Regional training and coordination interventions that provide timely reperfusion for ST-elevation myocardial infarction patients improve outcomes and the interval of first-medical-contact-to- device time, according to a study presented at Scientific Sessions on Tuesday.
In the study, investigators worked with leaders, healthcare professionals, paramedics, nurses, emergency medicine physicians and cardiologists in 12 major U.S. metropolitan regions to develop centralized STEMI plans for EMS catheterization lab activation and rapid transfer from non-PCI hospitals.
“At baseline across the 12 regions, 38 percent of patients had cath lab activation within 20 minutes,” said James G. Jollis, MD, FACC, of the Duke University Clinical Research Institute in Durham, North Carolina, who presented the findings of the Regional STEMI Systems of Care: Results of the Mission: Lifeline STEMI ACCELERATOR-2 Study. “But with the new process in place, we saw that increase to more than half of patients having a cath lab activated within 20 minutes of paramedic arrival.
“For the overall project, we increased from 67 percent to 74 percent of patients reaching the national standard of first medical contact to device within 90 minutes. This coordination of training was associated with significant reductions in heart failure and death, and demonstrated a marked and statistically significant decline in mortality,” Jollis said.
The study is a collaboration of Duke and the AHA’s Mission: Lifeline program.
Results of a New Zealand study suggest a national clinical guidance framework that assesses patients presenting to emergency departments with possible acute coronary syndromes is effective and safely reduces hospital length of stay.
The findings were presented Tuesday by Martin Than, MD, of Christchurch Hospital in New Zealand.
In the National Implementation of a Clinical Guidance Framework for the Emergency Department Assessment of Patients with Possible Acute Coronary Syndromes trial, researchers analyzed data from 11,529 patients before the framework was implemented and 19,803 post-implementation at seven diverse hospitals in New Zealand. The primary outcome was the proportion of patients successfully discharged within six hours of emergency department arrival. A successful discharge was defined as one with no major adverse cardiac event during the following 30 days.
Than reported that all sites had an increase in proportion of patients discharged within six hours (pre-implementation mean 8.3 percent; post-implementation mean 18.4 percent). Researchers found no difference in the proportion of patients with a MACE within 30 days of patients discharged within six hours: pre-implementation (0.52 percent) compared with post-implementation (0.44 percent).
The results of a recent trial conducted across 63 hospitals in Kerala, India, demonstrated that a quality improvement intervention led to improvements in in-hospital and discharge medications, but not in the rate of 30-day MACE in acute MI patients.
Findings from the Effect of a Quality Improvement Toolkit on Acute Myocardial Infarction in India: The ACS QUIK Cluster Randomized, Stepped Wedge Trial were presented Tuesday by Mark D. Huffman, MD, of Northwestern University in Chicago.
The researchers evaluated the effect of a locally adapted, evidence-based quality improvement toolkit on process measures and outcomes among 21,374 patients from November 2014-November 2016. The toolkit included audit and feedback, admission and discharge checklists, patient education materials and linkage to emergency cardiovascular care and quality improvement training.
“We saw improvements in process measures, including in-hospital and discharge medications, and clinical outcomes, including a reduction in our primary outcome of the rate of death, recurrent heart attack, stroke and major bleeding at 30 days — from 6.4 percent in the control group to 5.3 percent in the intervention group,” Huffman said.
A novel, technologically enabled, behaviorally targeted, pharmacist-based intervention improves adherence to medications for chronic diseases and disease control, according to findings from the Results of the Study of a Tele-Pharmacy Intervention for Chronic Diseases to Improve Treatment Adherence trial.
A total of 4,078 patients with diabetes, hypertension or hyperlipidemia who were both non-adherent and had poor disease control were randomized in equal numbers to the intervention and usual-care arms. The intervention consisted of a brief pharmacist-delivered telephone consultation, text messaging, mailed reports providing patients with updated biometric and adherence information and feedback from the pharmacists to patients’ primary care physicians.
“The intervention increased medication adherence but did not improve measures of disease control, including LDL cholesterol, blood pressure and hemoglobin A1C,” said Niteesh K. Choudhry, MD, PhD, of Brigham and Women’s Hospital and Harvard Medical School in Boston. “Future work should focus on strategies to increase the uptake of similar interventions and on improving the understanding of which patient groups derive the most clinical benefit from adherence improvement efforts.”
An analysis of data from a national myocardial infarction registry in Sweden shows a dramatic improvement in long-term survival and reduction in the risk of new ischemic events and heart failure in non-ST-elevation MI patients over the last 20 years.
The researchers believe these improvements in outcomes are attributable to the gradual uptake and widespread use of in-hospital coronary interventions and evidence-based medications.
Findings from the Improved Outcomes in Patients with Non-ST-Elevation Myocardial Infarction During 20 years are Related to Implementation of Evidence-Based Treatments study were presented Tuesday by Karolina Szummer, MD, of Karolinska University Hospital in Stockholm.
Szummer reported that the standardized, one-year mortality ratio in NSTEMI compared to the control population decreased from 5.53 (5.30-5.77) in 1995-96 to 3.03 (18.104.22.168) in 2013-14. After adjusting for differences in baseline characteristics, the change of one-year CV-death or MI corresponded to a linearly decreasing trend of 0.930 (95 percent CI: 0.926-0.935) per two-year period. This trend was substantially attenuated after adjusting for changes in coronary interventions, and almost eliminated after also adjusting for changes in discharge medications.
The findings of another recent trial suggest that a shared decision-making intervention for destination therapy left ventricular assist device (DT LVAD) improved patient decision quality based on patient knowledge and concordance between stated values and patient-reported treatment preference.
Results from the Effectiveness of a Shared Decision Making Intervention for Patients Offered a Destination Therapy Left Ventricular Assist Device for End-Stage Heart Failure trial were presented Tuesday by Larry A. Allen, MD, of the University of Colorado-Denver.
After randomly varying time in usual care, LVAD implanting centers were transitioned to an intervention consisting of clinician education and use of a DT LVAD pamphlet and video patient decision aids. Patients being considered for DT LVAD were enrolled and followed up at one and six months.
Allen reported that patient knowledge (mean test performance) during the decision-making period improved from 59.5 percent to 64.9 percent in control versus 59.1 percent to 70 percent in intervention. Correlation between stated values and patient-reported treatment preference at one month was stronger in intervention than control. However, there was no improved correlation between stated values and actual treatment received by six months for intervention compared to control. There were no differences in decision conflict, decision regret or preferred control.