Temporal Trends of System of Care for STEMI: Insights from the Jakarta Cardiovascular Care Unit Network System

<div><p>Aim</p><p>Guideline implementation programs are of paramount importance in optimizing acute ST-elevation myocardial infarction (STEMI) care. Assessment of performance indicators from a local STEMI network will provide knowledge of how to improve the system of care.</p><p>Methods and Results</p><p>Between 2008–2011, 1505 STEMI patients were enrolled. We compared the performance indicators before (n = 869) and after implementation (n = 636) of a local STEMI network. In 2011 (after introduction of STEMI networking) compared to 2008–2010, there were more inter-hospital referrals for STEMI patients (61% vs 56%, p<0.001), more primary percutaneous coronary intervention (PCI) procedures (83% vs 73%, p = 0.005), and more patients reaching door-to-needle time ≤30 minutes (84.5% vs 80.2%, p<0.001). However, numbers of patients who presented very late (>12 hours after symptom onset) were similar (53% vs 51%, NS). Moreover, the numbers of patients with door-to-balloon time ≤90 minutes were similar (49.1% vs 51.3%, NS), and in-hospital mortality rates were similar (8.3% vs 6.9%, NS) in 2011 compared to 2008–2010.</p><p>Conclusion</p><p>After a local network implementation for patients with STEMI, there were significantly more inter-hospital referral cases, primary PCI procedures, and patients with a door-to-needle time ≤30 minutes, compared to the period before implementation of this network. However, numbers of patients who presented very late, the targeted door-to-balloon time and in-hospital mortality rate were similar in both periods. To improve STEMI networking based on recent guidelines, existing pre-hospital and in-hospital protocols should be improved and managed more carefully, and should be accommodated whenever possible.</p></div

Demographic data and hospitalization information of STEMI patients (N = 1505).

<p>BMI = body mass index, CAD = coronary artery disease.</p

Patient distribution in the Jakarta Acute Coronary Syndrome registry.

<p>ACS = acute coronary syndrome, STEMI = ST-elevation myocardial infarction, PCI = percutaneous coronary intervention, TIMI = Thrombolysis in Myocardial Infarction.</p

Serum Cardiac Troponin-I is Superior to Troponin-T as a Marker for Left Ventricular Dysfunction in Clinically Stable Patients with End-Stage Renal Disease

<div><p>Background</p><p>Serum troponin assays, widely used to detect acute cardiac ischemia, might be useful biomarkers to detect chronic cardiovascular disease (CVD). Cardiac-specific troponin-I (cTnI) and troponin-T (cTnT) generally detect myocardial necrosis equally well. In dialysis patients however, serum cTnT levels are often elevated, unlike cTnI levels. The present study aims to elucidate the associations of cTnI and cTnT with CVD in clinically stable dialysis patients.</p><p>Methods</p><p>Troponin levels were measured using 5^th generation hs-cTnT assays (Roche) and STAT hs-cTnI assays (Abbott) in a cohort of dialysis patients. Serum troponin levels were divided into tertiles with the lowest tertile as a reference value. Serum troponins were associated with indicators of CVD such as left ventricular mass index (LVMI), left ventricular ejection fraction (LVEF) and the presence of coronary artery disease (CAD). Associations were explored using regression analysis.</p><p>Results</p><p>We included 154 consecutive patients, 68±7 years old, 77% male, 70% hemodialysis. Median serum cTnT was 51ng/L (exceeding the 99^th percentile of the healthy population in 98%) and median serum cTnI was 13ng/L (elevated in 20%). A high cTnI (T3) was significantly associated with a higher LVMI (Beta 31.60; p=0.001) and LVEF (Beta -4.78; p=0.005) after adjusting for confounders whereas a high serum cTnT was not. CAD was significantly associated with a high cTnT (OR 4.70 p=0.02) but not with a high cTnI. Unlike cTnI, cTnT was associated with residual renal function (Beta:-0.09; p=0.006).</p><p>Conclusion</p><p>In the present cohort, serum cTnI levels showed a stronger association with LVMI and LVEF than cTnT. However, cTnT was significantly associated with CAD and residual renal function, unlike cTnI. Therefore, cTnI seems to be superior to cTnT as a marker of left ventricular dysfunction in asymptomatic dialysis patients, while cTnT might be better suited to detect CAD in these patients.</p></div

Univariate association of serum troponins with baseline characteristics using linear regression.

<p>Univariate association of serum troponins with baseline characteristics using linear regression.</p

Baseline Characteristics.

<p>Baseline Characteristics.</p

Logistic regression for the association between tertiles of serum cardiac troponins and the presence of CAD.

<p>Logistic regression for the association between tertiles of serum cardiac troponins and the presence of CAD.</p

Unadjusted markers for cardiovascular disease divided per tertile of cTnI and cTnT.

<p>Box and Whisker plot of serum cTnI and cTnT concentrations divided into tertiles (T1, T2, T3) indicating the median, interquartile range, 2.5^th and 97.5^th percentile for unadjusted LVMI (A) and LVEF (B). The percentage of patients with significant CAD divided per tertile of serum cTnI and cTnT are shown in graph C. Serum cTnI is shown in shades of blue and serum cTnT is shown in shades of green. LVMI: Left Ventricular Mass Index; LVEF: Left Ventricular Ejection Fraction; CAD: Coronary Artery Disease.</p

Distribution of serum cTnI and serum cTnT.

<p>(A) Box Whisker plot of serum cTnI and cTnT concentrations indicating the median, interquartile range, 2.5^th and 97.5^th percentile. The dotted lines represent the 99^th percentile cut-off for a positive test. (B) Box and Whisker plot of serum cTnI and cTnT expressed as multiples of the 99^th percentile. ***; p<0.001.</p

Linear regression for the association between tertiles of serum cardiac troponins, LVMI and LVEF.

<p>Linear regression for the association between tertiles of serum cardiac troponins, LVMI and LVEF.</p