Recovery From the Impact of COVID-19 on Treatment Times and Clinical Outcomes of Patients With ST-Segment Elevation Myocardial Infarction: An Interim Analysis

BACKGROUND: Previous studies have documented a negative impact of the COVID-19 pandemic on emergent percutaneous treatment of patients with ST-segment elevation myocardial infarction (STEMI), but few have examined recovery of healthcare systems in restoring prepandemic STEMI care. METHODS: Retrospective analysis was performed of data from 789 patients with STEMI from a large tertiary medical center treated with percutaneous coronary intervention between January 1, 2019, and December 31, 2021. RESULTS: For patients with STEMI presenting to the emergency department, median time from door to balloon was 37 minutes in 2019, 53 minutes in 2020, and 48 minutes in 2021 (P \u3c .001), whereas median time from first medical contact to device changed from 70 to 82 to 75 minutes, respectively (P = .002). Treatment time changes in 2020 and 2021 correlated with median emergency department evaluation time (30 to 41 to 22 minutes, respectively; P = .001) but not median catheterization laboratory revascularization time. For transfer patients, median time from first medical contact to device changed from 110 to 133 to 118 minutes, respectively (P = .005). In 2020 and 2021, patients with STEMI had greater late presentation (P = .028) and late mechanical complications (P = .021), with nonsignificant increases in yearly in-hospital mortality (3.6% to 5.2% to 6.4%; P = .352). CONCLUSION: COVID-19 was associated with worsening STEMI treatment times and outcomes in 2020. Despite improving treatment times in 2021, in-hospital mortality had not decreased in the setting of a persistent increase in late patient presentation and associated STEMI complications

Risk factors for major bleeding in the SEATTLE II trial

Ultrasound-facilitated, catheter-directed, low-dose fibrinolysis minimizes the risk of intracranial bleeding compared with systemic full-dose fibrinolytic therapy for pulmonary embolism (PE). However, major bleeding is nevertheless a potential complication. We analyzed the 150-patient SEATTLE II trial of submassive and massive PE patients to describe those who suffered major bleeding events following ultrasound-facilitated, catheter-directed, low-dose fibrinolysis and to identify risk factors for bleeding. Major bleeding was defined as GUSTO severe/life-threatening or moderate bleeds within 72 hours of initiation of the procedure. Of the 15 patients with major bleeding, four (26.6%) developed access site-related bleeding. Multiple venous access attempts were more frequent in the major bleeding group (27.6% vs 3.6%; p<0.001). All patients with major bleeding had femoral vein access for device delivery. Patients who developed major bleeding had a longer intensive care stay (6.8 days vs 4.7 days; p=0.004) and longer hospital stay (12.9 days vs 8.4 days; p=0.004). The frequency of inferior vena cava filter placement was 40% in patients with major bleeding compared with 13% in those without major bleeding (p=0.02). Massive PE (adjusted odds ratio 3.6; 95% confidence interval 1.01–12.9; p=0.049) and multiple venous access attempts (adjusted odds ratio 10.09; 95% confidence interval 1.98–51.46; p=0.005) were independently associated with an increased risk of major bleeding. In conclusion, strategies for improving venous access should be implemented to reduce the risk of major bleeding associated with ultrasound-facilitated, catheter-directed, low-dose fibrinolysis. ClinicalTrials.gov Identifier: NCT01513759; EKOS Corporation 10.13039/10000652

Age-specific differences in the use of thrombolytic therapy and hospital outcomes in patients with acute myocardial infarction: a community-wide perspective

BACKGROUND: Relatively limited information is available about recent, and trends over time, use of thrombolytic therapy in patients of different ages hospitalized with acute myocardial infarction and the association between use of thrombolytic therapy and hospital outcomes. METHODS: We conducted an observational study of 5601 residents of the Worcester, Massachusetts, metropolitan area (1990 census = 437,000) with confirmed acute myocardial infarction in all local hospitals during 6 one-year periods between 1990 and 1999. RESULTS: Despite relatively stable use of thrombolytic therapy between 1990 and 1995, decreases in the use of thrombolytic therapy in all patients with acute myocardial infarction were observed in 1997 and 1999. There was a 1.6 fold decrease in the use of thrombolytic therapy between 1990 and 1999 in patients \u3c65 years. Patients 65-74 years (33.7% 1990; 11.7% 1999) and those 75 years and older (10.8% 1990; 6.7% 1999) experienced marked decreases in the receipt of thrombolytic therapy over time. Use of thrombolytic therapy was associated with reduced hospital mortality in each of the four age-specific groups under study (\u3c55, 55-64, 65-74, \u3e or =75) through the degree of benefit on hospital death rates associated with the use of thrombolytic therapy was attenuated after adjustment for additional confounders. CONCLUSIONS: Our findings indicate recent declines in the use of thrombolytic therapy in middle-aged and elderly patients with acute myocardial infarction. The impact of thrombolytic therapy on hospital outcomes was observed in each of our age strata under study though the magnitude of absolute and relative benefit varied according to age

Extent of, and factors associated with, delay to hospital presentation in patients with acute coronary disease (the GRACE registry)

Our primary study aim was to examine extent of, and factors associated with, delay in seeking medical care in a large multinational registry of patients with acute myocardial infarction (AMI) and unstable angina pectoris. A secondary goal was to examine the relation between duration of prehospital delay and receipt and timing of coronary reperfusion strategies. Investigators from 14 countries are participating in the Global Registry of Acute Coronary Events (GRACE) project. The study sample consisted of 3,693 patients with ST-segment elevation AMI, 2,935 with non-ST-segment elevation AMI, and 3,954 patients with unstable angina hospitalized between 1999 and 2001. The average and median delay times were longest in patients with non-ST-segment elevation AMI (6.1 and 3.0 hours, respectively) followed by patients with unstable angina (5.6 and 3.0 hours) and those with ST-segment elevation AMI (4.7 and 2.3 hours). Approximately 41% of patients with ST-segment elevation AMI presented to the 94 study hospitals within 2 hours of the onset of acute coronary symptoms; this compared with approximately one third of patients with non-ST-segment elevation AMI and unstable angina. Several demographic and clinical characteristics were associated with prehospital delay. In patients with ST-segment elevation AMI, duration of prehospital delay was inversely related to the receipt of thrombolytic therapy, but was inconsistently related to the use of percutaneous coronary interventions. The results of this study demonstrate that a large proportion of patients continue to exhibit prolonged delay in seeking medical care after the onset of acute coronary symptoms and remain in need of targeted educational efforts to reduce extent of delay

Revascularization, stenting, and outcomes of patients with acute myocardial infarction complicated by cardiogenic shock

Randomized clinical trials have demonstrated a reduction in mortality with early revascularization of patients with acute myocardial infarction (AMI) complicated by cardiogenic shock, and recent single-center studies have particularly suggested further benefit for coronary stenting. The purpose of this study was to examine the use of revascularization and coronary stenting for patients with shock from a multicenter, international perspective. Patients with AMI complicated by cardiogenic shock (n = 583) who enrolled between April 1999 and June 2001 were prospectively identified from the large, multinational, observational Global Registry of Acute Coronary Events. We examined the use of coronary reperfusion strategies, adjunctive therapy, and hospital mortality in this group of patients. Cardiac catheterization (52%) and revascularization (43%) were performed in approximately half of the cardiogenic shock patients. Elderly patients (age \u3e/=75 years) comprised 40% of the shock cohort. Regional differences were seen in the use of revascularization, adjunctive medical therapy, and type of revascularization used (coronary stenting). Total hospital mortality was 59%, but case fatality rates ranged from 35% for patients who underwent coronary stenting to 74% for patients who did not undergo any cardiac catheterization. Percutaneous coronary intervention with coronary stenting was the most powerful predictor of hospital survival (odds ratio 3.99, 95% confidence interval 2.41 to 6.62). Thus, cardiogenic shock continues to be a devastating complication of AMI, and relative underuse of a revascularization strategy may be related to the large proportion of elderly patients in this population. In this multinational registry study, coronary stenting was the most powerful independent predictor of hospital survival

Patterns of use of heparins in ACS. Correlates and hospital outcomes: the Global Registry of Acute Coronary Events (GRACE)

A systematic study that compares the patterns of use of unfractionated heparin (UFH) and low-molecular-weight heparin (LMWH) in patients with acute coronary syndromes (ACS) has, to date, not been carried out in the real-world setting. The aim of this report is to identify patterns of use of UFH and LMWH and to report their correlates and outcomes in a broad spectrum of ACS patients enrolled in the observational Global Registry of Acute Coronary Events (GRACE). The use of LMWH and UFH was analysed in 13,231 ACS patients according to patient history, concomitant treatment and invasive procedures in US and non-US sites. Frequency of use in hospitals with and without facilities for percutaneous coronary interventions (PCI) was investigated, and outcomes were analysed. Results show that younger patients (\u3c60 \u3eyears), those receiving antiplatelet therapies, thrombolytics, beta-blockers, angiotensin-converting enzyme inhibitors, patients admitted to hospitals with PCI facilities, and patients undergoing invasive procedures were more likely to receive UFH, or both UFH and LMWH than LMWH alone (80.1% enoxaparin, 19.9% other LMWH). LMWH was used less often in US than non-US sites. After adjusting for confounding variables, patients receiving LMWH had significantly lower rates of hospital mortality (P = 0.009) and major bleeding (P \u3c 0.0001). Similar results were observed in patients with ST-segment elevation myocardial infarction and non-ST-segment elevation myocardial infarction or unstable angina. We can conclude that UFH tends to be used more frequently than LMWH, but hospital outcomes appeared to be better with LMWH after adjusting for covariables