Quality improvement in the door‐to‐balloon times for ST‐elevation myocardial infarction patients presenting without chest pain

Objective: To assess a quality improvement initiative aimed at minimizing door‐to‐balloon (DTB) times for ST‐elevation myocardial infarction (STEMI) patients presenting without chest pain. Background: Timely percutaneous coronary intervention (PCI) is the cornerstone of STEMI care. The absence of chest pain delays PCI. Improvements in DTB times may need to focus on atypical presentation patients. Methods: We compared DTB times on all STEMI patients admitted through the emergency department who underwent PCI before (Phase I; October 2004–June 2007) and after (Phase II; July 2007–October 2009) the quality improvement effort, which mandated rapid electrocardiogram (ECG) triage for an expanded list of presenting symptoms. Results: In Phase I (69 patient, 60 with chest pain), patients with chest pain had a shorter mean time to first ECG (ECG Interval) by 32.0 min (P < 0.01) and nonsignificantly faster mean DTB time by 42.0 min (P = 0.07) compared to patients who presented without chest pain. In Phase II (62 patients, 56 with chest pain) compared to Phase I, mean ECG interval decreased by 44 min (P = 0.02) and mean DTB time by 99 min (P = 0.01) in patients without chest pain, eliminating the differences in ECG intervals between typical and atypical presentations (12 min vs. 11 min, P = 0.91). Multivariable analysis controlling for on/off hours and patient characteristics confirmed these findings. Conclusions: A simple modification of emergency room ECG triage protocol, which expands indications for rapid ECG performance, was successful in improving rapid reperfusion for patients with STEMI presenting without chest pain. © 2011 Wiley‐Liss, Inc.     

Chest‐lead ST‐J amplitudes using arm electrodes as reference instead of the Wilson central terminal in smartphone ECG applications: Influence on ST‐elevation myocardial infarction criteria fulfillment

Background

“Smartphone 12‐lead ECG” for the assessment of acute myocardial ischemia has recently been introduced. In the smartphone 12‐lead ECG either the right or the left arm can be used as reference for the chest electrodes instead of the Wilson central terminal. These leads are labeled “CR leads” or “CL leads.” We aimed to compare chest‐lead ST‐J amplitudes, using either CR or CL leads, to those present in the conventional 12‐lead ECG, and to determine sensitivity and specificity for the diagnosis of STEMI for CR and CL leads.

Methods

Five hundred patients (74 patients with ST elevation myocardial infarction (STEMI), 66 patients with nonischemic ST deviation and 360 controls) were included. Smartphone 12‐lead ECG chest‐lead ST‐J amplitudes were calculated for both CR and CL leads.

Results

ST‐J amplitudes were 9.1 ± 29 μV larger for CR leads and 7.7 ± 42 μV larger for CL leads than for conventional chest leads (V leads). Sensitivity and specificity were 94% and 95% for CR leads and 81% and 97% for CL leads when fulfillment of STEMI criteria in V leads was used as reference. In ischemic patients who met STEMI criteria in V leads, but not in limb leads, STEMI criteria were met with CR or CL leads in 91%.

Conclusion

By the use of CR or CL leads, smartphone 12‐lead ECG results in slightly lower sensitivity in STEMI detection. Therefore, the adjustment of STEMI criteria may be needed before application in clinical practice.     

Management of acute myocardial infarction during the COVID‐19 pandemic

The worldwide pandemic caused by the novel acute respiratory syndrome coronavirus 2 has resulted in a new and lethal disease termed coronavirus disease 2019 (COVID‐19). Although there is an association between cardiovascular disease and COVID‐19, the majority of patients who need cardiovascular care for the management of ischemic heart disease may not be infected with this novel coronavirus. The objective of this document is to provide recommendations for a systematic approach for the care of patients with an acute myocardial infarction (AMI) during the COVID‐19 pandemic. There is a recognition of two major challenges in providing recommendations for AMI care in the COVID‐19 era. Cardiovascular manifestations of COVID‐19 are complex with patients presenting with AMI, myocarditis simulating an ST‐elevation myocardial infarction (STEMI) presentation, stress cardiomyopathy, non‐ischemic cardiomyopathy, coronary spasm, or nonspecific myocardial injury, and the prevalence of COVID‐19 disease in the US population remains unknown with risk of asymptomatic spread. This document addresses the care of these patients focusing on (a) varied clinical presentations; (b) appropriate personal protection equipment (PPE) for health care workers; (c) the roles of the emergency department, emergency medical system, and the cardiac catheterization laboratory (CCL); and (4) regional STEMI systems of care. During the COVID‐19 pandemic, primary percutaneous coronary intervention (PCI) remains the standard of care for STEMI patients at PCI‐capable hospitals when it can be provided in a timely manner, with an expert team outfitted with PPE in a dedicated CCL room. A fibrinolysis‐based strategy may be entertained at non‐PCI‐capable referral hospitals or in specific situations where primary PCI cannot be executed or is not deemed the best option.     

Pre-hospital 12-lead electrocardiography programs: a call for implementation by emergency medical services systems providing advanced life support--National Heart Attack Alert Program (NHAAP) Coordinating Committee; National Heart, Lung, and Blood Institute (NHLBI); National Institutes of Health.

Emergency medical services (EMS) providers who administer advanced life support should include diagnostic 12-lead electrocardiography programs as one of their services. Evidence demonstrates that this technology can be readily used by EMS providers to identify patients with ST-segment elevation myocardial infarction (STEMI) before a patient's arrival at a hospital emergency department. Earlier identification of STEMI patients leads to faster artery-opening treatment with fibrinolytic agents, either in the pre-hospital setting or at the hospital. Alternatively, a reperfusion strategy using percutaneous coronary intervention can be facilitated by use of pre-hospital 12-lead electrocardiography (P12ECG). Analysis of the cost of providing this service to the community must include consideration of the demonstrated benefits of more rapid treatment of patients with STEMI and the resulting time savings advantage shown to accompany the use of P12ECG programs.     

Pre-hospital 12-lead electrocardiography programs: a call for implementation by emergency medical services systems providing advanced life support--National Heart Attack Alert Program (NHAAP) Coordinating Committee; National Heart, Lung, and Blood Institute (NHLBI); National Institutes of Health

Emergency medical services (EMS) providers who administer advanced life support should include diagnostic 12-lead electrocardiography programs as one of their services. Evidence demonstrates that this technology can be readily used by EMS providers to identify patients with ST-segment elevation myocardial infarction (STEMI) before a patient's arrival at a hospital emergency department. Earlier identification of STEMI patients leads to faster artery-opening treatment with fibrinolytic agents, either in the pre-hospital setting or at the hospital. Alternatively, a reperfusion strategy using percutaneous coronary intervention can be facilitated by use of pre-hospital 12-lead electrocardiography (P12ECG). Analysis of the cost of providing this service to the community must include consideration of the demonstrated benefits of more rapid treatment of patients with STEMI and the resulting time savings advantage shown to accompany the use of P12ECG programs.     

PR Depression Is Useful in the Differential Diagnosis of Myopericarditis and ST Elevation Myocardial Infarction

Background: Deviation of the PR segment is a common but often ignored ECG finding in acute myopericarditis, but seems to be rare in the acute phase of ST elevation myocardial infarction (STEMI). Since rapid bedside differential diagnosis of acute myopericarditis and STEMI is essential, we decided to assess the diagnostic power of PR depressions in patients presenting with ST elevations in the emergency room. Methods: Thirty‐four consecutive patients with acute myopericarditis and 46 STEMI patients presenting with ST elevations fulfilling the criteria for STEMI were included. The first ECG recorded in the emergency room was analyzed with a focus on the PR segment. The diagnoses of myopericarditis and STEMI were ascertained with clinical follow‐up together with rise in troponin levels, and in the STEMI patients also with coronary angiography. Results: In myopericarditis, the most common location for PR depression was lead II (55.9%), while this ECG finding least likely appeared in lead aVL (2.9%). PR depression in any lead had a high sensitivity (88.2%), but fairly low specificity (78.3%) for myopericarditis. The combination of PR depressions in both precordial and limb leads had the most favorable predictive power to differentiate myopericarditis from STEMI (positive 96.7% and negative power 90%). Conclusions: Our present observations show that PR segment analysis is a powerful tool in the differential diagnosis of myopericarditis and STEMI. This simple information should be added to the diagnostic workup of patients presenting with ST elevations.     

Prognostic Significance of T‐Wave Amplitude in Lead aVR on the Admission Electrocardiography in Patients with Anterior Wall ST‐Elevation Myocardial Infarction Treated by Primary Percutaneous Intervention

Background: T‐wave positivity in aVR lead patients with heart failure and anterior wall old ST‐segment elevation myocardial infarction (STEMI) are shown to have a higher frequency of cardiovascular mortality, although the effects on patients with STEMI treated with primary percutaneous coronary intervention (PCI) has not been investigated. In this study, we sought to determine the prognostic value of T wave in lead aVR on admission electrocardiography (ECG) for in‐hospital mortality in patients with anterior wall STEMI treated with primary PCI. Methods: After exclusion, 169 consecutive patients with anterior wall STEMI (mean age: 55 ± 12.9 years; 145 men) undergoing primary PCI were prospectively enrolled in this study. Patients were classified as a T‐wave positive (n = 53, group 1) or T‐wave negative (n = 116, group 2) in aVR based upon the admission ECG. All patients were evaluated with respect to clinical features, primary PCI findings, and in‐hospital clinical results. Results: T‐wave positive patients who received primary PCI were older, multivessel disease was significantly more frequent and the duration of the patient's hospital stay was longer than T‐wave negative patients. In‐hospital mortality tended to be higher in the group 1 when compared with group 2 (7.5% vs 1.7% respectively, P = 0.05). After adjusting the baseline characteristics, positive T wave remained an independent predictor of in hospital mortality (odds ratio: 4.41; 95% confidence interval 1.2–22.1, P = 0.05). Conclusions: T‐wave positivity in lead aVR among patients with an anterior wall STEMI treated with primary PCI is associated with an increase in hospital cardiovascular mortality.     

Electrocardiogram evolution of acute anterior ST‐segment elevation myocardial infarction following pericarditis

Electrocardiogram is a powerful tool for differentiating acute ST‐segment elevation myocardial infarction (STEMI) and pericarditis. However, an unusual ECG presentation of the simultaneous occurrence of the two conditions has not been reported previously. In this article, we report a case of ECG evolution of acute anterior STEMI following pericarditis with pericardial effusion (PE) and find that QRS complex widening in ECG lead with maximal ST‐segment elevation is also applicable for identifying STEMI even in patients with prior pericarditis. Undoubtedly, our case can help prevent emergency physicians from making incorrect diagnoses and administering inappropriate treatments.     

Smartphone ECG for evaluation of ST-segment elevation myocardial infarction (STEMI): Design of the ST LEUIS International Multicenter Study

In patients experiencing an ST-elevation myocardial infarction (STEMI), rapid diagnosis and immediate access to reperfusion therapy leads to optimal clinical outcomes. The rate-limiting step in STEMI diagnosis is the availability and performance of a 12–lead ECG. Recent technology has provided access to a reliable means of obtaining an ECG reading through a smartphone application (app) that works with an attachment providing all 12–leads of a standard ECG system. The ST LEUIS study was designed to validate the smartphone ECG app and its ability to accurately assess the presence or absence of STEMI in patients presenting with chest pain compared with the gold standard 12–lead ECG. We aimed to support the diagnostic utility of smartphone technology to provide a timely diagnosis and treatment of STEMI. The study will take place over 12 months at five institutions. Approximately 60 patients will be enrolled per institution, for a total recruitment of 300 patients.     

High‐Intensity Telemedicine‐Enhanced Acute Care for Older Adults: An Innovative Healthcare Delivery Model

Accessing timely acute medical care is a challenge for older adults. This article describes an innovative healthcare model that uses high‐intensity telemedicine services to provide rapid acute care for older adults without requiring them to leave their senior living community (SLC) residences. This program, based in a primary care geriatrics practice that cares for SLC residents, is designed to offer acute care through telemedicine for complaints that are felt to need attention before the next available outpatient visit but not to require emergency department (ED) resources. This option gives residents access to care in their residence. Measures used to evaluate the program include successful completion of telemedicine visits, satisfaction of residents and caregivers with telemedicine care, and site of care that would have been recommended had telemedicine been unavailable. During the first 2 years of the program's operation, 281 of 301 requested telemedicine visits were completed successfully. Twelve residents were sent to an ED for care after the telemedicine visit. Ninety‐four percent of residents reported being satisfied or very satisfied with telemedicine care. Had telemedicine not been available, residents would have been sent to an ED (48.1%) or urgent care center (27.0%) or been scheduled for an outpatient visit (24.4%). The project demonstrated that high‐intensity telemedicine services for acute illnesses are feasible and acceptable and can provide definitive care without requiring ED or urgent care use. Continuation of the program will require evaluation demonstrating equal or better resident‐level outcomes and the development of sustainable business models.     

Vectorcardiography Risk Stratifies Emergency Department Chest Pain Patients with Left Ventricular Hypertrophy on the Initial 12‐Lead ECG

Background: Vectorcardiographic (VCG) measurements of ST‐vector magnitude (VM) and QRS‐vector difference (VD) have been demonstrated to be independent predictors of adverse outcome (AO) and acute myocardial infarction (AMI) in emergency department (ED) chest pain patients with absence of bundle branch block or left ventricular hypertrophy (LVH) on the initial 12‐lead electrocardiogram (ECG). The prognostic value of ST‐VM and QRS‐VD in ED chest pain patients with LVH on the initial 12‐lead ECG has not been previously investigated. Methods: A prospective observational study was performed in 196 consecutive ED chest pain patients with suspected AMI and presence of voltage criteria for LVH on initial ECG who underwent continuous VCG monitoring during the initial evaluation. The optimal baseline ST‐VM value and 2‐hour QRS‐VD value were defined as the most accurate value on the receiver operator characteristic curve (value with lowest false‐negative and false‐positive rate). Thirty‐day AO was defined as AMI, percutaneous coronary intervention, coronary artery bypass grafting (CABG), or cardiac death occurring within 30 days of initial ED visit. Results: Fourteen patients (7.1%) were diagnosed as 24‐hour AMI and 28 patients (14.3%) experienced 30‐day AO. The optimal cut‐off value for predicting 30‐day AO was >124 μV for ST‐VM and >21.7 μV for QRS‐VD. Patients with either a positive ST‐VM or a positive QRS‐VD had 8.8 times increased odds of AMI (95% confidence interval, CI, 1.9–40.3; P = 0.003); 4.3 times increased odds of 30‐day PTCA/CABG (95% CI 1.3–13.8; P = 0.019); and 3.8 times increased odds of 30‐day AO (95% CI 1.6–9.3; P = 0.003). Conclusions: Baseline ST‐VM and 2‐hour QRS‐VD risk stratifies ED chest pain patients with LVH voltage criteria on the initial 12‐lead ECG.     

Appropriate cardiac cath lab activation: optimizing electrocardiogram interpretation and clinical decision-making for acute ST-elevation myocardial infarction

During the last few decades, acute ST-elevation on an electrocardiogram (ECG) in the proper clinical context has been a reliable surrogate marker of acute coronary occlusion requiring primary percutaneous coronary intervention (PPCI). In 2004, the American College of Cardiology/American Heart Association ST-elevation myocardial infarction (STEMI) guidelines specified ECG criteria that warrant immediate angiography in patients who are candidates for primary PPCI, but new findings have emerged that suggest a reappraisal is warranted. Furthermore, as part of integrated and efficient STEMI systems, emergency department and emergency medical services providers are now encouraged to routinely make the time-sensitive diagnosis of STEMI and promptly activate the cardiac catheterization laboratory (Cath Lab) team. Our primary objective is to provide a practical summary of updated ECG criteria for emergency coronary angiography with planned PPCI, thus allowing clinicians to maximize the rate of appropriate Cath Lab activation and minimize the rate of inappropriate Cath Lab activation. We review the evidence for ECG interpretation strategies that either increase diagnostic specificity for "classic" STEMI and left bundle-branch block or improve diagnostic sensitivity in identifying 4 STEMI-equivalents: posterior MI, acute left main occlusion, de Winter ST/T-wave complex, and certain scenarios of resuscitated cardiac arrest.     

Patients with Tombstoning Pattern on the Admission Electrocardiography Who Have Undergone Primary Percutaneous Coronary Intervention for Anterior Wall ST‐Elevation Myocardial Infarction: In‐Hospital and Midterm Clinical Outcomes

Background: A tombstoning pattern (T‐pattern) is associated with in‐hospital poor outcomes patients with ST‐segment elevation myocardial infarction (STEMI), but no data are available for midterm follow‐up. We sought to determine the prognostic value of a T‐pattern on admission electrocardiography (ECG) for in‐hospital and midterm mortality in patients with anterior wall STEMI treated with primary percutaneous coronary intervention (PCI). Methods: After exclusion, 169 consecutive patients with anterior wall STEMI (mean age: 55 ± 12.9 years; 145 men) undergoing primary PCI were prospectively enrolled in this study. Patients were classified as a T‐pattern (n = 32) or non–T‐pattern (n = 137) based upon the admission ECG. Follow‐up to 6 months was performed. Results: In‐hospital mortality tended to be higher in the T‐pattern group compared with non–T‐pattern group (9.3% vs 2.1% respectively, P = 0.05). All‐cause mortality was higher in the T‐pattern group than non–T‐pattern group for 6 month (P = 0.004). After adjusting the baseline characteristics, the T‐pattern remained an independent predictor of 6‐month all‐cause mortality (odds ratio: 5.18; 95% confidence interval: 1.25–21.47, P = 0.02). Conclusion: A T‐pattern is a strong independent predictor of 6‐month all‐cause mortality in anterior STEMI treated with primary PCI. Therefore, it may be an indicator of high risk among patients with anterior wall STEMI.     

Arterial access and door‐to‐balloon times for primary percutaneous coronary intervention in patients presenting with acute ST‐elevation myocardial infarction

Objectives: This study compares the transradial versus the transfemoral approach for time to intervention for patients presenting with ST elevation myocardial infarction (STEMI). Background: Survival following STEMI is associated with reperfusion times (door‐to‐balloon; D2B). For patients undergoing primary PCI for acute STEMI, potential effects of transradial approach (r‐PCI) as compared with the femoral artery approach (f‐PCI) on D2B times have not been extensively studied. Methods: Consecutive patients presenting with STEMI at a tertiary care medical center were enrolled in a comprehensive—Heart Alert program (HA) and included in this analysis. Time parameters measured included: door‐to‐ECG, ECG‐to‐HA activation, HA activation‐to‐cath lab team arrival, patient arrival in cath lab to arterial access, and arterial access‐to‐balloon inflation. Results: Of 240 total patients, 205 underwent successful PCI (n = 124 r‐PCI; n = 116 f‐PCI). No significant difference was observed in the pre‐cath lab times. Mean case start times for r‐PCI took significantly longer (12.5 ± 5.4 min vs. 10.5 ± 5.7 min, P = 0.005) due to patient preparation. Once arterial access was obtained, balloon inflation occurred faster in the r‐PCI group (18.3 vs. 24.1 min; P < 0.001). Total time from patient arrival to the cardiac cath lab to PCI was reduced in the r‐PCI as compared to the f‐PCI group (28.4 vs. 32.7 min, P = 0.01). There was a small but statistical difference in D2B time (r‐PCI 76.4 min vs. f‐PCI 86.5 min P = 0.008). Conclusions: Patients presenting with STEMI can undergo successful PCI via radial artery approach without compromise in D2B times as compared to femoral artery approach. © 2009 Wiley‐Liss, Inc.     

Telecardiology applied to a region-wide public emergency health-care service

Aim To assess feasibility and reliability of telecardiology technologies applied to a region-wide public emergency health-care service. Methods About 27,841 patients from all over Apulia (19.362 km², 4 million inhabitants) were referred from October 2004 until April 2006 to public emergency health-care number “118” and underwent ECG evaluation according to a previously fixed inclusion protocol. Data recorded were transmitted with mobile telephone support to a telecardiology “hub” active 24-h a day. Hospitalization or further examinations were arranged by emergency physicians on the basis of ECG diagnosis and consultation. Results Thirty-nine percent of patients complained of chest pain (CP) or epigastric pain, 26% loss of consciousness, 10% breathlessness, and 7% palpitations. Atrial fibrillation (AF) was diagnosed in 11.68% of patients and ST-elevation acute myocardial infarction (STEMI) in 1.91%. Among patients with CP, ECG showed STEMI in only 3.84% of cases, theoretically eligible for fibrinolysis or primary PCI; patients with STEMI complained of CP in 78.94% of cases. Of the patients, 65.28% with STEMI were from small towns without coronary care units, thus benefiting from an immediate pre-hospital diagnosis. Among patients with palpitations, only 10.27% of subjects showed ECG signs of supra-ventricular tachycardia and 25.18% of AF; other subjects avoided further improper hospitalization or emergency department monitoring. Conclusions This first region-wide leading experience shows the feasibility and reliability of telecardiology applied to a public emergency health-care service. Telemedicine protocols would probably be useful in lowering the number of improper hospitalizations and shortening delay in the diagnosis process of some heart diseases.     

Effect of prehospital 12-lead electrocardiogram on activation of the cardiac catheterization laboratory and door-to-balloon time in ST-segment elevation acute myocardial infarction

Reducing door-to-balloon (D + B) time during primary percutaneous coronary intervention for patients with ST-segment elevation myocardial infarction (STEMI) reduces mortality. Prehospital 12-lead electrocadiography (ECG) with cardiac catheterization laboratory (CCL) activation may reduce D + B time. Paramedic-performed ECG was initiated in the city of San Diego in January 2005 with STEMI diagnosis based on an automated computer algorithm. We undertook this study to determine the effect of prehospital CCL activation on D + B time for patients with acute STEMI brought to our institution. All data were prospectively collected for patients with STEMI including times to treatment and clinical outcomes. We evaluated 78 consecutive patients with STEMI from January 2005 to June 2006, and the study group consisted of all patients with prehospital activation of the CCL (field STEMI; n = 20). The control groups included concurrently-treated patients with STEMI during the same period who presented to the emergency department (nonfield STEMI; n = 28), and all patients with STEMI treated in the preceding year (2004) (historical STEMI; n = 30). Prehospital CCL activation significantly reduced D + B time (73 +/- 19 minutes field STEMI, 130 +/- 66 minutes nonfield STEMI, 141 +/- 49 minutes historical STEMI; p <0.001) with significant reductions in door-to-CCL and CCL-to-balloon times as well. The majority of patients with field STEMI achieved D + B times of <90 minutes (80% field STEMI, 25% nonfield STEMI, 10% historical STEMI; p <0.001). In conclusion, this study demonstrates that prehospital electrocardiographic diagnosis of STEMI with activation of the CCL markedly reduces D + B time.     

Mid‐Ventricular Obstructive Hypertrophic Cardiomyopathy and Apical Aneurysm Mimicking Acute ST‐Elevation Myocardial Infarction

Nonischemic ST‐segment elevation may be confused as acute ST‐elevation myocardial infarction (STEMI), especially in patients with atypical presenting symptoms. Among the possible differential diagnosis, hypertrophic cardiomyopathy (HCM) should be considered. Mid‐ventricular obstructive hypertrophic cardiomyopathy (MVOHCM) is a rare type of cardiomyopathy, accounting for approximately 5% of all HCM cases. ST‐segment elevation on electrocardiogram (ECG) in patients with MVOHCM is a rare clinical presentation. We present a case of MVOHCM and apical aneurysm mimicking acute STEMI     

Percutaneous Coronary Intervention,Comorbidities, and Mortality among Emergency Department–Admitted ST‐Elevation Myocardial Infarction Patients in Florida

Background: Risk of mortality following an ST‐elevation myocardial infarction (STEMI) can be significantly reduced by prompt percutaneous coronary intervention (PCI). National guidelines specify primary PCI as the preferred recommended treatment for STEMI. In this study, we examined same‐day PCI as an independent predictor of in‐hospital mortality, after adjustment for comorbidities, other patient factors, and hospital PCI‐volume using unselected surveillance data from Florida. Methods: We analyzed hospital discharge data for adults, 18+ years old, with a primary diagnosis of STEMI who were admitted to PCI‐capable hospitals through the emergency department during 2001–2005 (n = 43,849). Hierarchical (multilevel) logistic regression models were used for analysis. Results: Overall, 4,143 STEMI patients (9.4%) did not survive to hospital discharge. In late 2005, the in‐hospital mortality rates were 1.9% for those who received same‐day PCI versus 13.0% for those who did not. After adjustment for multiple patient factors, same‐day PCI was a significant predictor of in‐hospital survival with a strong protective effect (adjusted OR = 0.35, 95% CI 0.31–0.38 P < 0.0001). Restriction of the analysis to those patients who survived the first day of admission did not appreciably change this result (adjust OR = 0.37, 95% CI 0.33–0.42, P < 0.0001). Hospital PCI‐volume did not significantly impact mortality risk. Conclusions: Same‐day PCI markedly reduced the risk of in‐hospital mortality among STEMI patients after multivariate adjustment. Serious comorbidities and complications, older age, and female gender continued to predict elevated risk of mortality after control for treatment status. Our results provide additional evidence in support of national clinical recommendations and aggressive treatment of STEMI. (J Interven Cardiol 2010;23:205–215)     

Primary percutaneous coronary intervention for patients presenting with ST-segment elevation myocardial infarction: process improvement in a rural ST-segment elevation myocardial infarction receiving center

Background

Rural ST-segment elevation myocardial infarction (STEMI) care networks may be particularly disadvantaged in achieving a door-to-balloon time (D2B) of less than or equal to 90 minutes recommended in current guidelines.

ST-Elevation Myocardial Infarction Process Upgrade Project

A multidisciplinary STEMI process upgrade group at a rural percutaneous coronary intervention center implemented evidence-based strategies to reduce time to electrocardiogram (ECG) and D2B, including catheterization laboratory activation triggered by either a prehospital ECG demonstrating STEMI or an emergency department physician diagnosing STEMI, single-call catheterization laboratory activation, catheterization laboratory response time less than or equal to 30 minutes, and prompt data feedback.

Evaluating success

An ongoing regional STEMI registry was used to collect process time intervals, including time to ECG and D2B, in a consecutive series of STEMI patients presenting before (group 1) and after (group 2) strategy implementation. Significant reductions in time to first ECG in the emergency department and D2B were seen in group 2 compared with group 1.

Conclusions

Important improvement in the process of acute STEMI patient care was accomplished in the rural percutaneous coronary intervention center setting by implementing evidence-based strategies.     

Safety and efficacy of drug‐eluting stent for ST‐segment elevation myocardial infarction in an unselected consecutive cohort

Objective: The objective of this study is to investigate the clinical outcome of a large cohort of patients with ST‐segment elevation myocardial infarction (STEMI) treated with drug‐eluting stents (DES) compared to bare metal stents (BMS). Background: Several randomized controlled trials have demonstrated that PCI with the routine use of DES is safe and effective in patients with STEMI. However as randomized trials have strict inclusion criteria, further studies in unselected patient populations are needed. Methods: We performed a retrospective cohort analysis of the Mayo Clinic PCI database. A total of 552 consecutive STEMI patients who underwent a DES implantation between May 2003 and April 2006 were included in the study and compared to 557 who had BMS for STEMI earlier. No specific patient subsets were excluded. Results: Procedural success was achieved in 532 patients (96%). During initial hospitalization, 16 patients (2.9%) died and 8 (1.5%) suffered from a recurrent myocardial infarction. The median follow‐up was 23 months (IQR: 13–27 months). At 12 months post discharge, the rate of target lesion revascularization and death were 2.9% and 3.7%, respectively, and survival free of major adverse cardiac events (MACE) was 90.9%. These rates were similar to or lower than those of patients treated for STEMI with BMS prior to the availability of DES. Conclusion: DES are safe and effective in the treatment of STEMI in an unselected cohort; 90.9% of patients are free of MACE at 12 months post discharge. © 2008 Wiley‐Liss, Inc.