Risk-based and timely triage, early therapy could enhance STEMI care
MedWire News: Risk-based triage, early medical therapy, and timely triage to percutaneous coronary intervention (PCI) could enhance ST-segment elevation myocardial infarction (STEMI) care, say Canadian researchers.
Their research showed that although high-risk patients were more likely to be transported to PCI hospitals via emergency medical services (EMS) than those with lower risk, they were actually less likely to undergo cardiac catheterization.
This points to an unrealized opportunity to potentially improve patient outcomes through a focused approach including prehospital triage, initiation of medical therapy, and activation of an early invasive strategy, write Wayne Tymchak (University of Alberta, Canada) and colleagues.
The study, reported in the American Heart Journal, involved 263 consecutive patients who were admitted to hospital with STEMI between September and November 2008. All patients were categorized according to whether they were transported to hospital via EMS, or if they self-presented.
The results showed that 93 (35%) patients presented via EMS. Of these, 60 (64.5%) patients were transported to PCI hospitals, compared with 75 (44.1%) self-presenting patients who went to PCI hospitals (as opposed to community hospitals).
Compared with the patients who self-presented, EMS patients were more likely to be older (75 vs 62 years, p<0.001), female (43.0% vs 28.1%), diabetic (34.4% vs 22.9%, p=0.045), hypertensive (72.0 vs 57.1%, p=0.017), and have a high GRACE risk score (GRACE >140 points; median 166 vs 130, p<0.001).
Electrocardiogram analysis revealed that EMS patients more frequently had baseline Q waves (38.8 vs 25.5%, p=0.03) and ST depression of 2 mm or more (p=0.027) than those who self-presented.
Fewer EMS patients underwent cardiac catheterization than those who self-presented (60.2% vs 88.2%, p<0.001) and there was a paradoxical relationship between catheterization rates and GRACE risk score, say the researchers. Indeed, 93.4% of those with a low GRACE risk score underwent catheterization, as opposed to 59.3% of those with a high-risk score (GRACE <140 points).
Further analysis revealed that the composite of death, new myocardial infarction, congestive heart failure, and shock was greater in EMS patients than in those who self-presented (unadjusted odds ratio [OR]=3.96, p=0.001). However, after adjusting for GRACE risk score, this difference was attenuated.
The authors propose that regional strategies promoting efficient EMS use and pre-existing STEMI systems of care could establish early risk-based triage for timely catheterization in high-risk patients, which could improve patient outcomes.
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By Piriya Mahendra