Delay in Presentation and Reperfusion Therapy in ST-Elevation Myocardial Infarction

doi:10.1016/j.amjmed.2007.11.017

The American Journal of Medicine

Volume 121, Issue 4, April 2008, Pages 316-323

https://doi.org/10.1016/j.amjmed.2007.11.017 Get rights and content

Abstract

Background

We studied the relationship between longer delays from symptom onset to hospital presentation and the use of any reperfusion therapy, door-to-balloon time, and door-to-drug time.

Methods

Cohort study of patients with ST-elevation myocardial infarction enrolled in the National Registry of Myocardial Infarction from January 1, 1995 to December 31, 2004. Delay in hospital presentation was categorized into 1-hour intervals as ≤1 hour, >1-2 hours, >2-3 hours, etc, up to >11-12 hours. The study analyzed 3 groups: 440,398 patients for the association between delay and use of any reperfusion therapy; 67,207 patients for the association between delay and door-to-balloon time; 183,441 patients for the association between delay and door-to-drug time.

Results

In adjusted analyses, patients with longer delays between symptom onset and hospital presentation were less likely to receive any reperfusion therapy, had longer door-to-balloon times, and had longer door-to-needle times (all P <.0001 for linear trend). For patients presenting ≤1 hour, >1-2 hours, >2-3 hours, >9-10 hours, >10-11 hours, and >11-12 hours after symptom onset, the use of any reperfusion therapy were 77%, 77%, 73%, 53%, 50%, and 46%, respectively. Door-to-balloon times were 99, 101, 106, 123, 125, and 123 minutes, respectively, and door-to-drug times were 33, 34, 36, 46, 44, and 47 minutes, respectively.

Conclusions

Longer delays from symptom onset to hospital presentation were associated with reduced likelihood of receiving primary reperfusion therapy, and even among those treated, late presenters had significantly longer door-to-balloon and door-to-drug times.

Section snippets

Study Design and Sample

The study sample included patients enrolled in the National Registry of Myocardial Infarction, a voluntary, prospective registry of patients with acute myocardial infarction, from January 1, 1995 to December 31, 2004. Participating hospitals, data collection methods, verification methods, and reliability have been previously described.15, 16 Criteria for diagnosis of acute myocardial infarction used the International Classification of Diseases, 9^th Revision, Clinical Modifications discharge

Study Population

Baseline characteristics of the 3 groups, namely for the use of any reperfusion therapy, those treated with primary percutaneous coronary intervention, and those treated with fibrinolytic therapy, are shown in the Table. Patient and hospital characteristics were generally similar for all 3 groups, with a majority being younger (age <70 years), men, and white patients. Diabetic patients comprised 18% to 21%, and those with prior myocardial infarction comprised 17% to 19%. Patients treated with

Discussion

In our study of patients with ST-elevation myocardial infarction spanning a 10-year period (1995-2004), we found that longer time intervals from symptom onset to hospital presentation were associated with reduced likelihood of receiving primary reperfusion therapy, and even among those treated, late presenters had significantly longer door-to-balloon and door-to-drug times. Although guidelines state that patients with ST-elevation myocardial infarction who present within 12 hours after onset of

References (27)

R.J. Goldberg et al.
Impact of time to treatment with tissue plasminogen activator on morbidity and mortality following acute myocardial infarction (NRMI 2)
Am J Cardiol
(1998)
C.M. Gibson et al.
Association of duration of symptoms at presentation with angiographic and clinical outcomes after fibrinolytic therapy in patients with ST-segment elevation myocardial infarction
J Am Coll Cardiol
(2004)
G. De Luca et al.
Symptom-onset-to-balloon time and mortality in patients with acute myocardial infarction treated by primary angioplasty
J Am Coll Cardiol
(2003)
B.R. Brodie et al.
Impact of treatment delays on outcomes of primary percutaneous coronary intervention for acute myocardial infarction: analysis from the CADILLAC trial
Am Heart J
(2006)
B.R. Brodie et al.
Impact of time to treatment on myocardial reperfusion and infarct size with primary percutaneous coronary intervention for acute myocardial infarction (from the EMERALD Trial)
Am J Cardiol
(2007)
R.L. McNamara et al.
Effect of door-to-balloon time on mortality in patients with ST-segment elevation myocardial infarction
J Am Coll Cardiol
(2006)
E.M. Antman et al.
ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction; a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction)
J Am Coll Cardiol
(2004)
W.J. Rogers et al.
Temporal trends in the treatment of over 1.5 million patients with myocardial infarction in the U.S. from 1990 through 1999: The National Registry of Myocardial Infarction 1, 2, and 3
J Am Coll Cardiol
(2000)
N.R. Every et al.
A comparison of the National Registry of Myocardial Infarction 2 with the Cooperative Cardiovascular Project
J Am Coll Cardiol
(1999)
A.P. McGinn et al.
Trends in prehospital delay time and use of emergency medical services for acute myocardial infarction: experience in 4 U.S. communities from 1987-2000
Am Heart J
(2005)

R.V. Luepker

Delay in acute myocardial infarction: why don’t they come to the hospital more quickly and what we can do to reduce delay

Am Heart J

(2005)

Indications for fibrinolytic therapy in suspected acute myocardial infarction: collaborative overview of early mortality and major morbidity results from all randomised trials of more than 1000 patients

Lancet

(1994)

L.K. Newby et al.

Time from symptom onset to treatment and outcomes after thrombolytic therapy: GUSTO-1 investigators

J Am Coll Cardiol

(1996)

Cited by (48)

Improving STEMI management in the emergency department: Examining the role of minority groups and sociodemographic characteristics
2020, American Journal of Emergency Medicine
Citation Excerpt :
Overcrowded EDs have been thoroughly described and studied [25-27]. This issue is universal and most EDs exceed their planned maximal capacity. [11,26,27] It may leads to error in triage classification, causing prolonged ED waiting times, and adversely impacting DTBT [11,13,14,26,27].
To evaluate whether a fast-track intervention program will reduce time-lags of patients with STEMI considering minority groups, various socioeconomic status (SES) and clinical risk factors.
A retrospective-archive study was conducted according to clinical guidelines, comparing all STEMI patients (n = 140) admitted to the emergency department (ED) before (n = 60) and during (n = 80) implementation of the fast track intervention program. The program comprised four steps: (1) immediate bed rest, (2) marking patient chart, (3) assessing time-lags according to defined clinical guidelines, and (4) physician signing a dedicated sticker on the ECG.
The major ethnic group compared to other minority patients with STEMI were less delayed for physician examination (r = −0.398, p < 0.01), spent less time at ED (r = −0.541, p < 0.01) and reached percutaneous coronary intervention earlier (r = −0.672, p < 0.01). Patients with higher SES spent less time for physician (r = −338, p < 0.05) and in the ED (r = −0.415, p < 0.01). Before intervention patients with diabetes mellitus (DM) spent more time at ED compared to non DM patients, however during intervention this difference was blurred (β = −0.803, p < 0.001). Gaps regarding sociodemographic bias remained present throughout the intervention despite monthly staff evaluations considering patient cases.
The fast track intervention was associated with less time at ED and to cardiac reperfusion. Yet, sociodemographic bias was present. Our findings highlight the need for the healthcare profession to address the role of biases in disparities in healthcare.
Very late presentation in ST elevation myocardial infarction: Predictors and long-term mortality
2019, IJC Heart and Vasculature
Despite improvements in ST elevation myocardial infarction (STEMI) care, total ischemic time remains long in patients who present late. Our goal was to identify predictors of very late presentation (≥12 h) of STEMI and determine long-term mortality.
We retrospectively examined consecutive patients admitted with STEMI to our institution using the ACTION Registry™. Time of symptom onset to first medical contact (FMC) was calculated and categorized as <12 h or ≥12 h. Predictors of very late presentation were determined.
Compared to patients who presented <12 h (n = 365), those who presented ≥12 h (n = 49) after symptom onset were more likely women, diabetics, and those with prior coronary revascularization. In addition, patients who presented ≥12 h had worse ventricular function, were less likely to report chest pain, and were less likely to be transported by ambulance and to undergo coronary angiography. Late presenters had higher rates of heart failure, longer hospitalizations, and were less likely to be discharged home. Diabetes, female sex, and absence of chest pain were strong predictors of late presentation. Long-term survival was significantly lower in late presenters (73% vs. 93%, p = 0.007).
Female sex, diabetes, and absence of chest pain are strong predictors of presentation delay, and long-term mortality is significantly increased in those presenting very late.
Insurance and Prehospital Delay in Patients ≤55 Years with Acute Myocardial Infarction
2015, American Journal of Cardiology
This prospective study assessed whether gender differences in health insurance help explain gender differences in delay in seeking care for patients in the US, with acute myocardial infarction (AMI). We also assessed gender differences in such prehospital delay for AMI in Spain, a country with universal insurance. We used data from 2,951 US and 496 Spanish patients aged 18 to 55 years with AMI. US patients were grouped by insurance status: adequately insured, underinsured, or uninsured. For each country, we assessed the association between gender and prehospital delay (symptom onset to hospital arrival). For the US cohort, we modeled the relation between insurance groups and delay of >12 hours. US women were less likely than men to be uninsured but more likely to be underinsured, and a larger proportion of women than men experienced delays of >12 hours (38% vs 29%). We found no association between insurance status and delays of >12 hours in men or women. Only 17.3% of Spanish patients had delays of >12 hours, and there were no significant gender differences. In conclusion, women were more likely than men to delay, although it was not explained by differences in insurance status. The lack of gender differences in prehospital delays in Spain suggests that these differences may vary by health care system and culture.
Acute myocardial infarction in Morocco: FES-AMI registry data
2015, Annales de Cardiologie et d'Angeiologie
L’infarctus du myocarde représente l’extrême urgence coronaire. Sa prise en charge varie en fonction des régions et les données manquent dans les pays émergents. Le but de ce travail est d’analyser les caractéristiques cliniques et thérapeutiques de l’infarctus du myocarde au Maroc à travers un registre conduit au CHU Hassan II de Fès.
Il s’agit de l’analyse du registre prospectif monocentrique FES-AMI (Fès Acute Myocardial Infraction) qui a inclus tous les patients hospitalisés pour un infarctus du myocarde dans les 5 jours suivant le début des symptômes.
Entre janvier 2005 et août 2015, 1835 patients ont été inclus dans le registre. La population est essentiellement de sexe masculin avec un âge moyen de 60 ans. Cinquante et un pour cent des patients sont tabagiques, 27 % sont hypertendus et 14 % sont diabétiques. Soixante-six pour cent des patients ont au moins 2 facteurs de risque cardiovasculaire. Concernant les délais d’admission, uniquement 40 % des patients sont admis dans les 6 premières heures suivant le début des symptômes. Trente-six pour cent sont admis au-delà de 12 heures du début de la douleur thoracique. Soixante-trois pour cent des patients ont été traités de façon conventionnelle alors que 31 % ont été fibrinolysés et 6 % ont bénéficié d’une angioplastie primaire. L’évolution hospitalière a été marquée par une mortalité de 7,6 %.
Dans notre registre, les patients souffrant d’un infarctus du myocarde sont admis tardivement, ce qui diminue la chance de bénéficier d’une stratégie de reperfusion et aggrave le pronostic. La plupart de ces patients sont polyfactoriels, soulignant l’importance du contrôle des facteurs de risque.
Acute myocardial infarction is the most dangerous complication of coronary atherothrombosis. There are several disparities in regard to its management around the world. The aim of this study is to analyze the specificities of management of acute myocardial infarction in Morocco.
FES-AMI (Fès Acute Myocardial Infarction) is a prospective monocentric registry conducted in cardiology department of Hassan II university hospital in Fès. In this registry, we enrolled patients with acute myocardial infarction who presented within 5 days after symptom onset.
From January 2005 to August 2015, we enrolled 1835 patients. Seventy-five percent of patients were males and mean age was 60 years old. Fifty-one percent of patients were smokers, 27% were hypertensives and 14% were diabetics. Sixty-six percent of patients had more than 2 risk factors. Time from symptom onset to hospital admission was less than six hours for 40% of the patients. Thirty-six percent of patients were admitted more than twelve hours after the onset of chest pain. Only 37% of patients received reperfusion therapy, 31% with in-hospital thrombolysis and 6% with primary angioplasty. In-hospital mortality was 7.6%.
The patients enrolled in our registry have late presentation of acute myocardial infarction and less rate of reperfusion therapy. Furthermore, the majority of our patients have multiple risk factors and this result underlines the failure of preventive interventions.
Management of STEMI in low- and middle-income countries
2014, Global Heart
Citation Excerpt :
Whereas patients treated with pre-hospital fibrinolysis after 2 h had a 5-year mortality rate of 14.5% compared with 14.4% for primary PCI [28,29]. The benefit of pre-hospital fibrinolysis has also been demonstrated by registry data [30–32]. However, fibrinolysis alone is not optimal.
Impact of first contact on symptom onset-to-door time in patients presenting for primary percutaneous coronary intervention
2013, American Journal of Emergency Medicine
Citation Excerpt :
Such education should target both the general community at risk for CAD and the private physician offices that may take calls from these patients, in order to maximize direct utilization of EMS, reduce SODT, and ultimately improve mortality. Pre-hospital delays in STEMI patients are important to recognize as they influence long term mortality after PCI as demonstrated in our study by worse survival in patients not presenting directly to the ED, affect long term [11] and immediate outcomes after primary PCI [4,12], and may also impact effectiveness of other therapies to reduce infarct size [13]. Studies have estimated that pre-hospital delays contribute to 75% of total delays in administering reperfusion therapy [14].
To determine effect of first medical contact type on symptom onset–to-door time (SODT).
Shorter total ischemic time is associated with improved outcomes in ST-elevation myocardial infarction.
From 2005 to 2009, we reviewed records of all consecutive patients treated with primary percutaneous coronary intervention for ST-elevation myocardial infarction at our tertiary care teaching hospital (median follow-up 3.85 years). We compared SODT in patients whose first medical contact was a private physician (in person or via telephone) vs patients who presented to the emergency department (ED) directly (in person or via Emergency Medical Services).
Of 366 patients, 84 (23%) contacted a physician (group A) while 282 (77.6%) did not (group B). Group A had higher median SODT (239.5 vs 130 minutes, P = .0043) and significantly higher mortality (log rank P = .0392, Cox Proportional Hazard Model risk factors: physician contact first [P < .013], age [P < .0001] and peripheral vascular disease [P < .035]). Two factors associated with prolonged SODT: (1) contacting a physician first P = .002 and (2) personal mode of transportation, P = .002. Patients presenting during “on-hours” (weekdays) were more likely to first contact a physician compared with those presenting during “off-hours” (weeknights and weekends) (66.67% in group A vs 45.04% in group B, P < .001).
Patients whose first medical contact was a physician had greater pre-hospital delays and worse survival compared to those who sought emergent medical care directly. This pattern occurred more often during “on-hours.” Educational efforts aimed at both patient and physician office practices are warranted.

View all citing articles on Scopus

: Supported by grant R01 HL072575 from the National Heart, Lung, and Blood Institute, Bethesda, Maryland.

View full text

Clinical research studyDelay in Presentation and Reperfusion Therapy in ST-Elevation Myocardial Infarction

Abstract

Background

Methods

Results

Conclusions

Section snippets

Study Design and Sample

Study Population

Discussion

Am J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Am Heart J

Am J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Am Heart J

Am Heart J

Indications for fibrinolytic therapy in suspected acute myocardial infarction: collaborative overview of early mortality and major morbidity results from all randomised trials of more than 1000 patients

Lancet

Time from symptom onset to treatment and outcomes after thrombolytic therapy: GUSTO-1 investigators

J Am Coll Cardiol

Clinical research study
Delay in Presentation and Reperfusion Therapy in ST-Elevation Myocardial Infarction