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Predictors of hospital prenotification for STEMI and association of prenotification with outcomes
  1. David Blusztein1,
  2. Diem Dinh2,
  3. Dion Stub3,4,
  4. Luke Dawson1,
  5. Angela Brennan2,
  6. Christopher Reid5,
  7. Karen Smith6,
  8. Ziad Nehme6,
  9. Emily Andrew6,
  10. Stephen Bernard2,4,
  11. Jeffrey Lefkovits1
  1. 1Department of Cardiology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
  2. 2Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
  3. 3Department of Cardiology, Alfred Hospital, Melbourne, Victoria, Australia
  4. 4Ambulance Victoria, Melbourne, Victoria, Australia
  5. 5NHMRC Centre for Research Excellence in Cardiovascular Outcomes Improvement, Curtin University, Perth, Western Australia, Australia
  6. 6Department of Research and Evaluation, Ambulance Victoria, Melbourne, Victoria, Australia
  1. Correspondence to Dr David Blusztein, The Royal Melbourne Hospital, Melbourne, Victoria, Australia; davidblusztein{at}gmail.com

Abstract

Background Delay to reperfusion in ST-elevation myocardial infarction (STEMI) is detrimental, but can be minimised with prehospital notification by ambulance to the treating hospital. We aimed to assess whether prenotification was associated with improved first medical contact to balloon times (FMC-BT) and whether this resulted in better clinical outcomes. We also aimed to identify factors associated with use of prenotification.

Methods This was a retrospective study of prospective Victorian Cardiac Outcomes Registry data for patients undergoing primary percutaneous coronary intervention for STEMI from 2013-2018. Postcardiac arrest were excluded. Patients were grouped by whether they arrived by ambulance with prenotification (group 1), arrived by ambulance without prenotification (group 2) or self-presented (group 3). We compared groups by FMC-BT, incidence of major adverse cardiac and cerebrovascular events (MACCE), mortality and factors associated with the use of prenotification.

Results 2891 patients were in group 1 (79.3% male), 1620 in group 2 (75.7% male) and 1220 in group 3 (82.9% male). Patients who had prenotification were more likely to present in-hours (p=0.004) and self-presenters had lowest rates of cardiogenic shock (p<0.001). Prenotification had shorter FMC-BT than without prenotification (104 min vs 132 min, p<0.001) Self-presenters had superior clinical outcomes, with no difference between ambulance groups. Groups 1 and 2 had similar 30-day MACCE outcomes (7.4% group 1 vs 9.1% group 2, p=0.05) and similar mortality (4.6% group 1 vs 5.9% group 2, p=0.07). In multivariable analysis, male gender, right coronary artery culprit and in-hours presentation independently predicted use of prenotification (all p<0.05).

Conclusion Differences in clinical characteristics, particularly gender, time of presentation and culprit vessel may influence ambulance prenotification. Ambulance cohorts have high-risk features and worse outcomes compared with self-presenters. Improving system inequality in prehospital STEMI diagnosis is recommended for fastest STEMI treatment.

  • acute coronary syndrome
  • acute myocardial infarct
  • emergency ambulance systems
  • pre-hospital care

Data availability statement

Data are available on reasonable request. Data may be obtained from a third party and are not publicly available. Data are from the Victorian Cardiac Outcomes Registry (vcor@monash.edu), which gathers de-identified participant data with informed consent and opt-out required.

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Data availability statement

Data are available on reasonable request. Data may be obtained from a third party and are not publicly available. Data are from the Victorian Cardiac Outcomes Registry (vcor@monash.edu), which gathers de-identified participant data with informed consent and opt-out required.

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Footnotes

  • Handling editor Caroline Leech

  • Twitter @Ziad_Nehme1

  • Contributors The manuscript planning involved DB, JL, DD, AB and DS. DB authored the initial manuscript draft with extensive assistance from JL. DD was primarily responsible for data and analysis. DS, LD, AB, CR, KS, ZN, EA and SB all contributed to draft revision with the final version approved by JL. DB is responsible for overall content as a guarantor.

  • Funding DS is supported by an NHF Future Leadership Fellowship (#101908). ZN is supported by a National Health and Medical Research Council Early Career Fellowship (#1146809).

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.