ST-Segment Elevation Myocardial Infarction and Out-of-Hospital Cardiac Arrest: Contemporary Management From the Multicenter START Registry.

BACKGROUND: Recent studies suggest that primary percutaneous coronary intervention (PCI) and targeted temperature management (TTM) improve outcome in ST-segment elevation myocardial infarction (STEMI) complicated by out-of-hospital cardiac arrest (OHCA). The objective of this study was to evaluate a contemporary series of patients with STEMI and OHCA to characterize treatment approaches and predictors of neurologic outcome. METHODS: From January 2009 through November 2012, a total of 239 patients who underwent emergent coronary angiography at 10 medical centers across the United States were enrolled. All patients suffered OHCA with STEMI on either the prehospital or post-resuscitation electrocardiogram. Neurologic outcome was assessed using the cerebral performance category (CPC) score. Predictors of neurologic outcome were determined using multivariate logistic regression analysis. The primary endpoint was in-hospital survival with good neurologic function (CPC score 1 or 2). RESULTS: Mean age was 60 ± 13 years, 72% were male, and the majority of patients had a history of cardiovascular event. Initial rhythm was ventricular fibrillation in 72%. At hospital presentation, 76% of patients were intubated, 37% were in cardiogenic shock, and 33% were receiving vasopressors. Primary PCI was performed in 74%, with an average door-to-balloon time of 95 ± 77 minutes, and TTM was used in 51%. Forty-four percent of patients had full neurologic recovery (CPC score 1) and 55% had good neurologic function. Overall in-hospital survival rate was 66%. Independent predictors of in-hospital survival with good neurologic function were: receiving bystander cardiopulmonary resuscitation, location of arrest, receiving drug-eluting stents, and not experiencing a recurrent cardiac arrest. CONCLUSIONS: Short-term survival for patients with STEMI and OHCA undergoing emergent coronary angiography and revascularization with TTM in this contemporary, multicenter registry was high and neurologic outcome was good in more than half of patients.

Comparison of team-focused CPR vs standard CPR in resuscitation from out-of-hospital cardiac arrest: Results from a statewide quality improvement initiative.

BACKGROUND: Team-focused CPR (TFCPR) is a choreographed approach to cardiopulmonary resuscitation (CPR) with emphasis on minimally interrupted high-quality chest compressions, early defibrillation, discourages endotracheal intubation and encourages use of the bag-valve-mask (BVM) and/or blind-insertion airway device (BIAD) with a ventilation rate of 8-10 breaths/min to minimize hyperventilation. Widespread incorporation of TFCPR in North Carolina (NC) EMS agencies began in 2011, yet its impact on outcomes is unknown. OBJECTIVES: To determine whether TFCPR improves survival with good neurological outcome in out-of-hospital cardiac arrest (OHCA) patients compared to standard CPR. METHODS: This retrospective cohort analysis of NC EMS agencies reporting data to the Cardiac Arrest Registry for Enhanced Survival (CARES) database from January 2010 to June 2014 included adult, non-traumatic OHCA with presumed cardiac etiology where EMS performed CPR or patient received defibrillation. Exclusions were arrest terminated per EMS policy or DNR. EMS agencies self-reported the TFCPR implementation dates. Patients were categorized as receiving either TFCPR or standard CPR. The primary outcome was good neurologic outcome at time of hospital discharge defined as Pittsburgh Cerebral Performance Category (CPC) 1-2. RESULTS: Of 14,994 OHCAs, 14,129 patients were included for analysis with a mean age 65 (IQR 50-81) years, 61% male, 7.3% with good neurologic outcome, 24.3% with shockable initial rhythm, and 71.5% receiving TFCPR. Of the 3427 (24.3%) with an initial shockable rhythm, 739 (71.9%) had a good neurological outcome. Good neurologic outcome was higher with TFCPR [836 (8.3%, 95%CI 7.7-8.8%)] vs. standard CPR [193 (4.8%, 95%CI 4.2-5.5%)]. Logistic regression controlling for demographic and arrest characteristics revealed TFCPR (OR 1.5), witnessed arrest (OR 4.3), initial shockable rhythm (OR 7.1), and in-hospital hypothermia (OR 3.3) were associated with good neurologic outcome. Mechanical CPR device (OR 0.68), CPR feedback device (OR 0.47), and endotracheal intubation (OR 0.44) were associated with less likelihood for a good neurologic outcome. CONCLUSION: In our statewide OHCA cohort, TFCPR was associated with improved survival with good neurological outcome.

Characteristics of ST Elevation Myocardial Infarction Patients Who Do Not Undergo Percutaneous Coronary Intervention After Prehospital Cardiac Catheterization Laboratory Activation.

OBJECTIVES: To assess the clinical and electrocardiographic characteristics of patients diagnosed with ST elevation myocardial infarction (STEMI) that are associated with an increased likelihood of not undergoing percutaneous coronary intervention (PCI) after prehospital Cardiac Catheterization Laboratory activation in a regional STEMI system. METHODS: We performed a retrospective analysis of prehospital Cardiac Catheterization Laboratory activations in Mecklenburg County, North Carolina, between May 2008 and March 2011. Data were extracted from the prehospital patient record, the prehospital electrocardiogram, and the regional STEMI database. The independent variables of interest included objective patient characteristics as well as documented cardiac history and risk factors. Analysis was performed using descriptive statistics and logistic regression. RESULTS: Two hundred thirty-one prehospital activations were included in the analysis. Five independent variables were found to be associated with an increased likelihood of not undergoing PCI: increasing age, bundle branch block, elevated heart rate, left ventricular hypertrophy, and non-white race. The variables with the most significance were any type of bundle branch block [adjusted odds ratios (AOR), 5.66; 95% confidence interval (CI), 1.91-16.76], left ventricular hypertrophy (AOR, 4.63; 95% CI, 2.03-10.53), and non-white race (AOR, 3.53; 95% CI, 1.76-7.08). Conversely, the only variable associated with a higher likelihood of undergoing PCI was the presence of arm pain (AOR, 2.94; 95% CI, 1.36-6.25). CONCLUSIONS: Several of the above variables are expected electrocardiogram mimics; however, the decreased rate of PCI in non-white patients highlights an area for investigation and process improvement. This may guide the development of prehospital STEMI protocols, although avoiding false positive and inappropriate activations.

Impact of Society of Cardiovascular Patient Care accreditation on quality: an ACTION Registry®-Get With The Guidelines™ analysis.

BACKGROUND: The Society of Cardiovascular Patient Care (SCPC) accredits hospital acute coronary syndrome management. The influence of accreditation on the subset of patients diagnosed with acute myocardial infarction (AMI) is unknown. Our purpose was to describe the association between SCPC accreditation and hospital quality metric performance among AMI patients enrolled in ACTION Registry-GWTG (ACTION-GWTG). This program is a voluntary registry that receives self-reported hospital AMI quality metrics data and provides quarterly feedback to 487 US hospitals. METHODS: Using urban nonacademic hospital registry data from January 1, 2007, to June 30, 2010, we performed a 1 to 2 matched pairs analysis, selecting 14 of 733 (1.9%) SCPC accredited and 28 of 309 (9.1%) nonaccredited registry facilities to compare changes in quality metrics between the year before and after SCPC accreditation. RESULTS: All hospitals improved quality metric compliance during the study period. Nonaccredited hospitals started with slightly lower rates of AMI composite score 1 year before accreditation. Although improvement compared with baseline was greater for nonaccredited hospitals (odds ratio = 1.27; 95% confidence interval: 1.20, 1.35) than accredited hospitals (odds ratio = 1.15; 95% confidence interval: 1.07, 1.23) (P = 0.022), the group ended with similar compliance scores (92.1% vs. 92.2%, respectively). Improvements in evaluating left ventricular function (P = 0.0001), adult smoking cessation advice (P = 0.0063), and cardiac rehab referral (P = 0.0020) were greater among nonaccredited hospitals, whereas accredited hospitals had greater improvement in discharge angiotensin-converting-enzyme inhibitor or angiotensin II receptor blocker use for left ventricular systolic dysfunction (P = 0.0238). CONCLUSIONS: All hospitals had high rates of quality metric compliance and finished with similar overall AMI performance composite scores after 1 year.

The association between patients' perception of their overall quality of care and their perception of pain management in the prehospital setting.

OBJECTIVE: Our objective was to determine whether there is an association between a patient's impression of his or her overall quality of care and his or her satisfaction with the pain management provided. We hypothesized that satisfaction with pain management would show a significant positive association with a patient's impression of overall quality of care. METHODS: This was a retrospective review of patient satisfaction data initially collected by a third-party company from January 1, 2007, to September 1, 2010. Participants were randomly selected from all transported patients, proportional to their paramedic-defined acuity level, with a goal of 100 interviews per month. The proportions of patients sampled from each acuity level were 25% priority 1 (high), 50% priority 2 (medium), and 25% priority 3 (low). Patients were excluded if there was no telephone number recorded in the prehospital patient record, no transportation was recorded, or the call was labeled as a psychiatric complaint. All satisfaction questions used a five-point Likert scale with ratings from excellent to poor, which were dichotomized for analysis. The outcome variable was the patient's perception of his or her overall quality of care. The main independent variable was the patient's rating of his or her pain management by emergency medical services (EMS) staff at the scene. Demographic variables were assessed for potential confounding. RESULTS: There were 2,741 patients with complete data for the outcome and main independent variables; 41.7% of the respondents were male and the average age was 54.1 years (standard deviation = 22.6). The overall quality of care was rated as excellent by 65.9% of the patients, whereas 59.2% rated their pain management as excellent. Of the patients who rated their pain management as excellent, 79.0% rated the overall quality of care as excellent, whereas only 21.0% of the patients rated the overall quality of care as excellent if pain management was not excellent. When the patients rated EMS staff as excellent for both helping to control or reduce pain and explaining the medications given, they were 2.7 (95% confidence interval 1.4-5.4) times more likely to rate their overall quality of care as excellent. CONCLUSION: Our model indicated that pain management was associated with increased perception of overall quality of care only when EMS providers explained the medications provided and their potential side effects.

The association between prehospital endotracheal intubation attempts and survival to hospital discharge among out-of-hospital cardiac arrest patients.

OBJECTIVES: The benefit of prehospital endotracheal intubation (ETI) among individuals experiencing out-of-hospital cardiac arrest (OOHCA) has not been fully examined. The objective of this study was to determine if prehospital ETI attempts were associated with return of spontaneous circulation (ROSC) and survival to discharge among individuals experiencing OOHCA. METHODS: This retrospective study included individuals who experienced a medical cardiac arrest between July 2006 and December 2008 and had resuscitation efforts initiated by paramedics from Mecklenburg County, North Carolina. Outcome variables were prehospital ROSC and survival to hospital discharge, while the primary independent variable was the number of prehospital ETI attempts. RESULTS: There were 1,142 cardiac arrests included in the analytic data set. Prehospital ROSC occurred in 299 individuals (26.2%). When controlling for initial arrest rhythm and other confounding variables, individuals with no ETI attempted were 2.33 (95% confidence interval [CI] = 1.63 to 3.33) times more likely to have ROSC compared to those with one successful ETI attempt. Of the 299 individuals with prehospital ROSC, 118 (39.5%) were subsequently discharged alive from the hospital. Individuals having no ETI were 5.46 (95% CI = 3.36 to 8.90) times more likely to be discharged from the hospital alive compared to individuals with one successful ETI attempt. CONCLUSIONS: Results from these analyses suggest a negative association between prehospital ETI attempts and survival from OOHCA. In this study, the individuals most likely to have prehospital ROSC and survival to hospital discharge were those who did not have a reported ETI attempt. Further comparative research should assess the potential causes of the demonstrated associations.

Association between prehospital time intervals and ST-elevation myocardial infarction system performance.

BACKGROUND: Among individuals experiencing an ST segment-elevation myocardial infarction, current guidelines recommend that the interval from first medical contact to percutaneous coronary intervention be ≤90 minutes. The objective of this study was to determine whether prehospital time intervals were associated with ST-elevation myocardial infarction system performance, defined as first medical contact to percutaneous coronary intervention. METHODS AND RESULTS: Study patients presented with an acute ST-elevation myocardial infarction diagnosed by prehospital ECG between May 2007 and March 2009. Prehospital time intervals were as follows: 9-1-1 call receipt to ambulance on scene ≤10 minutes, ambulance on scene to 12-lead ECG acquisition ≤8 minutes, on-scene time ≤15 minutes, prehospital ECG acquisition to ST-elevation myocardial infarction team notification ≤10 minutes, and scene departure to patient on cardiac catheterization laboratory table ≤30 minutes. Time intervals were derived and analyzed with descriptive statistics and logistic regression. There were 181 prehospital patients who received percutaneous coronary intervention, with 165 (91.1) having complete data. Logistic regression indicated that table time, response time, and on-scene time were the benchmark time intervals with the greatest influence on the probability of achieving percutaneous coronary intervention in ≤90 minutes. Individuals with a time from scene departure to arrival on cardiac catheterization laboratory table of ≤30 minutes were 11.1 times (3.4 to 36.0) more likely to achieve percutaneous coronary intervention in ≤90 minutes than those with extended table times. CONCLUSIONS: In this patient population, prehospital timing benchmarks were associated with system performance. Although meeting all 5 benchmarks may be an ideal goal, this model may be more useful for identifying areas for system improvement that will have the greatest clinical impact.

Serial electrocardiography.

During the past 15 years, medicine has witnessed several important advances in coronary artery reperfusion therapy for acute myocardial infarction (AMI). Both percutaneous transluminal coronary angioplasty (PTCA) and thrombolytic therapy have made significant advances in the early treatment of the AMI patient. Given both the shown benefit of these treatment modalities and the cardiac injury that they can prevent, it behooves the emergency physician (EP) to make a timely diagnosis of AMI to restore adequate perfusion and to salvage the maximum amount of myocardium. A correct diagnosis is dependent on EP expertise in the evaluation of the chest pain patient--in large part, the electrocardiogram.