The Study Of Factors Associated With Delay In Reperfusion Therapy In Patients With Acute ST-elevation Mocardial Infarction

Part ⅠThe study of factors associated with delay in reperfusion therapy in patients with Acute ST-Elevation Mocardial Infarction Background and purpose:ST-elevation myocardial infarction(STEMI)is a major cardiovascular event.Myocardial damage caused by acute STEMI is a time-dependent process.Reperfusion therapy is early,adequate and sustained opening of infarct-related artery.Reperfusion therapy can reduce mortality of the patients with STEMI,but the effectiveness depends on how fast the patients receive treatment.Delay times exceeding 2.0 h are still commonly reported.Pre-hospital delay times have been constant for several years.Therefore,we also need further extensive studies to reduce pre-hospital delay of patients with STEMI,in order to reduce the mortality and improve the prognosis of patients.Atypical symptoms were more frequent among patients with diabetes than in patients without diabetes.Analysis of patterns in pre-hospital delay in patients with and without diabetes are important and may improve patient education aiming to reduce delay times in MI.Currently,few studies are about pre-hospital delay of reperfusion treatment and mortality of female patients with STEMI.Therefore,we need to strengthen research about diagnosis and treatment of coronary heart disease in women,in order to improve the prevention and treatment of coronary heart disease in women.In advanced age,there is a higher risk of adverse effects associated with both medical and surgical treatment.In addition,the elderly are a challenging group due to lack of evidence-based therapy,a high prevalence of comorbid disorders,and other factors such as treatment restriction orders.Therefore,we should further study reperfusion treatment,prehospital delay time and mortality of elderly patients with STEMI.A number of studies have almost consistently shown that the misinterpretation of symptoms is a major cause for deciding not to seek medical care.Studies found that between 25% and 75 % of the patients did not label their symptoms to the heart,but its specific relationship still needs further study.The patients with AMI were quite different in the symptoms.The relationship between pre-hospital delay and the atypical symptoms also need to be further explored.Current guidelines recommend that first medical contact-to-balloon time be within 90 min for patients presenting to a PCI-capable hospital and within 120 min for patients presenting to a non–PCI-capable hospital.But many hospitals don’t have the ability of perform PCI,so we should further study the effect of pre-hospital diagnosis and transport mode of the patients for reperfusion therapy.The present study was to analyze a series of social,clinical and other factors about STEMI patients’ pre-hospital delay,in order to provide a theoretical basis for clinical decision making.The aim of the present study was to investigate the influencing factors of prehospital and in-hospital delays.The present study was to investigate the pre hospital delay and prognosis of women,elderly,diabetes and other specific groups.The overall objective of the present study was to investigate the role of the interpretation of symptoms for the decision process to seek treatment for AMI patients.In this study,we investigated the clinical features of patients with chest pain and non-chest pain,pre-hospital and in--hospital delay and prognosis.We analyze the pre-hospital diagnosis and transporting mode of STEMI patients,and thus provide the basis for clinical treatment decisions.Objects and methods:The study was based on data from 450 patients aged 35-89 years old,with ST-elevation myocardial infarction(STEMI)registered in The First Affiliated Hospital of Zhengzhou University and Luoyang Central Hospital Affiliated to Zhengzhou University between 2013 October-2015 March.Age,gender,previous medical history,symptoms and the clinical condition on admission,by what means of visiting hospitals and pre-hospital delay time etc were registered.All patients were followed up for 1 year,and the incidence of MACE was registered.All patients were divided into two groups,pre-hospital delay time ≤ 120 min and pre-hospital delay time >120min,according to the pre-hospital delay time delay.The patients were divided into two groups according to different delay factors: male group and female group,according to their gender;an elderly group(>75 years)and a reference group(≤75 years),according to their age;≥2 risk factors group and <2 risk factors group,according to the risk factors of coronary heart disease;diabetic and non-diabetic group,according to whether they have diabetes;≥3 pain parts and < 3 pain parts,according to whether their pain parts.They were divided into two groups: the group who attributed their symptoms to the heart and the group who didn’t attribute their symptoms to the heart.They were divided into two groups: chest pain group and non-chest pain group according to the symptoms.They were divided into three groups: without pre-hospital diagnosis group,with pre-hospital diagnosis and without direct transport group and with pre-hospital diagnosis and direct transport group.The related factors of pre-hospital delay were analyzed.Logistic regression analysis was used to assess the related factors of pre-hospital delay time ≤2 hours.We further analyzed the major influencing factors,such as female gender,diabetes,advanced age,non chest pain,non-pre hospital ECG and the wrong interpretation of the symptoms.We compared clinical and demographic characteristics,pre-hospital delay time,incidence rate of the diabetic group and the non-diabetic group,the male group and the female group,the elderly group and the reference group,the chest pain group and the non chest pain group,the pre-hospital ECG group and the non-pre hospital ECG.We assessed the factors that contributed to the correct interpretation of the symptoms of the patient,and attributed to the cause of the heart.Logistic regression analysis was used to assess the relevant factors that attributed the symptoms to cardiac causes and the symptoms associated with pre-hospital delay time <2 hours.We compared the general information among without pre-hospital diagnosis group,with pre-hospital diagnosis and without direct transport group and with pre-hospital diagnosis and direct transport group.The incidence of MACE of patients in each group was analyzed.The time period from the symptom onset to coronary artery reperfusion was compared and analyzed.Results:1.33.6% of the patients arrived at the hospital within 2 hours after the onset of symptoms,and 7.9% of patients arrived at the hospital 24 hours after the onset of symptoms.2.Logistic regression analysis showed,female(OR=2.108,95% CI:1.275-8.274),diabetes(OR=2.292,95% CI:1.105-5.532),age >75 years old(OR=1.202,95% CI:1.275-8.274),living alone(OR=2.078,95% CI: 1.484-13.672),bystander’ not positive attitude(OR=2.108,95% CI:1.069-3.363),Junior middle school culture(OR=1.218,95%CI: 1.027-20.081),≤Primary school culture(OR=1.475,95%CI: 1.184-25.638),onset at home(OR=1.569,95%CI: 1.206-7.902),with atypical symptoms of MI(OR=2.591,95% CI:1.473-10.758),not called EMS for admission to the hospital(OR=4.085,95%CI:1.347-20.521),without pre-hospital ECG(OR=3.873,95%CI:1.109-15.898),not attributed symptoms to the heart(OR=1.976,95% CI:1.573-8.590),without pre-hospital diagnosis(OR=3.087,95% CI:2.409-13.566),with pre-hospital diagnosis but not directly transported to the hospitals capable of PCI(OR=2.899,95% CI:1.205-18.643),living in towns(OR=2.302,95% CI:1.123-7.506)or rural areas(OR=3.565,95% CI:1.341-9.817)were independent risk factor of more than 2 hours of pre-hospital delay time(P<0.05).3.In 450 patients,only 29.5% of the patients chose to call 120,and were transported directly to our hospital by ambulance.The patients were divided into two groups,pre hospital delay time more than 2 hours group and pre hospital delay time less than 2 hours.The proportion of the patients with pre hospital delay time more than 2 hours by taxi(36.1% vs 30.5%,P=0.012),by private car(19.7% vs 9.9%,P=0.001),transported to our hospital from other hospitals by their ambulance(7.8% vs 3.1%,P=0.020),transported to our hospital from other hospitals by our ambulance(5% vs 1.5%,P=0.040),walking(4.4% vs 0.7%,P=0.025),by bus(6% vs 1.5%,P=0.017)was relatively high,and there was statistical significance(P < 0.05).The proportion of the patients with pre hospital delay time more than 2 hours calling the EMS(20.4% vs 51.9%,P<0.001)was relatively low,and there was statistical significance(P < 0.05).4.In 450 patients,30.9% were female.Female patients were older than male patients(68.9±12.6 vs 62.9±11.7,P<0.05).At the time of admission,the clinical features of female patients were more serious than that of men,and the proportion of anterior wall myocardial infarction(56.5% vs 44.6%,P=0.021)and acute heart failure(Killip II 14.8% vs7.4% P=0.020: Killip III 8.3% vs 2.9% P=0.017: Killip IV 11.1% vs 3.3% P=0.001)were higher.Men had longer duration of ischemia(99.2% vs 92.6%,P=0.000).The proportion of pre hospital delay time <6 hours of women is less than that of men(55.6% vs 82.2%,P<0.001),and the proportion of reperfusion treatment was lower than that of men(55.6% vs 72.3%,P=0.001).The incidence of MACE in-hospital(6.47% vs 2.0%,P=0.013)and at 1 year(29.6% vs 9.3%,P=0.000)was significantly higher in female patients than in male patients.5.More patients with diabetes had a pre-hospital delay ≥ 2 h than patients without diabetes(64.3% vs58.2%,P=0.002).There was no difference in pre-hospital delay time between men and women with diabetes(62.8% vs 67.6%,P=0.494).The patients with diabetes had a significantly longer median time from first medical contact to coronary artery opening than patients without diabetes(3.5±1.9 h vs 1.6±1.7 h,P=0.039).6.The elderly patients had a significantly longer median time from first medical contact to coronary artery opening than a reference group(5.8±3.5h vs 3.0±2.8h,P=0.045).Elderly hospitalized patients with AMI were less often investigated with CA(34% vs 79%,P<0.001).The proportion of PCI(38% vs 65%,P<0.001)and CABG(2% vs 12%,P =0.002)in the elderly patients was less than that in the control group.The incidence of MACE in-hospital(7.7% vs 1.9%,P=0.008)and at 1 year(28.7% vs 12.3%,P<0.001)was significantly higher in elderly patients than in the control group.7.50.3% patients attributed their symptoms to heart.Multivariate regression analysis showed that chest pain,chest tightness(OR=6.11,95% CI:2.99-12.77),left upper limb pain(OR=1.85,95% CI:1.43-2.21)and feeling of impending death(OR=3.85,95% CI:1.43-12.21)helped patients to attribute their symptoms to cardiac causes.AMI(OR=1.32,95% CI:1.07-1.55),angina pectoris(OR=3.41,95% CI:2.44-4.32),hypertension(OR=1.21,95% CI:1.15-1.68),and hyperlipidemia(OR=1.34,95% CI:1.03-1.62)were more likely to be symptoms of the correct interpretation.Multivariate regression analysis showed,syncope(OR=2.17,95% CI:1.50-3.28),sweating(OR=1.25,95% CI:1.03-1.81),dizziness(OR=1.35,95% CI:1.08-1.70),shortness of breath(OR=1.23,95% CI:1.02-1.47)and feeling of impending death(OR=3.31,95% CI:1.08-11.79)were of predictive factor short time pre-hospital delay,and there were statistical significances(P<0.05).8.The STEMI patients without chest pain symptoms were older than those with chest pain symptoms(69.2±14.2 vs 61.7±13.2,P<0.05),had a higher proportion of women(32.3% vs 18.6%,P =0.001),a higher incidence of previous heart failure(6.5% vs 1.9%,P =0.013),a relatively lower proportion of EMS admission(23.3% vs 52.6%,P =0.001),a higher proportion of more than Killip II grade patients(Killip II 21.71% vs 13.3% P=0.018: Killip III 22.6% vs9.5% P=0.001: Killip IV 20.6% vs 10.5% P=0.004),and a higher incidence of MACE(28.5% vs 9.0%,P =0.002)when they were followed up for 1 year.The time for the first ECG(69.2±14.2min vs 30.35±9.93 min,P<0.001)and that from medical exposure to coronary artery opening(3.65±2.32 h vs 1.92±1.2 h,P=0.001)was longer,and there were statistical significances(P<0.05).9.The incidence of 1 year MACE of the patients with pre-hospital diagnosis and a direct transfer to hospital capable of PCI was significantly lower than the other two groups(7.1% vs 28.4% vs 17.7%,P =0.017),and there were significant differences(P<0.05).The time of the patients with pre-hospital diagnosis and a direct transfer to hospital capable of PCI from the onset of symptoms to catheterization room(127.89±29.45 min vs 168.00±28.39 min vs 228.82±51.67min),from medical contact to catheterization room(102.55±20.81vs129.54±24.89 minvs 149.68±30.81 min)and from patients’ arriving at the hospital to the coronary artery recanalization(30.09±6.49 min vs 34.42±7.91 min vs 41.74±10.05min)was shorter the other two groups,and there were significant differences(P<0.05).Conclusions:1.Female,diabetes,older age,relatively low degree of education,atypical symptoms,living alone,accompanied by attendants whose medical treatment attitude was not positive,at home,not called EMS,without pre-hospital diagnosis,with pre-hospital diagnosis but without direct transfer to the feasible PCI hospital and living in towns or rural areas were related factors of pre-hospital delay time more than 2 hours.2.EMS is the best way to transport patients with STEMI,which can significantly shorten the pre-hospital delay time.Female,aged and diabetes patients with STEMI had longer pre-hospital delay time and higher incidence of in-hospital and one-year MACE.3.In AMI patients,the wrong interpretation of symptoms was very common,which would affect the pre-hospital delay time.4.Patients with STEMI who had no chest pain had longer pre-hospital delay time,a higher in-hospital and one-year incidence of MACE than those with chest pain.5.Pre-hospital diagnosis and transferring STEMI patients directly to a PCI center can significantly shorten the pre-hospital and in-hospital delay time,and reduce incidence of MACE.Part II The effect of community health education and the establishment of regional cooperative chest pain center on pre-hospital and in-hospital delay of STEMI patients Background and purpose:For STEMI patients,many studies showed that the wrong understanding of the symptoms is the main reason of the delay in treatment.In addition,many patients didn’t well understand symptoms of AMI,the best treatment scheme of AMI,the concept of the emergency PCI operation and emergency PCI operation time window.Therefore,community health education of the knowledge about AMI for people is very important.At present,the knowledge of comprehensive cardiovascular disease prevention and the experience of rapid diagnosis and rescue of acute myocardial infarction of Chinese basic service doctor is still insufficient,which caused pre-hospital delay time of the patients with STEMI prolonged,needs to further improve urgently to short time delay and improve the prognosis of patients.Current guidelines recommended for STEMI patients in the feasible PCI surgery hospital,the first medical contact to balloon blood flow time should be within 90 minutes,and for the patient not in the feasible PCI surgery hospital,the time should be within 120 minutes.In China,only three grade hospitals have the ability of emergency PCI operation,a part of the two hospitals,community hospitals and township hospitals do not have the ability of emergency PCI operation.Henan is a province with a large population,and the economy and medical level of China is relatively backward,so how to make STEMI patients transported to the feasible emergency PCI hospital as soon as possible is an urgent problem.American College of Cardiology / American Heart Association(ACC/ AHA)STEMI guidelines recommended the establishment of STEMI system in order to increase the number of patients with timely emergency PCI.The establishment of STEMI system could be used to identify the STEMI in early stage.The patients can be transported directly to the heart center with the most feasible PCI operation.The catheter room could be started as soon as possible,which can significantly shorten the time of reperfusion and decrease the mortality rate.Genenral Hospital of PLA Guangzhou Military Area set up China’s first chest pain center in March 2011,extended emergency services from the hospital to pre-hospital care systems and in transit and realized seamless connection for the treatment of patients with chest pain.The reperfusion time of STEMI patients was shortened to 69 min.We conducted health education for a part of community residents and professional training for a part of community physicians near our research center.,but another part of the community and residents community physicians weren’t intervened.The patients were divided into two groups according to if they were intervened.The clinical data,incidence of the in-hospital malignant complications,in-hospital mortality and MCAE after 1 year,the time period from the symptom onset to coronary artery reperfusion of two groups were compared and analyzed.We analyzed whether the health education of the residents and professional training of community doctors can shorten in-hospita land pre-hospital delay time of the STEMI patients,and improve the prognosis of patients.AMI regional cooperative treatment center was established in our research center in 2015 and cooperated with primary hospitals through remote information system.The patients’ information(including ECG,vital signs,etc.)transmited to the central office,which implement 24 hours shifts of cardiovascular physicians for the timely processing of patient information and emergency treatment as soon as possible.The ambulances of our research center were equipped with ventilators,intra aortic balloon counterpulsation(IABP),temporary pacemaker emergency and other rescue facilities.Cardiovascular physicians with rescue experience visited for transfer patients.Cardiovascular intervention physicians stood by for the emergency reperfusion therapy at any time.The patients were divided into two groups according to if AMI regional cooperative treatment center was established.The clinical data,incidence of the in-hospital malignant complications,in-hospital mortality and MCAE after 1 year,the time period from the symptom onset to coronary artery reperfusion of two groups were compared and analyzed.We analyzed whether the establishment of AMI regional collaborative treatment center can shorten in-hospita land pre-hospital delay time of the STEMI patients,and improve the prognosis of patients.Objects and methods:There were a total of 20 communities around Luoyang Central Hospital Affiliated to Zhengzhou University.10 of the communities were selected from January 2015 to December 2015 to carry out health education for residents,and to conduct professional training for community doctors,and the other 10 communities weren’t intervened.The patients are divided into two groups according to whether the patients underwent health education and the community physicians underwent professional training.The intervention group included the patients who were intervened,and the control group included the patients who weren’t intervened.The distance between the two groups of patients from the hospital was not statistically different.The intervention group was further divided into two groups: 2014 group(before intervention)(n = 166)and 2015 group(after intervention)(n = 158),and the control group was divided into two groups: 2014 group(n = 160)and 2015 group(n = 139).A controlled study was conducted on STEMI patients in the intervention community and in the non intervention community,as well as in patients with STEMI before and after intervention.The clinical data of patients were retrospectively analyzed,including the clinical data,reperfusion therapy,complications during hospitalization,and in-hospital mortality.298 patients with STEMI were selected,excluded from the patients who underwent community health education and community physician professional training from January 2015 to December during the establishment of a regional collaborative treatment center in Luoyang Central Hospital Affiliated to Zhengzhou University.287 patients with STEMI were selected from January 2014 to December during not the establishment of a regional collaborative treatment center.A comparative study was conducted between the two groups.All the patients were followed up for 1 year.The clinical data,the incidence of complications during hospitalization,in-hospital mortality and the incidence of MCAE after 1 year of the patients in the two groups were analyzed and compared.Results:1.The proportion of the control rate of blood pressure control,blood glucose control,the rate of blood lipid control and the proportion of patients undergoing PCI in 2015 group(after intervention)of the intervention group was significantly higher than that in 2014 group(before intervention)of the intervention group(82.3% vs 51.3%,P<0.001),(61.7% vs 35.4%,P=0.003),(77.9% vs 49.2%,P=0.006)and 2015 group of the non intervention group(82.3% vs 50.8%,P<0.001),(61.7% vs 35.3%,P=0.006),(77.9% vs 47.6%,P=0.004)(P<0.05),and the difference was statistically significant(P<0.05).The proportion of emergency PCI in 2015 group(after intervention)of the intervention group was significantly higher than that in 2014 group(before intervention)of the intervention group(84.8% vs 62.1%,P<0.001)and in 2015 group of the non intervention group(84.8% vs 65.5%,P<0.001),and the difference was statistically significant(P<0.05).The proportion of TIMI<3 grade after operation in 2015 group(after intervention)of the intervention group was lower than that in 2014 group(before intervention)of the intervention group(5.1% vs 11.4%,P=0.038)and 2015 group of the non intervention group(5.1% vs 12.2%,P=0.026),and the difference was statistically significant(P<0.05).2.The proportion of the patients of 2015 group(after intervention)of the intervention group who known the concept of emergency PCI surgery,the concept of emergency PCI time window,consented to EMS transporters to improve outcome in patients with AMI,and known the symptoms of AMI,known to immediately dial 120 once the symptoms were significantly higher than those in 2014 group(before intervention)of the intervention group(57.2% vs 3.6%,P<0.001),(55.7% vs 3.01%,P<0.001),(88.6% vs 39.8%,P<0.001),(85.4% vs 45.2%,P<0.001),(87.3% vs 44.6%,P<0.001)and 2015 group of the non intervention group(57.2% vs 2.88%,P<0.001),(55.7% vs 2.88%,P<0.001),(88.6% vs 33.1%,P<0.001),(85.4% vs 49.6%,P<0.001),(87.3% vs 46.8%,P<0.001),and the difference was statistically significant(P<0.05).3.The incidence rate of malignant complications during hospitalization,in-hospital mortality,and MCAE after 1 year of 2015 group(after intervention)of the intervention group were significantly lower than those in 2014 group(before intervention)of the intervention group(8.2% vs 16.3%,P=0.028),(2.5% vs 7.8%,P=0.032),(15.8% vs 27.7%,P=0.010),(8.6±7.9 vs 13.9±12.5 day,P=0.040)and 2015 group of the non intervention group(8.2% vs 17.3%,P=0.019),(2.5% vs 7.9%,P=0.035),(15.8% vs 23.7%,P=0.045),(8.6±7.9 vs 15.7±10.5 day,P=0.029),and the difference was statistically significant(P<0.05).4.The time of 2015 group(after intervention)of the intervention group from the onset of symptoms to catheterization room,from medical contact to catheterization room and from patients’ arriving at the hospital to the coronary artery recanalization was shorter than that of 2014 group(before intervention)of the intervention group(167.3±42.6 min vs 198.8±51.7 min,P=0.025),(135.5±25.8 min vs 148.9±27.2 min,P=0.028),(37.3±12.6 min vs 46.1±16.9 min,P=0.012)and 2015 group of the non intervention group(167.3±42.6 min vs 199.1±55.1 min,P=0.021),(135.5±25.8 min vs 148.5±29.7 min,P=0.032),(37.3±12.6 min vs 44.1±15.1 min,P=0.034),and the difference was statistically significant(P<0.05)..The ratio of from the onset of symptoms to the catheter room time <2h was significantly higher than that in 2014 group(before intervention)of the intervention group(16.5% vs 8.4%,P=0.028)and 2015 group of the non intervention group(16.5% vs 7.9%,P=0.026),and the difference was statistically significant(P<0.05).5.The proportion of emergency PCI of the collaborative group was significantly higher than the non cooperative group(77.8% vs 62%,P=0.001),and there was statistical difference(P<0.05).The proportion of TIMI<3 grade after operation of the collaborative group was significantly lower than non cooperative group(5.4% vs 11.1%,P=0.011),and there was statistical difference(P<0.05).6.The time of the cooperative center group from the onset of symptoms to catheterization room(149.3±51.6 min vs 201.3±50.1 min,P=0.017),from medical contact to catheterization room(127.8±24.9 min vs 147.6±29.0min,P=0.028)and from patients’ arriving at the hospital to the coronary artery recanalization(36.7±13.2 min vs 47.5±17.2 min,P=0.019)was shorter than the non cooperative center group,and the ratio of from the onset of symptoms to the catheter room time <2h(17.1% vs 9.1%,P=0.004)was significantly higher than that in the non cooperative center group,and there were significant differences(P<0.05).7.The incidence rate of malignant complications during hospitalization(8.1% vs 17.8%,P=0.001),in-hospital mortality(2.7% vs 7.7%,P=0.006),MCAE after 1 year(13.8% vs 23%,P=0.004)and hospitalization days of the patients(7.76±8.1 vs 14.3±13.9 day,P=0.019)of the cooperative center group were significantly lower than those in the non cooperative center group,and there were significant differences(P<0.05).Conclusions:1.The training and education for residents and community doctors can improve primary and secondary prevention of coronary heart disease2.The training and education of residents and community doctors can shorten pre-hospital delay time of STEMI patients,reduce the incidence of serious complications,hospital mortality and the incidence of one-year MACE,and increase the proportion of PCI,which can improve the prognosis of patients.3.The establishment of a regional cooperative treatment center can shorten pre-hospital delay time of STEMI patients,increase the proportion of PCI,reduce the incidence of serious complications,hospital mortality and the incidence of one-year MACE.The establishment of a regional cooperative treatment center can improve the prognosis of patients.