Original Contribution
Factors associated with prehospital delay in patients with ST-segment elevation acute myocardial infarction in China,☆☆

https://doi.org/10.1016/j.ajem.2013.12.053Get rights and content

Abstract

Background

Prehospital delay is the most critical factor to prognosis of ST-elevation myocardial infarction (STEMI). Few study had examined a series of predictors of prehospital delay by multivariate analysis of sociodemographic and clinical characteristics, onset features, and symptom condition of STEMI in China.

Methods

A total of 1088 hospitalized STEMI participants were screened to collect sociodemographic data, medical history information, and symptom onset status from clinical medical records. Factors associated with prehospital delay were examined using bivariate and multivariate analysis method.

Results

The median prehospital delay time (PDT) was 130 minutes in STEMI participants. Multivariate regression models examining 8 predictors were associated with prehospital delay, including senior high school or above educational level, myocardial infarction (MI) history, vertigo onset symptom, ambulance transportation, onset in daytime (6:00-18:00), onset at home, anterior wall MI, and posterior wall MI. Mortality in PDT more than 120 minutes group was 5.5%, whereas it was 4.3% in PDT 120 minutes of less group without significant statistically difference (P > .05).

Conclusions

Multivariate analysis results found that symptom onset–related variables strongly influenced PDT. Onset-related status of STEMI needed to be combined into interventions of participants, and more emergency education should be recommended to both participants and their relatives. Most importantly, more efforts should be taken to educate the public about the symptoms and signs to increase the recognition of STEMI.

Introduction

Nowadays, ST-elevation myocardial infarction (STEMI) comprises approximately 25% to 40% of total myocardial infarction (MI) presentations [1], [2], [3], [4]. The in-hospital mortality of STEMI was approximately 5% to 6%, although the rate has decreased significantly in association with a substantial increase in the frequency of care that includes guideline-directed medical therapy and interventions [2], [4], [5], [6], [7]. Ventricular arrhythmias, especially the lethal ventricular arrhythmias, including sustained ventricular tachycardia and ventricular fibrillation, are common in early phase of STEMI. Cardiac arrest with STEMI is most often due to lethal ventricular arrhythmias. Almost 70% of the coronary heart disease deaths annually in the United States occur, usually presenting as “sudden death” due to cardiac arrest [8]. One of the most common causes of mortality in participants with STEMI is lethal ventricular arrhythmia. Timely administration of reperfusion therapy including percutaneous coronary intervention (PCI) and fibrinolytic therapy is critical for improving survival [9], [10], [11], [12]. Delays in the administration of reperfusion therapy among participants with STEMI can be classified as either prehospital delays (“onset to door time”) or in-hospital delays (“door to needle time”). According to the 2013 American College of Cardiology Foundation/American Heart Association (ACCF/AHA) Guideline for the Management of ST-Elevation Myocardial Infarction, the optimal “door to needle time” and “onset to door time” are recommended 90 minutes or less and 120 minutes or less, respectively [13]. Although in-hospital protocols seem to be effective, more efforts should be taken in reducing the prehospital delay. Prehospital delay in this context is the interval between STEMI symptom onset and presentation at the emergency center. Median prehospital delay time (PDT) ranged from 1 to 4.5 hours [14], [15], [16] and was skewed toward longer delay time [16]. Disconcertingly, PDT has hardly changed over the past 3 decades in the United States, and a consistent picture of factors influencing PDT has yet to emerge [17], [18], [19], [20]. Some large epidemiological and registry studies were held mainly in 4 aspects: sociodemographic; clinical; situational, appraisal, and behavioral factors; and knowledge and beliefs. However, they still hardly emerged a consistent picture of the factors that influence prehospital delay. This may be due to the difference in methodology, that is, use of PDT as a categorical or a continuous variable, and in sample or variable choices. Furthermore, to our knowledge, few study has evaluated predictors of PDT in China where STEMI is also a major concern. The objective of this study was to explore sociodemographic, clinical, and onset factors in the prediction of PDT to shorten prehospital delays and ensure more rapid administration of reperfusion therapy in participants with STEMI in China.

Section snippets

Participant and sample

Participants involved in the study were all confirmed with acute STEMI in the Emergency Center of Anzhen Hospital from March 2004 to March 2007, who were registered for the medical records, and then, all cases were reviewed by certified and trained doctors and researchers in Anzhen and Fuwai hospitals in 2007. A total of 1105 cases were identified. Seventeen cases were excluded because the onset time could not be determined; note that no cases were excluded due to the presence of other

Participant characteristics

A total of 1088 participants with AMI (mean age was 60.94 ± 12.82 years and 817 [75.1%] males) were finally considered eligible. Participant characteristics were all listed in the Table 1. From the result in the medical history variables, there were 261 participants (24.0%) with AMI history who were diagnosed by the hospital that they visited previously and using the percutaneous transluminal coronary angioplasty confirmed in this study. In all the onset symptoms, the most frequent one was

Discussion

Median and mean PDT have changed little over the past 3 decades [17], [18], [19], [20], [22]. The median PDT in our study was 130 minutes, exceeding the ACCF/AHA recommended time of 120 minutes or less [13]. Registry studies of patients in 21 countries with presumed MI report 1-month mortality rates as high as 50%, and approximately one half of these deaths occur within the first 2 hours from onset [23]. Therefore, 120 minutes was considered as “the golden time” for STEMI patients to interrupt

Limitations

Several limitations of this study would be taken into consideration. Firstly, the study was retrospective, the information was based on the hospital medical records; although we have checked all the records by trained doctors and nurses, it would still raise some recall bias in data collection, especially onset detail for some advanced participants. Secondly, this study was only conducted in a single emergency center that is a PCI-capable, heart disease–specialized hospital in Beijing.

Conclusion

Educational level of senior high school or above, MI history, ambulance transport, symptom onset in the daytime and at home, anterior wall MI, and posterior wall MI are associated with prehospital delays in STEMI patients in China. Although sociodemographic characteristics, clinical history, and onset symptoms contributed to prehospital delays, the main predictors in this study were onset characteristics, such as mode of transport to the emergency center, time of day of symptom onset, and

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    All these authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.

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    Competing interests: The authors have no competing interest to declare.

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