Heather Sherrard

A Citywide Protocol for Primary PCI in ST-Segment Elevation Myocardial Infarction

BACKGROUND If primary percutaneous coronary intervention (PCI) is performed promptly, the procedure is superior to fibrinolysis in restoring flow to the infarct-related artery in patients with ST-segment elevation myocardial infarction. The benchmark for a timely PCI intervention has become a door-to-balloon time of less than 90 minutes. Whether regional strategies can be developed to achieve this goal is uncertain. METHODS We developed an integrated-metropolitan-area approach in which all patients with ST-segment elevation myocardial infarction were referred to a specialized center for primary PCI. We sought to determine whether there was a difference in door-to-balloon times between patients who were referred directly from the field by paramedics trained in the interpretation of electrocardiograms and patients who were referred by emergency department physicians. RESULTS Between May 1, 2005, and April 30, 2006, a total of 344 consecutive patients with ST-segment elevation myocardial infarction were referred for primary PCI: 135 directly from the field and 209 from emergency departments. Primary PCI was performed in 93.6% of patients. The median door-to-balloon time was shorter in patients referred from the field (69 minutes; interquartile range, 43 to 87) than in patients needing interhospital transfer (123 minutes; interquartile range, 101 to 153; P<0.001). Door-to-balloon times of less than 90 minutes were achieved in 79.7% of patients who were transferred from the field and in 11.9% of those transferred from emergency departments (P<0.001). CONCLUSIONS Guideline door-to-balloon-times were more often achieved when trained paramedics independently triaged and transported patients directly to a designated primary PCI center than when patients were referred from emergency departments.

Telehome monitoring in patients with cardiac disease who are at high risk of readmission

Patients with chronic conditions are heavy users of the health care system. There are opportunities for significant savings and improvements to patient care if patients can be maintained in their homes. A randomized control trial tested the impact of 3 months of telehome monitoring on hospital readmission, quality of life, and functional status in patients with heart failure or angina. The intervention consisted of video conferencing and phone line transmission of weight, blood pressure, and electrocardiograms. Telehome monitoring significantly reduced the number of hospital readmissions and days spent in the hospital for patients with angina and improved quality of life and functional status in patients with heart failure or angina. Patients found the technology easy to use and expressed high levels of satisfaction. Telehealth technologies are a viable means of providing home monitoring to patients with heart disease at high risk of hospital readmission to improve their self-care abilities.

Reduction in Mortality as a Result of Direct Transport From the Field to a Receiving Center for Primary Percutaneous Coronary Intervention

OBJECTIVES This study sought to determine whether mortality complicating ST-segment elevation myocardial infarction (STEMI) was impacted by the design of transport systems. BACKGROUND It is recommended that regions develop systems to facilitate rapid transfer of STEMI patients to centers equipped to perform primary percutaneous coronary intervention (PCI), yet the impact on mortality from the design of such systems remains unknown. METHODS Within the framework of a citywide system where all STEMI patients are referred for primary PCI, we compared patients referred directly from the field to a PCI center to patients transported beforehand from the field to a non-PCI-capable hospital. The primary outcome was all-cause mortality at 180 days. RESULTS A total of 1,389 consecutive patients with STEMI were assessed by the emergency medical services (EMS) and referred for primary PCI: 822 (59.2%) were referred directly from the field to a PCI center, and 567 (40.8%) were transported to a non-PCI-capable hospital first. Death at 180 days occurred in 5.0% of patients transferred directly from the field, and in 11.5% of patients transported from the field to a non-PCI-capable hospital (p < 0.0001. After adjusting for baseline characteristics in a multivariable logistic regression model, mortality remained lower among patients referred directly from the field to the PCI center (odds ratio: 0.52, 95% confidence interval: 0.31 to 0.88, p = 0.01). Similar results were obtained by using propensity score methods for adjustment. CONCLUSIONS A STEMI system allowing EMS to transport patients directly to a primary PCI center was associated with a significant reduction in mortality. Our results support the concept of STEMI systems that include pre-hospital referral by EMS.

Hospitalization Costs of Primary Stenting Versus Thrombolysis in Acute Myocardial Infarction Cost Analysis of the Canadian STAT Study

Background—We previously showed that primary stenting was more effective than accelerated tPA in reducing the 6-month composite of death, reinfarction, stroke, or repeat revascularization for ischemia. This study looks at the hospitalization costs of primary stenting compared with accelerated tPA. Methods and Results—Initial and 6-month hospitalization costs were computed for all patients randomly assigned to primary stenting (n=62) or accelerated tPA (n=61) in the Stenting versus Thrombolysis in Acute myocardial infarction Trial (STAT). Costs and resource usage were collected in detail for each patient. Physician fees were obtained directly from billings to the Ontario Health Insurance Plan. The length of initial hospitalization was 6.7±11.3 days in the stent group and 8.7±6.7 days in the tPA group (P <0.001). Total hospitalization days at 6 months were 8.3±13 days in the stent group and 12.1±14.0 days in the tPA group (P =0.001). Hospitalization costs were less in the stent group for the initial hospitalization,

Sex-Specific Trends in Incidence and Mortality for Urban and Rural Ambulatory Patients with Heart Failure in Eastern Ontario from 1994 to 2013

6354±6382 versus

A prospective evaluation of telemonitoring use by seniors with chronic heart failure: Adoption, self-care, and empowerment

7893±4429 (P =0.001), and at 6 months,

Telemonitoring for Seniors with Chronic Heart Failure: Patient Self-Care, Empowerment, and Adoption Factors

7100±7111 versus

An automated external defibrillator in the home did not reduce all-cause mortality in patients at risk of cardiac arrest.

9559±6933 (P =0.001). Conclusions—In centers in which facilities and experienced interventionists are available, primary stenting is less costly and more effective than thrombolysis.

Comparison of Early Mortality of Paramedic-Diagnosed ST-Segment Elevation Myocardial Infarction With Immediate Transport to a Designated Primary Percutaneous Coronary Intervention Center to That of Similar Patients Transported to the Nearest Hospital

BACKGROUND Differences in outcomes have previously been reported between urban and rural settings across a multitude of chronic diseases. Whether these discrepancies have changed over time, and how sex may influence these findings is unknown for patients with ambulatory heart failure (HF). We examined the temporal incidence and mortality trends by geography in these patients. METHODS AND RESULTS We conducted a retrospective cohort study of 36,175 eastern Ontario residents who were diagnosed with HF in an outpatient setting from 1994 to 2013. The primary outcome was 1-year mortality. We examined temporal changes in mortality risk factors with the use of multivariable Cox proportional hazard models. The incidence of HF decreased in women and men across both rural and urban settings. Age-standardized mortality rates also decreased over time in both sexes but remained greater in rural men compared with rural women. CONCLUSIONS The incidence of HF in the ambulatory setting was greater for men than women and greater in rural than urban areas, but mortality rates remained higher in rural men compared with rural women. Further research should focus on ways to reduce this gap in the outcomes of men and women with HF.

Determination of the Burden of Care in Families of Cardiac Surgery Patients

Telemonitoring leverages technology for the follow-up of patients with heart failure. Limited evidence exists on how telemonitoring influences senior patients’ attitudes and self-care practices. This study examines telemonitoring impacts on patient empowerment and self-care, and explores adoption factors among senior patients. A longitudinal study design was used, involving three surveys of elderly with chronic heart failure (n = 23) 1 week, 3 months, and 6 months after beginning telemonitoring use. Self-care, patient empowerment, and adoption factors were assessed using existing scales. The patients involved in this study perceived value of using telemonitoring, did not expect it to be difficult to use, and did not encounter adoption barriers. There was a significant improvement in patients’ confidence in their ability to evaluate their symptoms, address them, and evaluate the effectiveness of the measures taken to address these symptoms. Yet, patients performed less self-care maintenance activities, and the capability of involvement in the decision-making related to their condition decreased. Telemonitoring can improve seniors’ confidence in evaluating and addressing their symptoms in relation to heart failure. This patient management approach should be coupled with targeted education geared toward self-maintenance and self-management practices.