Impact of patient delay in a modern real world STEMI network

Fabris, Enrico; Arrigoni, Paola; Falco, Luca; Barbati, Giulia; Stolfo, Davide; Peratoner, Alberto; Vitrella, Giancarlo; Rakar, Serena; Perkan, Andrea; Sinagra, Gianfranco

doi:10.1016/j.ajem.2020.02.028

Cited by 15 publications

(17 citation statements)

References 13 publications

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“…Women are on average older than men, they have a worse risk profile (more hypertension, diabetes mellitus, peripheral vascular disease), are more prone to developing mechanical complications and they have more often microvascular dysfunction. 19 Ischemia time was shorter in CS patients compared with no-CS patients, probably because of shorter 'patient delay', an important component of ischemia time, 20 due to the more severe symptoms. Indeed, the presence of higher peak troponin and lower LVEF indicates more extensive damage.…”

Section: Discussionmentioning

confidence: 99%

Early prognostic stratification and identification of irreversibly shocked patients despite primary percutaneous coronary intervention

Falco¹,

Fabris²,

Gregorio

et al. 2021

Journal of Cardiovascular Medicine

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BackgroundDespite prognostic improvements in ST-elevation myocardial infarction (STEMI), patients presenting with cardiogenic shock (CS) have still high mortality. Which are the relevant early prognostic factors despite revascularization in this high-risk population is poorly investigated.MethodsWe analyzed STEMI patients treated with primary percutaneous coronary intervention (PCI) and enrolled at the University Hospital of Trieste between 2012 and 2018. A decision tree based on data available at first medical contact (FMC) was built to stratify patients for 30-day mortality. Multivariate analysis was used to explore independent factors associated with 30-day mortality.ResultsAmong 1222 STEMI patients consecutively enrolled, 7.5% presented with CS. CS compared with no-CS patients had worse 30-day mortality (33% vs 3%, P < 0.01). Considering data available at FMC, CS patients with a combination of age ≥76 years, anterior STEMI and an expected ischemia time > 3 h and 21 min were at the highest mortality risk, with a 30-day mortality of 85.7%. In CS, age (OR 1.246; 95% CI 1.045–1,141; P = 0.003), final TIMI flow 2–3 (OR 0.058; 95% CI 0.004–0.785; P = 0.032) and Ischemia Time (OR = 1.269; 95% CI 1.001–1.609; P = 0.049) were independently associated with 30-day mortality.ConclusionsIn a contemporary real-world population presenting with CS due to STEMI, age is a relevant negative factor whereas an early and successful PCI is positively correlated with survival. However, a subgroup of elderly patients had severe prognosis despite revascularization. Whether pPCI may have an impact on survival in a very limited number of irreversibly critically ill patients remains uncertain and the identification of irreversibly shocked patients remains nowadays challenging.

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Section: Discussionmentioning

confidence: 99%

Early prognostic stratification and identification of irreversibly shocked patients despite primary percutaneous coronary intervention

Falco¹,

Fabris²,

Gregorio

et al. 2021

Journal of Cardiovascular Medicine

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“…This may also highlights the importance of reducing patients delay, 6 one of the main component of total ischemia time, and the importance of an efficient organization of STEMI networks which may allow the initiation of STEMI treatment at FMC.…”

Section: Discussionmentioning

confidence: 99%

“…This may suggest that the therapeutic effect of pre‐H treatment is likely to be modulated by the duration of coronary occlusion and may support the rationale of early administration of anticoagulant and DAPT when coronary thrombus is more susceptible to antithrombotic therapy. This may also highlights the importance of reducing patients delay, 6 one of the main component of total ischemia time, and the importance of an efficient organization of STEMI networks which may allow the initiation of STEMI treatment at FMC.…”

Section: Discussionmentioning

confidence: 99%

Effect of prehospital treatment in STEMI patients undergoing primary PCI

Fabris

Menzio

Gregorio

et al. 2022

Cathet Cardio Intervent

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Background: The appropriate timing to administer antithrombotic therapies in ST-elevation myocardial infarction (STEMI) remains uncertain. This study aims to evaluate the role of antithrombotic therapy administration at first medical contact (FMC) compared with the administration in the Cathlab. Methods:We conducted a "before-after" observational study enrolling STEMI undergoing primary percutaneous coronary intervention (PCI). Outcomes were evaluated during two successive periods, before (control group: aspirin only at FMC) and after (pretreated intervention group: heparin, aspirin plus ticagrelor at FMC) the introduction of a new regional pretreatment protocol.Results: A total of 537 consecutive patients (300 in control vs. 237 in intervention group) were enrolled. The pretreated compared with no pretreated population showed better basal reperfusion, expressed as basal Thrombolysis in Myocardial Infarction (TIMI)-flow (p for trend p < 0.001). Pretreated population showed lower frequency of TIMI 0 (56.5% vs. 73.7%, odds ratio [OR]: 0.46, 95% confidence interval [CI]: 0.32-0.67, p < 0.001) and higher frequency of TIMI 2-3 (33.3% vs.19.3% OR: 2.0, 95% CI: 1.38-2.00, p < 0.001) and TIMI 3 (14.3% vs. 9.7%, OR: 1.56, 95% CI: (0.92-2.65), p = 0.094). Pretreated compared with no pretreated population showed reduced infarct size expressed as Troponin Peak (20,286 (8726-75,027) versus 48,676 (17,229-113,900), p = 0.001), and higher left ventricular ejection fraction at discharge (53% (44-59) vs. 50% (44-56), p = 0.027). In-hospital BARC ≥ 2 bleeding were similar (2.1% vs. 2.0%, p = 0.929, in pretreated versus no pretreated population, respectively). Conclusion:This study provides support for an early pretreatment strategy in STEMI patients and confirmed the importance of an efficient organization of STEMI networks which allow initiation of antithrombotic treatment at FMC.

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“…The timing of invasive treatment in MI patients with STEMI and non-ST-segment elevation MI infarction (NSTEMI) needs to adhere to the guidelines 1,27 . While in STEMI patients, immediate invasive strategy with PPCI is generally recommended 1,28 , timing of intervention in NSTEMI patients depends on patient's risk profile 29,30 . In very high risk patients, immediate invasive approach is indicated, whereas early invasive strategy (<24h) and invasive strategy (<72h) are indicated in high risk patients and in intermediate risk patients, respectively 31 .…”

Section: Discussionmentioning

confidence: 99%

Primary percutaneous coronary intervention is appropriate in transient ST-elevation myocardial infarction

Koc¹,

Mikolášková²,

Novotný³

et al. 2022

Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub

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Introduction.Reperfusion therapy by primary percutaneous coronary intervention (PPCI) is generally indicated in patients suffering from acute myocardial infarction (MI) with ST-segment elevation (STEMI). Prior to hospital admission, full ST-segment resolution (fSTR) may occur. Optimal management of such patients with transient STEMI (TSTEMI) is potentially challenging. Our aim was to evaluate the hypothesis that in TSTEMI patients, patency of infarct related artery (IRA) is achieved before PPCI, and to compare the outcome of TSTEMI and STEMI patients during a prolonged follow-up. Material and Methods. Three hundred consecutive adult STEMI patients were referred to catheterization laboratory. In all patients, standard 12 lead ECGs were obtained both at the time of the first medical contact, and on catheterization laboratory admission. Results. TSTEMI occurred in 20 patients (6.7%). Despite fSTR (isoelectric ST segment), occluded IRA was found in 5 of these patients (25%). Pre-PPCI TIMI flow grade 2 was found in 6 TSTEMI patients (30%). Troponin T value at 24 h after symptom onset was lower in the TSTEMI group (1.8±2.5 mg/L vs. 3.6±3.5 mg/L, P=0.008). These patients also had a lower value of brain natriuretic peptide (156.3±119.5 ng/L vs. 438.5±429.0 ng/L, P<0.001) and higher left ventricular ejection fraction (59.9±6.3% vs. 51.6±10.2%, P<0.001). All patients were followed for a median of 5.6 years during which the overall survival did not differ between the TSTEMI and STEMI groups. Conclusion. Primary PCI is strongly recommended in TSTEMI patients because of a relatively high incidence of occluded infarct related arteries. The rate of patients with TSTEMI is relatively low.

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Impact of patient delay in a modern real world STEMI network

Cited by 15 publications

References 13 publications

Early prognostic stratification and identification of irreversibly shocked patients despite primary percutaneous coronary intervention

Early prognostic stratification and identification of irreversibly shocked patients despite primary percutaneous coronary intervention

Effect of prehospital treatment in STEMI patients undergoing primary PCI

Primary percutaneous coronary intervention is appropriate in transient ST-elevation myocardial infarction

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