How to avoid system delay in the managing of patients with ST-segment elevation myocardial infarction – experience from Western Slavonia

    Authors

    Abstract

    **Introduction**: Primary percutaneous coronary intervention (PCI) is recommended for patients with ST-segment elevation myocardial infarction (STEMI) if it can be performed in a timely manner. Universal access is the major limitation of a PCI strategy, especially for STEMI patients who are usually initially transferred to a non-PCI hospital. A PCI network-oriented approach that bypasses non PCI centers in favor of PCI capable centers can reduce system delay and improve patient outcomes. (1-3) **Patients and Methods**: The General Hospital “Dr Josip Benčević” is a PCI-center in Western Slavonia within the Croatian PCI Network. We have developed a regional protocol for transfer of field-triaged patients directly to our hospital, bypassing local non-PCI hospitals. The Cath Lab was notified by the field emergency medical service (EMS) when a STEMI was suspected. Premedication with a loading dose of aspirin and a P2Y12 inhibitor was administered according to established protocol, and patients were admitted directly to the Cath Lab. Patient- and procedure-specific information as well as data from the Hospital Information Service and EMS register were documented in our register. **Results**: Between January 2020 and October 2021, a total of 37 patients with suspected STEMI infarction were transferred to the Cath Lab, including 13 women with a mean age of 75 years (53-91 years) and 24 men with a mean age of 61 years (46-80 years). STEMI diagnosis was confirmed in 33 patients, 2 patients had pericarditis, 1 patient had Takotsubo cardiomyopathy, and 1 patient had hypertensive crisis. The culprit artery was he right coronary artery (RCA) in 17 (51.5%) patients, left anterior descending artery in 9 (27.3%) patients, circumflex artery in 5 (15.2%) patients, venous bypass graft in 1 (3%) patient, and 1 (3%) patient refused the procedure. All patients received aspirin, 14 (42.4%) patients received a P2Y12 inhibitor. Two patients suffered cardiac arrest during transport due to malignant arrhythmias (VF/VT). Patients with RCA occlusion were transported faster (median 37 minutes) than those with LAD occlusion (median 41 minutes). **Conclusion**: Direct communication between EMS and field-triaging patients to the PCI center resulted in safe and efficient transport of patients to the cath lab. A shorter health care system delay can reduce reperfusion time and may be the key to further improving cardiovascular outcomes in STEMI patients.

    Keywords

    ST-segment elevation myocardial infarction, field-triage, percutaneous coronary intervention network

    DOI

    https://doi.org/10.15836/ccar2023.84

    Literature

    1. Terkelsen CJ, Sørensen JT, Maeng M, Jensen LO, Tilsted HH, Trautner S, et al. System delay and mortality among patients with STEMI treated with primary percutaneous coronary intervention. JAMA. 2010 August 18;304(7):763–71. https://doi.org/10.1001/jama.2010.1139
    2. Henry TD, Sharkey SW, Burke MN, Chavez IJ, Graham KJ, Henry CR, et al. A regional system to provide timely access to percutaneous coronary intervention for ST-elevation myocardial infarction. Circulation. 2007 August 14;116(7):721–8. https://doi.org/10.1161/CIRCULATIONAHA.107.694141
    3. Collet JP, Thiele H, Barbato E, Barthélémy O, Bauersachs J, Bhatt DL, et al. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J. 2021 April 7;42(14):1289–367. https://doi.org/10.1093/eurheartj/ehaa575
    Cardiologia Croatica
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    How to avoid system delay in the managing of patients with ST-segment elevation myocardial infarction – experience from Western Slavonia

    Extended Abstract
    Issue3-4
    Published
    Pages84
    PDF via DOIhttps://doi.org/10.15836/ccar2023.84
    ST-segment elevation myocardial infarction
    field-triage
    percutaneous coronary intervention network

    Authors

    Katica Cvitkušić Lukenda*ORCIDGeneral Hospital “Dr. Josip Benčević” Slavonski Brod, Slavonski Brod, Croatia
    Marijana Knežević PravečekORCIDGeneral Hospital “Dr. Josip Benčević” Slavonski Brod, Slavonski Brod, Croatia
    Ivica DunđerORCIDGeneral Hospital “Dr. Josip Benčević” Slavonski Brod, Slavonski Brod, Croatia
    Antonija RagužORCIDGeneral Hospital “Dr. Josip Benčević” Slavonski Brod, Slavonski Brod, Croatia
    Ivan BitunjacORCIDGeneral Hospital “Dr. Josip Benčević” Slavonski Brod, Slavonski Brod, Croatia
    Domagoj MiškovićORCIDGeneral Hospital “Dr. Josip Benčević” Slavonski Brod, Slavonski Brod, Croatia
    Jelena JakabORCIDGeneral Hospital “Dr. Josip Benčević” Slavonski Brod, Slavonski Brod, Croatia
    Ivana GrgićORCIDGeneral Hospital “Dr. Josip Benčević” Slavonski Brod, Slavonski Brod, Croatia
    Blaženka MiškićORCIDGeneral Hospital “Dr. Josip Benčević” Slavonski Brod, Slavonski Brod, Croatia
    Branka BardakORCIDInstitute of Emergency Medicine of Brod-Posavina County, Slavonski Brod, Croatia
    Anto LukendaORCIDGeneral Hospital “Dr. Josip Benčević” Slavonski Brod, Slavonski Brod, Croatia
    Krešimir GabaldoORCIDGeneral Hospital “Dr. Josip Benčević” Slavonski Brod, Slavonski Brod, Croatia

    *Correspondence email: kclukenda@gmail.com

    Abstract

    **Introduction**: Primary percutaneous coronary intervention (PCI) is recommended for patients with ST-segment elevation myocardial infarction (STEMI) if it can be performed in a timely manner. Universal access is the major limitation of a PCI strategy, especially for STEMI patients who are usually initially transferred to a non-PCI hospital. A PCI network-oriented approach that bypasses non PCI centers in favor of PCI capable centers can reduce system delay and improve patient outcomes. (1-3) **Patients and Methods**: The General Hospital “Dr Josip Benčević” is a PCI-center in Western Slavonia within the Croatian PCI Network. We have developed a regional protocol for transfer of field-triaged patients directly to our hospital, bypassing local non-PCI hospitals. The Cath Lab was notified by the field emergency medical service (EMS) when a STEMI was suspected. Premedication with a loading dose of aspirin and a P2Y12 inhibitor was administered according to established protocol, and patients were admitted directly to the Cath Lab. Patient- and procedure-specific information as well as data from the Hospital Information Service and EMS register were documented in our register. **Results**: Between January 2020 and October 2021, a total of 37 patients with suspected STEMI infarction were transferred to the Cath Lab, including 13 women with a mean age of 75 years (53-91 years) and 24 men with a mean age of 61 years (46-80 years). STEMI diagnosis was confirmed in 33 patients, 2 patients had pericarditis, 1 patient had Takotsubo cardiomyopathy, and 1 patient had hypertensive crisis. The culprit artery was he right coronary artery (RCA) in 17 (51.5%) patients, left anterior descending artery in 9 (27.3%) patients, circumflex artery in 5 (15.2%) patients, venous bypass graft in 1 (3%) patient, and 1 (3%) patient refused the procedure. All patients received aspirin, 14 (42.4%) patients received a P2Y12 inhibitor. Two patients suffered cardiac arrest during transport due to malignant arrhythmias (VF/VT). Patients with RCA occlusion were transported faster (median 37 minutes) than those with LAD occlusion (median 41 minutes). **Conclusion**: Direct communication between EMS and field-triaging patients to the PCI center resulted in safe and efficient transport of patients to the cath lab. A shorter health care system delay can reduce reperfusion time and may be the key to further improving cardiovascular outcomes in STEMI patients.

    Literature

    1. 1.
      Terkelsen CJ, Sørensen JT, Maeng M, Jensen LO, Tilsted HH, Trautner S, et al. System delay and mortality among patients with STEMI treated with primary percutaneous coronary intervention. JAMA. 2010 August 18;304(7):763–71.DOI
    2. 2.
      Henry TD, Sharkey SW, Burke MN, Chavez IJ, Graham KJ, Henry CR, et al. A regional system to provide timely access to percutaneous coronary intervention for ST-elevation myocardial infarction. Circulation. 2007 August 14;116(7):721–8.DOI
    3. 3.
      Collet JP, Thiele H, Barbato E, Barthélémy O, Bauersachs J, Bhatt DL, et al. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J. 2021 April 7;42(14):1289–367.DOI