Lower mortality after prehospital recognition and treatment followed by fast tracking to coronary care compared with admittance via emergency department in patients with ST-elevation myocardial infarction
Introduction
In Göteborg, two-thirds of patients who are hospitalized due to suspected acute myocardial infarction (AMI) are transported by ambulance [1]. Patients who call the emergency medical services (EMS) dispatch centre due to chest pain, and who are subsequently transported by the EMS (ambulance), have been shown to be older and to have a higher prevalence of a previous AMI, angina pectoris, hypertension, diabetes mellitus and congestive heart failure, as well as larger infarct sizes and higher mortality than those patients who transport themselves to hospital [1]. Furthermore, patients with chest pain who choose the EMS system for transport have a higher incidence of cardiac arrest during transport, develop AMI more frequently and are more frequently diagnosed with an acute coronary syndrome compared with patients using private transportation [2], [3], [4]. Based on the high-risk pattern for patients with chest pain who call the EMS dispatch centre, it is therefore an alarming sign per se when patients or their relatives decide to call for an ambulance.
Early reperfusion is crucial in ST-elevation myocardial infarction (STEMI) [5]. In major clinical trials, the median time from the onset of symptoms until the start of fibrinolytic treatment has remained at approximately three hours [6], [7]. Among patients undergoing percutaneous coronary interventions (PCI), it has been shown that each 30 min of delay is associated with an 8% increase in the risk of death during one year [8]. A substantial part of the delay in STEMI patients takes place in hospital. One study analysing the reasons for hospital delay revealed extended time intervals caused by delays in the decision by the emergency department (ED) nurse or physician to call a cardiologist, as well as delays in the arrival of the cardiologist at the ED. The other component was the interval between the cardiologist's decision to admit patients to the CCU and patients' departure from the ED [9].
The objective of the present study was to describe the outcome among patients with STEMI assessed and treated by the EMS in relation to whether they were fast tracked to the CCU (bypassing the emergency department) or admitted via the ED. The hypothesis was that patients who were fast tracked to the CCU have a shorter time interval from hospital arrival to the start of reperfusion therapy and thereby an improved outcome.
Section snippets
Study setting
Göteborg is the second largest city in Sweden with a population of approximately half a million. At the time of the study, Sahlgrenska Hospital was one of three Göteborg city hospitals to which emergency patients with suspected AMI were admitted.
All medical emergencies are handled and dispatched by one EMS dispatch centre according to a two-tier EMS response system for the Municipality of Göteborg. For calls assessed as a life-threatening condition, an advanced life support unit (ALS unit) and
Results
Two hundred and sixty-one patients constituted the direct CCU group, while the ED group comprised 235 patients.
Discussion
Our study suggests a substantially improved outcome in STEMI patients when fast tracked to the CCU as compared to those who are hospitalised via the ED. There are other studies that report that fast tracking and revascularisation at “point of entry” is more effective and that a chain of care that requires the transportation of patients between wards within the hospital steals valuable time [11], [12]. However, the difference in the delay to treatment between groups in this study does not
Conclusions
Among patients transported with ambulance due to STEMI there was a significant association between early recognition and treatment followed by fast tracking to the CCU and long term survival. A higher rate of and a more rapid revascularisation were probably of significant importance for the outcome.
References (18)
- et al.
Early identification of acute myocardial infarction and prognosis in relation to mode of transport to hospital
Am J Emerg Med
(1992) - et al.
Incidence of cardiac arrest during self transport for chest pain
Ann Emerg Med
(1996) - et al.
Acute coronary syndromes without chest pain, an underdiagnosed and undertreated high-risk group
Chest
(2004) - et al.
Mortality and morbidity in suspected acute myocardial infarction in relation to ambulance transport
Eur Heart J
(1987) - et al.
Characteristics and outcome for patients with acute chest pain in relation to whether or not they were transported by ambulance
Eur J Emerg Med
(2000) - et al.
Early thrombolytic treatment in acute myocardial infarction; reappraisal of the golden hour
Lancet
(1996) An international randomised trial comparing. Four thrombolytic strategies for acute myocardial infarction
N Engl J Med
(1993)Comparison of reteplase with alteplase for acute myocardial infarction
N Engl J Med
(1997)- et al.
Time delay to treatment and mortality in primary angioplasty for acute myocardial infarction: every minute of delay counts
Circulation
(2004)
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