QUALITY OF CARE : Effect of system delay on hospital mortality among STEMI patient in Gaza
Mohammed Habib*, Hind Abbas, Mohammed Zaqout
Affiliation
Cardiology Department, AlShifa Hospital- Gaza- Palestine
Corresponding Author
Mohammed Habi, Cardiology Department, AlShifa Hospital- Gaza- Palestine, Email: cardiomohammad@yahoo.com
Citation
Mohammed, H., et al. QUALITY OF CARE: Effect of System Delay on hospital Mortality among STEMI Patient in Gaza (2020) J Heart Cardiol 5(1): 4-6.
Copy rights
© 2020 Mohammed, H. This is an Open access article distributed under the terms of Creative Commons Attribution 4.0 International License.
Keywords
System Delay, STEMI, Hospital mortality
Abstract
Objective: System delay in STEMI patients have been introduced as a performance indicator or marker of quality of care. As they are only one part of a very complex medical process. At this study we comparison the STEMI system delay from FMC to reperfusion by streptokinase or primary PCI between 2016 and 2019 in Al Shifa hospital.
Methods: Retrospective cohort study in a single coronary care unit at Al Shifa hospital. All patients presents with STEMI divided into two group: First group receiving streptokinase for acute myocardial infarction. Second group: underwent primary PCI. End point was: time from FMC to reperfusion by intravenous streptokinase or primary PCI and total intrahospital Cardiac mortality, and mortality related to cardiogenic shock.
Results: In 2019: Total 145 patients, the timefrom FMC to primary PCI was 75.2+20 minutes and mean time from FMC to streptokinase was 33.2+17 minutes. A 81.25% of the patients were underwent primary PCI with 90 minutes, and 46% of the patients received streptokinase with 20 minutes and 46% of the patients received streptokinase with 30 minutes.
In 2016: The study included 64 patients; the mean time patients spent in the Emergency Room (ER) was 82 minutes, with a total of 91.5% spent more than 30 minutes. The time from First Medical Contact (FMC) to thrombolysis therapy was less than 30 min in only 10%, while FMC to Primary PCI was less than 90 min in 33.3%.
The intrahospital mortality: for primary PCI was 6.3% in 2016 and 4.6% in 2019. For streptokinase was 9.8% in 2016 and 4.9% in 2019. Mortality related to cardiogenic shock was 62.5% in 2016 and 43% in 2019.
Conclusion: The time from first medical contact to primary PCI or streptokinase was reduced between 2016 and 2019, and the reduction was effect on total intra hospital mortality and mortality related to cardiogenic shock.
Introduction
STEMI system delays from first medical contact to reperfusion by thrombolytic or primary PCI have been introduced as a marker of quality of care. The importance of reperfusion time in patients with ST-elevation myocardial infarction (STEMI) is well established. If performed by experienced operators, primary percutaneous coronary intervention (PCI) is the preferred method of reperfusion, with a 2% absolute reduction in mortality risk compared with thrombolytic therapy [1]. However, the benefits of primary PCI over fibrinolytic therapy are clearly time dependent and faster reperfusion of the infarct-related artery, as measured by a shorter door-to-balloon time (DBT), is associated with decreased rates of mortality [2–4].
Our aim of the study to evaluate the time from FMC to reperfusion by intravenous streptokinase or primary PCI and total intra hospital Cardiac mortality, and mortality related to cardiogenic shock.
Methods and Results
Study design
This study involved 2 trial focused in the system delay (time from first medical contact to reperfusion by streptokinase or primary PCI)
The first trial as clinical audit: And as retrospective evaluation and contain 64 patients, in 2016, the mean time patients spent in the Emergency Room (ER) was 82 minutes, with a total of 91.5% spent more than 30 minutes. The time from First Medical Contact (FMC) to thrombolysis therapy was less than 30 min in only 10%, while FMC to Primary PCI was less than 90 min in 33.3%[5]. in this trial streptokinase was received for all patients in coronary care unit after transfer from emergency room and after streptokinase the PCI was done within 72 hours.
The second trial: The study population was single Center trial derived from al shifa hospital between January 2019 and October 2019. We identified 145 patients (≥18 years) with STEMI (<12 hours) eligible for streptokinase (1.5 MU intravenously over 60 minutes) followed by pharmaco-invasive strategy or Primary PCI.
64 (44.1%) patients underwent standard primary PCI and 81 (55.9%) patient underwent pharmacoinvasive PCI. The Rescue intervention was performed if there was < 50% ST-segment resolution in the single lead of an electrocardiogram or clinical evidence of failed reperfusion within 90 minutes after streptokinase. The rate of rescue PCI was performed in 32 patients (39.5% of pharmacoinvasive PCI strategy).
There was no difference in 30-day mortality (4.7% in primary PCI and 4.9% in pharmaco invasive strategy (P = 0.94) but emergency angiography was required in 39.5% of the patients in the pharmaco-invasive strategy.
The time from FMC to primary PCI was 75.2 + 20 minutes and mean time from FMC to streptokinase was 33.2+17 minutes. A 81.25% of the patients were underwent primary PCI with 90 minutes. And 46% of the patients received streptokinase with 20 minutes and 60% of the patients received streptokinase with 20 minutes and 60% [6]. In this trial streptokinase was received in emergency room and then transfer to cardiac catheterization laboratory for pharmaco-invasive PCI within 24 hours.
Table 1: system delay of reperfusion in 2016 and 2019
|
|
2016 |
2019 |
|
System delay of primary PCI |
93 ± 20 min |
75.25 ± 20 min |
|
Percentage of primary PCI < 90min |
33.3% |
81.25% |
|
System delay for streptokinase |
82 minutes |
33+17 minutes |
|
Percentage of streptokinase < 30 min |
10% |
60% |
The intra hospital mortality: For primary PCI was 6.3% in 2016 and 4.6% in 2019. For streptokinase was 9.8% in 2016 and 4.9% in 2019. Mortality related to cardiogenic shock was 62.5% in 2016 and 43% in 2019.
Discussion
Our results demonstrate that in patients with an STEMI, system delay was significantly reduced from 2016 to 2019, and this reduction in time associated with lower intrahospital mortality and Mortality related to cardiogenic shock.
Our result was similar to Terkelsen et al, trial that demonstrated system delay was independently associated with mortality [7] and Sonja Postma et al. who suggested that prolonged system delay significantly increased short-term as well as long-term mortality in patients with an anterior MI. This effect was not demonstrated in patients with a non-anterior MI [8].
The STREAM trial suggested that thrombolytic failure and requirement rescue PCI in patient who underwent tenecte place was 36%, in our trial we use streptokinase and failure rate was 40.2% [9]. In (Gulf RACE-3Ps) study, the system delay was 130 min (mainly related to EMS delay), which was within the range of 60 to 177 min reported Furthermore, among patients with STEMI, only 30% had DNTs < 30 min, and only 25% had rescue PCIs for failed reperfusion[10]., In a Swedish multicenter study, only 51% reported that the first medical contact was with EMS; 14% went directly to the ED; and the remaining patients chose to discuss their symptoms first by either going to a clinic or consulting a public health care advisory service[11].
Recent published AHA STATISTICAL UPDATE. Heart Disease and Stroke Statistics-2019 Update suggested that Timely Reperfusion for STEMI, Thrombolytic agents within 30 min in 52.0 and PCI within 90 min was in 95.9% of the patients [12].
Conclusion
The time from first medical contact to primary PCI or streptokinase can be help of the reduction of total intra hospital mortality and mortality related to cardiogenic shock in patients with ST elevation myocardial infarction.
Potential Conflict of Interest: No potential conflict of interest relevant to this article was reported.
Finance: None
References
- 1. Keeley, E.C., Boura, J.A., Grines, C.L. Primary Angioplasty vs. intravenous thrombolytic therapy for acute myocardial infarction: a quantitativereview of 23 randomized trials. (2003) Lancet 361(9351): 13-20.
- 2. Berger, P.D., Ellis, S.G., Holmes, D.R., et al. Relationship between delays in performingdirect coronary angioplasty and early clinical outcomes in patientswith acute myocardial infarction: results from the global use of strategies to open occluded arteries in acute coronary syndromes(Gusto-IIb) trial. (1999) Circulation 100(1): 14–20.
- 3. Cannon, C.P., Gibson, C.M., Lanbrew, C.T., et al. Relationship ofsymptom-onset-to-balloon time and door-to-balloon time with mortalityin patients undergoing angioplasty for acute myocardial infarction. (2000) JAMA 283(22): 2941-2947.
- 4. De Luca, g., Suryapranata, H., Ottervanger, J.P., et al. Time delay tominute of delay counts. (2004) Circulation 109: 1223–1225
Pubmed| Crossref| Others
- 5. Habib, H., Aghaalkurdi, M. R., Assalqawy, A. M., et al. Management of STEMI, a clinical audit. (2018) Eur Heart J 471: 225-226
Pubmed| Crossref| Others
- 6. Mohammed, H., mohammed, H. ST-Segment– Elevation Myocardial Infarction for Pharmacoinvasive Strategy or Primary Percutaneous Coronary Intervention in Gaza (STEPP- PCI). (2019) Online J Cardiovascular Res.
Pubmed| Crossref| Others
- 7. Terkelsen, C.J., Sørensen, J.T., Maeng, M., et al. System delay andmortality among patients with STEMI treated with primarypercutaneous coronary intervention. (2010) JAMA 304(7): 763–771.
- 8. Postma, S., Dambrink, J. H., Gosselink, A.T., et al. The influence of system delay on 30-dayand on long-term mortality in patientswith anterior versus non-anteriorST-segment elevation myocardialinfarction: a cohort study. (2015) Open Heart 2(1): e000201.
- 9. Armstrong, P.W., Gershlick, A.H., Goldstein, P., et al. Fibrinolysis or primary PCI in ST-segment elevation myocardial infarction. (2013) N Engl J Med 368: 1379–1387.
Pubmed| Crossref| Others
- 10. AlHabib, K. F., Sulaiman, K., Al Suwaidi, J., et al. Patient and System-Related Delays ofEmergency Medical Services Use in Acute ST-Elevation Myocardial Infarction: Results fromthe Third Gulf Registry of Acute Coronary Events (Gulf RACE-3Ps). (2016) Plos One 11(1): 14.
- 11. Thylén, I., Ericsson, M., Hellström Ängerud, K., et al. First medical contact in patients withSTEMI and its impact on time to diagnosis; an explorativecross-sectional study. (2015) BMJ Open 5(4): e007059.
- 12. Benjamin, E. J., Muntner, P., Alexander, R. C., et al. Heart Disease and Stroke Statistics—2019 Update. (2019) Circulation 139(10): e56–e528.
Pubmed| Crossref| Others
