Leveraging Existing STEMI Networks to Regionalize Cardiogenic Shock Systems of Care: Efforts to Expand the Scope Could Improve Shock Outcomes

Roston, Thomas M.; So, Derek; Liu, Shuangbo; Fordyce, Christopher B.; Grunau, Brian; Jentzer, Jacob C.; Bagai, Akshay; Luk, Adriana; Goodman, Shaun G.; Diepen, Sean van

doi:10.1016/j.cjca.2022.11.005

Cited by 6 publications

(9 citation statements)

References 5 publications

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“…The concept that CS care could be improved via STEMI systems has previously been suggested. 28 This study has some limitations. We attempted to correct for relevant clinical characteristics known to effect STEMI outcomes; however, it is possible that unaccounted for confounding variables may be present.…”

Section: Discussionmentioning

confidence: 91%

Reperfusion Delays and Outcomes Among Patients With ST-Segment–Elevation Myocardial Infarction With and Without Cardiogenic Shock

Kochan,

Lee,

Moghaddam

et al. 2023

Circ: Cardiovascular Interventions

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Background: Mortality remains high in patients with ST-segment–elevation myocardial infarction (STEMI) complicated by cardiogenic shock (CS), and early reperfusion has been shown to improve outcomes. We analyzed the association between first medical contact (FMC)-to-percutaneous coronary angiography time with mortality and major adverse cardiovascular events among patients with STEMI with and without CS. Methods: We performed a retrospective analysis of the Vancouver Coastal Health Authority STEMI registry, including all patients with STEMI who received primary percutaneous coronary angiography between January 1, 2010, and December 31, 2020, and stratified them by presence or absence of CS at hospital arrival. The primary outcome was in-hospital mortality, the secondary outcome was in-hospital major adverse cardiovascular events, defined as a composite of the first occurrence of mortality, cardiac arrest, heart failure, intracerebral hemorrhage, cerebrovascular accident, or reinfarction. Mixed effects logistic regression with restricted cubic splines was used to estimate the relationships between FMC-to-device time and the outcomes in the CS and non-CS groups. Results: 2929 patients were included, 9.4% (n=275) had CS. Median FMC-to-device time was 113.5 (interquartile range, 93.0–145.0) and 103.0 (interquartile range, 85.0–130.0) minutes for patients with CS and without CS, respectively. More patients with CS had FMC-to-device times above guideline recommendations (76.6% versus 54.1%, P <0.001). Between 60 and 90 minutes, for each 10-minute increase in FMC-to-device time, absolute mortality for patients with CS increased by 4% to 7%, whereas for patients without CS, it increased by <0.5%. Conclusions: Among patients with STEMI undergoing primary percutaneous coronary angiography, reperfusion delays among patients with CS are associated with significantly worse outcomes. Strategies to reduce FMC-to-device times for patients with STEMI presenting with CS are required.

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Section: Discussionmentioning

confidence: 91%

Reperfusion Delays and Outcomes Among Patients With ST-Segment–Elevation Myocardial Infarction With and Without Cardiogenic Shock

Kochan,

Lee,

Moghaddam

et al. 2023

Circ: Cardiovascular Interventions

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“…Accreditation, ongoing quality review, and publication of outcomes have become a standard in many industries and, over the last decades, the medical field has been following suit. Centers now need formal accreditation to offer certain interventions, and this has resulted in centralization of care and improvement of outcomes for conditions requiring complex multidisciplinary management such as stroke, 1 cardiovascular disease, 2 and cancer 3 . Fetal therapy, as a relatively new and developing field, has so far escaped formal auditing and there is wide variability in data reporting.…”

Section: Introductionmentioning

confidence: 99%

International Society for Prenatal Diagnosis 2022 DEBATE: There should be formal accreditation and ongoing quality assurance/review for units offering fetal therapy that includes public reporting of outcomes

2022

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The field of fetal therapy has so far escaped from formal accreditation and quality control. Despite that, current published evidence shows that outcomes of interventions in younger fetal therapy centers are similar to what is achieved in more experienced centers and outcomes of interventions have improved over time. The question however remains what is not being published and what should be the standard of care, given the lack of level 1 evidence from randomized controlled trials for many interventions. Formal collaborative networks such as NAFTnet and others allow for anonymized benchmarking of center outcomes, without publicly shaming (and financially punishing) underperforming centers. Large registries also allow for tracking of rare complications and may result in improved patient outcomes over time. Core outcome sets, which could serve as a basis for outcome reporting, are available for some conditions, but certainly not for all, resulting in communication difficulties between centers. Formal accreditation, quality control, and outcome reporting are hard to implement, expensive, and may result in decreasing access to care by pushing smaller centers out of the market. Despite the existing difficulties, international societies have committed to quality improvement, and fetal therapy programs are strongly recommended to participate in voluntary outcome tracking.

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“…1,12 The implementation of STEMI revascularization systems has been shown to decrease door-to-balloon time, facilitate early thrombolysis, and improve major adverse cardiovascular events. 1,13 Such regional STEMI networks can help define optimal reperfusion strategies for patients with STEMI-CS accounting for transport and geographic variables. Existing regional systems for care coordination have been shown to improve outcomes not only among patients with STEMI but also in those with time-sensitive conditions, including stroke, trauma, and cardiac arrest.…”

mentioning

confidence: 99%

“…Existing regional systems for care coordination have been shown to improve outcomes not only among patients with STEMI but also in those with time-sensitive conditions, including stroke, trauma, and cardiac arrest. 1,13…”

mentioning

confidence: 99%

“…Accordingly, expanding STEMI networks to include CS has been proposed as the logical approach. 13 When presenting to a spoke hospital or to emergency medical services, the on-call STEMI physician may not only determine the optimal reperfusion strategy but also engage a multidisciplinary shock team. Additional considerations including initial stabilization strategies, identification of an appropriate hub center, transportation, and mechanical circulatory support candidacy may be addressed.…”

mentioning

confidence: 99%

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Prioritizing Rapid Reperfusion in ST-Segment–Elevation Myocardial Infarction Complicated by Cardiogenic Shock: Leveraging Regionalized Systems of Care

Yuriditsky,

Horowitz

2024

Circ: Cardiovascular Interventions

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Leveraging Existing STEMI Networks to Regionalize Cardiogenic Shock Systems of Care: Efforts to Expand the Scope Could Improve Shock Outcomes

Cited by 6 publications

References 5 publications

Reperfusion Delays and Outcomes Among Patients With ST-Segment–Elevation Myocardial Infarction With and Without Cardiogenic Shock

Reperfusion Delays and Outcomes Among Patients With ST-Segment–Elevation Myocardial Infarction With and Without Cardiogenic Shock

International Society for Prenatal Diagnosis 2022 DEBATE: There should be formal accreditation and ongoing quality assurance/review for units offering fetal therapy that includes public reporting of outcomes

Prioritizing Rapid Reperfusion in ST-Segment–Elevation Myocardial Infarction Complicated by Cardiogenic Shock: Leveraging Regionalized Systems of Care

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