Fate of Patients With Prehospital Resuscitation for ST-Elevation Myocardial Infarction and a High Rate of Early Reperfusion Therapy (Results from the PREMIR [Prehospital Myocardial Infarction Registry])

doi:10.1016/j.amjcard.2012.02.013

The American Journal of Cardiology

Volume 109, Issue 12, 15 June 2012, Pages 1733-1737

https://doi.org/10.1016/j.amjcard.2012.02.013 Get rights and content

Patients with acute ST-segment elevation myocardial infarction (STEMI) needing prehospital cardiopulmonary resuscitation (CPR) have a very high adverse-event rate. However, little is known about the fate of these patients and predictors of mortality in the era of early reperfusion therapy. From March 2003 through December 2004, 2,317 patients with prehospital diagnosed STEMI were enrolled in the Prehospital Myocardial Infarction Registry. One hundred ninety patients (8.2%) underwent prehospital CPR and were included in our analysis. Overall 90% of patients were treated with early reperfusion therapy, 56.3% received prehospital thrombolysis and 1/2 of these patients received early percutaneous coronary intervention after thrombolysis, 28.4% of patients were treated with primary percutaneous coronary intervention, and 5.3% received in-hospital thrombolysis. Total mortality was 40.0%. The highest mortality was seen in patients with asystole (63%) or pulseless electric activity (64%). Independent predictors of mortality were need for endotracheal intubation and older age, whereas ventricular fibrillation as initial heart rhythm was associated with survival. In conclusion, in this large registry with prehospital diagnosed STEMI, incidence of prehospital CPR was about 8%. Even with a very high rate of early reperfusion therapy, in-hospital mortality was high. Especially in elderly patients with asystole as initial heart rhythm and with need for endotracheal intubation, prognosis is poor despite aggressive reperfusion therapy.

Section snippets

Methods

The PREMIR was a collaboration of the Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte and the Bundesverband der Arbeitsgemeinschaft der Notärzte Deutschlands. The design of the registry is reported in more detail elsewhere.6, 7 In brief, consecutive patients were included who presented with typical chest pain or equivalent symptoms >20 minutes within 24 hours after symptom onset, prehospital 12-lead electrocardiogram with STE in ≥2 contiguous leads (≥2 mm precordial leads, ≥1 mm

Results

From March 2003 through December 2004, 2,317 patients with prehospital diagnosed STEMI were enrolled in the PREMIR. One hundred ninety patients (8.2%) needed prehospital CPR. Baseline characteristics and prehospital findings of patients with and without CPR are listed in Table 1. Patients with STEMI and prehospital resuscitation were younger and more often had an anterior MI or LBBB compared to patients with STEMI without prehospital resuscitation. Table 2 presents adjunctive prehospital

Discussion

This is 1 of the largest reports of consecutive patients with STEMI and prehospital CPR. Incidence of prehospital resuscitation in patients with STEMI diagnosed in the prehospital phase was about 8% in our study. Only a few specific data in patients with STEMI and prehospital CPR are currently available.1, 4, 5, 8 These reports have revealed that 10% to 21% of patients with STEMI need defibrillation and CPR.9, 10, 11 An analysis of the American Nationwide Inpatient Sample database has shown

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Cited by (18)

Influence of Culprit Lesion Intervention on Outcomes in Infarct-Related Cardiogenic Shock With Cardiac Arrest
2023, Journal of the American College of Cardiology
Cardiac arrest (CA) is common in patients with infarct-related cardiogenic shock (CS).
The goal of this study was to identify the characteristics and outcomes of culprit lesion percutaneous coronary intervention (PCI) of patients with infarct-related CS stratified according to CA in the CULPRIT-SHOCK (Culprit Lesion Only PCI Versus Multivessel PCI in Cardiogenic Shock) randomized trial and registry.
Patients with CS with and without CA from the CULPRIT-SHOCK study were analyzed. All-cause death or severe renal failure leading to renal replacement therapy within 30 days and 1-year death were assessed.
Among 1,015 patients, 550 (54.2%) had CA. Patients with CA were younger, more frequently male, had lower rates of peripheral artery disease, a glomerular filtration rate <30 mL/min, and left main disease, and they presented more often with clinical signs of impaired organ perfusion. The composite of all-cause death or severe renal failure within 30 days occurred in 51.2% of patients with CA vs 48.5% in non-CA patients (P = 0.39) and 1-year death in 53.8% vs 50.4% (P = 0.29), respectively. In a multivariate analysis, CA was an independent predictor of 1-year mortality (HR: 1.27; 95% CI: 1.01-1.59). In the randomized trial, culprit lesion–only PCI was superior to immediate multivessel PCI in patients both with and without CA (P for interaction = 0.6).
More than 50% of patients with infarct-related CS had CA. These patients with CA were younger and had fewer comorbidities, but CA was an independent predictor of 1-year mortality. Culprit lesion–only PCI is the preferred strategy, both in patients with and without CA. (Culprit Lesion Only PCI Versus Multivessel PCI in Cardiogenic Shock [CULPRIT-SHOCK]; NCT01927549)
Advanced airway management during adult cardiac arrest: A systematic review
2019, Resuscitation
Citation Excerpt :
The 71 comparative studies were published between 1985 and 2018 and were primarily from North-America (n = 24), Asia (n = 23), and Europe (n = 20). Sixty-one studies included OHCA17,22–81, nine included IHCA82–90, and one combined OHCA and IHCA91. Additional details including results of the individual studies are provided in the Supplemental Content.
To systematically review the literature on advanced airway management during adult cardiac arrest in order to inform the International Liaison Committee of Resuscitation (ILCOR) consensus on science and treatment recommendations.
The review was performed according to PRISMA guidelines and registered on PROSPERO (CRD42018115556). We searched Medline, Embase, and Evidence-Based Medicine Reviews for controlled trials and observational studies published before October 30, 2018. The population included adult patients with cardiac arrest. Two investigators reviewed studies for relevance, extracted data, and assessed the risk of bias of individual studies.
We included 78 observational studies and 11 controlled trials. Most of the observational studies and all of the controlled trials only included patients with out-of-hospital cardiac arrest. The risk of bias for individual observational studies was overall assessed as critical or serious, with confounding and selection bias being the primary sources of bias. Three of the controlled trials, all published in 2018, were powered for clinical outcomes with two comparing a supraglottic airway to tracheal intubation and one comparing bag-mask ventilation to tracheal intubation. All three trials had some concerns regarding risk of bias primarily due to lack of blinding and variable adherence to the protocol. Clinical and methodological heterogeneity across studies, for both the observational studies and the controlled trials, precluded any meaningful meta-analyses.
We identified a large number of studies related to advanced airway management in adult cardiac arrest. Three recently published, large randomized trials in out-of-hospital cardiac arrest will help to inform future guidelines. Trials of advanced airway management during in-hospital cardiac arrest are lacking.
The Safety of Bypass to Percutaneous Coronary Intervention Facility by Basic Life Support Providers in Patients with ST-Elevation Myocardial Infarction in Prehospital Setting
2018, Journal of Emergency Medicine
Citation Excerpt :
This study, however, excluded patients who were hemodynamically unstable at the scene or during transport. A study from Germany reported a cardiac arrest rate of 8.2% in patients diagnosed with STEMI by prehospital providers (20). In our system, BLS providers can provide cardiopulmonary resuscitation (CPR) and defibrillation, the two most important determinants of survival in out-of-hospital cardiac arrest, and it is currently unclear if patients with cardiac arrest benefit from immediate provision of more advanced skills (21).
Most patients transferred from a non–percutaneous coronary intervention (PCI) facility for primary PCI do not meet target reperfusion times. Direct transportation of patients with ST-elevation myocardial infarction (STEMI) from the scene by advanced life support (ALS) paramedics has been shown to improve reperfusion times and outcomes.
The aim of this study was to determine whether it is safe to bypass the closest hospital and transport by basic life support (BLS) provider to a PCI facility.
This was a health records review of consecutive patients transported to a regional PCI center under an STEMI bypass protocol. Under the PCI bypass protocol, patients were eligible if they presented with symptoms of chest pain, a 12-lead electrocardiogram meeting STEMI criteria, and if transported to the regional PCI center within 60 min. The occurrence of predefined adverse events during transport was determined, which included bradycardia < 50 beats/min, tachycardia > 140 beats/min, hypotension, cardiac arrest, and death.
There were 46 cases of STEMI bypass between February 2005 and February 2013. Mean transport time was 29.9 min (range 20−62 min). Mean contact-to-balloon time was 95.2 min (range 68–159 min). Twenty-five adverse events occurred in 20 patients during transport. In 16 of the 20 patients, the adverse events were transiently abnormal vital sign requiring no intervention. In 3 of the patients, the adverse event was clinically significant and it is believed that the patient would have benefitted from advanced cardiac life support care not within the scope of practice of the BLS providers.
In our region, STEMI patients can be diagnosed accurately and transported safely on bypass to a PCI center for primary PCI while respecting target reperfusion times.
Mobile emergency care service: A time-course assessment and characterization of demand
2018, International Emergency Nursing
Citation Excerpt :
Middle-aged adults were the segment of the population which benefited most from the SAMU service, with patients in the age range of 41–50 years accounting for the majority of requests handled, both for prehospital care and for elective interfacility transfer; these findings is similar from those described in the state of Rio Grande do Sul, where the most prevalent patient age range was 41–60 years. Age verification is important because people over the age of 60 years, a population which has tended to grow in recent years with increasing longevity in high-income sectors of Rio de Janeiro [18], are predisposed to specific health problems including orthopedic injuries, myocardial infarction [19,20], and cardiac arrest [21]. Women in general, at all stages of the life course, received the majority of prehospital care interventions, with a higher monthly average call volume for female than for male patients.
Prehospital care is defined as any medical attention provided outside the hospital environment. This study aims to study the operation of a regional SAMU by assessing electronic records of cases managed and to evaluate demand patterns over time.
A retrospective, cross-sectional study was conducted through an analysis of emergency calls handled between the years of 2009 and 2013 by the SAMU Metropolitan 2 Region mobile emergency care service, located in Niterói, Brazil. Nonparametric tests were used to evaluate differences in the variables of interest between the two halves of the 5-year period of analysis and annually.
The total call volume during the period of analysis was 590,902 (monthly mean [SD], 9848 [3764]; 95%CI = 8875 to 10,820). Analysis of calls over time revealed a significant decline in call volume (p = 0.008), mainly between the year 2009 and subsequent years (p < 0.001). The vast majority of patients were adults with clinical conditions (average = 2311). Predominantly, calls were made to request prehospital assistance at the patient’s home, and the most prevalent age range was 41–50 years.
The SAMU Metropolitan 2 regional emergency medical service predominantly attended to middle-aged women at their homes. Total call volume has been decreasing, perhaps reflecting a multifactorial phenomenon and improvements in the primary health care network.
Prognostic significance of shockable and non-shockable cardiac arrest in ST-segment elevation myocardial infarction patients undergoing primary angioplasty
2018, Resuscitation
Citation Excerpt :
In a large nation-based retrospective study [6] including the whole spectrum of STEMI (regardless the presence or the type of reperfusion therapy), patients with CA due to asystole were at increased risk of 30-day mortality compared to patients with either ventricular arrhythmia or pulseless electrical activity. In the setting of PPCI, few studies enrolling small [7–9] or selected [10] series of STEMI patients showed that CA with non-shockable rhythm is associated with an increased risk of mortality compared to patients experiencing a CA with an initial shockable rhythm. Thus, objectives of the present study enrolling a large unselected cohort of patients undergoing PPCI in the context of a territorial network for STEMI treatment were the following: 1) to evaluate the risk of 1 year cardiac mortality in patients with initial shockable CA and non-shockable CA as compared to patients without CA, 2) to determine in patients with CA the independent predictors of both 1-y cardiac mortality and 3) poor neurological outcome.
To determine, in patients with ST-segment Elevation Myocardial Infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI), the prognostic weight of cardiac arrest (CA) according to the type of rhythm (shockable vs. non-shockable).
We prospectively enrolled 3278 consecutive STEMI patients undergoing PPCI. Multivariable Cox regression was used to establish the relation to 1-year cardiac mortality of both type of CA. In patients suffering from CA we identified predictors of both poor neurological outcome (cerebral performance categories 3–5) and cardiac mortality at 1 year.
The incidence of CA was 7.26% (n = 238). Of these, 196 (5.98%) had an initial shockable rhythm and 42 (1.28%) a non shockable rhythm. During 1-year follow up 311(9.48%) patients died from cardiac causes. Shockable rhythm (adjusted-HR = 1.61; 95%CI 1.08–2.43, p = 0.02) and non-shockable rhythm (adjusted-HR = 3.83; 95%CI 2.36–6.22, p < 0.001) were independently associated with 1-year cardiac mortality. Among patients with CA those with shockable rhythm had a lower risk of poor neurological outcome at 1 year follow up (adjusted OR = 0.22: 95%CI; 0.08–0.55, p = 0.001). Independent predictors of 1-y cardiac mortality were: non shockable rhythm (adjusted HR = 2.6; 95%CI; 1.48–4.5, p = 0.001), crew-witnessed CA, diabetes mellitus, left ventricle ejection fraction and creatinine on admission. There was a significant interaction between type of rhythm and crew-witnessed CA (p = 0.026).
In patients with STEMI undergoing PPCI patients with both shockable and non shockable CA are at increased risk of 1-year cardiac mortality. Among patients with CA those with non shockable rhythm have an higher risk of both poor neurological outcome and cardiac mortality at 1 year.
High-degree atrioventricular block, asystole, and electro-mechanical dissociation complicating non-ST-segment elevation myocardial infarction
2016, American Heart Journal
Citation Excerpt :
Our findings are consistent with a previous study of 278 ACS patients (91% NSTEMI patients) that identified a 1% rate of in-hospital asystole.22 Higher rates of asystole or EMD have been reported in STEMI.23 Rates of complete heart block have been previously reported as high as 2% to 5%,13-17 and this is in part due to inclusion of STEMI patients.
Non–ST-segment myocardial infarction (NSTEMI) can be complicated by high-degree atrioventricular (AV) block, asystole, or electromechanical dissociation (EMD), but these events are not well characterized in the contemporary era. This analysis assesses the incidence of and factors associated with these dysrhythmias in acute NSTEMIs.
Patients with NSTEMI in the EARLY ACS, PLATO, and TRACER trials were included in the pooled cohort (N = 29,677). Logistic regression was used to identify factors associated with in-hospital high-degree AV block and asystole or EMD, and Kaplan-Meier methods were used to assess mortality.
High-degree AV block occurred in 112 (0.4%) patients, asystole in 157 (0.5%), and EMD in 38 (0.1%). Pacemakers were inserted in 241 patients (0.8%) during the index hospitalization: 30 (12%) for AV block. Among patients with high-degree AV block, we observed more frequent right coronary artery lesions (47% vs 29%). Age, diabetes, lower heart rate, and lower blood pressure were associated with high-degree AV block. Higher Killip class, ST-segment depression, prior myocardial infarction, and peripheral vascular disease were most strongly associated with asystole or EMD. Ten-day unadjusted survival was 90% for patients with high-degree AV block and 43% for those with asystole or EMD.
Although high-degree AV block, asystole, and EMD were infrequent complications of NSTEMI, they were associated with substantial short-term mortality. Only 1 in 8 pacemakers placed in NSTEMI patients during the acute hospitalization was for high-degree AV block.

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: The registry was supported by unrestricted funding from Boehringer Ingelheim, Ingelheim, Germany. Dr. Zeymer, Dr. Arntz, Dr. Nibbe, and Dr. Ellinger were or are members of the speakers bureau of Boehringer Ingelheim.

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Coronary artery diseaseFate of Patients With Prehospital Resuscitation for ST-Elevation Myocardial Infarction and a High Rate of Early Reperfusion Therapy (Results from the PREMIR [Prehospital Myocardial Infarction Registry])

Section snippets

Methods

Results

Discussion

Resuscitation

Lancet

Resuscitation

Ann Emerg Med

Am J Cardiol

Am J Cardiol

Am J Cardiol

Chest

J Am Coll Cardiol

Coronary artery disease
Fate of Patients With Prehospital Resuscitation for ST-Elevation Myocardial Infarction and a High Rate of Early Reperfusion Therapy (Results from the PREMIR [Prehospital Myocardial Infarction Registry])