Reperfusion Times and Outcomes in Patients With ST-Elevation Myocardial Infarction Presenting Without Pre-Hospital Notification.

BACKGROUND: Primary percutaneous coronary intervention (PCI) for patients with ST-elevation myocardial infarction (STEMI) is recommended within 90 min of first medical contact. Those without pre-hospital notification (PN) are less likely to meet reperfusion targets and are an understudied subset of the STEMI population. METHODS: An observational cohort study from a multicentre PCI registry of consecutive patients undergoing primary PCI for STEMI between 2012 and 2017. Exclusion criteria included out-of-hospital cardiac arrest, prior thrombolysis, symptom onset >12 h prior, and cardiogenic shock. RESULTS: 2519 patients were included: 1392 (55.3%) without PN (no-PN group) and 1127 (44.7%) with PN (PN group). Those without PN had longer median DTBT (78 min vs 51 min, p < 0.001) and STBT (206 min vs 161 min, p < 0.001), with only 55% meeting DTBT targets out-of-hours in the no-PN group. No-PN patients had lower rates of AHA/ACC type B2/C lesions, GP IIb/IIIa use, aspiration thrombectomy and had smaller stent diameter (all p ≤ 0.003), suggesting smaller areas of ischemic myocardium. There were no significant differences in 30-day MACE (no-PN 5.6% vs PN 6.5%, p = 0.36) or long-term National Death Index linked mortality (no-PN 6.2% vs PN 7.9%, p = 0.09). Lack of PN did not independently predict long-term mortality. CONCLUSION: Despite comparably excellent outcomes overall, those without PN had longer ischemic times and were less likely to meet DTBT targets, especially after hours. Ischemic times may be a better evaluation of PN networks than hard clinical outcomes, and efficient systems of care tailored to the individual health service are essential to ensure timely reperfusion of patients with STEMI.

Frontline barriers to effective paramedic and emergency nursing STEMI management: clinician perspectives.

BACKGROUND: Factors that hinder the pivotal role frontline clinicians play in STEMI management are under-reported. We aimed to explore perceived barriers to effective STEMI management by addressing the following questions: 1. What are the most commonly occurring barriers to timely STEMI management for paramedics and emergency nurses? 2. Are there differences in barriers experienced by paramedics and emergency nurses? 3. Are there differences in barriers experienced by frontline clinicians in rural and metropolitan settings? METHODS: A 79-item online survey was offered to paramedics and emergency nurses. Descriptive statistics and exploratory factor analysis identified the most frequently experienced types of barriers. Professional groups and geographical locations were compared. RESULTS: There were 333 respondents. Response rates for paramedics was 10% and 9% for members of an emergency nursing association. Most commonly occurring barriers across all respondents were: 'lack of skills development'; 'lack of feedback'; 'untimely support'; 'distance to scene/hospital facilities'; 'hospital-related delays'. Statistically significant differences were found by professional group and geographical location. CONCLUSION: Barriers to timely management were present, but not frequently experienced. Survey responses indicate a need for improved continuing professional development opportunity, clearer feedback mechanisms, streamlined facilitation of STEMI processes in hospitals, and enhanced access to expert advice/resources for all frontline clinicians.

Impact of Gender and Door-to-Balloon Times on Long-Term Mortality in Patients Presenting With ST-Elevation Myocardial Infarction.

Guidelines mandate emergent revascularization in patients presenting with ST-elevation myocardial infarction (STEMI) irrespective of gender. We sought to compare the door-to-balloon times and the impact of timely reperfusion on clinical outcomes in women compared with men presenting with STEMI undergoing primary percutaneous coronary intervention (PPCI). We analyzed data from 6,179 consecutive patients presenting with STEMI undergoing PPCI from the Melbourne Interventional Group registry (2005 to 2017). The primary outcome was long-term mortality. Of the 6,179 patients included 1,258 (20.3%) were female. Female patients were older (69 ± 13 vs 62 ± 12 years; p < 0.001), had more co-morbidities and had longer median symptom-to-balloon times (204 [interquartile range {IQR} 154 to 294] vs 181 [IQR 139 to 258] minutes; p < 0.001) and longer median door-to-balloon times (81 [IQR 55 to 102] vs 75 [IQR 51 to 102)] minutes; p < 0.001), while receiving less drug-eluting stents (39% vs 43%; p = 0.01) and having less radial access for PPCI (15% vs 21%; p < 0.001). Furthermore, female patients received less guideline-directed medical therapy than men with less prescription of aspirin (93.4% vs 95.4%; p = 0.02), statins (96.5% vs 97.6%; p < 0.05), and beta blockers (84.3% vs 89.4%; p < 0.001). Unadjusted in-hospital and 30-day mortality rates were higher in women (8.8% vs 6.2%, 9.8% vs 6.9%; p < 0.001). However, on Cox-proportional hazards modeling, gender was not an independent predictor of long-term mortality (hazards ratio 0.99, 95% confidence interval 0.83 to 1.18; p = 0.92) at a mean follow-up of 4.8 ± 3.5 years. In conclusion, in this large multicenter registry of patients with STEMI, women had longer ischemic times, higher risk profiles, and differing interventional approaches compared with men. Addressing these gender inequalities with early identification of symptoms, adherence to guideline-directed medical therapy, as well as higher rates of radial access and use of drug-eluting stents has the potential to further improve outcomes in women with STEMI.

The impact on long term health outcomes for STEMI patients during a period of process change to reduce door to balloon time.

BACKGROUND: Guidelines for the management of ST-segment elevation myocardial infarction (STEMI) recommend a 'door to balloon time' (DTBT) within 90 minutes. It is unclear whether strategies to reduce DTBT translate to improved longer-term health outcomes for STEMI patients. AIMS: This study sought to determine whether implemented strategies to improve timely management of STEMI reduced DTBT and impacted upon health outcomes such as length of stay, unplanned readmission and 12-month mortality. Predictors of timely management for STEMI were also examined. METHODS: A five-year review was undertaken on primary percutaneous coronary intervention for STEMI in one tertiary hospital. Comparisons were made between process change groups and DTBT. Logistic regression identified predictors of timely management. RESULTS: 470 STEMI patients underwent immediate primary percutaneous coronary intervention. Process change improved the median DTBT (109 min vs. 72 min, p<0.001) with no significant effect on length of stay (p=0.83), unplanned cardiac readmissions (p=0.68) or 12-month mortality (9.0% vs. 8.6%, p=0.64). Those receiving timely treatment (i.e. DTBT< 90 min) were younger (p<0.05), male (p<0.03), presented via ambulance (p<0.004), during business hours (p<0.0001) and had a lower Thrombolysis In Myocardial Infarction score (p<0.006). Timely treatment was associated with lower 12-month mortality (3.7% vs. 15.7%, p<0.0001) and increased uptake of inpatient cardiac rehabilitation (p<0.005), with length of stay and unplanned readmission similar between groups (p=NS). CONCLUSIONS: Process changes improved DTBT but had no effect on length of stay, readmission rate or 12-month mortality. Yet, timely management was critical to 12-month outcomes. Further studies are required to explore the barriers to timely treatment.

Timely treatment for acute myocardial infarction and health outcomes: an integrative review of the literature.

BACKGROUND: Coronary heart disease is the most common condition affecting Australians. The time sensitive nature of treating ST-segment elevation myocardial infarction (STEMI) has been the subject of extensive research for several years. Despite important advances in strategies to reduce time to treatment, time continues to represent a major determinant of mortality and morbidity. Door to balloon time (DTBT) is a key indicator of quality of care for STEMI. Nurses play a pivotal role in streamlining the care processes to influence timely management of STEMI. PURPOSE: The aim of this paper is to review the evidence on the time to treat STEMI, the associated factors impacting upon health outcomes and explore systems of care that reduce time to treatment, using an integrative review approach. METHOD: Established databases were searched from 2000 to 2012. The search terms 'myocardial infarction', 'emergency medicine', 'angioplasty balloon', 'time factors', 'treatment outcome', 'mortality', 'prognosis', 'female', 'age factors', and 'readmission', were used in various combinations. Research studies that addressed the aims of this paper were examined. FINDINGS: Twenty-nine papers were included in this integrative review. The literature demonstrates a strong relationship between shorter DTBT and reduced in-hospital mortality. Factors such as age, gender, time of presentation and co-morbid condition were associated with increased in-hospital mortality. There is sparse literature examining the effect timely reperfusion has on longer-term mortality and other longer-term outcomes such as readmission rates and occurrence of heart failure. Additionally, strategies that effectively reduced DTBT were identified, yet little has been reported on the impact reduced DTBT has had upon health outcomes and whether these improvements were sustained. CONCLUSION: Whilst the importance of timely reperfusion is now well recognised, additional efforts to streamline the process of care and demonstrate sustained improvement for STEMI patients is required. Nurses in the areas of emergency medicine and cardiac care, play an essential role in facilitating this.