Evaluation, Treatment, and Outcomes of Patients With Suspected Acute Coronary Syndrome in the Prehospital and Emergency Department: Findings From a Prospective Multicenter Registry in China

Abstract

Background: Early evaluation and treatment of patients with suspected acute coronary syndrome (ACS) poses a huge challenge to the emergency care system worldwide, but little is known about the contemporary prehospital and emergency department management of these patients. We aimed to investigate the early evaluation, treatment, and outcome of suspected ACS in a representative population of China. \n \nMethods: We did a prospective registry study involving a network of 23 emergency departments in China. Each participating site consecutively enrolled adult patients presenting with symptoms suggestive of ACS for at least 12 months between August 2015 and September 2017. All findings were weighted by sampling ratio and variation among EDs in enrollment period. \n \nFindings: A total of 13 919 patients were screened. Of those included in the analysis, mean age was 63·8±13·6 years, 57·9% were men. After symptom onset, 40·5% of the patients arrived at emergency department within two hours, and 17·9% were transported by ambulance. Upon arrival to the emergency department, 75·6% had their first ECG completed within ten minutes. Among patients without ST-segment elevation, 10·3% had serial ECGs, 56·6% had serum cardiac biomarkers measured, and 6·4% had serial cardiac biomarkers. Stress test and computed tomography angiography were rarely performed for evaluation. Among patients with ST-segment elevation, 57·3% underwent reperfusion therapy, with 51·3% receiving primary percutaneous coronary intervention and 6·3% receiving fibrinolysis. Post-hoc adjudication showed that over 60% of patients could be attributed to ACS, of which 10·2% received antiplatelet therapy prior to presentation, and by the time of emergency department disposition, 51·1% received antiplatelet therapy. Overall, the emergency department mortality rate was 0·5%, and the 30-day mortality and major adverse cardiac event rates were 3·8% and 6·8%, respectively. \n \nInterpretation: The pre-hospital and emergency department evaluation of patients with suspected ACS is insufficient in China. For those with ACS, gaps existed in the early medication and reperfusion therapy as per guidelines. These findings suggest opportunities to improve the quality of early management for suspected ACS and further reduce adverse cardiac events in China. \n \nClinical Trial Registration Details: This study was registered at URL: https://www.clinicaltrials.gov \n(Unique identifier: NCT02536677). \n \nFunding Information: This work was supported by National S&T Fundamental Resources Investigation Project [2018FY100600, 2018FY100602], Shandong Provincial Natural Science Foundation [ZR2017PH070], Taishan Pandeng Scholar Program of Shandong Province [tspd20181220], Taishan Young Scholar Program of Shandong Province [tsqn20161065, tsqn201812129], Key R&D Program of Shandong Province [2020SFXGFY03, 2019GSF108073] and Qilu Young Scholar Program. \n \nDeclaration of Interests: All authors declare no competing interests. \n \nEthics Approval Statement: The study complies with the Declaration of Helsinki and was approved by the ethical committees of all participating sites. Informed consent was required from each patient to participate in the study.