Original ContributionFactors associated with prehospital delay in patients with ST-segment elevation acute myocardial infarction in China☆,☆☆
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
References (42)
- et al.
Recent trends in the incidence, treatment, and outcomes of participants with STEMI and NSTEMI
Am J Med
(2011) - et al.
Treatments, trends, and outcomes of acute myocardial infarction and percutaneous coronary intervention
J Am Coll Cardiol
(2010) - et al.
2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines
J Am Coll Cardiol
(2013) - et al.
Predictors of pre-hospital delay among participants with acute myocardial infarction
Participant Educ Couns
(2009) - et al.
Prehospital delay in participants with acute coronary syndromes (from the Global Registry of Acute Coronary Events [GRACE])
Am J Cardiol
(2009) - et al.
Trends in prehospital delay in participants with acute myocardial infarction (from the Worcester Heart Attack Study)
Am J Cardiol
(2008) - et al.
Sex and age specific time patterns and long term time trends of pre-hospital delay of participants presenting with acute ST-segment elevation myocardial infarction
Int J Cardiol
(2011) - et al.
Contribution of trends in survival and coronary-event rates to changes in coronary heart disease mortality: 10-year results from 37 WHO MONICA project populations. Monitoring trends and determinants in cardiovascular disease.
Lancet
(1999) - et al.
Predictors of delay in presentation to the ED in participants with suspected acute coronary syndromes
Am J Emerg Med
(2003) - et al.
Factors related to delay times in participants with suspected acute myocardial infarction
Heart Lung
(2004)
Prehospital delay in acute coronary syndrome—an analysis of the components of delay
Int J Cardiol
Comparison of mortality patterns in participants with ST-elevation myocardial infarction arriving by emergency medical services versus self-transport (from the prospective Ottawa hospital STEMI Registry)
Am J Cardiol
Trends in prehospital delay time and use of emergency medical services for acute myocardial infarction: experience in 4 U.S. communities from 1987-2000
Am Heart J
Prehospital transport of participants with acute myocardial infarction: a community-wide perspective
Heart Lung
Multivariate analysis of predictors of pre-hospital delay in acute coronary syndrome
Int J Cardiol
Association of bleeding and in-hospital mortality in black and white participants with ST-segment elevation myocardial infarction receiving reperfusion
Circulation
Decline in rates of death and heart failure in acute coronary syndromes, 1999-2006
JAMA
Population trends in the incidence and outcomes of acute myocardial infarction
N Engl J Med
The second Euro Heart Survey on acute coronary syndromes: characteristics, treatment, and outcome of participants with ACS in Europe and the Mediterranean Basin in 2004
Eur Heart J
Association between adoption of evidence-based treatment and survival for participants with ST-elevation myocardial infarction
JAMA
Heart disease and stroke statistics-2010 update: a report from the American Heart Association. Circulation. 2010;121:e46-215. Errata in: Circulation. 2011;124:e425 and
Circulation
Cited by (42)
The relationship between symptom onset-to-needle time and ischemic outcomes in patients with acute myocardial infarction treated with primary PCI: Observations from Prague-18 Study
2022, Journal of CardiologyCitation Excerpt :The probable reason for these findings is that some patients perceive seriousness of the disease and potential threat after the first event while others think it is not likely to have a second MI after a successful CABG operation. Moreover, socio-demographic factors (e.g. marital status), cognitive (higher educational level [42,45]) and behavioral factors play a role when deciding to call emergency system or come to a hospital to seek help [46]. There is limited evidence that community media-based MI-awareness campaigns lead to shortening time delays [44,47], therefore a face-to-face educational intervention in selected high-risk patients (post MI/CABG, with diabetes) was proposed to be more beneficial.
Before the door: Comparing factors affecting symptom onset to first medical contact for STEMI patients between a high and low-middle income country
2022, IJC Heart and VasculatureCitation Excerpt :Another important contribution to delay is the time taken to reach FMC after an individual has made the decision to seek care. It has been previously shown that patients presenting via EMS have a shorter delay to care [7,19,20]. The majority of patients at HGH either arrived by EMS or were driven to the hospital, compared to AHC where taxi and public transport were the most frequently used transportation methods.
Time-to-Treatment and Its Association With Complications and Mortality Rate in Patients With Acute Myocardial Infarction: A Prospective Cohort Study
2021, Journal of Emergency NursingCitation Excerpt :Menees et al10 performed a study in the US and showed that despite improvement in DTBT from 2005 to 2009, no significant changes were observed in in-hospital and 30-day mortality. Elsewhere, Peng et al34 conducted a study in China and indicated that an increase in prehospital delay led to an increase in mortality rate. Most studies demonstrated that an increase in pain onset-to-treatment time led to a higher mortality rate.
Factors Associated with Symptom-to-Door Delay in Patients with ST-Segment Myocardial Infarction: A Systematic Review
2023, Prehospital and Disaster Medicine
- ☆
All these authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.
- ☆☆
Competing interests: The authors have no competing interest to declare.