The Barriers to Rapid Reperfusion in Acute ST-Elevation Myocardial Infarction

Abstract

Introduction This study aimed to quantify the contribution of various obstacles to timely reperfusion therapy in acute ST-elevation myocardial infarction (STEMI) and to improve performance in a mixed remote rural/urban region. Methods From November 1, 2020 to April 23, 2021, patients with acute STEMI were prospectively monitored with the critical time intervals, treatment modalities, and outcomes registered. Selected clinical decision-makers in 11 hospitals were appointed as improvement agents and systematically provided with weekly updated information about absolute and relative performance. Suggestions for improvements were invited and shared. Results Only 29% of the 146 patients received reperfusion therapy within recommended time limits [prehospital thrombolysis, 2/48; in-hospital thrombolysis, 0/20; primary percutaneous coronary intervention (pPCI), 37/68, with median intervals from the first medical contact of 44, 49, and 133 min, respectively]. Efficiency varied considerably between health trusts: median time from the first medical contact to prehospital thrombolysis ranged from 29 to 54 min (hazard ratio 4.89). The predominant, remediable causes for delays were erroneous tactical choices and protracted electrocardiographic diagnostication, decision-making, and administration of fibrinolytic medication. During the trial, the time to pPCI was non-significantly reduced. Conclusion We found several targets for system improvements in order to mitigate reperfusion delays along the entire chain of care, regardless of reperfusion modality chosen. More patients should receive prehospital thrombolysis. The most important measures will be training to ensure a more efficient on-site workflow, improved protocols and infrastructure facilitating the communication between first responders and in-hospital clinicians, and education emphasizing prehospital transport times. Clinical Trials Identifier NCT04614805. Supplementary Information The online version contains supplementary material available at 10.1007/s40119-022-00281-7.

Exploring variation in timely reperfusion treatment in ST-segment elevation myocardial infarction in Norway: a national register-based cohort study

“…In the most rural northern parts of Norway, fixed-wing air ambulance flight time to the nearest PCI centre varies from 20 to 75 min. 15 However, the speed of air travel may cause time optimism regarding the use of pPCI as the preferred strategy. An overly optimistic assumption that in-hospital fibrinolysis or pPCI could be administered in a timely manner was frequently a cause of delays in Northern Norway in 2020–2021.…”

“…The explanations for this may be found at the system level. Bartnes et al 15 found that delayed establishment of a correct ECG diagnosis was the dominant cause of delayed fibrinolytic treatment. As in our study, they also found that a long time interval from symptom onset to FMC was an important obstacle, leaving some patients out of the 3-hour window where fibrinolysis has its best effect.…”

“…An overly optimistic assumption that in-hospital fibrinolysis or pPCI could be administered in a timely manner was frequently a cause of delays in Northern Norway in 2020-2021. 15 In the USA, only 17% of patients presenting in a non-PCI centre received pPCI in a timely manner during 2018-2021. 13 Only 16% of the 7607 patients who received reperfusion in our study were treated with prehospital fibrinolysis.…”

“…4 Despite being feasible for about 75% of the patients, the use of prehospital fibrinolysis in the most rural areas of northern Norway was Open access reduced from about 40% to 30% from 2006 to 2011 32 and was used for only 33% of the patients in 2020-2021. 15…”

“…A study of time delay to reperfusion treatment has been conducted in the rural areas of Northern Norway. 15 Determinants of geographical variation in timely reperfusion treatment have not been investigated.…”