Yonsei Med J.  2014 May;55(3):617-624. 10.3349/ymj.2014.55.3.617.

Performance of Reperfusion Therapy and Hospital Mortality in ST-Elevation Myocardial Infarction Patients with Non-Chest Pain Complaints

Affiliations
  • 1Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea. boringzzz@yuhs.ac
  • 2Department of Emergency Medicine, Kangwon National University, Chuncheon, Korea.
  • 3Department of Emergency Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea.

Abstract

PURPOSE
ST-elevation myocardial infarction (STEMI) patients may visit the emergency department (ED) complaining of sensations of pain other than the chest. We investigated our performance of reperfusion therapy for STEMI patients presenting with non-chest pains.
MATERIALS AND METHODS
This was a retrospective observational cohort study. STEMI patients who underwent primary percutaneous coronary intervention (PCI) were divided into a chest pain group and a non-chest pain group. Clinical differences between the two groups and the influence of presenting with non-chest pains on door-to-electrocardiograms (ECG) time, door-to-balloon time, and hospital mortality were evaluated.
RESULTS
Of the 513 patients diagnosed with STEMI, 93 patients presented with non-chest pains. Patients in the non-chest pain group were older, more often female, and had a longer symptom onset to ED arrival time and higher Killip class than patients in the chest pain group. There was a statistically significant delay in door-to-ECG time (median, 2.0 min vs. 5.0 min; p<0.001) and door-to-balloon time (median, 57.5 min vs. 65.0 min; p<0.001) in patients without chest pain. In multivariate analysis, presenting with non-chest pains was an independent predictor for hospital mortality (odds ratio, 2.3; 95% confidence interval, 1.1-4.7). However, door-to-ECG time and door-to-balloon time were not factors related to hospital mortality.
CONCLUSION
STEMI patients presenting without chest pain showed higher baseline risk and hospital mortality than patients presenting with chest pain. ECG acquisition and primary PCI was delayed for patients presenting with non-chest pains, but not influencing hospital mortality. Efforts to reduce pre-hospital time delay for these patients are necessary.

Keyword

Chest pain; electrocardiography; myocardial infarction; reperfusion

MeSH Terms

Aged
Aged, 80 and over
Chest Pain/*diagnosis
Electrocardiography
Female
Hospital Mortality
Humans
Male
Middle Aged
Myocardial Infarction/mortality/*surgery
Retrospective Studies

Figure

  • Fig. 1 Distribution and frequency of chief complaints.

  • Fig. 2 Proportion of patients who achieved the goal door-to-ECG time and door-to-balloon time. ECG, electrocardiogram.


Reference

1. Gupta M, Tabas JA, Kohn MA. Presenting complaint among patients with myocardial infarction who present to an urban, public hospital emergency department. Ann Emerg Med. 2002; 40:180–186.
Article
2. Canto JG, Shlipak MG, Rogers WJ, Malmgren JA, Frederick PD, Lambrew CT, et al. Prevalence, clinical characteristics, and mortality among patients with myocardial infarction presenting without chest pain. JAMA. 2000; 283:3223–3229.
Article
3. Coronado BE, Pope JH, Griffith JL, Beshansky JR, Selker HP. Clinical features, triage, and outcome of patients presenting to the ED with suspected acute coronary syndromes but without pain: a multicenter study. Am J Emerg Med. 2004; 22:568–574.
Article
4. Brieger D, Eagle KA, Goodman SG, Steg PG, Budaj A, White K, et al. Acute coronary syndromes without chest pain, an underdiagnosed and undertreated high-risk group: insights from the Global Registry of Acute Coronary Events. Chest. 2004; 126:461–469.
Article
5. Glickman SW, Shofer FS, Wu MC, Scholer MJ, Ndubuizu A, Peterson ED, et al. Development and validation of a prioritization rule for obtaining an immediate 12-lead electrocardiogram in the emergency department to identify ST-elevation myocardial infarction. Am Heart J. 2012; 163:372–382.
Article
6. Graff L, Palmer AC, Lamonica P, Wolf S. Triage of patients for a rapid (5-minute) electrocardiogram: a rule based on presenting chief complaints. Ann Emerg Med. 2000; 36:554–560.
Article
7. Osborne AD, Ali K, Lowery-North D, Capes J, Keadey M, Franks N, et al. Ability of triage decision rules for rapid electrocardiogram to identify patients with suspected ST-elevation myocardial infarction. Crit Pathw Cardiol. 2012; 11:211–213.
Article
8. McNamara RL, Wang Y, Herrin J, Curtis JP, Bradley EH, Magid DJ, et al. Effect of door-to-balloon time on mortality in patients with ST-segment elevation myocardial infarction. J Am Coll Cardiol. 2006; 47:2180–2186.
Article
9. Hannan EL, Zhong Y, Jacobs AK, Holmes DR, Walford G, Venditti FJ, et al. Effect of onset-to-door time and door-to-balloon time on mortality in patients undergoing percutaneous coronary interventions for st-segment elevation myocardial infarction. Am J Cardiol. 2010; 106:143–147.
Article
10. O'Connor RE, Brady W, Brooks SC, Diercks D, Egan J, Ghaemmaghami C, et al. Part 10: acute coronary syndromes: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010; 122:18 Suppl 3. S787–S817.
11. Killip T 3rd, Kimball JT. Treatment of myocardial infarction in a coronary care unit. A two year experience with 250 patients. Am J Cardiol. 1967; 20:457–464.
12. Phelan MP, Glauser J, Smith E, Martin C, Schrump S, Mahone P, et al. Improving emergency department door-to-electrocardiogram time in ST segment elevation myocardial infarction. Crit Pathw Cardiol. 2009; 8:119–121.
Article
13. Borden WB, Fennessy MM, O'Connor AM, Mulliken RA, Lee L, Nathan S, et al. Quality improvement in the door-to-balloon times for ST-elevation myocardial infarction patients presenting without chest pain. Catheter Cardiovasc Interv. 2012; 79:851–858.
Article
14. Dreyer RP, Beltrame JF, Tavella R, Air T, Hoffmann B, Pati PK, et al. Evaluation of gender differences in Door-to-Balloon time in ST-elevation myocardial infarction. Heart Lung Circ. 2013; 22:861–869.
Article
15. Kaul P, Armstrong PW, Sookram S, Leung BK, Brass N, Welsh RC. Temporal trends in patient and treatment delay among men and women presenting with ST-elevation myocardial infarction. Am Heart J. 2011; 161:91–97.
Article
16. Angeja BG, Gibson CM, Chin R, Frederick PD, Every NR, Ross AM, et al. Predictors of door-to-balloon delay in primary angioplasty. Am J Cardiol. 2002; 89:1156–1161.
Article
17. Mehta RH, Bufalino VJ, Pan W, Hernandez AF, Cannon CP, Fonarow GC, et al. Achieving rapid reperfusion with primary percutaneous coronary intervention remains a challenge: insights from American Heart Association's Get With the Guidelines program. Am Heart J. 2008; 155:1059–1067.
Article
18. Rathore SS, Curtis JP, Nallamothu BK, Wang Y, Foody JM, Kosiborod M, et al. Association of door-to-balloon time and mortality in patients > or =65 years with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention. Am J Cardiol. 2009; 104:1198–1203.
Article
19. Benamer H, Tafflet M, Bataille S, Escolano S, Livarek B, Fourchard V, et al. Female gender is an independent predictor of in-hospital mortality after STEMI in the era of primary PCI: insights from the greater Paris area PCI Registry. EuroIntervention. 2011; 6:1073–1079.
Article
20. Eitel I, Desch S, de Waha S, Fuernau G, Gutberlet M, Schuler G, et al. Sex differences in myocardial salvage and clinical outcome in patients with acute reperfused ST-elevation myocardial infarction: advances in cardiovascular imaging. Circ Cardiovasc Imaging. 2012; 5:119–126.
Article
21. Jackson EA, Moscucci M, Smith DE, Share D, Dixon S, Greenbaum A, et al. The association of sex with outcomes among patients undergoing primary percutaneous coronary intervention for ST elevation myocardial infarction in the contemporary era: Insights from the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2). Am Heart J. 2011; 161:106–112.
Article
22. Gibson CM, Pride YB, Frederick PD, Pollack CV Jr, Canto JG, Tiefenbrunn AJ, et al. Trends in reperfusion strategies, door-to-needle and door-to-balloon times, and in-hospital mortality among patients with ST-segment elevation myocardial infarction enrolled in the National Registry of Myocardial Infarction from 1990 to 2006. Am Heart J. 2008; 156:1035–1044.
Article
23. Flynn A, Moscucci M, Share D, Smith D, LaLonde T, Changezi H, et al. Trends in door-to-balloon time and mortality in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention. Arch Intern Med. 2010; 170:1842–1849.
Article
24. Bradley EH, Roumanis SA, Radford MJ, Webster TR, McNamara RL, Mattera JA, et al. Achieving door-to-balloon times that meet quality guidelines: how do successful hospitals do it? J Am Coll Cardiol. 2005; 46:1236–1241.
25. Bradley EH, Herrin J, Wang Y, Barton BA, Webster TR, Mattera JA, et al. Strategies for reducing the door-to-balloon time in acute myocardial infarction. N Engl J Med. 2006; 355:2308–2320.
Article
26. Willson AB, Mountain D, Jeffers JM, Blanton CG, McQuillan BM, Hung J, et al. Door-to-balloon times are reduced in ST-elevation myocardial infarction by emergency physician activation of the cardiac catheterisation laboratory and immediate patient transfer. Med J Aust. 2010; 193:207–212.
Article
27. Khot UN, Johnson ML, Ramsey C, Khot MB, Todd R, Shaikh SR, et al. Emergency department physician activation of the catheterization laboratory and immediate transfer to an immediately available catheterization laboratory reduce door-to-balloon time in ST-elevation myocardial infarction. Circulation. 2007; 116:67–76.
Article
28. Rathore SS, Curtis JP, Chen J, Wang Y, Nallamothu BK, Epstein AJ, et al. Association of door-to-balloon time and mortality in patients admitted to hospital with ST elevation myocardial infarction: national cohort study. BMJ. 2009; 338:b1807.
Article
29. Cannon CP, Gibson CM, Lambrew CT, Shoultz DA, Levy D, French WJ, et al. Relationship of symptom-onset-to-balloon time and door-to-balloon time with mortality in patients undergoing an gioplasty for acute myocardial infarction. JAMA. 2000; 283:2941–2947.
Article
30. Diercks DB, Kirk JD, Lindsell CJ, Pollack CV Jr, Hoekstra JW, Gibler WB, et al. Door-to-ECG time in patients with chest pain presenting to the ED. Am J Emerg Med. 2006; 24:1–7.
Article
31. Takakuwa KM, Burek GA, Estepa AT, Shofer FS. A method for improving arrival-to-electrocardiogram time in emergency department chest pain patients and the effect on door-to-balloon time for ST-segment elevation myocardial infarction. Acad Emerg Med. 2009; 16:921–927.
Article
32. Shiomi H, Nakagawa Y, Morimoto T, Furukawa Y, Nakano A, Shirai S, et al. Association of onset to balloon and door to balloon time with long term clinical outcome in patients with ST elevation acute myocardial infarction having primary percutaneous coronary intervention: observational study. BMJ. 2012; 344:e3257.
Article
33. Heitzler VN, Babić Z, Milicić D, Starcević B, Mirat J, Strozzi M, et al. Evaluation of importance of door-to-balloon time and total ischemic time in acute myocardial infarction with ST-elevation treated with primary percutaneous coronary intervention. Acta Clin Croat. 2012; 51:387–395.
34. Towae F, Juenger C, Mudra H, Glunz HG, Hauptmann E, Grube E, et al. The development of door-to-angiography time in the last 14 years for patients with acute ST-elevation myocardial infarction treated with primary coronary intervention: Determinants and outcome. Results from the MITRAplus and OPTAMI registry. Acute Card Care. 2011; 13:35–39.
Article
35. Song YB, Hahn JY, Gwon HC, Kim JH, Lee SH, Jeong MH, et al. The impact of initial treatment delay using primary angioplasty on mortality among patients with acute myocardial infarction: from the Korea acute myocardial infarction registry. J Korean Med Sci. 2008; 23:357–364.
Article
36. El-Menyar A, Zubaid M, Sulaiman K, AlMahmeed W, Singh R, Alsheikh-Ali AA, et al. Atypical presentation of acute coronary syndrome: a significant independent predictor of in-hospital mortality. J Cardiol. 2011; 57:165–171.
Article
37. Rollando D, Puggioni E, Robotti S, De Lisi A, Ferrari Bravo M, Vardanega A, et al. Symptom onset-to-balloon time and mortality in the first seven years after STEMI treated with primary percutaneous coronary intervention. Heart. 2012; 98:1738–1742.
Article
Full Text Links
  • YMJ
Actions
Cited
CITED
export Copy
Close
Share
  • Twitter
  • Facebook
Similar articles
Copyright © 2024 by Korean Association of Medical Journal Editors. All rights reserved.     E-mail: koreamed@kamje.or.kr