifiable factor contributing to prolonged D2B times among self-transport patients with STEMI, additional factors (age, race, and gender) indicate that historic disparities for cardiovascular care still persist in terms of contemporary metrics for STEMI reperfusion.