Importance of Hospital Entry: Walk-in STEMI and Primary Percutaneous Coronary Intervention

Abstract

IntroductionPatients with ST elevation myocardial infarction (STEMI) require rapid identification and triage to initiate reperfusion therapy. Walk-in STEMI patients have longer treatment times compared to emergency medical service (EMS) transported patients. While effective triage of large numbers of critically ill patients in the emergency department is often cited as the reason for treatment delays, additional factors have not been explored. The purpose of this study was to evaluate baseline demographic and clinical differences between walk-in and EMS-transported STEMI patients and identify factors associated with prolonged door to balloon (D2B) time in walk-in STEMI patients.MethodsWe performed a retrospective review of 136 STEMI patients presenting to an urban academic teaching center from January 2009 through December 2010. Baseline demographics, mode of hospital entry (walk-in versus EMS transport), treatment times, angiographic findings, procedures performed and in-hospital clinical events were collected. We compared walk-in and EMS-transported STEMI patients and identified independent factors of prolonged D2B time for walk-in patients using stepwise logistic regression analysis.ResultsWalk-in patients (n=51) were more likely to be Latino and presented with a higher heart rate, higher systolic blood pressure, prior history of diabetes mellitus and were more likely to have an elevated initial troponin value, compared to EMS-transported patients. EMS-transported patients (n=64) were more likely to be white and had a higher prevalence of left main coronary artery disease, compared to walk-in patients. Door to electrocardiogram (ECG), ECG to catheterization laboratory (CL) activation and D2B times were significantly longer for walk-in patients. Walk-in patients were more likely to have D2B time >90 minutes, compared to EMS- transported patients; odds ratio 3.53 (95% CI 1.03, 12.07), p=0.04. Stepwise logistic regression identified hospital entry mode as the only independent predictor for prolonged D2B time.ConclusionBaseline differences exist between walk-in and EMS-transported STEMI patients undergoing primary percutaneous coronary intervention (PCI). Hospital entry mode was the most important predictor for prolonged treatment times for primary PCI, independent of age, Latino ethnicity, heart rate, systolic blood pressure and initial troponin value. Prolonged door to ECG and ECG to CL activation times are modifiable factors associated with prolonged treatment times in walk-in STEMI patients. In addition to promoting the use of EMS transport, efforts are needed to rapidly identify and expedite the triage of walk-in STEMI patients.

Electrocardiographic indicators of acute coronary syndrome are more common in patients with ambulance transport compared to those who self-transport to the emergency department journal of electrocardiology

“…These findings confer those of Bansal et al (2013) who found door-to-ECG times to be significantly longer in STEMI walk-in patients compared to EMS-transported patients (40 min vs 6 min, p<0.0001). 3 Our results demonstrate that door-to-ECG times increase for all patients arriving by self-transport, including women. This directly contributes to the inhospital phase of delay to treatment that has been previously described.…”

“…6,19 Bansal and colleagues (2013) examined STEMI patients (n=136) who self-presented to the ED and found them more likely to be Latino, have higher systolic blood pressure, prior history of diabetes, and an elevated initial troponin value compared to EMS-transported patients. 3 Prior studies have focused on STEMI patients only, which is a limitation because patients with NSTE-ACS comprise the majority of ACS diagnoses (70% NSTE-ACS versus 29% STEMI) according to NRMI-4 data, and the numbers of STEMI patients appears to be declining. 3,20 It might be argued that early detection of NSTE-ACS is not as urgent as that of STEMI, yet the failure to diagnose ischemia in these patients could result in delayed thrombolytic therapy or being mistakenly sent home with a non-cardiac diagnosis.…”

“…3 Prior studies have focused on STEMI patients only, which is a limitation because patients with NSTE-ACS comprise the majority of ACS diagnoses (70% NSTE-ACS versus 29% STEMI) according to NRMI-4 data, and the numbers of STEMI patients appears to be declining. 3,20 It might be argued that early detection of NSTE-ACS is not as urgent as that of STEMI, yet the failure to diagnose ischemia in these patients could result in delayed thrombolytic therapy or being mistakenly sent home with a non-cardiac diagnosis.…”

“…2 Mode of transportation to the hospital is an important consideration for treatment delays because rapid triage and detection of myocardial ischemia/infarction are essential to reducing total ischemic burden and salving vulnerable myocardium. 3 Studies consistently demonstrate that delays in time-to-reperfusion are correlated with increased morbidity and mortality. 4,5 Efforts to reduce door-to-reperfusion times have been applied to ACS benchmarks; however it is increasingly clear that the prehospital period significantly influences patient outcomes.…”

Onset‐to‐device time of patients who arrive at off‐hours: Importance of prehospital management and public awareness for patients with ST‐segment elevation myocardial infarction

“…Bansal et al. demonstrated that the mode of hospital entry (EMS transport or walk‐in transport) was the most important predictor for prolonged DTD time in STEMI patients undergoing pPCI . Although several studies have suggested that STEMI patients with private insurance were less likely to use EMS, in our country, all patients are able to use EMS without any charges.…”