Importance of total ischemic time on immediate and longer-term outcomes after primary PCI - The burning need to push harder for pharmacoinvasive therapies!!

BACKGROUND We wanted to assess the clinical profile and in-hospital outcomes of Primary Percutaneous Coronary Intervention (PPCI) for ST-segment Elevation Myocardial Infarction (STEMI) in India in ESI (Employee Scheme Insurance) beneficiaries. METHODS From January 2017 to July 2018, 122 consecutive acute STEMI patients undergoing PPCI under ESI scheme were included in the study. Patients’ clinical profile, detailed procedural characteristics, time variables along with in-hospital major adverse cardiovascular events (MACE) were also assessed. RESULTS 122 patients underwent primary PCI during the study period. In the study, mean age was 55.23 (27 - 85) years; 94 (77.04 %) were males; 53 (43.44 %) were hypertensives; 38 (31.14 %) were smokers; and 44 (36.06 %) were diabetics. Ten (8.19 %) patients were in cardiogenic shock (CS). Anterior myocardial infarction was present in 70 (57.37 %) patients. The median chest-pain-onset to hospitalarrival-time was 270 (70 - 720), door-to-balloon time was 55 (20 - 180) and total ischemic time was 325 (105 - 780) minutes. In-hospital adverse events occurred in 14 (11.4 %) patients [death 8 (6.55 %), major bleeding 2 (1.63 %), urgent CABG 3 (2.45 %) and stroke 1 (0.81 %)]. Seven patients with cardiogenic shock died. CONCLUSIONS The mean age of our cohort was 55.23 years. In our study, majority of patients were males (77.05 %), hypertension was associated with 43.44 %, and diabetes was associated with 36.06 % of patients. Procedural success was achieved in 95.89 %. The overall in-hospital mortality was 6.55 % and 70 % in the cardiogenic shock subset. KEYWORDS Primary PCI, STEMI, ESI, PCI

Download Full-text

Abstract 120: Assessing the Impact of a Rural STEMI System of Care Initiative: Mission: Lifeline Wyoming

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/circoutcomes.9.suppl_2.120 ◽

2016 ◽

Vol 9 (suppl_2) ◽

Author(s):

James R Langabeer ◽

Daniel Gerard ◽

Derek T Smith ◽

Benjamin Leonard ◽

Wendy Segrest ◽

...

Keyword(s):

Myocardial Infarction ◽

Systems Of Care ◽

Heart Association ◽

Mortality Rates ◽

Baseline Period ◽

System Of Care ◽

Primary Pci ◽

Post Intervention ◽

Ischemic Time ◽

The Impact

Introduction: Regional systems of care for ST-elevation myocardial infarction (STEMI), such as in Minnesota and North Carolina, have demonstrated improvements in quality of care outcomes. The objective in this study was to collect baseline data on Wyoming statewide STEMI incidence and assess changes in ischemic times and mortality following deployment of a statewide, system of care initiative in the rural state of Wyoming. Methods: American Heart Association organized a STEMI initiative in 2012 in Wyoming to address the needs for enhanced rural cardiovascular care. Participating were all 10 STEMI-receiving centers in and around the state, 25 acute care/critical access hospitals, Wyoming Department of Health, 56 emergency medical service (EMS) agencies, and hundreds of volunteer multidisciplinary stakeholders. The initiative deployed approximately 30 training programs, placed 165 12-lead electrocardiogram (ECG) devices in ambulance service, and developed dozens of protocols concerning transfers, treatment, and transport for Wyoming and surrounding border-states. The study design was pre-posttest design, using observational methods of de-identified myocardial infarction data extracted from all 10 participating percutaneous coronary intervention (PCI) facilities’ National Cardiovascular Data Registry (NCDR) submissions. There were 2,301 total MI’s, and 889 STEMIs during calendar years 2013-2014 (24 months). We established the first two quarters as our baseline period, and compared differences in median values using Kruskal-Wallis (KW) and chi-square analyses of variances relative to the the subsequent 6 quarters across several outcome measures (total ischemic time, mortality, thrombolytic administration rates). Results: Wyoming has an extremely high transfer rates into PCI, over twice the national average (62%). These transfers produced a long total ischemic time of 291 minutes (nearly 5 hours) in the baseline period, with door-in-door-out times consuming nearly 120 minutes, median. There was a statistically significant 51 minute median reduction in total ischemic times following the program (291 in baseline quarters vs. 241 minutes in subsequent post-intervention periods; KW χ2=4.327, p<.05). There was simultaneously a significant increase in the percent of patients undergoing primary PCI (pPCI) from 54% to 57% (χ2=7.610, p<.01), coupled with a statistically significant reduction in the rate of thrombolytic administration s (46% in the baseline period vs. 37% in the subsequent periods; χ2=6.359, p<.05). Mortality rates were lower than national benchmarks, averaging 3.9% for all MI (5.3% for STEMI), but there were no statistical changes in mortality rates over time. Conclusions Mission: Lifeline Wyoming demonstrated statistically significant reductions in median total ischemic time and higher primary PCI reperfusion rates.

Download Full-text

Interhospital Transfer versus Direct Admission in Patients with Acute ST-Segment Elevation Myocardial Infarction

International Journal of Angiology ◽

10.1055/s-0040-1714686 ◽

2020 ◽

Author(s):

Surya Dharma ◽

Iwan Dakota ◽

Hananto Andriantoro ◽

Isman Firdaus ◽

Citra P. Anandira ◽

...

Keyword(s):

Myocardial Infarction ◽

Coronary Intervention ◽

Primary Pci ◽

Ischemic Time ◽

St Segment Elevation ◽

Segment Elevation Myocardial Infarction ◽

Interhospital Transfer ◽

St Segment ◽

Direct Admission ◽

Transferred Patients

AbstractThere is concern whether patients with ST-segment elevation myocardial infarction (STEMI) who admitted to a percutaneous coronary intervention (PCI) center from interhospital transfer is associated with longer reperfusion time compared with direct admission. We evaluated the reperfusion delays in patients with STEMI who admitted to a primary PCI center through interhospital transfer or direct admission. We retrospectively analyzed 6,494 consecutive STEMI patients admitted between 2011 and 2019. Compared with direct admission (n = 4,121; 63%), interhospital transferred patients (n = 2,373) were younger (55 ± 10 vs. 56 ± 10 years, p < 0.001), had similar gender (85.6 vs. 86% male, p = 0.67), greater proportion of off-hour admission (65.2 vs. 48.3%, p < 0.001), less diabetes mellitus (28 vs. 30.8%, p = 0.019), and received more primary PCI (70.5 vs. 48.7%, p < 0.001). Interhospital transferred patients who received primary PCI (n = 3,677) or fibrinolytic (n = 238) had longer symptom-to-PCI center admission time (median, 360 vs. 300 minutes, p < 0.001), shorter door-to-device (DTD) time for primary PCI (median, 74 vs. 87 minutes, p < 0.001), and longer total ischemic time (median, 465 vs. 414 minutes, p < 0.001). Logistic regression in interhospital transferred patients showed that delay in door-in-to-door-out (DI-DO) time at the first hospital was strongly associated with prolonged total ischemic time (adjusted odds ratio = 3.92; 95% confidence interval: 3.06–5.04, p < 0.001). This study suggests that although interhospital transferred patients received more primary PCI with shorter DTD time, interhospital transfer creates longer total ischemic time that associates with the delay in DI-DO time at the first hospital that should be improved.

Download Full-text

Glycaemic status and reperfusion injury in patients with ST-segment elevation myocardial infarction

European Heart Journal ◽

10.1093/eurheartj/ehab724.0220 ◽

2021 ◽

Vol 42 (Supplement_1) ◽

Author(s):

M Reindl ◽

I Lechner ◽

C Tiller ◽

M Holzknecht ◽

A Rangger ◽

...

Keyword(s):

Myocardial Infarction ◽

Magnetic Resonance ◽

Reperfusion Injury ◽

T2 Mapping ◽

Anterior Wall ◽

Adverse Outcomes ◽

Primary Pci ◽

Culprit Lesion ◽

Ischemic Time ◽

Microvascular Injury

Abstract Background Failed myocardial tissue reperfusion due to microvascular injury despite successful culprit lesion percutaneous coronary intervention (PCI) is associated with poor clinical outcome in patients with ST-elevation myocardial infarction (STEMI). A possible influence of dysglycaemia on myocardial reperfusion injury is unclear. Objectives To investigate the association between glycaemic status and microvascular injury determined by magnetic resonance imaging in STEMI patients. Methods This prospective observational cohort study included 260 consecutive STEMI patients undergoing primary PCI between 2016 and 2019. Peripheral venous blood samples for glucose and HbA1c measurements were drawn on admission. Primary microvascular injury endpoint was defined as presence of intramyocardial haemorrhage (IMH) assessed by cardiac magnetic resonance T2* mapping at 4 (interquartile range [IQR]:2–5) days after PCI. Results HbA1c (odds ratio [OR]: 1.73 [95% CI: 1.24–2.40]; p=0.001), pre-diagnosis of diabetes (OR: 2.63 [95% CI: 1.18–5.90]; p=0.02) and glucose concentration (OR: 1.01 [95% CI: 1.00–1.01]; p=0.01) significantly predicted IMH, which was present in 90 (35%) patients. Of these three parameters, only HbA1c remained significantly associated with IMH (OR: 2.12 [95% CI: 1.12–3.99]; p=0.02) after adjusting for total ischemic time, culprit lesion location, pre- and post-interventional TIMI flow and peak biomarker concentrations (troponin, N-terminal pro-B-type natriuretic peptide and C-reactive protein). The rate of IMH was 24% in patients with HbA1c <5.7%, 43% in patients with HbA1c ≥5.7 to 6.4% and 59% in patients with HbA1c ≥6.5% (p<0.001). Conclusions In STEMI patients undergoing primary PCI, admission HbA1c was independently associated with reperfusion injury as determined by IMH. These findings suggest that IMH could represent the underlying pathophysiological link between dysglycaemia and adverse outcomes following STEMI. FUNDunding Acknowledgement Type of funding sources: Public grant(s) – EU funding. Main funding source(s): FWF - Austrian Science Fund; ÖKG - Austrian Society of Cardiology Figure 1. This figure illustrates the relation between HbA1c and IMH by two patient examples successfully treated with PCI (intervention with stent implantation schematically shown on the very left side). The first patient (upper line), representing the patient group with HbA1c <5.7% (associated IMH risk 24%), showed an anterior wall STEMI without IMH (T2* mapping on the very right, corresponding schematic picture of the infarct area without IMH next on the left). The second patient (lower line), representing the patients with HbA1c ≥5.7% (associated IMH risk 47%), showed an anterior wall STEMI with large IMH (arrows point to the hypo-intense core on the T2* mapping image and to the corresponding dark-red area in the schematic illustration). The zoomed view of one microvessel indicates the complex pathophysiology of IMH (including endothelial destruction, embolisation of thrombotic material and inflammation). (Created with BioRender)

Download Full-text

Impact of Time Delay on Short Term Outcome of Primary Percutaneous Coronary Intervention (PCI) in Bangladeshi Population

University Heart Journal ◽

10.3329/uhj.v14i2.40287 ◽

2019 ◽

Vol 14 (2) ◽

pp. 77-82

Author(s):

Md Golam Morshed ◽

MG Azam ◽

Md Minhaj Arefin ◽

Khondker Shaheed Hussain ◽

Jafrin Jahan ◽

...

Keyword(s):

Time Delay ◽

Clinical Outcome ◽

Coronary Intervention ◽

Minor Bleeding ◽

Primary Pci ◽

Short Term ◽

Term Outcome ◽

Ischemic Time ◽

Short Term Outcome ◽

Percutaneous Coronary

Background: Now-a-days primary percutaneous coronary intervention (pPCI) is being increasingly done in our country as the treatment of acute ST elevation myocardial infarction (STEMI). Time until treatment is paramount in the management of STEMI. But the time delay to pPCI how much influencing the outcome in our setting is mostly unknown.So we evaluated the influence of total ischemic time on myocardial reperfusion and short term clinical outcome in patients with STEMI treated with primary PCI. Materials and methods: This prospective observational study was conducted from August 2016 to March 2017in the Department of Cardiology, National Institute of Cardiovascular Diseases (NICVD), Dhaka. Forty-eight (48) acute STEMI patients were selected by purposive sampling based on inclusion and exclusion criteria dividing into two groups as early treatment group (group-A) in whom pain to pPCI time was <6 hours and late treatment group (group-B) in whom pain to pPCI time was 6-12 hours. Angiographic (TIMI flow grade 3 & MBG 3) & short term clinical outcome (MACE, heart failure, major bleeding, minor bleeding, cardiogenic shock, significant arrhythmia, instent thrombosis) were observed and compared between these two groups. Results: The relationship between total ischemic time and 30-day mortality & morbidity were assessed and compared with early and late pPCI group. The overall 30-day mortality rate was 4.2%, heart failure was 6.2%, cardiogenic shock was 4.2%, major bleeding was 2.1% and minor bleeding was 14.6%. Mortality and morbidity were higher in longer ischemic time group than shorter ischemic time group. In multivariate regression analysis, the factors independently influencing the adverse short term outcome were advance age (OR 1.51, 95% CI 1.105 to 4.101, p=0.03), hypertension (OR 2.44, 95% CI 1.102 to 4.281, p=0.02), diabetes mellitus (OR 2.51, 95% CI 1.200 to 4.987, p=0.02), anterior MI (OR 1.38, 95% CI 1.001 to 2.872, p=0.03), multivessel disease (OR 2.35, 95% CI 1.010 to 5.371, p=0.02), pain to door time (OR 1.66, CI 1.099 to 2.2.722, p=0.04), and total ischemic time (OR 2.67, 95% CI 1.122 to 5.784, p=0.02). Even after correction for predictive baseline and procedural variables of the univariate analysis, longer total ischemic time was the most significant independent predictor (OR 2.67, p=0.02) of short term adverse outcome of primary PCI. The current status of time delay in our country revealed symptom onset to door time was 5.6±2.4 hours, door to balloon time was 1.9±1.1 hours and total ischemic time was 7.3±2.6 hours. Conclusion: According to this study finding, there is prognostic implication of time delay in patients with STEMI undergoing primary PCI. Therefore, all efforts should be made to shorten total ischemic time, including reduction in patient related delays, to improve clinical outcome of STEMI patients. University Heart Journal Vol. 14, No. 2, Jul 2018; 77-82

Download Full-text

Time-to-reperfusion in ST-segment elevation myocardial infarction undergoing inter-hospital transfer using WhatsApp smartphone application

European Heart Journal ◽

10.1093/ehjci/ehaa946.3471 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

A Bendary ◽

A.M Mansour ◽

H.K Kabil ◽

S.M Mostafa

Keyword(s):

Myocardial Infarction ◽

Coronary Intervention ◽

Smartphone Application ◽

Study Groups ◽

Time Frame ◽

Primary Pci ◽

Ischemic Time ◽

St Segment Elevation ◽

Catheterization Laboratory ◽

Hospital Transfer

Abstract Aim Current guidelines recommend that patients with ST-elevation myocardial infarction (STEMI) receive primary percutaneous coronary intervention (PCI) with a door-to-balloon (D2B) time of 90 minutes. This time frame has been difficult to achieve in developing countries. We aimed to test the hypothesis that using WhatsApp for inter-hospital transfer in STEMI primary PCI would result in shorter D2B time through avoiding emergency department (ED) waiting. Methods In the period from May 2018 to April 2019, 300 patients with STEMI treated with primary PCI were prospectively enrolled in a multi-center observational study covering 3 PCI-capable centers in our city. Patients were categorized into 3 groups: G-1; Self-presenting to the ED, G-2; Transferred by ambulance to the ED and G-3; those transferred from non-PCI capable centers directly to catheterization laboratory (bypassing the ED as possible) after the team was pre-activated through an ECG image sent using WhatsApp. The primary endpoint was between-groups difference in total ischemic and D2B times. Results All groups were matched regarding baseline criteria. WhatsApp use was associated with significantly shorter D2B time (166.5±33.8 vs 157.8±29.6 vs 120.8±35.2 minutes in groups 1, 2 and 3 respectively, P<0.001) and shorter total ischemic time (258.9±33.9 vs 249.6±29.4 vs 212.7±35.4 minutes in groups 1, 2 and 3 respectively, P<0.001). Linear regression showed that WhatsApp referral significantly reduces ED waiting time by about 20.4 minutes (95% CI −21.6 to −19.3 minutes, P<0.001). Conclusion Using WhatsApp for inter-hospital transfer in primary PCI is associated with significantly shorter D2B times. Key time intervals among study groups Funding Acknowledgement Type of funding source: None

Download Full-text

Predictors of Short Term Outcomes of Primary Percutaneous Coronary Intervention

Bangladesh Heart Journal ◽

10.3329/bhj.v33i2.39307 ◽

2018 ◽

Vol 33 (2) ◽

pp. 112-120

Author(s):

Farhana Ahmed ◽

Afzalur Rahman ◽

Mohammad Arifur Rahman ◽

Tariq Ahmed Chowdhury ◽

Md Shahabul Huda Chowdhury ◽

...

Keyword(s):

Diabetes Mellitus ◽

Myocardial Infarction ◽

Coronary Intervention ◽

Primary Pci ◽

Multivessel Coronary Artery Disease ◽

Short Term ◽

Anterior Myocardial Infarction ◽

Ischemic Time ◽

Percutaneous Coronary ◽

Artery Disease

Background: Acute myocardial infarction (AMI) is one of the leading causes of death and disability all over the world. Primary percutaneous coronary intervention (PCI) is the treatment of choice for patients with acute ST segment elevation myocardial infarction (STEMI). Primary PCI is being increasingly done in our country also. But the factor influencing the outcome of primary PCI in our setting are mostly unknown. The present study was conducted to investigate factors that influencing the short term outcomes of primary PCI. Materials and methods: This prospective observational study was conducted from September 2014 to January 2016in the Department of Cardiology, National Institute of Cardiovascular Diseases (NICVD), Dhaka. 48 patients were selected by purposive sampling. Patients with acute STEMI treated with primary PCI were included in the study based on inclusion and exclusion criteria. Effect of factors including advanced age, male sex, diabetes mellitus, hypertension, dyslipidemia, serum creatinine, left ventricular ejection fraction, anterior myocardial infarction (MI), thrombolysis in myocardial infarction (TIMI) flow, multi vessel disease, angiographic severity score (Leaman score), thrombus aspiration, door to balloon time and total ischemic time on major adverse cardiac events (MACE) i.e. death, post procedural MI, target vessel revascularization (TVR), stroke as well as, on other adverse events like heart failure, cardiogenic shock, major bleeding, significant arrhythmia and stent thrombosis were studied. Results: The overall incidence of MACE was 2.1%, major bleeding 2.1%, heart failure 4.2% and cardiogenic shock 2.1%. In multivariate analysis, the factors independently influencing the adverse short term outcomes (MACE and other adverse events) were diabetes mellitus (odds ratio (OR) 2.55, 95% confidence interval (CI) 1.180 to 4.124, p=0.02), anterior MI (OR 1.48, 95% CI 1.020 to 1.926, p=0.04), total ischaemic time (OR 1.49, 95% CI 1.044 to 2.444, p=0.04), multivessel coronary artery disease (OR 1.77, 95% CI 1.26 to 3.261, p=0.03) and Leaman score (OR 2.5, 95% CI 1.100-4.504, p=.03). Conclusion: According to our finding, diabetes mellitus, anterior myocardial infarction, total ischemic time, multivessel coronary artery disease and high Leaman score are predictors of adverse short term outcomes of primary PCI Bangladesh Heart Journal 2018; 33(2) : 112-120

Download Full-text

AS-015: Total Ischemic Time and Primary PCI: Optimal Time Period from Symptom-onset to Reperfusion Therapy

The American Journal of Cardiology ◽

10.1016/j.amjcard.2012.01.012 ◽

2012 ◽

Vol 109 (7) ◽

pp. S7

Author(s):

Hiroki Shiomi ◽

Yoshihisa Nakagawa ◽

Takeshi Morimoto ◽

Yutaka Furukawa ◽

Akira Nakano ◽

...

Keyword(s):

Symptom Onset ◽

Reperfusion Therapy ◽

Optimal Time ◽

Primary Pci ◽

Ischemic Time ◽

Time Period

Download Full-text

Prasugrel compared to ticagrelor in primary PCI

European Heart Journal ◽

10.1093/ehjci/ehaa946.1737 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

J Doerler ◽

M Edlinger ◽

H Alber ◽

R Berger ◽

M Frick ◽

...

Keyword(s):

Multiple Logistic Regression Analysis ◽

Univariate Analysis ◽

Multivariable Analysis ◽

Funding Source ◽

Primary Pci ◽

Bleeding Events ◽

Hospital Outcomes ◽

Ischemic Time ◽

Improved Outcomes ◽

St Elevation

Abstract Background Prasugrel and ticagrelor have similar recommendations in the setting of primary PCI by current guidelines. Data comparing both in daily clinical practice of primary PCI for ST-elevation myocardial infarction is limited. Purpose To compare the effect of prasugrel and ticagrelor on in-hospital outcomes after primary PCI. Methods and results We prospectively enrolled 5365 patients treated with prasugrel (n=2785, 51.9%) or ticagrelor (n=2580; 48.1%) in the setting of primary PCI from January 2011 to December 2018 in a nationwide registry. In-hospital outcomes were compared and multiple logistic regression analysis was performed. Prasugrel treated patients were younger, less often in cardiogenic shock, with lower rates of previous stroke and had shorter ischemic time. Both groups showed similar rates of previous MI, diabetes and current resuscitation. In the univariate analysis mortality was lower in patients with prasugrel (2.5% vs. 4.4% p<0.01). Similarly, MACE (3.3% vs. 5.3%, p<0.01) and NACE (4.0% vs. 5.7% p<0.01) were lower in prasugrel treated patients, whereas major bleeding events did not differ (0.4% vs. 0.6% p=0.24). After adjustment in multivariable analysis mortality (0.99 95% CI 0.57 to 1.72), MACE (OR 0.99 95% CI 0.65 to 1.52) as well as NACE (0.86 95% CI 0.61 to 1.22) did not differ in patients treated with prasugrel compared to ticagrelor. Conclusion Patients treated with prasugrel showed improved outcomes compared to ticagrelor in a large cohort of primary PCI. However, after adjustment for confounders the Advantage of prasugrel in primary PCI did not persist. Funding Acknowledgement Type of funding source: Other. Main funding source(s): Austrian Society of Cardiology

Download Full-text