Treatment Delays in Patients With Acute Myocardial Infarction
論文ID: CJ-22-0033
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論文ID: CJ-22-0033
Although the rate of in-hospital mortality among patients with acute myocardial infarction (AMI) has decreased with improved in-hospital management administering emergency revascularization therapy, AMI is still a life-threatening disease worldwide.1,2 It is important to minimize the total ischemic time from the onset of symptoms to reperfusion in patients with AMI to reduce morbidity and mortality. Prompt revascularization with primary coronary intervention is critical in patients with ST-elevation myocardial infarction (STEMI). A previous study showed that approximately half of the patients with AMI died before arriving at hospital.3 Many efforts to reduce the total ischemic time and improve in-hospital treatment have been made to prevent death from AMI. The total ischemic time is affected by delays in treatment, which are commonly divided into 2 components: patient delays and system delays. Prehospital delay is the time from symptom onset to arrival at the door of a hospital and includes both patient delays and emergency medical system (EMS) delays.4 A previous report showed that the majority of the time delay is during the prehospital period from the onset of symptoms to hospital arrival.5 Several researchers have attempted to assess and minimize prehospital and hospital delays in treatment.
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Most of the recently reported studies evaluating treatment delays in AMI patients have focused on system delays, especially longer door-to-balloon times (DTB; i.e., from hospital arrival to wire crossing). A prehospital electrocardiogram (ECG) to diagnose STEMI is useful to quickly activate the percutaneous coronary intervention team and cardiac catheterization laboratory while the patient is en route to the hospital, resulting in reduced system delays, including DTB.6 Mori et al demonstrated that prehospital 12-lead ECG had a significant impact on door-to-device time and in-hospital mortality.7
Several studies were conducted in Western countries around the year 2000 to identify characteristics predictive of increased patient delay in the treatment of AMI. Older age, female sex, low education level, low socioeconomic status, and Black race were associated with increased delays in seeking treatment.8 In their study, Ogushi et al, for the first time, clearly identify factors associated with prehospital delay among Japanese AMI patients in a large-scale multicenter prospective observational registry, namely the Osaka Acute Coronary Insufficiency Study (OACIS) registry.9 Ogushi et al concluded that older age, diabetes, and night-time onset were associated with prehospital time delay in AMI patients, whereas smoking and ambulance use were associated with no prehospital time delay (Figure). Consistent with the findings of previous reports,10,11 older age, diabetes, and night-time onset were significantly associated with prehospital delay.9 The longer prehospital delay among elderly patients with diabetes may contribute to their higher risk of mortality in AMI. Conflicting results have been reported regarding sex differences in prehospital delay. Stehli et al showed that female patients with STEMI experienced greater prehospital and hospital delays than men.12 Differences in the health insurance system between Japan and Western countries may have affected the results of these studies.
The total ischemic time is influenced by delays in treatment, which are commonly divided into 2 components: patient delays and system delays. Prehospital delays consist of the time from symptom onset to arrival at the door of a hospital, and include patient delays and emergency medical system (EMS) delays.
Interventions to reduce prehospital delays in seeking treatment are challenging and essential. A previous study demonstrated that a public campaign in Switzerland was associated with a reduction in prehospital delay in patients with AMI.13 In contrast, the Rapid Early Action for Coronary Treatment (REACT) trial, which was a randomized study evaluating the efficacy of an 18-month community intervention in AMI patients, failed to reduce the time from symptom onset to hospital arrival despite the increased use of the EMS system.14 Conflicting findings have been reported regarding the effect of public education campaigns on reducing prehospital delays. In Japan, the STOP MI campaign, developed by the Japanese Circulation Society, is being used to prevent death from AMI through public education.15 Continuous education programs and campaigns are expected to improve public awareness of AMI symptoms and knowledge of the appropriate actions to take, resulting in a reduction in total ischemic time and an improvement in clinical outcomes for AMI patients, especially among elderly patients with diabetes.
The authors report no conflicts of interest.
