The role of process mining tools in STEMI networks: where should we build a new primary PCI centre?

Abstract Background In ST-segment elevation myocardial infarction (STEMI), time delay between symptom onset and treatment is critical to improve outcome. The expected transport delay between patient location and percutaneous coronary intervention (PCI) centre is paramount for choosing the adequate reperfusion therapy. The “Centre” region of Portugal has heterogeneity in PCI assess due to geographical reasons. Purpose We aimed to explore time delays between regions using process mining (PM) tools. Methods We retrospectively assessed the Portuguese Registry of Acute Coronary Syndromes for patients with STEMI from October 2010 to September 2019, collecting information on geographical area of symptom onset, reperfusion option, and in-hospital mortality. We used a PM toolkit (PM4H – PMApp Version) to build two models (one national and one regional) that represent the flow of patients in a healthcare system, enhancing time differences between groups. One-way analysis of variance was employed for the global comparison of study variables between groups and post hoc analysis with Bonferroni correction was used for multiple comparisons. Results Overall, 8956 patients (75% male, 48% from 51 to 70 years) were included in the national model (Fig. 1A), in which primary PCI was the treatment of choice (73%), with the median time between admission and primary PCI <120 minutes in every region; “Lisboa” and “Centro” had the longest delays, (orange arrows). Fibrinolysis was performed in 4.5%, with a median time delay <1 hour in every region. In-hospital mortality was 5%, significantly higher for those without reperfusion therapy compared to PCI and fibrinolysis (10% vs. 4% vs. 4%, P<0.001). In the regional model (Fig. 1B) corresponding to the “Centre” region of Portugal divided by districts (n=773, 74% male, 47% from 51 to 70 years), only 61% had primary PCI, with “Guarda” (05:04) and “Castelo Branco” (06:50) showing significant longer delays between diagnosis and reperfusion treatment (orange and red arrows, respectively) than “Coimbra” (01:19) (green arrow); only 15% of patients from “Castelo Branco” had primary PCI. Fibrinolysis was chosen in 10% of patients, mostly in “Castelo Branco” (53%), followed by “Guarda” (30%), with a median time delay of 39 and 48 minutes, respectively. Regarding mortality, PCI and fibrinolysis groups had similar death rates while those patients without reperfusion had higher mortality (5% vs. 3% vs. 13%, P=0.001). Conclusion Process mining tools help to understand referencing networks visually, easily highlighting inefficiencies and potential needs for improvement. The “Centre” region of Portugal has lower rates and longer delay to primary PCI partially due to the geographical reasons, with worse outcomes in remote regions. The implementation of a new PCI centre in one of these districts, is critical to offer timely first-line treatment to their population. FUNDunding Acknowledgement Type of funding sources: None. Figure 1

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The role of process mining tools in STEMI networks: where should we build a new primary PCI centre?

European Heart Journal - Digital Health ◽

10.1093/ehjdh/ztab104.3160 ◽

2021 ◽

Vol 2 (4) ◽

Author(s):

J Borges-Rosa ◽

M Oliveira-Santos ◽

M Simoes ◽

P Carvalho ◽

G Ibanez-Sanchez ◽

...

Keyword(s):

Time Delay ◽

Hospital Mortality ◽

Median Time ◽

Symptom Onset ◽

Process Mining ◽

Reperfusion Therapy ◽

Primary Pci ◽

Global Comparison ◽

Centre Region ◽

Mining Tools

Abstract Background In ST-segment elevation myocardial infarction (STEMI), time delay between symptom onset and treatment is critical to improve outcome. The expected transport delay between patient location and percutaneous coronary intervention (PCI) centre is paramount for choosing the adequate reperfusion therapy. The “Centre” region of Portugal has heterogeneity in PCI assess due to geographical reasons. Purpose We aimed to explore time delays between regions using process mining (PM) tools. Methods We retrospectively assessed the Portuguese Registry of Acute Coronary Syndromes for patients with STEMI from October 2010 to September 2019, collecting information on geographical area of symptom onset, reperfusion option, and in-hospital mortality. We used a PM toolkit (PM4H – PMApp Version) to build two models (one national and one regional) that represent the flow of patients in a healthcare system, enhancing time differences between groups. One-way analysis of variance was employed for the global comparison of study variables between groups and post hoc analysis with Bonferroni correction was used for multiple comparisons. Results Overall, 8956 patients (75% male, 48% from 51 to 70 years) were included in the national model (Fig. 1A), in which primary PCI was the treatment of choice (73%), with the median time between admission and primary PCI <120 minutes in every region; “Lisboa” and “Centro” had the longest delays, (orange arrows). Fibrinolysis was performed in 4.5%, with a median time delay <1 hour in every region. In-hospital mortality was 5%, significantly higher for those without reperfusion therapy compared to PCI and fibrinolysis (10% vs. 4% vs. 4%, P<0.001). In the regional model (Fig. 1B) corresponding to the “Centre” region of Portugal divided by districts (n=773, 74% male, 47% from 51 to 70 years), only 61% had primary PCI, with “Guarda” (05:04) and “Castelo Branco” (06:50) showing significant longer delays between diagnosis and reperfusion treatment (orange and red arrows, respectively) than “Coimbra” (01:19) (green arrow); only 15% of patients from “Castelo Branco” had primary PCI. Fibrinolysis was chosen in 10% of patients, mostly in “Castelo Branco” (53%), followed by “Guarda” (30%), with a median time delay of 39 and 48 minutes, respectively. Regarding mortality, PCI and fibrinolysis groups had similar death rates while those patients without reperfusion had higher mortality (5% vs. 3% vs. 13%, P=0.001). Conclusion Process mining tools help to understand referencing networks visually, easily highlighting inefficiencies and potential needs for improvement. The “Centre” region of Portugal has lower rates and longer delay to primary PCI partially due to the geographical reasons, with worse outcomes in remote regions. The implementation of a new PCI centre in one of these districts, is critical to offer timely first-line treatment to their population. Funding Acknowledgement Type of funding sources: None. Figure 1

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Primary PCI for STEMI Patients: Has Patient’s Access and Hospital Outcome Improved over the Last 5 Years

Journal of Clinical Review & Case Reports ◽

10.33140/jcrc/03/10/00010 ◽

2018 ◽

Vol 3 (10) ◽

Keyword(s):

Hospital Mortality ◽

Public Awareness ◽

Reperfusion Therapy ◽

Late Presentation ◽

Direct Access ◽

Primary Pci ◽

Apparent Lack ◽

St Segment Elevation ◽

Hospital Outcome ◽

Evidenced Based

Background: Reperfusion therapy by Primary PCI in ST-segment elevation myocardial infarction (STEMI result in great benefit than from fibrin lytic therapy, The fast access to PPCI will improve hospital outcome, We believe that patient access to PPCI facility would have improved due to improved public awareness and expanding evidenced-based health provision. Method: This is a retrospective study to analyze and compare data for STEMI patients during 2010 (Group l = 223 pts) and those treated between August 2014 and August 2015 (Group 2 = 288 pts). We compared demographic and baseline characteristics, patient’s access, reason for no access and hospital mortality for the two groups. Results: Among the 288 patients in G2, 247 patients (85%) were males with average age of 57 yrs. 49% were diabetics, 48% hypertensive, 48% were smokers and 27% were obese. These were not different in G1. Of G2, 164 pts (57%) only had access to PPCI compared to 56% in G1 (p = 0.536-NS). In G2, the main reasons for no PPCI was late presentation in 47% vs 53% in G1; P = 0.34-NS and 27% due to thrombolysis vs 17% in G1 (p = 0.11NS). Hospital mortality in G2 was 4% in those treated with PPCI compared to 2.3% in Gi (P = 0.522-NS). Mortality In pts who did not receive PPCI in G2 was 8% compared to 11.3% in G1 (p = 0.49-NS). Females in G2 have about 3 times higher mortality. Compared to 2010, pts treated for STEMI in the last 12 months at KACC still have same, relatively low access to pPCI due mainly to persistent pattern of late presentation and prior thrombolysis which reflect apparent lack of direct access to hospitals with PPCI facilities. Conclusion: Comparing the two periods there was no change in the practice, the low access to PPCI was mainly due to late presentation and Prior thrombolysis, Hospital mortality rate for patients treated with PPCI remained low during the two eras, this seemingly relates to both lack of public awareness and health provision factors in PPCI organizations.

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Comparison of Outcomes after Reperfusion Therapy between In-Hospital and Out-of-Hospital Stroke Patients

Cerebrovascular Diseases ◽

10.1159/000381787 ◽

2015 ◽

Vol 40 (1-2) ◽

pp. 28-34 ◽

Cited By ~ 4

Author(s):

Joonsang Yoo ◽

Dongbeom Song ◽

Kijeong Lee ◽

Young Dae Kim ◽

Hyo Suk Nam ◽

...

Keyword(s):

Hospital Mortality ◽

Symptom Onset ◽

Reperfusion Therapy ◽

University Hospital ◽

Time Interval ◽

Time Intervals ◽

Symptomatic Intracerebral Hemorrhage ◽

All Cause Mortality ◽

Tissue Plasminogen ◽

Favorable Functional Outcome

Background: Patients may experience stroke while being admitted to the hospital (in-hospital stroke (IHS)) and they may be important candidates for reperfusion therapy. IHS patients may have various comorbidities and show worse outcomes compared with patients with an out-of-hospital stroke (OHS). On the other hand, the time from onset to treatment may be shorter in IHS patients than OHS patients. Most outcome studies of reperfusion therapy have been based on findings in OHS patients, and little information is currently available regarding outcomes of IHS, whether the outcomes differ between patients with IHS and those with OHS who receive reperfusion therapy. Methods: This is a retrospective observational study using prospectively registered data. Consecutive patients who underwent the reperfusion therapy (intravenous (IV), intra-arterial (IA), or combined IV and IA) between July 2002 and June 2014 in a university hospital were included for this study. We compared the demographics, time interval from symptom onset to treatment, and outcomes between IHS and OHS patients and analyzed the factors associated with in-hospital mortality. Results: A total of 686 patients received the reperfusion therapy during the study period. Of them, 256 (37.3%) patients received the IV tissue plasminogen activator (t-PA) therapy only, 243 (35.4%) patients received the IA therapy only, and 187 (27.3%) patients received the combined IV and IA therapy. Among these, 104 (15.2%) were IHS patients. The time intervals from symptom onset to IV t-PA administration (87.5 ± 48.4 vs. 113.4 ± 38.3 min, p < 0.001) and IA puncture (221.8 ± 195.0 vs. 343.6 ± 155.4 min, p < 0.001) were shorter for IHS than OHS. The rates of successful recanalization and symptomatic intracerebral hemorrhage, and the favorable functional outcome at 3 months were similar between the groups. In-hospital all-cause mortality was higher in IHS than OHS (16.3 vs. 8.4%, p = 0.019), but after adjustment, IHS was not an independent factor. The stroke mortality did not differ between the groups (9.6 vs. 6.9%, p = 0.432). Conclusions: Although IHS patients more frequently had comorbid diseases and higher overall in-hospital mortality, the standard outcomes of the reperfusion therapy were similar between IHS and OHS patients, which might be, in part, ascribed to the shorter interval from symptom onset to treatment in IHS. Considering a substantial portion of IHS patients, we should pay more attention to these patients.

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Disentangling Sex Differences in Use of Reperfusion Therapy in Patients With Acute Ischemic Stroke

Stroke ◽

10.1161/strokeaha.119.028589 ◽

2020 ◽

Vol 51 (8) ◽

pp. 2332-2338

Author(s):

Jeppe Mainz ◽

Grethe Andersen ◽

Jan Brink Valentin ◽

Martin Faurholdt Gude ◽

Søren Paaske Johnsen

Keyword(s):

Sex Differences ◽

Ischemic Stroke ◽

Time Delay ◽

Acute Ischemic Stroke ◽

Emergency Medical Services ◽

Symptom Onset ◽

Odds Ratio ◽

Stroke Unit ◽

Intravenous Thrombolysis ◽

Reperfusion Therapy

Background and Purpose: Previous studies from local settings have reported that women with acute ischemic stroke have a lower chance of receiving reperfusion therapy treatment, including intravenous thrombolysis and thrombectomy, than men, but the underlying mechanisms of this disparity have not been identified. We aimed to examine sex differences in the utilization of reperfusion therapy focusing on all the phases of pre- and in-hospital time delay in a nationwide population-based cohort. Methods: This study was based on data from nationwide public registries. The study population included patients aged at least 18 years admitted with acute ischemic stroke using emergency medical services in Denmark dispatched after an emergency call in the period 2016 to 2017. Study outcomes included time delays from symptom onset to start of reperfusion therapy and use of reperfusion therapy. Data were analyzed using multivariable quantile regression and logistic regression. Results: A total of 5356 stroke events fulfilled the inclusion criteria. Women (26.6%) were less likely to receive intravenous thrombolysis than men (30.2 %), corresponding to an unadjusted odds ratio of 0.84 (95% CI, 0.74–0.95). In addition, women experienced a 20 minutes longer median time delay from stroke symptom onset to stroke unit arrival than men. Adjusting for onset-to-door time only appeared to have a limited effect on the sex differences in use of intravenous thrombolysis, whereas the odds ratio was 1.06 (95% CI, 0.93–1.21) when adjusting for age at stroke, stroke severity, and cohabitation status. No sex difference was observed for the use of thrombectomy. Conclusions: Women received less reperfusion therapy than men and had a longer time delay from symptom onset to stroke unit arrival, primarily due to a longer delay from symptom onset to emergency medical services call. These differences appeared to be due to the higher age and the higher proportion of women living alone at the time of the stroke.

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TIME DELAY FROM SYMPTOM ONSET-TO-REPERFUSION AND LABORATORY EFFICACY OF P2Y12 INHIBITORS IN PATIENTS WITH STE: MYOCARDIAL INFARCTION TREATED WITH PRIMARY PCI

Journal of the American College of Cardiology ◽

10.1016/s0735-1097(14)60107-8 ◽

2014 ◽

Vol 63 (12) ◽

pp. A107

Author(s):

Zuzana Motovska ◽

Ondrakova Martina ◽

Teodora Vichova ◽

Jiri Knot ◽

Frantisek Bednar ◽

...

Keyword(s):

Myocardial Infarction ◽

Time Delay ◽

Symptom Onset ◽

Primary Pci ◽

P2y12 Inhibitors

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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

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Treatment delay in STEMI is associated with heart failure and mortality. National data from the Norwegian myocardial infarction register

European Heart Journal ◽

10.1093/ehjci/ehaa946.1350 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

K.K Halle ◽

R.E.S Govatsmark ◽

K.H Bonaa

Keyword(s):

Myocardial Infarction ◽

Heart Failure ◽

Acute Myocardial Infarction ◽

Time Delay ◽

Symptom Onset ◽

Missing Values ◽

Outcome Variable ◽

P Value ◽

Primary Pci ◽

Increased Risk

Abstract Background European guidelines in ST-segment elevation acute myocardial infarction (STEMI) recommends a primary PCI (P-PCI) strategy if wire crossing of the occluded artery can be performed within 120 min of ECG diagnosis. A large proportion of the Norwegian population lives in remote geographical areas where P-PCI may not be performed expeditiously. Time delay from first medical contact to primary PCI is expected to be related to outcomes like heart failure and mortality. Norwegian hospitals are by law required to register clinical data for all patients treated for acute myocardial infarction in the Norwegian Myocardial Infarction. The register includes >90% of eligible patients. Purpose The aim of the study was to investigate the association of time from first medical contact (FMC) to P-PCI with heart failure (EF <50%) and mortality. Methods The study includes all patients registered during 2015–2018 in the Norwegian Myocardial Infarction Registry with STEMI who were <85 years of age and had <12 hours from symptom onset to FMC. For patients with missing values, FMC was calculated as time of prehospital ECG minus 10 minutes. The primary outcome variable was heart failure (defined as ejection fraction <50% during hospitalization) or all-cause mortality within 1 year after hospitalization. We calculated ORs (95% CI) adjusted for age, gender, and history of myocardial infarction, hypertension, diabetes, and heart failure. Results During 2015–2018 a total of 6398 STEMI patients <85 years of age were registered in the Norwegian Myocardial Infarction Registry with less than 12 hours from symptom onset to FMC. Time delay from FMC to P-PCI were <90 minutes, 90–119 minutes, and >120 minutes in 40%, 25%, and 35% of the patients, respectively. Compared to patients with P-PCI within 90 minutes after FMC, the multivariable adjusted OR (95% CI; p-value) for heart failure or 1 year mortality was 1.05 (1.02–1.08; p<0.01) for patients with P-PCI within 90–119 minutes after FMC, and 1.05 (1.02–1.08; p<0.001) for patients with P-PCI >120 minutes after FMC. The corresponding ORs for 1 year mortality were 1.01 (0.99–1.02) and 1.03 (1.02–1.04), respectively, and the corresponding ORs for EF<50% were 1.07 (1.04–1.11) and 1.07 (1.04–1.11). Conclusion In Norway, only 40% of STEMI patients undergo P-PCI within 90 minutes after FMC, and 35% of patients undergoes P-PCI >120 minutes after FMC. Time delays of more than 90 minutes after FMC are associated with increased risk of heart failure and mortality. A fibrinolysis strategy may be preferred over P-PCI for a substantial proportion of STEMI patients. Funding Acknowledgement Type of funding source: None

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The effect of preloading statins prior to primary reperfusion on in-hospital mortality risk in a contemporary large-scale cohort of patients with ST-elevation myocardial infarction

European Heart Journal ◽

10.1093/ehjci/ehaa946.1464 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

R Fu ◽

C.X Song ◽

X.D Li ◽

Y.J Yang

Keyword(s):

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Hospital Mortality ◽

Mortality Risk ◽

Large Scale ◽

Reperfusion Therapy ◽

St Elevation Myocardial Infarction ◽

Control Group ◽

Funding Source ◽

St Elevation

Abstract Background The benefit of statins in secondary prevention of patients stabilized after acute coronary syndrome (ACS) has been well established. However, the benefit of preloading statins, i.e. high-intensity statins prior to reperfusion therapy remains unclear. Most previous studies included all types of ACS patients, and subgroup analysis indicated the benefit of preloading statins was only seen in ST-elevation myocardial infarction (STEMI) patients who underwent percutaneous coronary intervention (PCI). However, the sample size of subgroup population was relatively small and such benefit requires further validation. Objective To investigate the effect of loading dose of statins before primary reperfusion on 30-mortality in patients with STEMI. Methods We enrolled patients in China Acute Myocardial Infarction (CAMI) registry from January 2013 to September 2014. CAMI registry was a prospective multicenter registry of patients with acute acute myocardial infarction in China. Patients were divided into two groups according to statins usage: preloading group and control group. Patients in preloading group received loading does of statins before primary reperfusion and during hospitalization. Patients in control group did not receive statins during hospitalization or at discharge. Primary outcome was in-hospital mortality. Baseline characteristics, angiographic characteristics and outcome were compared between groups. Propensity score (PS) matching was used to mitigate baseline differences between groups and examine the association between preloading statins on in-hospital mortality risk. The following variables were used to establish PS matching score: age, sex, classification of hospitals, clinical presentation (heart failure at presentation, cardiac shock, cardiac arrest, Killip classification), hypertension, diabetes, prior angina, prior myocardial infarction history, prior stroke, initial treatment. Results A total of 1169 patients were enrolled in control group and 6795 in preloading group. A total of 833 patients (334 in control group and 499 in preloading group) died during hospitalization. Compared with control group, preloading group were younger, more likely to be male and present with Killip I classification. The proportion of hypertension and diabetes were higher in preloading group. After PS matching, all the variables used to generate PS score were well balanced. In the PS-matched cohort, 30-day mortality risk was 26.3% (292/1112) in the control group and 11.9% (132/1112) in the preloading group (p<0.0001). Conclusions The current study found preloading statins treatment prior to reperfusion therapy reduced in-hospital mortality risk in a large-scale contemporary cohort of patients with STEMI. Funding Acknowledgement Type of funding source: Public Institution(s). Main funding source(s): Chinese Academy of Medical Sciences

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