Search

There are several differences between younger and older adults with acute coronary syndrome (ACS). However, few studies have evaluated these differences. We analysed the pre-hospital time interval [symptom onset to first medical contact (FMC)], clinical characteristics, angiographic findings, and in-hospital mortality in patients aged ≤50 (group A) and 51–65 (group B) years hospitalised for ACS. We retrospectively collected data from 2010 consecutive patients hospitalised with ACS between 1 October 2018 and 31 October 2021 from a single-centre ACS registry. Groups A and B included 182 and 498 patients, respectively. ST-segment elevation myocardial infarction (STEMI) was more common in group A than group B (62.6 and 45.6%, respectively; P < 0.001). The median time from symptom onset to FMC in STEMI patients did not significantly differ between groups A and B [74 (40–198) and 96 (40–249) min, respectively; P = 0.369]. There was no difference in the rate of sub-acute STEMI (symptom onset to FMC > 24 h) between groups A and B (10.4% and 9.0%, respectively; P = 0.579). Among patients with non-ST elevation acute coronary syndrome (NSTE-ACS), 41.8 and 50.2% of those in groups A and B, respectively, presented to the hospital within 24 h of symptom onset (P = 0.219). The prevalence of previous myocardial infarction was 19.2% in group A and 19.5% in group B (P = 1.00). Hypertension, diabetes, and peripheral arterial disease were more common in group B than group A. Active smoking was more common in group A than group B (67 and 54.2%, respectively; P = 0.021). Single-vessel disease was present in 52.2 and 37.1% of participants in groups A and B, respectively (P = 0.002). Proximal left anterior descending artery was more commonly the culprit lesion in group A compared with group B, irrespective of the ACS type (STEMI, 37.7 and 24.2%, respectively; P = 0.009; NSTE-ACS, 29.4 and 21%, respectively; P = 0.140). The hospital mortality rate for STEMI patients was 1.8 and 4.4% in groups A and B, respectively (P = 0.210), while for NSTE-ACS patients it was 2.9 and 2.6% in groups A and B, respectively (P = 0.873). No significant differences in pre-hospital delay were found between young (≤50 years) and middle-aged (51–65 years) patients with ACS. Although clinical characteristics and angiographic findings differ between young and middle-aged patients with ACS, the in-hospital mortality rate did not differ between the groups and was low for both of them.

Background Coronavirus disease 2019 (COVID-19) has forced dramatic changes to the healthcare systems throughout the world. Time-sensitive management of cardiovascular emergencies such as ST-elevation myocardial infarction (STEMI) has yet to be evaluated in the context of these new policies, particularly in so-called “hot spot” cities. Methods We evaluated the early impact of the pandemic on STEMI performance in the Greater Montreal Area. A total of 167 patients from 3 different study periods were included. Patients presenting in the lockdown period from mid-March to mid-May 2020 (Group C, 53 patients) were compared to those from mid-March to mid-May 2019 (Group A, 60 patients) and the 2020 pre-COVID-19 period (Group B, 54 patients). Results The number of STEMI admissions was unaffected during the lockdown. However, significantly longer delays between symptom onset and first medical contact (FMC) were noted (Group C 189.0 IQR [70.0, 840.0] min vs. Group A 103.0 IQR [42.5, 263.0] min vs. Group B 91.0 IQR [38.0, 235.5 min], P = 0.007). In contrast, additional safety protocols do not appear to have significantly affected delays between FMC and first intracoronary device activation (Group C 102 IQR [73.0, 133.0] min vs. Group A 104 IQR [87.0, 146.0] min vs. Group B 99.5 IQR [80.0, 150.0] min, P = 0.37). Patients that presented during the outbreak were more likely to be unstable with a higher incidence of Killip classes II-IV compared to groups A and B (28.3% vs. 18.3% vs. 5.6% respectively, P = 0.008). Worse in-hospital outcomes were also noted with a significantly higher rate of major adverse cardiac events (Group A 5.0% vs. Group B 11.1% vs. Group C 22.6%, P = 0.007). Conclusion During the lockdown period, many patients appear to have been reluctant to present to hospitals. This was associated with more unstable STEMI presentations and worse in-hospital course. Importantly, the health care system appears able to ensure timely acute cardiac care while ensuring that COVID-19 protocols are respected., Highlights • The COVID-19 outbreak led to significant healthcare barriers, affecting STEMI care. • Longer durations between symptom onset and first medical contact were observed. • The rate of STEMI admissions was unaffected during the lockdown period. • Patients were more unstable at initial presentation during the COVID-19 outbreak. • Higher rates of MACE and mechanical complications were observed during the pandemic.

Background Women with ST‐elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention historically experience worse in‐hospital outcomes compared to men. Hypothesis Implementation of a regional STEMI system will reduce care gaps in reperfusion times and in‐hospital outcomes between women and men. Methods 1928 patients (413 women, 21.4%) presented with an acute STEMI between June 2007 and March 2016. The population was divided into an early cohort (n = 728 patients, 2007‐May 2011), and a late cohort (n = 1200 patients, June 2011–2016). The primary endpoints evaluated were reperfusion times and in‐hospital outcomes. Results Compared to men, women experienced significant delays in first medical contact (FMC) to arrival at the emergency room (26.0 vs. 22.0 min, p

Background:. It remains unclear whether the outcomes of ST-elevation myocardial infarction (STEMI) patients treated with primary percutaneous coronary intervention (PPCI) during off-hours are as favorable as those treated during on-hours, especially those with a first medical contact-to-device (FMC-to-device) time within 90 min. We aimed to determine whether off-hours admission impacted late outcomes in patients undergoing PPCI and with an FMC-to-device time ≤90 min. Methods:. This multicenter retrospective study included 670 STEMI patients who underwent successful PPCI and had an FMC-to-device time ≤90 min from 19 chest pain centers in Beijing from January 2018 to December 2018. Patients were divided into on-hours group and off-hours group based on their arrival time. Baseline characteristics, clinical data, and key time intervals during treatment were collected from the Quality Control & Improvement Center of Cardiovascular Intervention of Beijing by the “Heart and Brain Green Channel” app. Results:. Overall, the median age of the patients was 58.8 years and 19.9% (133/670) were female. Of these, 296 (44.2%) patients underwent PPCI during on-hours and 374 (55.8%) patients underwent PPCI during off-hours. Compared with the on-hours group, the off-hours group had a longer FMC-to-device time and fewer patients with FMC-to-device time ≤60 min (P 0.05). According to the Cox regression analyses, off-hours admission was not a predictor of 2-year MACEs (P = 0.788). Similarly, the Kaplan-Meier curves showed that the risks of a MACE, all-cause death, reinfarction, and target vessel revascularization were not significantly different between the two groups (P > 0.05). Conclusions:. This real-world, multicenter retrospective study demonstrated that for STEMI patients who underwent PPCI within 90 min, off-hours admission was safe, with no difference in the risk of 2-year MACEs compared with those with on-hours admission.

Összefoglaló. Bevezetés: Heveny myocardialis infarctusban a szívizommentés sikere, a beteg életkilátása nagymértékben függ a panasz kezdete és az elzáródott koszorúér rekanalizálása között eltelt ischaemiás időtől. Jelenleg az ér nyitása optimális esetben minden betegnél koszorúér-intervencióval történik. Célkitűzés: Annak vizsgálata, hogy öt év alatt mennyit változtak az ischaemiás idő összetevői, és miben változott az elzáródott ér nyitásának módszere ST-elevációs myocardialis infarctus (STEMI) miatt végzett primer coronariaintervencióban. Módszer: 2014. 01. 01. és 2018. 12. 31. között 1663, STEMI miatt koszorúér-intervencióval kezelt betegnél (1173 férfi és 490 nő) vizsgáltuk évenkénti bontásban a panasztól a koszorúér nyitásáig eltelt idő összetevőit és a 30 napos halálozást. Eredmények: Öt év alatt a panasztól az első egészségügyi kontaktusig medián 2:53 vs. 2:10 óra (p = 0,0132), ettől az intervenciós centrumba történt felvételig medián 1:17 vs. 1:03 óra (p = 0,009), a felvételtől a ballon nyitásáig medián 0:31 vs. 0:29 óra (p = ns) telt el. A panasztól a ballon nyitásáig eltelt idő (medián 5:29 vs. 4:07 óra, p = 0,0001) rövidült, döntően 2014 és 2015 között. A gyógyszerkibocsátó stent beültetése 15%-ról 96%-ra nőtt. A vizsgált években a légzés/keringés támogatás aránya 8,2–10,6–13,9–7,6–8,4, a 30 napos halálozásé 4,1–6,8–11,1–7,4–5,7% volt; a két érték korrelációt mutat (p = 0,827). Következtetés: Öt év alatt a panasztól az első egészségügyi kontaktusig és a kórházi beszállításig eltelt idő rövidült, de az Európai Kardiológiai Társaság ajánlásához képest hosszú; a kórházi felvételtől a ballon nyitásáig eltelt idő megfelelő. A négy órán belüli reperfúzió a betegek közel felében valósult meg. Az intervenciós centrumba való gyorsabb bekerülés javíthatna az eredményen. Orv Hetil. 2021; 162(13): 497–503. Summary. Introduction: In acute myocardial infarction, the heart muscle salvage, the patient’s life expectancy is highly dependent on the elapsed ischaemic time from the onset of complaint to target vessel recanalisation. Nowadays, target vessel recanalisation is performed with coronary intervention in all patients in optimal case. Objective: To examine how the components of ischemic time and the opening procedure of the occluded coronary have changed over five years in primary intervention done in acute ST-elevation myocardial infarction (STEMI). Method: Authors studied data of 1663 (1173 male and 480 female) STEMI patients in annual breakdowns treated with coronary intervention between 01. 01. 2014 and 31. 12. 2018, time from complaint to coronary artery opening, details of intervention and 30 days mortality rate. Results: During the five years, time intervals were as follows: from onset of complaint to first medical contact: median 2:53 vs. 2:10 hours (p = 0.0132), from this to admission in the interventional centre: median 1:17 vs. 1:03 hours (p = 0.009), from hospital admission to balloon opening: median 0:31 vs. 0:29 hours (p = ns). In total, the complaint to balloon opening time (median 5:29 vs. 4:07 hours, p = 0.0001) diminished, decisively from 2014 to 2015. Ratio of drug-eluting stent implantation increased from 15% to 96%. In the investigated years, the need of respiratory and/or circulatory device support ratio was 8.2–10.6–13.9–7.6–8.4, 30-day mortality rate between 4.1–6.8–11.1–7.4–5.7%; these two values showed a correlation (p = 0.827). Conclusion: The time from complaint to first medical contact and transfer to hospital against the significant decrease is still longer than the recommendation of the European Society of Cardiology. The time from hospital admission to balloon opening is adequate. Reperfusion within four hours was achieved in half of the patients in total. Faster hospitalization may improve results. Orv Hetil. 2021; 162(13): 497–503.

A significant concern in current coronavirus disease-2019 (COVID-19) pandemic era is delay in first medical contact in patients with ST-segment elevation myocardial infarction (STEMI), due to reluctance to visit the hospital. We report a case of delayed presentation of STEMI as ventricular septal rupture during the COVID-19 pandemic, a rare presentation in the current age of primary percutaneous coronary intervention. (Level of Difficulty: Beginner.), Graphical abstract, A significant concern in current coronavirus disease 2019 (COVID-19) pandemic era is delay in first medical contact in patients with ST-segment elevation…

Background: Reducing door-to-balloon time may not reduce mortality, but reducing the time from symptom onset to first medical contact (FMC) may alone improve patient outcomes. The purpose of this s...

Aims Despite the spike in COVID-19 hospitalizations, the number of acute coronary syndrome (ACS) admissions has declined significantly. It raises concerns about the long-term consequences of cardiovascular problems. This study aims to provide new insights into our awareness of the pandemic situation in ACS settings. Methods We performed a single centre retrospective analysis of 397 patients from iSTEMI Registry between March-October 2019 (Pre-COVID-19 pandemic) and March-October 2020 (COVID-19 pandemic) with ACS (i.e., unstable angina (UA), non-ST-segment elevation myocardial infarction (NSTEMI), and STEMI). We analyzed case fatality rate, delay to First Medical Contact (FMC), and troponin findings. Results The number of ACS patients admissions in March-October 2019 (254 patients) and 2020 (143 patients) had significantly reduced by 43.7%. Admission of ACS significantly dropped for STEMI (35.76%, p=0.048) and NSTEMI (65.70%, p=0.001), but not for UA (31.90%, p=0.262). There was non-significant case fatality rate between-group of STEMI (p = 0.168), NSTEMI (p = 0.388), or UA (p = 0.343). We found a significant delay to FMC during pandemic (39.8%, p=0.000) and correlated with the higher troponin I level (30,6%, p=0.001). Conclusion This study reveals that local conditions in our institution are similar to the other centers during the COVID-19 pandemic. In parallel to the COVID-19 burden, we will have to deal with the morbidity and mortality caused by delays in FMC and patients severity in the future. Further studies are needed to analyze the factors that decreased ACS patients' admission.

ObjectivesTo evaluate emergency medical services (EMS) delays and their impact on time to treatment and mortality in patients with ST-elevation myocardial infarction (STEMI).MethodWe collected data on EMS time intervals from published studies across five electronic databases. The primary EMS interval was the time in minutes between first medical contact and arrival at hospital door (FMC-to-door time). Secondary intervals were other components of EMS delay. Weighted means were measured using random-effects models. Meta-regression was used to identify factors associated with EMS delays and to assess the impact of EMS delay on the proportion of patients treated within90 min and mortality.ResultsTwo independent reviewers included 100 studies (125 343 patients) conducted in 20 countries. The weighted mean FMC-to-door time was 41 min (n=101 646; 95% CI 39 to 43, range 21–88). However, substantial heterogeneity was observed with each interval, which could be explained by region and urban classification, distance to hospital and method of ECG interpretation. In a meta-regression adjusted for door-to-balloon time, a 10 min increase in FMC-to-door time was associated with a 10.6% (95% CI 7.6% to 13.5%; pConclusionEMS delays account for half of the total system delay in STEMI. There is a fourfold global variation in EMS delays, which are not completely explained by differences in system characteristics. Reducing unexplained variation could yield improvements in the time to treatment and outcome of STEMI patients.PROSPERO registration numberCRD42017074118.

RESUMEN 31. Introducción: La iniciativa Stent-Save a Life! (SSL) es un programa europeo que busca mejorar el acceso de pacientes con infarto agudo de miocardio con elevación del ST (IAMCEST) a un tratamiento de reperfusión basado en las recomendaciones de las guías clínicas, reduciendo así su morbimortalidad. Objetivo: Describir los resultados de los primeros tres años de la iniciativa SSL Argentina Material y métodos: Se realizó inicialmente un mapeo para analizar la situación local y luego se desarrolló el Programa Puerta-Balón (PPB) como un proceso de mejora continua para centros con capacidad de realizar angioplastia primaria (ATCp). Resultados: Desde marzo de 2016 hasta marzo de 2018 se trataron 3041 pacientes con IAMCEST en 38 centros participantes del citado programa. El 20% (n = 610) de esos pacientes tuvo su primer contacto médico (PCM) con el servicio de emergencias médicas. Excluyendo los 184 pacientes sin lesiones coronarias (6% del total), el 93% fue reperfundido, principalmente con ATCp (95%). El tiempo global de isquemia fue de 117 minutos, variando según el momento del PCM. La mortalidad global intrahospitalaria fue del 7%. Conclusiones: La falta de una “cultura de reperfusión” fue la barrera en común de centros públicos y privados que motivó el desarrollo del PPB. La identificación de los puntos críticos que impiden un tratamiento a tiempo, junto con la organización de los centros puertas adentro, representan el primer paso para mejorar la atención de estos pacientes. Es necesario el trabajo integrado de todos los actores involucrados a partir de la organización de redes de atención, adaptadas a la realidad local de cada centro y región. ABSTRACT 39. Introduction: The Stent-Save a Life! (SSL) initiative is a European program that seeks to improve the access of patients with ST-segment elevation acute myocardial infarction (STEMI) to reperfusion therapies based on clinical guideline recommendations, thus reducing morbidity and mortality. Objective: The aim of this study was to describe the results of the first three years of the SSL Argentina initiative. Methods: Initially, a mapping was carried out to analyze the local situation and then the Door-to- Balloon Program (DBP) was developed as a continuous improvement process for centers with primary percutaneous coronary intervention (pPCI) capability. Results: From March 2016 to March 2018, 3,041 patients with STEMI were treated in 38 centers participating in this program. In 20% of cases (n=610) patients had their first medical contact with the emergency medical services. After excluding 184 patients (6%) without coronary lesions, reperfusion therapy was performed in 93% of cases, mainly by pPCI (95%). Total ischemic time was 117 minutes, with differences according to the time of first medical contact. Overall in-hospital mortality was 7%. Conclusions: The lack of a “reperfusion culture” was the common barrier of public and private centers that motivated the development of the DBP. The identification of critical points that prevent treatment on time, together with enhancement of in-hospital organization, represent the first step to improve the care of these patients. The integrated work of all the involved parties is necessary to develop care networks adapted to the local reality of each center and region.

Aim. To study the features of disease progress and approaches to the diagnostics of acute myocardial infarction (MI) among elderly and senile patients and their influence on the management in the acute period of disease.Materials and methods. The study was performed using the WHO program “Register of acute myocardial infarction” (Tomsk). The study included 410 patients (60 years and older), who had acute MI. The study group is represented by a comparable number of men (n=212) and women (n=198). The mean age of patients was 71 (66; 77) years (women are 5 years older than men (pResults. Most of the patients had history comorbid pathology. In one in five patients (17,8%), the disease had an atypical manifestations, which in 41% of cases was represented by the asymptomatic form. Atypical manifestation of MI lengthened the prehospital phase of medical care due to a longer time before the first medical contact (p=0,005), as well as a late help-seeking (120 [49; 311,5] minutes). In 28% of patients, the level of creatine kinase-MB remained normal, and the indicator of troponin I exceeded the maximum values only in half of the cases. One fifth of the patients underwent acute MI treatment in non-core hospitals, which resulted in a low frequency of intervention (38%) and increasing by 2 times the chance of death within 5 years. The level of hospital mortality from acute MI in elderly patients in noncore hospitals was 3 times higher than in specialized departments (pConclusion. Difficulties in diagnostics of MI in patients of older age groups is caused by the prevalence of comorbid pathology, an atypical manifestations of the disease and low information content of biochemical markers of myocardial necrosis. It leads to an increase in time delays at the prehospital phase and frequent hospitalization of patients in non-core hospitals, making it impossible for them to receive timely, preferred therapy.

Objective: The COVID-19 pandemic placed heavy burdens on emergency care and posed severe challenges to ST-segment-elevation myocardial infarction (STEMI) treatment. This study aimed to investigate the impact of COVID-19 pandemic on mechanical reperfusion characteristics in STEMI undergoing primary percutaneous coronary intervention (PPCI) in a non-epicenter region.Methods: STEMI cases undergoing PPCI from January 23 to March 29 between 2019 and 2020 were retrospectively compared. PPCI parameters mainly included total ischemic time (TIT), the period from symptom onset to first medical contact (S-to-FMC), the period from FMC to wire (FMC-to-W) and the period from door to wire (D-to-W). Furthermore, the association of COVID-19 pandemic with delayed PPCI risk was further analyzed.Results: A total of 14 PPCI centers were included, with 100 and 220 STEMI cases undergoing PPCI in 2020 and 2019, respectively. As compared to 2019, significant prolongations occurred in reperfusion procedures (P < 0.001) including TIT (420 vs. 264 min), S-to-FMC (5 vs. 3 h), FMC-to-W (113 vs. 95 min) and D-to-W (83 vs. 65 min). Consistently, delayed reperfusion surged including TIT ≥ 12 h (22.0 vs.3.6%), FMC-to-W ≥ 120 min (34.0 vs. 6.8%) and D-to-W ≥ 90 min (19.0 vs. 4.1%). During the pandemic, the patients with FMC-to-W ≥ 120 min had longer durations in FMC to ECG completed (6 vs. 5 min, P = 0.007), FMC to DAPT (24 vs. 21 min, P = 0.001), catheter arrival to wire (54 vs. 43 min, P < 0.001) and D-to-W (91 vs. 78 min, P < 0.001). The pandemic was significantly associated with high risk of delayed PPCI (OR = 7.040, 95% CI 3.610–13.729, P < 0.001).Conclusions: Even in a non-epicenter region, the risk of delayed STEMI reperfusion significantly increased due to cumulative impact of multiple procedures prolongation.

Background Women with ST‐segment–elevation myocardial infarction experience delays in reperfusion compared with men with little data on each time component from symptom onset to reperfusion. This study analyzed sex discrepancies in patient delays, prehospital system delays, and hospital delays. Methods and Results Consecutive patients with ST‐segment–elevation myocardial infarction treated with percutaneous coronary intervention across 30 hospitals in the Victorian Cardiac Outcomes Registry (2013–2018) were analyzed. Data from the Ambulance Victoria Data warehouse were used to perform linkage to the Victorian Cardiac Outcomes Registry for all patients transported via emergency medical services (EMS). The primary end point was EMS call‐to‐door time (prehospital system delay). Secondary end points included symptom‐to‐EMS call time (patient delay), door‐to‐device time (hospital delay), 30‐day mortality, major adverse cardiovascular events, and major bleeding. End points were analyzed according to sex and adjusted for age, comorbidities, cardiogenic shock, cardiac arrest, and symptom onset time. A total of 6330 (21% women) patients with ST‐segment–elevation myocardial infarction were transported by EMS. Compared with men, women had longer adjusted geometric mean symptom‐to‐EMS call times (47.0 versus 44.0 minutes; P P P =0.006). Compared with men, women had higher 30‐day mortality (odds ratio [OR], 1.38; 95% CI, 1.06–1.79; P =0.02) and major bleeding (OR, 1.54; 95% CI, 1.08–2.20; P =0.02). Conclusions Female patients with ST‐segment–elevation myocardial infarction experienced excess delays in patient delays, prehospital system delays, and hospital delays, even after adjustment for confounders. Prehospital system and hospital delays resulted in an adjusted excess delay of 10 minutes compared with men.

Background The present study set out to investigate the epidemiological and clinical characteristics of 65 patients with tsutsugamushi disease. Methods The clinical data of 65 patients with tsutsugamushi disease, who were admitted to the Affiliated Hospital of Nantong University were retrospectively analyzed. The clinical symptoms, laboratory examination results, clinical treatment plans, treatments, and outcomes of the patients were analyzed. Results The 65 patients with tsutsugamushi disease, included 40 males (61.54%) and 25 females (38.46%). The patients were aged from 1 year and 7 months to 88 years old, and the peak age was 60-70 years old. Geographically, the patients were concentrated in Rugao and Tongzhou District. Infections were most common between October and December (categorized as "autumn type"), and peaked in November. Farmers had the highest infection rate of any occupation (66%). All patients had the symptom of fever, with the body temperature of 60 (92.31%) patients exceeding 38.5 °C, while 58 (89%) and 51 (78%) patients had characteristic eschar and skin rash, respectively. There were 56 (86.15%) patients with varying degrees of liver damage, 8 (12.31%) cases of elevated D-dimer, 3 (4.62%) cases of myocardial injury, 38 (58.46%) cases of superficial lymph node enlargement, 8 (12.31%) cases of splenomegaly, and 2 cases (3.08%) of bulbar conjunctival congestion. Of the 65 patients enrolled, the overall misdiagnosis rate of first medical contact was 64.62. Conclusions Tsutsugamushi disease, infection has obvious seasonality and a susceptible population, especially among farmers and the elderly.

Background: Functional outcomes are improved when AIS patients receive faster treatment. The first medical contact for many AIS patients is with emergency medical services (EMS) providers. We hypothesize that AIS treatment is faster when EMS providers suspect stroke. Methods: We performed a retrospective analysis of the Greater Cincinnati/Northern Kentucky Stroke Study, a comprehensive study of stroke patients in a large geographical area with 1.3 million inhabitants whose demographics are representative of the United States. We compared AIS patients age ≥18 years transported by EMS in 2015 with an EMS impression of “stroke” or “weakness/numbness” to those with other EMS impressions. Primary outcome was thrombolysis rate, and secondary outcomes were times from EMS scene arrival to ED arrival, CT, and treatment and times from ED arrival to CT and treatment. Chi-square and Mann-Whitney U-tests were used to compare treatment rates and times, respectively. Logistic regression (for rates) and median regression (for times) adjusted for NIHSS, GCS, age, sex, race, and prior stroke history. Results: Among 2,486 confirmed AIS patients from 1/1/2015-12/31/2015, 868 were transported by EMS, including 595 (69%) with EMS suspected stroke. Compared to EMS non-suspected strokes, patients with EMS suspected stroke patients were more likely to receive thrombolysis (18% vs 8%; OR 2.67, 95% CI 1.63-4.47) and had faster prehospital transport (30 vs 32 min, p=0.02), ED arrival to CT (27 vs 46 min, p Conclusions: In a large population-based study, EMS stroke identification is associated with a higher rate of and faster thrombolysis. Efforts to increase accuracy of EMS stroke identification is likely to have significant clinical impact by shortening treatment times.

Early management of sepsis and septic shock is crucial for patients’ prognosis. As the Emergency Department (ED) is the place where the first medical contact for septic patients is likely to occur, emergency physicians play an essential role in the early phases of patient management, which consists of accurate initial diagnosis, resuscitation, and early antibiotic treatment. Since the issuing of the Surviving Sepsis Campaign guidelines in 2016, several studies have been published on different aspects of sepsis management, adding a substantial amount of new information on the pathophysiology and treatment of sepsis and septic shock. In light of this emerging evidence, the present narrative review provides a comprehensive account of the recent advances in septic patient management in the ED.

Background. At present, COVID-19 is sweeping the world, and all countries are actively responding. During the COVID-19 epidemic, the treatment of patients with acute myocardial infarction (AMI) may be affected. Methods. We reviewed data of patients with AMI from January 23 to April 23, 2020 (2020), and January 23 to April 23, 2019 (2019), who were admitted to two hospitals from Southern China. We collected clinical characteristics, comorbidities, treatment, prognosis, and key time segments to analyze. Results. The total number of patients that had been diagnosed with AMI in the two hospitals was 218 in 2020 and 260 in 2019. The number of AMI patients that were admitted to hospitals per day decreased in 2020. The percentage of patients with AMI who refused hospitalization in 2020 was significantly higher than that in 2019 (5.0% vs 1.5%, p = 0.028 ). There is no statistical difference in symptoms of the first medical contact (S2FMC) time between 2020 and 2019 ( p = 0.552 ). Door-to-balloon (D2B) time of ST-elevation myocardial infarction (STEMI) patients who were treated with a primary percutaneous coronary intervention (pPCI) in 2020 was 79 (63.75–105.25) mins, while D2B time in 2019 was 57.5 (41.5–76.5) mins, which was statistically different from the two groups. Conclusions. COVID-19 had an impact on the number of AMI patients who were admitted to hospitals and the time of treatment. During the COVID-19 epidemic, the number of AMI patients that were admitted to hospitals per day was decreased, while the percentage of AMI patients that refused therapy in these two hospitals increased, and the D2B time of STEMI patients was also delayed.

Objective Delayed revascularisation in patients with ST‐segment elevation myocardial infarction (STEMI) is associated with poor prognosis. The aim of this study is to investigate how the timeline in STEMI treatment was affected during the Covid‐19 outbreak. Method Consecutive 165 STEMI patients were enrolled in the study during the Covid‐19 pandemic period (Pandemic period) and the prepandemic period (Control period). The time period until patients' leaving their current position after the onset of pain (home delay), the time from the onset of pain to the first medical contact (FMC delay), door‐to‐balloon time, procedure time and hospitalisation time were recorded. Results A total of 165 patients, 82 in the Pandemic period and 83 in the Control period, were included in the study. When compared with the control period, home delay [30 (5‐6912) minutes vs 165 (10‐360) minutes, P

Acute Stroke (AS) is the most common time-dependent disease attended in the Emergency Medicine Service (EMS) of Madrid (SUMMA 112). Community of Madrid has been one of the most affected regions in Spain by the coronavirus disease 2019 (COVID19) pandemic. A significant reduction in AS hospital admissions has been reported during the COVID-19 pandemic compared to the same period one year before. As international clinical practice guidelines support those patients with suspected acute stroke should be accessed via EMS, it is important to know whether the pandemic has jeopardized urgent pre-hospital stroke care, the first medical contact for most patients. We aimed to examine the impact of the COVID-19 in stroke codes (SC) in our EMS among three periods of time: the COVID-19 period, the same period the year before, and the 2019-2020 seasonal influenza period. Methods: We compared the SC frequency among the periods with high cumulative infection rate (above the median of the series) of the first wave of COVID-19, seasonal influenza, and also with the same period of the year before. Results: 1,130 SC were attended during the three periods. No significant reduction in SC was found during the COVID-19 pandemic. The reduction of hospital admissions might be attributable to patients attending the hospital by their means. The maximum SC workload seen during seasonal influenza has not been reached during the pandemic. We detected a non-significant deviation from the SC protocol, with a slight increase in hospitals’ transfers to hospitals without stroke units.

Background: ST-elevation myocardial infarction diagnosis at first medical contact (FMC) and prehospital cardiac catheterization laboratory (CCL) activation are associated with reduced total ischemic time and therefore have become the dominant ST-elevation myocardial infarction referral method in primary percutaneous coronary intervention systems. We sought to determine whether physician oversight was associated with improved diagnostic performance in a prehospital CCL activation system and what effect the additional interpretation has on treatment delay. Methods: Between 2012 and 2015, all patients in 2 greater Montreal catchment areas with a chief symptom of chest paint or dyspnea had an in-the-field electrocardiogram (ECG). A machine diagnosis of “acute myocardial infarction” resulted either in automatic CCL (automated cohort without oversight) or transmission of the ECG to the receiving centre emergency physician for reinterpretation before CCL activation. System performance was assessed in terms of the proportion of false positive and inappropriate activations (IA), as well as the proportion of patients with FMC-to-device times ≤ 90 minutes. Results: Four hundred twenty-eight (428) activations were analyzed (311 automated; 117 with physician oversight). Physician oversight tended to decrease IAs (7% vs 3%; P = 0.062), but was also associated with a smaller proportion of patients achieving target FMC-to-device (76% vs 60%; P < 0.001). There was no significant effect on the proportion of false positive activation. Conclusions: Real-time physician oversight might be associated with fewer IAs, but also appears to have a deleterious effect on FMC-to-device performance. Identifying predictors of IA could improve overall performance by selecting ECGs that merit physician oversight and streamlining others. Larger clinical studies are warranted. Résumé: Contexte: Un diagnostic d’infarctus du myocarde avec élévation du segment ST au moment du premier contact avec un professionnel de la santé et l’activation du processus de cathétérisme cardiaque avant l’arrivée à l’hôpital sont associés à une réduction de la durée totale de l’épisode ischémique, et sont donc désormais la méthode de préférence en cas d’infarctus du myocarde avec élévation du segment ST dans les établissements où l’intervention coronarienne percutanée primaire est possible. Nous avons voulu déterminer si la supervision par un médecin était associée à une amélioration de la justesse du diagnostic dans un tel contexte et les répercussions d’une interprétation additionnelle sur les délais de traitement. Méthodologie: De 2012 à 2015, tous les patients de deux zones desservies du Grand Montréal qui présentaient comme principal symptôme une douleur à la poitrine ou une dyspnée ont subi un électrocardiogramme (ECG) sur le terrain. Un diagnostic d’infarctus aigu du myocarde posé par l’appareil a automatiquement donné lieu à l’activation du processus de cathétérisme cardiaque (cohorte automatisée sans supervision) ou à la transmission de l’ECG à l’urgentologue de l’établissement où le patient était conduit pour la réinterprétation des résultats avant l’activation du processus de cathétérisme cardiaque. La performance du système a été évaluée en fonction de la proportion de faux positifs et d’activations inappropriées, ainsi que de la proportion de patients chez qui le délai entre le premier contact avec un professionnel de la santé et l’intervention était ≤ 90 minutes. Résultats: Quatre cent vingt-huit (428) activations du processus ont été analysées (311 automatisées; 117 après la supervision par un médecin). La supervision par un médecin était associée à une baisse non significative des activations inappropriées du processus (7 % vs 3 %; p = 0,062), mais était aussi associée à une plus faible proportion de patients chez qui le délai visé entre le premier contact avec un professionnel de la santé et l’intervention était respecté (76 % vs 60 %; p < 0,001). Aucun effet significatif quant à la proportion de faux positifs n’a été observé. Conclusions: La supervision en temps réel par un médecin pourrait être associée à une réduction des activations inappropriées du processus de cathétérisme cardiaque urgent, mais pourrait également nuire aux résultats quant au délai entre le premier contact avec un professionnel de la santé et l’intervention. L’identification des facteurs prédictifs d’une activation inappropriée du processus pourrait améliorer les résultats globaux en permettant de choisir les résultats d’ECG qui mériteraient d’être passés en revue par le médecin, et en déclenchant le processus habituel pour les autres. Des études cliniques de plus grande envergure sont de mise.

Objective: To determine the time from onset of symptoms to start of fibrinolysis and treatment in acute ST elevated myocardial infarction patients and identify the factors which cause delay in treatment. Methods: A cross sectional study was conducted at National Institute of Cardiovascular Diseases, Karachi on 360 conveniently selected patients of ST elevated myocardial infarction from July to September in the year 2017. Structured questionnaire was used to obtain detailed information on socio-demographics, factors which cause delay and timing of onset of symptoms to arrival of patient in emergency ward. Results: Overall, the total average time from the start of symptoms to initiation of treatment was 119.85±63.32 minutes. Only 5.1% patient reached within one hour while 57.7% reached within two hours. Old age group of 60 and above was positively associated with timely arrival (OR=2.75, 95% CI 1.33-5.68, p=0.006). Significant positive association of using personal car as mode of transport to reach the hospital (OR=5.25, 95% CI 2.94-9.35, p

Purpose: To compare the number of admissions, clinical features and therapeutic outcomes of patients treated for acute ST- elevation myocardial infarction (STEMI), before and after the COVID-19 pandemic state of emergency in Peru. Methods: Comparative and descriptive study of cohorts, derivated from the PEruvian Registry of ST-segment Elevation Myocardial Infarction II (PERSTEMI II). We compared the patients treated for STEMI, between 45 days before and during the first 45 days of the COVID-19 state of emergency in Peru. Results: During the first 45 days of the COVID-19 state of emergency, the team found a 59% decrease on the number of admissions for STEMI. There was a larger proportion of patients with high blood pressure and dyslipidemia. We noticed a decreasing trend in the access to reperfusion therapies (73% vs. 66.6%); the fibrinolysis was the most commonly used therapy. The most frequent reason of not reperfusion was the late onset >24 hours (41.7%, p=0.004). There was a trend of time reduction to first medical contact and less ischemia time to reperfusion. A lower incidence of post-infarction heart failure was registered. The mortality was similar in both groups (3.4% vs. 2.7%). Conclusions: COVID-19 pandemic in Peru has generated a significant reduction of STEMI admissions and a trend in less use of reperfusion therapies. The late onset of patients was the most common reason of not reperfusion. Key words: Resumen Objetivo: Comparar el número de ingresos, características clínicas y resultados terapéuticos de los pacientes atendidos por infarto de miocardio con elevación del segmento ST (IMCEST) antes y durante el estado de emergencia por COVID-19 en Perú. Métodos: Se realizó un estudio descriptivo y comparativo de cohortes, derivadas del PEruvian Registry of ST-segment Elevation Myocardial Infarction II (PERSTEMI II). Se comparó los pacientes atendidos por IMCEST 45 días antes y durante los 45 días iniciales del estado de emergencia por COVID-19 en Perú. Resultados: Durante los primeros 45 días del período de emergencia se encontró una disminución del 59% en el número de ingresos por IMCEST. Hubo una mayor proporción de pacientes con antecedentes de hipertensión arterial y dislipidemia. Se observó una tendencia a reducción en el acceso a terapias de reperfusión (73.5% vs 66.6%), siendo la fibrinólisis la terapia más utilizada. El motivo más frecuente de no reperfusión fue la presentación tardía >24 horas (41.7%, p=0.004). Hubo una tendencia a reducción del tiempo al primer contacto médico y del tiempo de isquemia hasta la reperfusión. Se registró menor incidencia de falla cardíaca post infarto. La mortalidad fue similar en ambos grupos (3.4% vs 2.7%). Conclusiones: La pandemia por COVID-19 en el Perú ha generado una disminución significativa en los ingresos por IMCEST, además de una tendencia a menor empleo de terapias de reperfusión. La presentación tardía de los pacientes fue la causa más frecuente de no reperfusión. &nbsp

AIM: Autism spectrum disorder (ASD) is a common neurodevelopmental disorder in children. Family physicians with the first medical contact of children are among the most frequent physicians with ASD. We aimed to investigate family physicians' awareness of ASD. METHODS: This study was carried out family physicians in between September 25-October 15, 2018. The questionnaire form on autism awareness prepared by the researcher was delivered to family physicians electronically and in printed form, and it was filled out by volunteers. RESULTS: Forty-eight family physicians with an average professional experience of 16.9 ± 8.8 years participated in the study. A group of 66.7% of the participants had not previously received education on ASD, and 70.8% of them did not refer any child to child psychiatry with suspected ASD in the last 6 months. The participants stated that the most common clinical features in children with ASD were the inability to make eye contact (72.9%) and repetitive movements (47.9%), and 56.3% of them stated one or more features that are not observed in ASD. The compliance of the participants' answers about the clinical features observed in children with ASD with the DSM-5 criteria was determined to be 54.6 ± 18.4%. Significantly higher compliance rates were observed in the participants with education on autism and those working as a physician below 15 years. CONCLUSION: In our study, family physicians' awareness of ASD was not found to be adequate. Education programs on autism awareness should be applied to family physicians who are probably the most frequently encountered physicians by children with ASD.

Background Despite improvements in ST elevation myocardial infarction (STEMI) care, total ischemic time remains long in patients who present late. Our goal was to identify predictors of very late presentation (≥12 h) of STEMI and determine long-term mortality. Methods We retrospectively examined consecutive patients admitted with STEMI to our institution using the ACTION Registry™. Time of symptom onset to first medical contact (FMC) was calculated and categorized as, Highlights • A proportion of patients with acute myocardial infarction present late after symptom onset. • Women, diabetics and patients who do not experience typical chest pain are more likely to present late. • Patients with myocardial infarction who present late have increased mortality at one year.

Background The symptoms of acute carbon monoxide (CO) poisoning are unspecific, ranging from headaches to unconsciousness and death. In addition to acute symptoms, delayed severe neurological sequelae may occur. While a total of 440 deaths by CO poisoning were registered in Germany in 1999, a total of 594 patients died (0.73 per 100,000 inhabitants) in 2014 and in 2015 the number even increased to 648 deaths. A national database on clinical symptoms, course of illness or quality of care concerning CO poisoning does not yet exist. Methods The treatment data of patients admitted to the Hyperbaric Emergency Centre Wiesbaden (HEC) from 2013 to 2017 with CO poisoning formed the basis of the study. This was a comparative evaluation of patient demographics, poisoning sources, symptom spectrum, course of treatment and time intervals registered on the preclinical and clinical levels. Results From 2013 to 2017 a total of 476 patients (282 men and 194 women) with an average non-invasively measured CO-Hb of 15% (Q0.25 = 7.6%, Q0.75 = 22.3%) were treated with hyperbaric oxygen. Heaters (n = 131), charcoal barbecues (n = 93), fires (n = 90), hookahs (n = 78) and combustion engines (n = 37) were the most frequent CO sources identified. Headaches, vertigo, nausea and syncope were the most prevalent symptoms. A median of 91 min (Q0.25 = 53 min; Q0.75 = 147 min) passed between first medical contact and BGA-validated diagnosis. In total, 151 patients were transferred directly to the HEC, whereas 325 patients were secondarily transferred. The delay in this subgroup took 183 min (median Q0.25 = 138 min; Q0.75 = 248 min). After receiving the first hyperbaric treatment, 80% were free of symptoms. Remaining symptoms included headache (10%), fatigue (8%), vertigo (5%) and nausea (3%) and 45 patients terminated further treatment. Of the patients 417 received a second hyperbaric treatment and 370 patients were treated 3 times. After the third treatment, 89% were free of symptoms and 5% still reported headaches, 3% vertigo and 2% fatigue. In total, 6 patients died and 430 patients were symptom-free after treatment. Conclusion Commonly known sources (fire, charcoal grills) aside, many poisonings by smoking a hookah were observed. This study highlights the importance of considering CO poisoning as a differential diagnosis when encountering patients, especially of younger age, with non-specific neurological symptoms, as well as the importance of early initiation of treatment. A direct correlation between CO-Hb values (whether measured noninvasively or by invasive BGA) and the initial symptoms could not be demonstrated. In total, substantial time expired between the diagnosis and start of treatment of patients transported to a primary care hospital compared to those transported directly to the HEC. Although analysis showed adequate treatment with oxygen in the preclinical interval, administration of oxygen during primary hospital stay showed room for improvement. Introducing a national CO poisoning register and uniform treatment guidelines could improve in-house clinical processes. Multicenter studies are needed to close the gaps identified in the quality of care in Germany.

In case of suspected acute coronary syndrome (ACS), international guidelines recommend to obtain a 12-lead ECG as soon as possible after first medical contact, to administrate platelet aggregation inhibitors and antithrombins, and to transfer the patient as quickly as possible to an emergency department.A German emergency care service database was retrospectively analysed from 2014 to 2016. Data were tested for normal distribution and the Mann-Whitney test was used for statistical analysis. Results are presented as medians (IQR).A total of 1424 patients with suspected ACS were included in the present analysis. A 12-lead ECG was documented in 96% of patients (n = 1369). The prehospital incidence of ST-segment elevation myocardial infarction (STEMI) was 18% (n = 250). In 981 patients (69%), acetylsalicylic acid (ASA), unfractionated heparin (UFH), or ASA and UFH was given. Time in prehospital care differed significantly between non-STEMI (NSTEMI) ACS (37 [IQR 30, 44] min) and STEMI patients (33 [IQR 26, 40] min, n = 1395, p 0.0001). Most of NSTEMI ACS and STEMI patients were brought to the emergency care unit, while 30% of STEMI patients were directly handed over to a cardiac catheterization laboratory.Prehospital ECG helps to identify patients with STEMI, which occurs in 18% of suspected ACS. Patients without ST-elevations suffered from longer prehospital care times. Thus, it is tempting to speculate that ST-elevations in patients prompt prehospital medical teams to act more efficiently while the absence of ST-elevations even in patients with suspected ACS might cause unintended delays. Moreover, this analysis suggests the need for further efforts to make the cardiac catheterization laboratory the standard hand-over location for all STEMI patients.EINFüHRUNG: Internationale Leitlinien empfehlen die umgehende Ableitung eines 12-Kanal-Elektrokardiogramms bei Patienten mit akuter Angina-pectoris-Symptomatik. Ebenfalls wird die präklinische Gabe von Azetylsalizylsäure, Heparin sowie der sofortige Transport in ein Krankenhaus mit der Möglichkeit einer koronarinvasiven Diagnostik empfohlen.Es wurden die Einsatzprotokolle einer Rettungsstellendatenbank retrospektiv für den Zeitraum von 2014–2016 auf diese Merkmale untersucht. Die Daten wurden auf Normalverteilung getestet und für die statistische Analyse wurde ein Mann-Whitney-Test verwendet. Die Ergebnisse sind als Mediane (Interquartilsabstand, IQR) dargestellt.Es wurden 1424 Patienten mit Angina-pectoris-Symptomatik eingeschlossen. In 96 % (n = 1369) der Fälle wurde ein 12-Kanal-Elektrokardiogramm aufgezeichnet. Präklinisch wurden 250 Patienten (18 %) mit ST-Strecken-Hebungs-Infarkt (STEMI) diagnostiziert. Insgesamt 981 Patienten (69 %) erhielten Azetylsalizylsäure bzw. Heparin oder Azetylsalizylsäure und Heparin. Die präklinischen Zeiten unterschieden sich signifikant zwischen Patienten mit akutem Koronarsyndrom ohne Ischämiezeichen im Elektrokardiogramm (NSTEMI ACS; 37 min [IQR 30,44]) und Patienten mit ST-Hebungen (STEMI; 33 min [IQR 26,40]). Der Großteil der Patienten wurde in der Notaufnahme übergeben, während 30 % der STEMI-Patienten direkt in das Herzkatheterlabor transferiert wurden.Die Inzidenz von ST-Hebungen liegt im präklinischen Bereich bei Patienten mit Angina-pectoris bei 18 %. Patienten ohne Ischämiezeichen wurden langsamer einem Krankenhaus zugeführt als Patienten mit STEMI. Dieses Ergebnis kann auf die geltenden Leitlinien zurückzuführen sein, da bei STEMI-Patienten die Zeit von Diagnosestellung bis zur koronarinvasiven Diagnostik120 min betragen soll.

Background Pre-hospital delay is currently a major factor limiting early reperfusion among ST-elevation myocardial infarction (STEMI) patients worldwide. This study aims to determine pre-hospital factors affecting symptom-to-door time among STEMI patients in Malaysia. Methods This cross-sectional study included 222 STEMI patients admitted to two tertiary hospitals in Malaysia. By determining symptom-to-door time, the study population was categorised into two definitive treatment seeking groups: early (≤ 3 h) and delayed (> 3 h). Data was collected focusing on socio-demographical data, risk factors and comorbidities, clinical presentation, situational factors and action taken by patients. Results The mean age of our patients was 58.0 (SD = 11.9) years old, and the population consisted of 186 (83.8%) males and 36 (16.2%) females. Our study found that the median symptom-to-door time was 130.5 (IQR 240) min, with 64% of subjects arriving early and 36% arriving late. Pre-hospital delays were found to be significant among females (adj OR = 2.42; 95% CI: 1.02, 5.76; P = 0.046), patients with recurrence of similar clinical presentations (adj OR = 2.74; 95% CI: 1.37, 5.46; P = 0.004), patients experiencing atypical symptoms (adj OR = 2.64; 95% CI: 1.11, 6.31; P = 0.029) and patients who chose to have their first medical contact (FMC) for their symptoms with a general practitioner (adj OR = 2.80; 95% CI: 1.20, 6.56; P = 0.018). However, patients with hyperlipidaemia (adj OR = 0.46; 95% CI: 0.23, 0.93; P = 0.030), self-perceived cardiac symptoms (adj OR = 0.36; 95% CI: 0.17, 0.73; P = 0.005) and symptoms that began in public places (adj OR = 0.21; 95% CI: 0.06, 0.69; P = 0.010) tended to seek treatment earlier. Conclusion The symptom-to-door time among the Malaysian population is shorter in comparison to other developing countries. Nevertheless, identified, modifiable pre-hospital factors can be addressed to further shorten symptom-to-door time among STEMI patients.

INTRODUCTION Timely reperfusion, preferably via percutaneous coronary intervention (PCI) following myocardial infarction, improves mortality rates. Emergency medical services play a pivotal role in recognising and transporting patients with ST-elevation myocardial infarction directly to a PCI facility to avoid delays to reperfusion. Access to PCI is, in part, dependant on the geographic distribution of patients around PCI facilities. The aim of this study was to determine the proportion of South Africans living within 60 and 120 minutes of a PCI facility. METHODS PCI facility and population data were subjected to proximity analysis to determine the average drive times from municipal ward centroids to PCI facilities for each province in South Africa. Thereafter, the population of each ward living within 60 and 120 minutes of a PCI facility was extrapolated. RESULTS Approximately 53.8 and 71.53% of the South African population live within 60 and 120 minutes of a PCI facility. The median (IQR, range) drive times and distances to a PCI facility are 100 minutes (120.4 min, 0.7-751.8) across 123.6 km (157.6 km, 0.3-940.8). CONCLUSION Based on the proximity of South Africans to PCI facilities, it seems possible that most patients could receive timely PCI within 120 minutes of first medical contact. However, this may be unlikely for some due to a lack of medical insurance, under-developed referral networks or other system delays. Coronary care networks should be developed based on the proximity of communities to 12-lead ECG and reperfusion therapies (such as PCI facilities). Public and private healthcare partnerships should be fortified to allow for patients without medical insurance to have equal accesses to PCI facilities.

The 2017 Clinical Guidelines for ST-segment elevation myocardial infarction of the European Society of Cardiology updated many important aspects of the pre-hospital phase, the selection of a reperfusion strategy, interventional and pharmacological treatment, and patient quality assessment. The principal changes are a clear definition of the first medical contact, elimination of the door-to-balloon time from consideration, recommended radial access intervention, a recommendation that drug-eluting stents should be preferred to bare metal stents, recommended complete revascularization during hospitalization, and early discharge of selected patients. Routine manual thrombus aspiration and oxygen supplementation for patients who are not hypoxemic are now discouraged. (Korean J Med 2018;93:25-32)

Acute sstroke is the most common time-dependent disease attended in the emergency medical service (EMS) of Madrid (SUMMA 112). Community of Madrid has been one of the most affected regions in Spain by the coronavirus disease 2019 (COVID-19) pandemic. A significant reduction in acute sstroke hospital admissions has been reported during the COVID-19 pandemic compared to the same period 1 year before. As international clinical practice guidelines support those patients with suspected acute stroke should be accessed via EMS, it is important to know whether the pandemic has jeopardized urgent pre-hospital stroke care, the first medical contact for most patients. We aimed to examine the impact of the COVID-19 in stroke codes (SC) in our EMS among 3 periods of time: the COVID-19 period, the same period the year before, and the 2019-2020 seasonal influenza period.We compared the SC frequency among the periods with high cumulative infection rate (above the median of the series) of the first wave of COVID-19, seasonal influenza, and also with the same period of the year before.One thousand one hundred thirty SC were attended during the 3 periods. No significant reduction in SC was found during the COVID-19 pandemic. The reduction of hospital admissions might be attributable to patients attending the hospital by their means. The maximum SC workload seen during seasonal influenza has not been reached during the pandemic. We detected a nonsignificant deviation from the SC protocol, with a slight increase in hospitals' transfers to hospitals without stroke units.

Background ST-Segment Elevation Myocardial Infarction (STEMI) causes the release of soluble ST2 biomarkers at high level on acute phase. However, sST2 has never been used as adjunct biomarker in ESC/AHA guideline for STEMI. Furthermore, the specific onset that sST2 may have role in acute phase of STEMI related with infarct location has not been established. This study aimed to prove the association between serum ST2 levels and infarct location in STEMI. Material and methods This study was cross-sectional. STEMI patients with onset of anginal pain 12–24 h were included in study. The exclusion criterias were patients with AMI aside from STEMI and other potential confounders affecting the sST2 level. Serum sST2 was collected on first medical contact when admitted to emergency unit. The patients were grouped into anterior STEMI and non-anterior STEMI. sST2 levels were compared with demographics data, clinical and laboratory variables using Student's t-test. Correlation of sST2 levels was analyzed using Spearman's correlation coefficient. Results 19 subjects were included in the anterior STEMI and 20 subjects were included in the non-anterior STEMI. We found no difference in sST2 levels between anterior STEMI and non-anterior STEMI (mean ± SD; 729.97 pg/mL ± 147.78 pg/mL vs 606.87 pg/mL ± 147.78 pg/mL, p = 0.119). Onset was correlated with serum sST2 levels in male subjects (r = −0.459, p = 0.012). We found significant difference of mean sST2 between 2 onset groups divided at median (12–18 h vs 19–24 h, Δ mean = 107.75 pg/mL, p-value = 0.021). Conclusion sST2 was not associated with infarct location within 12–24 h onset of STEMI. This results suggest that infarct location might not responsible for the elevation of serum sST2 levels in acute phase of STEMI., Highlights • STEMI causes the release of soluble ST2 biomarkers at high level on acute phase. • sST2 and it association with infarct location within 12–24 h. • Infarct location might not responsible for the elevation of serum sST2 levels.

To evaluate the association between total medical contact, prehospital, and emergency department delays in antibiotic administration and in-hospital mortality among patient encounters with community-acquired sepsis.Retrospective cohort study.Nine hospitals served by 21 emergency medical services agencies in southwestern Pennsylvania from 2010 through 2012.All emergency medical services encounters with community acquired sepsis transported to the hospital.Among 58,934 prehospital encounters, 2,683 had community-acquired sepsis, with an in-hospital mortality of 11%. Median time from first medical contact to antibiotic administration (total medical contact delay) was 4.2 hours (interquartile range, 2.7-8.0 hr), divided into a median prehospital delay of 0.52 hours (interquartile range, 0.40-0.66 hr) and a median emergency department delay of 3.6 hours (interquartile range, 2.1-7.5 hr). In a multivariable analysis controlling for other risk factors, total medical contact delay was associated with increased in-hospital mortality (adjusted odds ratio for death, 1.03 [95% CI, 1.00-1.05] per 1-hr delay; p0.01), as was emergency department delay (p = 0.04) but not prehospital delay (p = 0.61).Both total medical contact and emergency department delay in antibiotic administration are associated with in-hospital mortality in community-acquired sepsis.

Women have generally worse outcomes after myocardial infarction (MI) compared to men. The reasons for these disparities are multifactorial. At the beginning is the notion-widespread in the community and health care providers-that women are at low risk for MI. This can impact on primary prevention of cardiovascular disease in women, with lower use of preventative therapies and lifestyle counselling. It can also lead to delays in presentation in the event of an acute MI, both at the patient and health care provider level. This is of particular concern in the case of ST elevation MI (STEMI), where "time is muscle". Even after first medical contact, women with acute MI experience delays to diagnosis with less timely reperfusion and percutaneous coronary intervention (PCI). Compared to men, women are less likely to undergo invasive diagnostic testing or PCI. After being diagnosed with a STEMI, women receive less guideline-directed medical therapy and potent antiplatelets than men. The consequences of these discrepancies are significant-with higher mortality, major cardiovascular events and bleeding after MI in women compared to men. We review the sex disparities in pathophysiology, risk factors, presentation, diagnosis, treatment, and outcomes for acute MI, to answer the question: are they due to biology or bias, or both?

Background: States without a recognized directive for stroke care and transport risk the ability to monitor, assess and review stroke patient movement from first medical contact (FMC) to delivery/and/or transfer to hospitals. We are seeking to determine a new tracking program’s efficacy from emergency medical systems (EMS) to telestroke sites and other receiving hospitals utilizing Get-With-The-Guidelines (GWTG) in data reporting. Hypothesis: We hypothesized that all three entities (EMS, telestroke sites and other hospitals) would record suspected and positive strokes into their electronic databases and integrate the process into their standard of practice, protocols and guidelines. Methods: Statewide EMS agencies, receiving hospitals in the Arkansas Stroke Registry and telestroke sites received educational training about placing blue wristbands on all suspected strokes. Stroke bands were to be placed on all patients arriving via EMS or privately owned vehicle. The bands contained a unique number sequence for recording in both EMS and hospital GWTG electronic databases. We retrospectively reviewed all prospectively collected data from January 1, 2019 to May 31, 2019 for wristband placement by the EMS systems and determined the percentage match to hospital emergency department (ED) discharge data using the GWTG data and telestroke data. Results: From the five months of retrospective analysis of prospectively collected data for 5 months showed, 4,668 strokes were seen in hospitals complying with GWTG. Forty-two% of the positive strokes in hospital (EDs) had stroke bands placed. Of these 8.4% had matching stroke wristband numbers to the EMS database. The telestroke system reported 636 consultations with 95% band placement, 39% placed by EMS. Matching telestroke band ID’s to EMS records was 37%. Wristbands placed by EMS were associated with positive screen tests, pre-notification and shortened Door to CT time (p < 0.0021). Conclusions: Wrist-bands were associated with improved EMS response and provided informed response to hospital care teams. For consistent tracking of positive stroke patient data from FMC to discharge both prehospital and hospital, systems must undergo additional training followed by surveys to determine informed training.

Background and Purpose— We quantified population access to endovascular-capable centers, timing, and rates of thrombectomy in Los Angeles County before and after implementing 2-tiered routing in a regional stroke system of care. Methods— In 2018, the Los Angeles County Emergency Medical Services Agency implemented transport of patients with suspected large vessel occlusions identified by Los Angeles Motor Scale ≥4 directly to designated endovascular-capable centers. We calculated population access to a designated endovascular-capable center within 30 minutes comparing 2016, before 2-tiered system planning began, to 2018 after implementation. We analyzed data from stroke centers in the region from 1 year before and after implementation to delineate changes in rates and speed of administration of tPA (tissue-type plasminogen activator) and thrombectomy and frequency of interfacility transfer. Results— With implementation of the 2-tier system, certified endovascular-capable hospitals increased from 4 to 19 centers, and within 30-minute access to endovascular care for the public in Los Angeles County, from 40% in 2016 to 93% in 2018. Comparing Emergency Medical Services–transported stroke patients in the first post-implementation year (N=3303) with those transported in the last pre-implementation year (N=3008), age, sex, and presenting deficit severity were similar. The frequency of thrombolytic therapy increased from 23.8% to 26.9% (odds ratio, 1.2 [95% CI, 1.05–1.3]; P =0.006), and median first medical contact by paramedic-to-needle time decreased by 3 minutes ([95% CI, 0–5] P =0.03). The frequency of thrombectomy increased from 6.8% to 15.1% (odds ratio, 2.4 [95% CI, 2.0–2.9]; P P =0.2). The frequency of interfacility transfers declined from 3.2% to 1.0% (odds ratio, 0.3 [95% CI, 0.2–0.5]; P Conclusions— After implementation of 2-tiered stroke routing in the most populous US county, thrombectomy access increased to 93% of the population, and the frequency of thrombectomy more than doubled, whereas interfacility transfers declined.

BACKGROUND : In a previous quality control assessment of the management of STEMI in our centre–a tertiary centre in a rural area–we observed a decrease in intrahospital delays over time (2004→2013) from 98→39 minutes (median) but unchanged extrahospital delays (203–220 minutes). AIM :To elucidate the determinants of these long extrahospital delays, 181 patients, undergoing PCI for STEMI (2013–2017) in our centre, were carefully interviewed. The first medical contact (FMC) allowed to assess 2 periods: onset of symptoms–FMC (period 1) and FMC–diagnosis (period 2). Results are given as mean values (median). RESULTS :In 36%, the FMC took place via the general practitioner (GP). Period 1 was associated with the type of FMC (GP: 210 ± 294, median = 79 min/EM call: 78 ± 114, median = 43 min/direct hospital admission: 222 ± 44, median = 115 min), the moment of symptoms onset (0–4 am: 198 ± 192, median 142 min/8–12 am: 96 ± 126, median 60 min), age (70–80 y: 262 ± 324, median 120 min/50–60 y: 198 ± 438, median 63 min) and the distance to our PCI centre expressed in minutes by car (< 30′: 108 ± 156, median = 60 min/ > 60′: 216 ± 288, median = 116 min). Period 2 was depending on the type of FMC (GP: 234 ± 600, median 56 min/EM call: 31 ± 29, median 22 min/direct hospital admission: 25 ± 55, median 10 min). CONCLUSION :In our local experience, FMC via the GP in case of STEMI is a major determinant for a longer extrahospital delay and should therefore be discouraged.

Background Time from symptom onset to reperfusion in STEMI patients has been described to depend on a fast and valid pre-hospital STEMI diagnosis which not only decreases pre-hospital, but also in-hospital treatment delays. A publicly funded, prospective joint intervention program (QS-Notfall) has been initiated within our regional myocardial infarction (MI) registry (B2HIR) between hospitals and emergency medical services (EMS). The objective of the program is to reduce care delays of MI patients by supporting emergency care personnel in diagnosing STEMI trough real-time telemedical ECG counselling and by introducing a respective e-learning platform: “STEMI recognition made easy!” Methods Comprehensive baseline data on pre-hospital and in-hospital care have been collected from EMS and hospital records of all 1927 STEMI diagnosed patients with symptom onset Results Pre-hospital phase: Mode of hospital admission of STEMI patients comprised physician-escorted EMS (60%), EMS w/o an escorting physician (10%) in the city, referral by a primary care physician (10%), and self-presentation to the emergency department (14%). Some patients were primarily admitted to a non-PCI-capable hospital and underwent secondary transfer to a PCI-capable hospital. The respective percentages were found to differ between the metropolitan (4%) and rural areas (17%), Treatment delays Time from symptom onset to arrival of the EMS took 33min (median) in the city and 38 min in rural areas. Time between EMS arrival and ECG recording was 16 min and did not differ between metropolitan and rural sites. The delay from ECG recording to arrival at the hospital was 32 min in the city and 44 min at rural sites. Door to balloon time was similar (63 min) at both regions. Time delay from symptom onset to reperfusion for STEMI patients without physician escorted EMS was up to 370 min and differed according to the admission mode. Shortest care Patients, who alarmed the EMS and were cared for by physician escorted EMS, were brought to a PCI-capable hospital, and were directly admitted to the cath-lab, bypassing the emergency room, attained a delay from symptom onset to ECG recording of 48 min in the city and 37 min at rural areas. The delay from ECG recording to reperfusion was 67 min at urban sites and 77 min at rural sites in these fastest-treated patients. At metropolitan and rural sites 18,5% and 11% of patients belonged to this group, respectively. Conclusion This pre-interventional baseline dataset shows that guideline-prescribed care delays are attainable for patients with acute MI. But the proportion of patients with optimal care delays is small and needs to be increased considerably, which is the objective of our ongoing joint intervention QS-Notfall program. Acknowledgement/Funding Innovation Fonds, Ministry of Health, Germany