Door-to-Balloon Time in ST-Elevation Myocardial Infarction (STEMI) Patients Undergoing Primary Angioplasty in Myocardial Infarction (PAMI): An Observational Study From a Tertiary Care Centre.

Background ST-elevation myocardial infarction (STEMI) requires swift intervention, with primary percutaneous coronary intervention (PCI) being essential to limit myocardial damage. The key factor affecting PCI effectiveness is the door-to-balloon (DTB) time. This observational study evaluated DTB times in STEMI patients at a tertiary care center who underwent primary angioplasty, examining adherence to benchmarks and identifying factors contributing to delays. Methodology This prospective observational study was conducted from March 2017 to August 2018 at Fortis Hospital Mulund, Mumbai, India. It included 171 STEMI patients aged 18 and older who underwent primary angioplasty. Patients with non-ST elevation myocardial infarction (NSTEMI), those who received thrombolysis, or had medical contraindications to primary angioplasty were excluded. Data on key time intervals were collected via direct observation and then analyzed using SPSS for Windows, Version 15 (Released 2006; SPSS Inc., Chicago, United States). Qualitative data were summarized using frequency and percentages, whereas quantitative data were presented as mean (±SD). T-test was applied to compare the mean duration between the two groups, i.e., DTB time ≤90 minutes and DTB time >90 minutes, and a p-value <0.05 was considered statistically significant. Results The participants had a mean age of 56.5 (±13.1) years and were predominantly male (78.4%). The mean DTB time was 70.21 (±29.16) minutes, with 79.5% achieving ≤90 minutes. Patient-related delays (48.6%) were mainly due to consent issues (31.4%), which was the most predominant cause. Hospital-related delays (51.4%) included catheterization laboratory occupancy (14.3%) and diagnostic delays (14.3%). Patients with DTB times >90 minutes had significantly longer durations in all procedural steps except door-to-ECG time. Conclusion This study underscores the complex challenges in achieving timely DTB times for STEMI patients undergoing primary angioplasty. Overcoming these barriers through targeted interventions is essential for optimizing management and enhancing outcomes. Insights into delay factors inform evidence-based strategies to improve the timeliness and effectiveness of STEMI care delivery.

Optimal door-to-balloon time for primary percutaneous coronary intervention for ST-elevation myocardial infarction.

BACKGROUND: Door-to-balloon time (DTBT) for ST-elevation myocardial infarction (STEMI) is a performance metric by which primary percutaneous coronary intervention (PPCI) services are assessed. METHODS: Consecutive patients presenting with STEMI undergoing PPCI between January 2007 to December 2019 from the Singapore Myocardial Infarction Registry were included. Patients were stratified based on DTBT (≤60 min, 61-90 min, 91-180 min) and Killip status (I-III vs. IV). Outcomes assessed included all-cause mortality and major adverse cardiovascular events (MACE) at 30-days and 1-year. RESULTS: In total, 13,823 patients were included, with 82.59% achieving DTBT ≤90 min and 49.77% achieving DTBT ≤60 min. For Killip I-III (n = 11,591,83.85%), the median DTBT was 60[46-78]min. The 30-day all-cause mortality for DTBT of ≤60 min, 61-90 min and 91-180 min was 1.08%, 2.17% and 4.33% respectively (p < 0.001). On multivariate analysis, however, there was no significant difference for 30-day and 1-year outcomes across all DTBT (p > 0.05). For Killip IV, the median DTBT was 68[51-91]min. The 30-day all-cause mortality for DTBT of ≤60 min, 61-90 min and 91-180 min was 11.74%, 20.48% and 35.06% respectively (p < 0.001). On multivariate analysis for 30-day and 1-year outcomes, DTBT 91-180 min was an independent predictor of worse outcomes (p < 0.05), but there was no significant difference between DTBT of ≤60 min and 61-90 min (p > 0.05). CONCLUSION: In Killip I-III patients, DTBT had no significant impact on outcomes upon adjustment for confounders. Conversely, for Killip IV patients, a DTBT of >90 min was associated with significantly higher adverse outcomes, with no differences between a DTBT of ≤60 min vs. 61-90 min. Outcomes in STEMI involve a complex interplay of factors and recommendations of a lowered DTBT of ≤60 min will require further evaluation.

Influence of time-to-diagnosis on time-to-percutaneous coronary intervention for emergency department ST-elevation myocardial infarction patients: Time-to-electrocardiogram matters.

Objectives: Earlier electrocardiogram (ECG) acquisition for ST-elevation myocardial infarction (STEMI) is associated with earlier percutaneous coronary intervention (PCI) and better patient outcomes. However, the exact relationship between timely ECG and timely PCI is unclear. Methods: We quantified the influence of door-to-ECG (D2E) time on ECG-to-PCI balloon (E2B) intervention in this three-year retrospective cohort study, including patients from 10 geographically diverse emergency departments (EDs) co-located with a PCI center. The study included 576 STEMI patients excluding those with a screening ECG before ED arrival or non-diagnostic initial ED ECG. We used a linear mixed-effects model to evaluate D2E's influence on E2B with piecewise linear terms for D2E times associated with time intervals designated as ED intake (0-10 min), triage (11-30 min), and main ED (>30 min). We adjusted for demographic and visit characteristics, past medical history, and included ED location as a random effect. Results: The median E2B interval was longer (76 vs 68 min, p < 0.001) in patients with D2E >10 min than in those with timely D2E. The proportion of patients identified at the intake, triage, and main ED intervals was 65.8%, 24.9%, and 9.7%, respectively. The D2E and E2B association was statistically significant in the triage phase, where a 1-minute change in D2E was associated with a 1.24-minute change in E2B (95% confidence interval [CI]: 0.44-2.05, p = 0.003). Conclusion: Reducing D2E is associated with a shorter E2B. Targeting D2E reduction in patients currently diagnosed during triage (11-30 min) may be the greatest opportunity to improve D2B and could enable 24.9% more ED STEMI patients to achieve timely D2E.

Sex differences in delay times in ST-segment elevation myocardial infarction: A cohort study.

BACKGROUND: The present study analyzes a cohort of consecutive patients with ST-segment elevation acute myocardial infarction (STEMI), evaluating the ischemia-reperfusion times from the perspective of gender differences (females versus males), with a long-term follow-up. METHODS: Single-center analytical cohort study of patients with STEMI in a tertiary hospital, between January 2015 and December 2020. RESULTS: A total of 2668 patients were included, 2002 (75%) men and 666 (25%) women. The time elapsed from the onset of symptoms to the opening of the artery was 197min (IQR 140-300) vs 220min (IQR 152-340), p=0.004 in men and women respectively. A delay in health care significantly impacts the occurrence of cardiovascular adverse events at follow-up, HR 1.34 [95%CI 1.06-1.70]; p=0.015. CONCLUSIONS: Women took longer to go to health care services and had a longer delay both in the diagnosis of STEMI and in coronary reperfusion. It is imperative to emphasize the necessity of educating women about the recognition of ischemic heart disease symptoms, empowering them to raise early alarms and seek timely medical attention.

Factors associated with the delay in informed consent procedures of patients with ST-segment elevation myocardial infarction and its influence on door-to-balloon time: a nationwide retrospective cohort study.

Background and Objectives: ST-segment elevation myocardial infarction (STEMI) is the deadliest and most time-sensitive acute cardiac event. However, failure to achieve timely informed consent is an important contributor to in-hospital delay in STEMI care in China. We investigated the factors associated with informed consent delay in patients with STEMI undergoing percutaneous coronary intervention (PCI) and the association between the delay and door-to-balloon time. Methods: We conducted a nationally representative retrospective cohort study using patient data reported by hospital-based chest pain centers from 1 January 2016 to 31 December 2020. We applied generalized linear mixed models and negative binomial regression to estimate factors independently predicting informed consent delay time. Logistic regressions were fitted to investigate the association of the informed consent delay time and door-to-balloon time, adjusting for patient characteristics. Results: In total, 257, 510 patients were enrolled in the analysis. Mean informed consent delay time was 22.4 min (SD = 24.0), accounting for 39.3% in door-to-balloon time. Older age (≥65 years) was significantly correlated with informed consent delay time (RR: 1.034, P = 0.001). Compared with ethnic Han patients, the minority (RR: 1.146, P < 0.001) had more likelihood to extend consent giving; compared with patients who were single, longer informed consent time was found in married patients (RR: 1.054, P = 0.006). Patients with intermittent chest pain (RR: 1.034, P = 0.011), and chest pain relief (RR: 1.085, P = 0.005) were more likely to delay informed consent. As for transfer modes, EMS (RR: 1.063, P < 0.001), transfer-in (RR: 1.820, P < 0.001), and in-hospital onset (RR: 1.099, P = 0.002) all had positive correlations with informed consent delay time compared to walk-in. Informed consent delay was significantly associated with prolonged door-to-balloon time (OR: 1.002, P < 0.001). Conclusion: Informed consent delay is significantly associated with the door-to-balloon time which plays a crucial role in achieving better outcomes for patients with STEMI. It is essential to shorten the delay time by identifying and intervening modifiable factors that are associated with shortening the informed consent procedure in China and other countries.

Unloading of the Left Ventricle With More Delayed Reperfusion May Reduce Reperfusion Injury.

Early reperfusion therapy is crucial and the standard of care for the management of acute ST-elevation myocardial infarction (STEMI). We report a case of STEMI with unloading followed by more delayed reperfusion, which challenges current clinical practice. It also highlights the importance of more translational research to better understand STEMI on a mechanistic level including the crucial role of mitochondria and anaerobic respiration during vessel occlusion and ischemia. This can also help in preventing post-myocardial infarction complications such as reperfusion injury, which leads to the development of heart failure.

Door-to-Balloon Time and Mortality Among Patients Undergoing Primary PCI, Challenges and Experience from Somalia's Largest PCI Center.

Introduction: The door-to-balloon time, the time between a patient's arrival at the hospital and percutaneous coronary intervention, is crucial for managing myocardial infarction. Aiming for less than 90 minutes is recommended, as shortened times are associated with improved outcomes. However, limited healthcare resources, infrastructure, transportation and poverty impact management, leading to poorer outcomes and delayed door to balloon time. Addressing these challenges and their causes is essential for optimal care. Methodology: A retrospective analysis of 103 patients' medical history records from May 2022 to June 2023 at the Mogadishu Somali Turkish Training and Research Hospital in Somalia was conducted. The data was mainly collected from the hospital's electronic medical records system, analyzing patient demographics, clinical characteristics, and angiographical records. The study analyzed variables responsible for door-to-balloon (D2B) time delay, patient angiography results, cause of delay, procedure length, etc. Results: A study of 103 patients who had angiography performed between May 2022 and July 2023 was done. The predominant gender in the study was 73% male, with a mean age of 58 years. The most common risk factors were hypertension (33%), smoking (38%), and diabetes (39%). Of all the vessels, the Left Anterior Descending (LAD) was the most commonly obstructed (63%). Time delays from door-to-balloon were frequent, median door-to-balloon time was 169 minutes, frequently brought on by social problems and financial limitations. The majority (77.4%) of the patients had only percutaneous angiography (PCI), while 22.6% were recommended for bypass following PCI of the infarct-related artery (IRA). Complications in the delayed treatment group were the main cause of the death rate of 24.2%. Conclusion: Door-to-balloon time is crucial for acute myocardial infarction treatment which is challenging in impoverished countries like Somalia. Investments in healthcare infrastructure, public health education, and emergency services can improve patient outcomes.

Prolonged Door-to-Balloon Time Leads to Endothelial Glycocalyx Damage and Endothelial Dysfunction in Patients with ST-Elevation Myocardial Infarction.

Damage to the endothelial glycocalyx (eGC) has been reported during acute ischemic events like ST-elevation myocardial infarction (STEMI). In STEMI, a door-to-balloon time (D2B) of <60 min was shown to reduce mortality and nonfatal complications. Here, we hypothesize that eGC condition is associated with D2B duration and endothelial function during STEMI. One hundred and twenty-six individuals were analyzed in this study (STEMI patients vs. age-/sex-matched healthy volunteers). After stimulating endothelial cells with patient/control sera, the eGC's nanomechanical properties (i.e., height/stiffness) were analyzed using the atomic force microscopy-based nanoindentation technique. eGC components were determined via ELISA, and measurements of nitric oxide levels (NO) were based on chemiluminescence. eGC height/stiffness (both p < 0.001), as well as NO concentration (p < 0.001), were reduced during STEMI. Notably, the D2B had a strong impact on the endothelial condition: a D2B > 60 min led to significantly higher serum concentrations of eGC components (syndecan-1: p < 0.001/heparan sulfate: p < 0.001/hyaluronic acid: p < 0.0001). A D2B > 60 min led to the pronounced loss of eGC height/stiffness (both, p < 0.001) with reduced NO concentrations (p < 0.01), activated the complement system (p < 0.001), and prolonged the hospital stay (p < 0.01). An increased D2B led to severe eGC shedding, with endothelial dysfunction in a temporal context. eGC components and pro-inflammatory mediators correlated with a prolonged D2B, indicating a time-dependent immune reaction during STEMI, with a decreased NO concentration. Thus, D2B is a crucial factor for eGC damage during STEMI. Clinical evaluation of the eGC condition might serve as an important predictor for the endothelial function of STEMI patients in the future.

Hemo-metabolic impairment in patients with ST-segment elevation myocardial infarction: Data from the INTERSTELLAR registry.

BACKGROUND: Not only hemo-dynamic (HD) factors but also hemo-metabolic (HM) risk factors reflecting multi-organ injuries are considered as important prognostic factors in ST-segment elevation myocardial infarction (STEMI). However, studies regarding HM risk factors in STEMI patients are currently limited. METHOD: Under analysis were 1,524 patients with STEMI who underwent primary percutaneous coronary intervention in the INTERSTELLAR registry. Patients were divided into HM (≥ 2 risk factors) and non-HM impairment groups. The primary outcome was in-hospital all-cause mortality, and the secondary outcome was 1-year all-cause mortality. RESULTS: Of 1,524 patients, 214 (14.0%) and 1,310 (86.0%) patients were in the HM and non-HM impairment groups, respectively. Patients with HM impairment had a higher incidence of in-hospital mortality than those without (24.3% vs. 2.7%, p < 0.001). After adjusting for confounders, HM impairment was independently associated with in-hospital mortality (inverse probability of treatment weighting [IPTW]-adjusted odds ratio: 1.81, 95% confidence interval: 1.08-3.14). In the third door-to-balloon (DTB) time tertile (≥ 82 min), HM impairment was strongly associated with in-hospital mortality. In the first DTB time tertile ( < 62 min), indicating relatively rapid revascularization, HM impairment was consistently associated with increased in-hospital mortality. CONCLUSIONS: Hemo-metabolic impairment is significantly associated with increased risk of in-hospital and 1-year mortality in patients with STEMI. It remains a significant prognostic factor, regardless of DTB time.

A Single Transradial Guiding Catheter in Patients With ST-Segment Elevation Myocardial Infarction Undergoing Percutaneous Coronary Intervention: A Door-to-Balloon Optimized Strategy.

Background Acute coronary syndrome (ACS) is the leading cause of morbidity and mortality worldwide. The different reperfusion strategies have evolved over the years, and efforts have been directed to reduce its complications. Among these strategies, the one that has shown the best results is percutaneous coronary intervention, which has significantly improved the survival and prognosis of these patients; however, this procedure is not free of complications since multiple factors are involved. Among them is the time of patient care from the time of diagnosis until the coronary reperfusion therapy is performed. Methodology In this study, we describe the experience in our center with the 6-French Ikari Left guide catheter as a strategy of radial angiography-angioplasty with a single catheter to reduce the care times of patients with acute ST-elevation myocardial infarction (STEMI) in our center and compare it with the series reported by other international centers since. To establish an alternative to the usual approach that consists of the use of Judkins catheters, diagnosis, and guiding. Results Our study showed a success rate for diagnostic angiography and percutaneous coronary intervention (PCI) with the 6- French Ikari Left catheter comparable to those obtained in other centers, even with lower complication rates than the usual approach with Judkins' Catheters. Conclusions The use of the 6-French Ikari Left catheter demonstrated shorter needle-device time and compared to other international series, it was shown to be shorter and related to shorter fluoroscopy time. Our study has a small sample and only included a highly selected population, which represents a limitation. This study is vulnerable to the different practices of the operators, with involvement in procedure time and use of contrast volume.

Role of pre-hospital emergency medical systems in the rescue of patients with ST-elevation myocardial infarction.

BACKGROUND: Myocardial infarction (MI) is a series of clinical syndromes caused by ischemic necrosis of myocardial cells that results from severe and persistent acute ischemia of the myocardium due to a dramatic reduction or interruption of coronary blood supply. OBJECTIVE: In this study, we analyzed the role of pre-hospital emergency services in the rescue of patients suffering from ST-elevation myocardial infarction (STEMI). METHODS: We enrolled 229 patients with STEMI who were transported to the Second Hospital of Tianjin Medical University by Tianjin Emergency Center from January 2017 to June 2021. With the development of the pre-hospital emergency medical system in Tianjin (2019) as the time node, the patients were divided into three groups: A (87 cases), B (68 cases), and C (74 cases). The onset-to-call time, emergency response time, door-to-balloon (D-B) time, first medical contact to balloon dilation (FMC-B) time, symptom onset-to-balloon dilation (S-B) time, proportion of patients receiving prehospital administration of bispecific antibodies, number of days hospitalized, total hospitalization expenses, and in-hospital incidence and mortality of heart failure were compared between the three groups. RESULTS: Group C differed significantly from group A and group B in terms of emergency response time, D-B time, FMC-B time, S-B time, the proportion of patients who received prehospital administration of bispecific antibodies, and the number of days of hospitalization (P< 0.05), but there was no significant difference in the onset-to-call time (P> 0.05) and the decreasing trends in the in-hospital incidence and mortality of heart failure were not statistically significant (incidence: 9.50% vs. 13.23%, 12.64%; mortality: 4.10% vs. 5.90%, 4.60%). CONCLUSION: A reasonable pre-hospital emergency medical network layout and resource investment, as well as the strengthening of the interface between pre-hospital and in-hospital medical emergencies and pre-hospital standardized rescue, can shorten the emergency response time and the total ischemic time in patients with chest pain, which can improve patient prognosis to a certain extent.

Usefulness of Prehospital 12-Lead Electrocardiography System in ST-Segment Elevation Myocardial Infarction Patients in Oita　- Comparison Between Urban and Rural Areas, Weekday Daytime and Weekday Nighttime/Holidays.

BACKGROUND: We have reported that a prehospital 12-lead electrocardiography system (P-ECG) contributed to transport of suspected acute coronary syndrome (ACS) patients to appropriate institutes and in this study, we compared its usefulness between urban and rural areas, and between weekday daytime and weekday nighttime/holiday.Methods and Results: Consecutive STEMI patients who underwent successful primary percutaneous coronary intervention after using P-ECG were assigned to the P-ECG group (n=123; 29 female, 70±13 years), and comparable STEMI patients without using P-ECG were assigned to the conventional group (n=117; 33 females, mean age 70±13 years). There was no significant difference in door-to-reperfusion times between the rural and urban cases (70±32 vs. 69±29 min, P=0.73). Door-to-reperfusion times in the urban P-ECG group were shorter than those in the urban conventional group for weekday nighttime/holiday (65±21 vs. 83±32 min, P=0.0005). However, there was no significance different between groups for weekday daytime. First medical contact to reperfusion time (90±22 vs. 105±37 min, P=0.0091) in the urban P-ECG group were significantly shorter than in the urban conventional groups for weekday nighttime/holiday, but were not significantly different between the groups for weekday daytime. CONCLUSIONS: P-ECG is useful even in urban areas, especially for patients who develop STEMI during weekday nighttime or while on a holiday.

Racial Disparities and Outcomes of Percutaneous Coronary Interventions in Patients Above 65 Years in America: A Systematic Review.

This systematic review aims to examine the racial disparities and outcomes of percutaneous coronary interventions (PCIs) in patients above 65 years in America. The review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines 2020 and includes a comprehensive search strategy, study selection, data extraction, and quality assessment. The search strategy identified 10 relevant articles that were included in the review. The findings indicate that racial disparities exist in access to PCI, door-to-balloon (DTB) time, procedure utilization, and outcomes among elderly patients. African American and Hispanic patients were found to experience longer door-to-balloon time and lower rates of PCI utilization compared to White patients. Moreover, racial and ethnic minorities had worse clinical outcomes, including higher mortality rates and increased risk of major adverse cardiovascular events. The review also highlights the impact of Medicaid expansion on reducing disparities in access, treatment, and outcomes for patients with acute myocardial infarction (AMI). However, limitations in data availability and representation of racial and ethnic minorities in clinical trials were identified. The discussion section provides a robust analysis of the findings, exploring potential underlying factors contributing to the observed disparities. The review concludes that addressing racial disparities in PCI outcomes among elderly patients is crucial for achieving equitable healthcare delivery and improving cardiovascular health outcomes in America.

Clinical Efficacy of Pre-Hospital Electrocardiogram Transmission in Patients Undergoing Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction.

Rapid reperfusion by primary percutaneous coronary intervention (pPCI) is an established strategy for the treatment of patients with ST-segment elevation myocardial infarction (STEMI). Pre-hospital electrocardiogram (PH-ECG) transmission by the emergency medical services (EMS) facilitates timely reperfusion in these patients. However, evidence regarding the clinical benefits of PH-ECG in individual hospitals is limited.This retrospective, observational study investigated the clinical efficacy of PH-ECG in STEMI patients who underwent pPCI. Of a total of 382 consecutive STEMI patients, 237 were enrolled in the study and divided into 2 groups: a PH-ECG group (n = 77) and non-PH-ECG group (n = 160). Door-to-balloon time (D2BT) was significantly shorter in the PH-ECG group (66 [52-80] min), compared to the non-PH-ECG group (70 [57-88] minutes, P = 0.01). The 30-day all-cause mortality rate was 6% in the PH-ECG group, which was significantly lower than that in the non-PH-ECG group (16%) (P = 0.037, hazard ratio [HR]: 0.38, 95% CI: 0.15-0.98). This trend was particularly evident in severely ill patients when stratified by GRACE score.The use of PH-ECG improved the survival rate of STEMI patients undergoing pPCI due to the improved pre-arrival preparation based on the EMS information. Coordination between EMS and PCI-capable institutes is essential for the management of PH-ECG.

The Impact of Emergency Department Arrival Time on Door-to-Balloon Time in Patients with ST-Segment Elevation Myocardial Infarction Receiving Primary Percutaneous Coronary Intervention.

Door-to-balloon (DTB) time significantly affects the prognosis of patients with ST-segment elevation myocardial infarction (STEMI). The effects of temporal differences in emergency department (ED) arrival time on DTB time and on different segments of DTB time remain inconclusive. Therefore, we performed a retrospective study in a tertiary hospital between January 2013 and December 2021 and investigated the relationship between a patient's arrival time and both their DTB time and different segments of their DTB time. Of 732 STEMI patients, 327 arrived during the daytime (08:01-16:00), 268 during the evening (16:01-24:00), and 137 at night (00:01-08:00). Significantly higher odds of delay in DTB time were observed during the nighttime (adjusted odds ratio (aOR): 2.87; 95% confidence interval (CI): 1.50-5.51, p = 0.002) than during the daytime. This delay was mainly attributed to a delay in cardiac catheterization laboratory (cath lab) activation-to-arrival time (aOR: 6.25; 95% CI: 3.75-10.40, p < 0.001), particularly during the 00:00-04:00 time range. Age, sex, triage level, and whether patients arrived during the COVID-19 pandemic also had independent effects on different segments of DTB time. Further studies are required to investigate the root causes of delay in DTB time and to develop specific strategies for improvement.

The role of complement C3 in the outcome of regional myocardial infarction.

Coronary heart disease leading to myocardial ischemia is a major cause of heart failure. A hallmark of heart failure is myocardial fibrosis. Using a murine model of myocardial ischemia/reperfusion injury (IRI), we showed that, following IRI, in mice genetically deficient in the central factor of complement system, C3, myocardial necrosis was reduced compared with WT mice. Four weeks after the ischemic period, the C3-/- mice had significantly less cardiac fibrosis and better cardiac function than the WT controls. Overall, our results suggest that innate immune response through complement C3 plays an important role in necrotic cell death, which contributes to the cardiac fibrosis that underlies post-infarction heart failure.

Shorter door-to-balloon time, better long-term clinical outcomes in ST-segment elevation myocardial infarction patients: J-MINUET substudy.

BACKGROUND: The impact of shorter door-to-balloon (DTB time on long-term outcomes in ST-segment elevation myocardial infarction (STEMI treated with primary percutaneous coronary intervention (PPCI has not been fully elucidated. METHODS: We investigated 3283 consecutive patients with acute myocardial infarction selected from a prospective, nationwide, multicenter registry (J-MINUET database comprising 28 institutions in Japan between July 2012 and March 2014. Among the study population, we analyzed 1639 STEMI patients who had PPCI within 12 h of onset. Patients were stratified into four groups (DTB time < 45 min, 45-60 min, 61-90 min, >90 min. The primary endpoint was a composite of all-cause death, non-fatal MI, non-fatal stroke, cardiac failure, and urgent revascularization for unstable angina up to 3 years. We performed landmark analysis for incidence of the primary endpoint from 31 days to 3 years among the four groups. RESULTS: The primary endpoint rate from 31 days to 3 years increased significantly and time-dependently with DTB time (10.2 % vs. 15.3 % vs. 16.2 % vs. 19.3 %, respectively; log-rank p = 0.0129. Higher logarithm-transformed DTB time was associated with greater risk of a primary endpoint from 31 days to 3 years, and the increased number of adverse long-term clinical outcomes persisted even after adjusting for other independent variables. CONCLUSION: Shorter DTB time was associated with better long-term clinical outcomes in STEMI patients treated with PPCI in contemporary clinical practice. Further efforts to shorten DTB time are recommended to improve long-term clinical outcomes in STEMI patients. TRIAL REGISTRATION: UMIN Unique trial Number: UMIN000010037.

Comparison of STEMI Door-To-Device Time During the COVID-19 Crisis in a New Jersey Inner City Community Hospital.

As the novel COVID-19 pandemic was on the rise, its impact on the healthcare system was devastating. Patients became more reluctant to present to the hospital and elective procedures were being postponed for patient safety. We wanted to assess the effects of the COVID-19 pandemic on the door-to-device time in our small community hospital in the heart of Trenton, New Jersey. We created a retrospective study that evaluated all STEMI cases that presented to our institute from January 2018 until the end of May, 2021. Our primary outcome was the door-to-device time. Secondary outcomes were the length of hospital stay, ICU admission, length of ICU stay, cardiac arrest, and death during the hospitalization. We studied 114 patients that presented with STEMI to our emergency department, 77 of these patients presented pre-COVID-19, and 37 presented during the pandemic. Our median door-to-device for STEMI cases pre-COVID-19, and during the pandemic were 70 min (IQR 84-57) and 70 min (IQR 88-59) respectively with no significant difference found (P-value 0.55, Mann Whitney Test). It is, however, interesting to note that the number of STEMI admissions significantly decreased during the pandemic era. There are limitations to our study, most noticeably the number of STEMI cases at our small community hospital which limits its generalizability. Moreover, we did not assess other comorbidities which might have confounded our outcomes and we were also unable to follow patients post-discharge to assess the long-term sequela of their STEMI admission. Therefore, more dedicated studies of this clinical conundrum are required to further assess and implement guidelines for the future.

Off-Hours Presentation, Door-to-Balloon Time, and Clinical Outcomes in Patients Referred for Primary Percutaneous Coronary Intervention.

OBJECTIVES: Presentation with ST-segment-elevation myocardial infarction (STEMI) during off-hours may impact timely reperfusion and clinical outcomes. We investigated the association between off-hours presentation, door-to-balloon time, and in-hospital mortality in patients with STEMI referred for primary percutaneous coronary intervention (PCI). METHODS: We included consecutive patients referred for primary PCI at the University of Ottawa Heart Institute between July 2004 and December 2017. The off-hours group included patients presenting on weekends, statutory holidays, or between 18:00 to 07:59 hours on weekdays. The on-hours group included patients presenting between 08:00 and 17:59 hours on weekdays. The primary clinical outcome was the adjusted in-hospital mortality. The primary quality-of-care indicator was door-to-balloon time. RESULTS: A total of 5132 patients were included, with 3152 (61.4%) in the off-hours group and 1980 (38.6%) in the on-hours group. The median door-to-balloon time was longer in the off-hours group compared with the on-hours group (102 minutes vs 77 minutes; P<.001), while the median onset-to-door time was similar (P=.40). There was no difference in the rates of in-hospital mortality (3.5% vs 3.0%; P=.32) or in the adjusted mortality (odds ratio, 1.2; 95% confidence interval, 0.8-1.8; P=.44) between off-hours and on-hours groups. However, door-to-balloon time was an independent predictor of in-hospital mortality (P<.01) and off-hours presentation was an independent predictor of longer door-to-balloon time (P<.001), with an excess of 22.1 minutes. CONCLUSION: Patients treated with primary PCI during off-hours had longer door-to-balloon times. Treatment during off-hours was an independent predictor of longer door-to-balloon time and longer door-to-balloon times were associated with higher mortality.

Clinical Features of the Aslanger Pattern to Compensate for the Limitation of ST-Elevation Myocardial Infarction (STEMI) Criteria.

BACKGROUND: ST-elevation is one of the most valuable electrocardiogram findings to diagnose acute myocardial infarction. However, more than a quarter of acute coronary occlusions are missed by this criterion, causing a delay in revascularization. Therefore, there should be awareness of the limitations of the current criteria and new electrocardiographic findings are required as a diagnostic tool to compensate for them. The Aslanger pattern is a specific electrocardiographic finding in acute inferior myocardial infarction with multivessel disease and allows the detection of inferior myocardial infarction that does not show ST-elevation, leading to rapid revascularization. However, in patients with the Aslanger pattern, the hemodynamic characteristics, such as the rate of shock and the use of mechanical circulatory support, as well as prognostic characteristics such as the in-hospital mortality rate, have not yet been clarified. METHODS: In this study, we retrospectively surveyed the current practice on the basis of ST-elevation myocardial infarction (STEMI) criteria in patients with acute coronary artery occlusion presenting with inferior myocardial infarction. We examined the clinical characteristics of the Aslanger pattern. RESULTS: Based on the STEMI criteria, 71.8% (51/72) of patients were diagnosed with STEMI from an acute electrocardiogram, and 28.2% (21/78) were diagnosed with non-STEMI. As expected, ruling out in all acute coronary artery occlusions using STEMI criteria alone was difficult. A total of 48% of patients with non-STEMI had the Aslanger pattern. In addition, 80% of patients with the Aslanger pattern had multivessel disease, 30% had the use of the mechanical circulatory support, and 20% had in-hospital mortality. CONCLUSION: This study suggests that the Aslanger pattern is useful not only for diagnosis, but also for predicting hemodynamic collapse and a poor prognosis. Therefore, we should share information on Aslanger pattern with other physicians and use this pattern in daily practice.