The Barriers to Rapid Reperfusion in Acute ST-Elevation Myocardial Infarction

Kristian Bartnes; Hilde Albrigtsen; Johanne M Iversen; Henrik Brovold; Niels H Møller; Bjørn Wembstad; Frode Arstad; Andreas H Kristensen; Julia Cortis; Siv J Olsen; Ståle N S Nygaard; Sven G Kindler; Oddgeir Moe; Christian Hansen; Jan T Mannsverk

doi:10.1007/s40119-022-00281-7

The Barriers to Rapid Reperfusion in Acute ST-Elevation Myocardial Infarction

Cardiol Ther. 2022 Dec;11(4):559-574. doi: 10.1007/s40119-022-00281-7. Epub 2022 Oct 6.

Authors

Affiliations

¹ Division of Cardiothoracic and Respiratory Medicine, University Hospital of North Norway, P.O. Box 100, 9038, Tromsø, Norway. kristian.bartnes@unn.no.
² Institute of Clinical Medicine, University of Tromsø, The Arctic University of Norway, 9037, Tromsø, Norway. kristian.bartnes@unn.no.
³ Department of Cardiology, University Hospital of North Norway, P.O. Box 100, 9038, Tromsø, Norway.
⁴ Department of Medicine, Nordlandssykehuset Bodø, 8092, Bodø, Norway.
⁵ Department of Medicine Narvik, University Hospital of North Norway, P.O. Box 273, 8504, Narvik, Norway.
⁶ Clinic of Medicine, Helgelandssykehuset, P.O. Box 601, 8607, Mo i Rana, Norway.
⁷ Department of Medicine, Clinic of Hammerfest, Finnmarkssykehuset, Sykehusveien 35, 9601, Hammerfest, Norway.
⁸ Clinic of Medicine, Helgelandssykehuset, P.O. Box 613, 8801, Sandnessjøen, Norway.
⁹ Department of Medicine, Nordlandssykehuset Vesterålen, Ivar Bergmos gt. 3, 8450, Stokmarknes, Norway.
¹⁰ Division of Internal Medicine Harstad, University Hospital of North Norway, P.O. Box 1065, 9480, Harstad, Norway.
¹¹ Department of Medicine, Clinic of Kirkenes, Finnmarkssykehuset, P.O. Box 410, 9915, Kirkenes, Norway.
¹² Department of Medicine, Nordlandssykehuset Lofoten, Sykehusbakken 23, 8372, Gravdal, Norway.
¹³ Division of Cardiothoracic and Respiratory Medicine, University Hospital of North Norway, P.O. Box 100, 9038, Tromsø, Norway.
¹⁴ Clinic of Medicine, Helgelandssykehuset, P.O. Box 568, 8801, Mosjøen, Norway.

Abstract

Introduction: This study aimed to quantify the contribution of various obstacles to timely reperfusion therapy in acute ST-elevation myocardial infarction (STEMI) and to improve performance in a mixed remote rural/urban region.

Methods: From November 1, 2020 to April 23, 2021, patients with acute STEMI were prospectively monitored with the critical time intervals, treatment modalities, and outcomes registered. Selected clinical decision-makers in 11 hospitals were appointed as improvement agents and systematically provided with weekly updated information about absolute and relative performance. Suggestions for improvements were invited and shared.

Results: Only 29% of the 146 patients received reperfusion therapy within recommended time limits [prehospital thrombolysis, 2/48; in-hospital thrombolysis, 0/20; primary percutaneous coronary intervention (pPCI), 37/68, with median intervals from the first medical contact of 44, 49, and 133 min, respectively]. Efficiency varied considerably between health trusts: median time from the first medical contact to prehospital thrombolysis ranged from 29 to 54 min (hazard ratio 4.89). The predominant, remediable causes for delays were erroneous tactical choices and protracted electrocardiographic diagnostication, decision-making, and administration of fibrinolytic medication. During the trial, the time to pPCI was non-significantly reduced.

Conclusion: We found several targets for system improvements in order to mitigate reperfusion delays along the entire chain of care, regardless of reperfusion modality chosen. More patients should receive prehospital thrombolysis. The most important measures will be training to ensure a more efficient on-site workflow, improved protocols and infrastructure facilitating the communication between first responders and in-hospital clinicians, and education emphasizing prehospital transport times.

Clinical trials identifier: NCT04614805.

Keywords: Acute ST-elevation myocardial infarction; Primary percutaneous coronary intervention; Thrombolysis.

Associated data

ClinicalTrials.gov/NCT04614805