Reperfusion delay in patients treated with primary percutaneous coronary intervention: insight from a real world Danish ST-segment elevation myocardial infarction population in the era of telemedicine

Schoos, Mikkel Malby; Sejersten, Maria; Hvelplund, Anders; Madsen, Mette; Lønborg, Jacob; Steinmetz, Jacob; Treschow, Philip Michael; Pedersen, Frants; Jørgensen, Erik; Grande, Peer; Kelbæk, Henning; Clemmensen, Peter

doi:10.1177/2048872612455143

Cited by 26 publications

(31 citation statements)

References 40 publications

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“…This difference may be due to geographical differences, but further studies are required to explain this difference. Notably, the system delay for patients living more than 100 km from the PCI centre in our study was comparable to the system delay achieved for patients living 65–100 km from the PCI centre in a previous Danish study,15 which highlights the optimal setup in the present study.…”

Section: Discussionsupporting

confidence: 86%

“…Patients transported >11 km can bypass the city centre and save some transport time, and system delay may therefore be shorter for these patients. A recently published study15 using data from a prehospital setup that was nearly identical with the one used by us found a median system delay of 173 min in patients living >100 km from a PCI centre. We found a median system delay of 133 min in patients living >100 km from the PCI centre (table 3), which is considerably lower.…”

Section: Discussionmentioning

confidence: 68%

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Diagnostic performance and system delay using telemedicine for prehospital diagnosis in triaging and treatment of STEMI

Rasmussen

Frost

Stengaard

et al. 2014

Heart

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Section: Discussionsupporting

confidence: 86%

Section: Discussionmentioning

confidence: 68%

Diagnostic performance and system delay using telemedicine for prehospital diagnosis in triaging and treatment of STEMI

Rasmussen

Frost

Stengaard

et al. 2014

Heart

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“…Also, the finding that 72% of patients are directly referred for primary PCI after prehospital diagnosis closely resembles the rate of 73% recently reported in a small single-centre study. 18 Remarkably, we found that distance travelled by EMS was not predictive of ischemic time in multivariable analysis. This suggests that, within our geographical context, distance travelled by EMS is of minor relevance for total ischemic time.…”

Section: Discussionmentioning

confidence: 71%

Interhospital transfer due to failed prehospital diagnosis for primary percutaneous coronary intervention: an observational study on incidence, predictors, and clinical impact

Mahmoud

Nijsten

et al. 2013

European Heart Journal: Acute Cardiovascular Care

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Background: For patients with ST-elevation myocardial infarction (STEMI), guidelines recommend prehospital triage and direct referral to a percutaneous coronary intervention (PCI)-capable centre in order to minimize ischemic time. However, few have studied failed prehospital diagnosis. We assessed the incidence, predictors, and clinical impact of interhospital transfer for primary PCI after initial referral to a non-PCI-capable centre due to a failed prehospital STEMI diagnosis. Methods: We studied 846 consecutive STEMI patients undergoing primary PCI between January 2008 and January 2010. Results: We found that 609 patients (72%) were directly admitted through prehospital triage and 127 patients (15%) required interhospital transfer after failed prehospital diagnosis. Median first medical contact to treatment time was 88 min in the prehospital diagnosis group and 155 min in the interhospital transfer group (p<0.001). In the interhospital transfer group, the first available electrocardiogram was diagnostic for STEMI in 77% of cases. Predictors of interhospital transfer were female gender, diabetes, prior myocardial infarction, and greater event location to PCI-capable centre distance. Interhospital transfer independently accounted for a 47% increase in ischemic time (95% CI 33 to 63%; p<0.001). One-year mortality was higher in the interhospital transfer group (10 vs. 5.3%; p=0.030). Conclusions: Despite an often-diagnostic electrocardiogram, interhospital transfer after failed prehospital diagnosis occurred in 15% of STEMI patients undergoing primary PCI. Interhospital transfer was a major predictor of ischemic time and 1-year mortality was significantly higher. Continuing efforts to optimize prehospital triage are warranted, especially among patients at higher risk of failed prehospital diagnosis.

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“…Several studies have clearly demonstrated how pre-hospital diagnosis and networking strongly reduce ischaemia time and increase the percentage of patients undergoing reperfusion within the golden hours [248,249]. The large STEMI campaign launched by the ''Stent for Life'' initiative (www.stentforlife.com) to support STEMI networks in Europe as well as in several other continents, together with public campaigns, will certainly contribute in coming years to significantly increase the proportion of patients presenting at first medical contact within the early phase (golden hours) of infarction and therefore highly suitable for a more aggressive pharmacoinvasive approach started in the ambulance, especially when long-distance transportation is needed.…”

Section: Upstream Therapymentioning

confidence: 99%

Platelet GP IIb-IIIa Receptor Antagonists in Primary Angioplasty: Back to the Future

Luca

Savonitto

Hof

et al. 2015

Drugs

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Coronary artery disease and acute myocardial infarction still represent the leading cause of mortality in developed countries. Therefore, great efforts have been made in the last decades to improve reperfusion strategies and adjunctive antithrombotic therapies. In fact, despite optimal epicardial recanalisation, a large proportion of patients still experience impaired reperfusion and in-stent thrombosis. The adjunctive use of glycoprotein (GP) IIb-IIIa inhibitors may certainly contribute in the reduction of such complications, especially when administered in the early phase of infarction. In fact, in this phase a larger platelet composition of the thrombus and the presence of a larger amount of viable myocardium, as compared to a delayed phase, may increase the benefits from this therapy and counterbalance the potential higher risk of bleeding. A large body of evidence has been accumulated on the benefits from GP IIb-IIIa inhibitors in terms of prevention of stent thrombosis, and benefits in mortality, especially among high-risk patients and as upstream strategy. Therefore, based on current available data, GP IIb-IIIa inhibitors can be recommended as early as possible (upstream strategy) among high-risk patients, such as those with advanced Killip class or anterior myocardial infarction (MI), and those presenting within the first three hours. Even though it is not universally accepted, in our opinion this strategy should be implemented in a pre-hospital setting (in ambulance) or at first hospital admission (Emergency Room or Coronary Care Unit, irrespective of whether they are in the spoke or hub hospitals). Peri-procedural intracoronary administration of GP IIb-IIIa inhibitors has not provided additional benefits as compared to intravenous administration and therefore cannot be recommended. Even though the vast majority of trials have been conducted with abciximab, several meta-analyses comparing small molecules (mainly high-dose tirofiban rather than eptifibatide) versus abciximab showed similar angiographic and clinical results between the molecules. Several recent investigations and meta-analyses have documented the higher risk of stent thrombosis associated with bivalirudin as compared to unfractionated heparin (UFH). Being that these results are independent from the use of GP IIb-IIIa inhibitors, UFH should still remain the anticoagulation therapy of choice in ST-segment elevation myocardial infarction (STEMI) patients. Minimisation of bleeding complications by extensive use of the radial approach, in the setting of STEMI, may further contribute to the adoption of a more aggressive antithrombotic and antiplatelet therapy incorporating the use of GP IIb-IIIa inhibitors. The establishment of dedicated networks for STEMI, and the large STEMI campaign, will certainly contribute to increase the proportion of patients presenting at first medical contact within the early phase (3 h) of infarction and therefore highly suitable for a more aggressive pharmacoinvasive approach with upstream administration of GP IIb-II...

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Reperfusion delay in patients treated with primary percutaneous coronary intervention: insight from a real world Danish ST-segment elevation myocardial infarction population in the era of telemedicine

Cited by 26 publications

References 40 publications

Diagnostic performance and system delay using telemedicine for prehospital diagnosis in triaging and treatment of STEMI

Diagnostic performance and system delay using telemedicine for prehospital diagnosis in triaging and treatment of STEMI

Interhospital transfer due to failed prehospital diagnosis for primary percutaneous coronary intervention: an observational study on incidence, predictors, and clinical impact

Platelet GP IIb-IIIa Receptor Antagonists in Primary Angioplasty: Back to the Future

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