Patients with NSTEMI in this study expressed very different perceptions of their illness compared to those experiencing STEMI. Patients' clinical presentation and treatment experience during an AMI can impact on their illness perception, motivation for behavioural change and uptake of cardiac rehabilitation. Nurses should consider the patients' illness experience and perception when planning secondary prevention interventions.
BackgroundPrimary PCI (PPCI) is the preferred treatment for patients presenting with ST-elevation myocardial infarction (STEMI). Strategies to minimise PCI-related delayinclude bringing patients directly to the cath lab following ECG transmission. The aim of this study was to assess the frequency, appropriateness and clinical outcomes of patients turned down for PPCI by this process.MethodsThe Belfast PPCI pathway is activated by CCU nurses according to a regionally agreed protocol. Electrocardiograms (ECG) are faxed to a central hub in conjunction with a focussed telephone conversation. If a decision is made not to activate the PPCI team, the referral is deemed a turn-down and the clinical data are retained. All primary PCI turn-downs from the end of September 2013 until the end of March 2014 were reviewed retrospectively with analysis of electronic care records, laboratory results, referral ECG and angiographic images and procedural reports where relevant. A turn-down was deemed inappropriate if retrospective review demonstrated diagnostic ECG criteria with either a culprit lesion at subsequent angiography or significant troponin rise or new regional wall motion abnormalities at echocardiography.ResultsBetween 30th September 2013 and 31stMarch 2014, 945 cases were referred to the PPCI service (about 5 per day). The majority (556/945: 59%) were turned down. Of the remainder, 315 (33%) patients underwent primary PCI and 74 (8%) activated the PPCI team but did not proceed to PCI.The Northern Ireland Ambulance Service (NIAS) was the commonest source of referrals (667 cases) the majority of which were turned down (Table 1).Abstract 6 Table 1Sources of referral to PPCI service and frequency of turn-down
Source
Number of patients referred
Number of patients turned down
Turned down from each source (%)
NIAS66744767%ED2208137%INPATIENT371130%GP22100%NOTRECORDED1915Total94555659%Three percent of turn-downs (17 patients) were deemed inappropriate. 3 were due to logistical problems whilst 14 were due to inaccurate reading of the ECG or interpretation of clinical history. 28 cases were re-referred from emergency departments, having been initially turned down; 7 of these were subsequently categorised as inappropriate turn-downs. Within the group deemed inappropriate turndowns 53% (9 cases) had been reviewed by the medical team compared with 12% overall. Six-month mortality among the patients appropriately turned down was 13.5% (73 patients) compared with 11.8% (2 patients) among the inappropriate turndowns.ConclusionIn this PPCI service, the majority of patients referred are turned down appropriately, largely due to a high rate of turn-down from the ambulance service. Clinical outcomes were similar among patients turned down appropriately and inappropriately.
Presentations of acute myocardial infarction (MI) can be divided into diagnostic subcategories that require different treatments. This article reports the results of a study that explored and compared patients' perceptions of their illness and motivation for behavioural change after different treatments for MI. Results suggest that patients who have had non-ST elevation MI (NSTEMI) and whose initial diagnosis is uncertain take their condition less seriously than those who have had STEMI and invasive or 'urgent' treatments. This tendency can make them less motivated to change their lifestyles. Healthcare professionals in emergency departments should be aware of, and address, patients' misconceptions and provide clear and consistent advice to improve their long-term outcomes.
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