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      Outcomes of Physician‐Staffed Versus Non‐Physician‐Staffed Helicopter Transport for ST‐Elevation Myocardial Infarction

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          Abstract

          Background

          The effect of physician‐staffed helicopter emergency medical service ( HEMS) on ST‐elevation myocardial infarction ( STEMI) patient transfer is unknown. The purpose of this study was to evaluate the characteristics and outcomes of physician‐staffed HEMS (Physician‐ HEMS) versus non‐physician‐staffed (Standard‐ HEMS) in patients with STEMI.

          Methods and Results

          We studied 398 STEMI patients transferred by either Physician‐ HEMS (n=327) or Standard‐ HEMS (n=71) for primary or rescue percutaneous coronary intervention at 2 hospitals between 2006 and 2014. Data were collected from electronic medical records and each institution's contribution to the National Cardiovascular Data Registry. Baseline characteristics were similar between groups. Median electrocardiogram‐to‐balloon time was longer for the Standard‐ HEMS group than for the Physician‐ HEMS group (118 vs 107 minutes; P=0.002). The Standard‐ HEMS group was more likely than the Physician‐ HEMS group to receive nitroglycerin (37% vs 15%; P<0.001) and opioid analgesics (42.3% vs 21.7%; P<0.001) during transport. In‐hospital adverse outcomes, including cardiac arrest, cardiogenic shock, and serious arrhythmias, were more common in the Standard‐ HEMS group (25.4% vs 11.3%; P=0.002). After adjusting for age, sex, Killip class, and transport time, patients transferred by Standard‐ HEMS had increased risk of any serious in‐hospital adverse event (odds ratio=2.91; 95% CI=1.39–6.06; P=0.004). In‐hospital mortality was not statistically different between the 2 groups (9.9% in the Standard‐ HEMS group vs 4.9% in the Physician‐ HEMS group; P=0.104).

          Conclusions

          Patients with STEMI transported by Standard‐ HEMS had longer transport times, higher rates of nitroglycerin and opioid administration, and higher rates of adjusted in‐hospital events. Efforts to better understand optimal transport strategies in STEMI patients are needed.

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          Most cited references 20

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          Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials.

          Many trials have been done to compare primary percutaneous transluminal coronary angioplasty (PTCA) with thrombolytic therapy for acute ST-segment elevation myocardial infarction (AMI). Our aim was to look at the combined results of these trials and to ascertain which reperfusion therapy is most effective. We did a search of published work and identified 23 trials, which together randomly assigned 7739 thrombolytic-eligible patients with ST-segment elevation AMI to primary PTCA (n=3872) or thrombolytic therapy (n=3867). Streptokinase was used in eight trials (n=1837), and fibrin-specific agents in 15 (n=5902). Most patients who received thrombolytic therapy (76%, n=2939) received a fibrin-specific agent. Stents were used in 12 trials, and platelet glycoprotein IIb/IIIa inhibitors were used in eight. We identified short-term and long-term clinical outcomes of death, non-fatal reinfarction, and stroke, and did subgroup analyses to assess the effect of type of thrombolytic agent used and the strategy of emergent hospital transfer for primary PTCA. All analyses were done with and without inclusion of the SHOCK trial data. Primary PTCA was better than thrombolytic therapy at reducing overall short-term death (7% [n=270] vs 9% [360]; p=0.0002), death excluding the SHOCK trial data (5% [199] vs 7% [276]; p=0.0003), non-fatal reinfarction (3% [80] vs 7% [222]; p<0.0001), stroke (1% [30] vs 2% [64]; p=0.0004), and the combined endpoint of death, non-fatal reinfarction, and stroke (8% [253] vs 14% [442]; p<0.0001). The results seen with primary PTCA remained better than those seen with thrombolytic therapy during long-term follow-up, and were independent of both the type of thrombolytic agent used, and whether or not the patient was transferred for primary PTCA. Primary PTCA is more effective than thrombolytic therapy for the treatment of ST-segment elevation AMI.
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            Association of intravenous morphine use and outcomes in acute coronary syndromes: results from the CRUSADE Quality Improvement Initiative.

            Although intravenous morphine is commonly used for the treatment of chest pain in patients presenting with non-ST-segment elevation acute coronary syndromes (NSTE ACS), its safety has not been evaluated. The CRUSADE Initiative is a nonrandomized, retrospective, observational registry enrolling patients with NSTE ACS to evaluate acute medications and interventions, inhospital outcomes, and discharge treatments. The study population comprised patients presenting with NSTE ACS at 443 hospitals across the United States from January 2001 through June 2003 (n = 57,039). Outcomes were evaluated in patients receiving morphine versus not and between patients treated with morphine versus intravenous nitroglycerin. A total of 17,003 patients (29.8%) received morphine within 24 hours of presentation. Patients treated with any morphine had a higher adjusted risk of death (odds ratio [OR] 1.48, 95% CI 1.33-1.64) than patients not treated with morphine. Relative to those receiving nitroglycerin, patients treated with morphine also had a higher adjusted likelihood of death (OR 1.50, 95% CI 1.26-1.78). Utilizing a propensity score matching method, the use of morphine was associated with increased inhospital mortality (OR 1.41, 95% CI 1.26-1.57). The increased risk of death in patients receiving morphine persisted across all measured subgroups. Use of morphine either alone or in combination with nitroglycerin for patients presenting with NSTE ACS was associated with higher mortality even after risk adjustment and matching on propensity score for treatment. This analysis raises concerns regarding the safety of using morphine in patients with NSTE ACS and emphasizes the need for a randomized trial.
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              Development of systems of care for ST-elevation myocardial infarction patients: executive summary.

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                Author and article information

                Contributors
                anr@medicine.wisc.edu
                Journal
                J Am Heart Assoc
                J Am Heart Assoc
                10.1002/(ISSN)2047-9980
                JAH3
                ahaoa
                Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease
                John Wiley and Sons Inc. (Hoboken )
                2047-9980
                02 February 2017
                February 2017
                : 6
                : 2 ( doiID: 10.1002/jah3.2017.6.issue-2 )
                Affiliations
                [ 1 ] Division of Cardiovascular Medicine Department of Medicine University of Wisconsin Madison WI
                [ 2 ] Department of Biostatistics and Medical Informatics University of Wisconsin Madison WI
                [ 3 ] Mayo Clinic Health System‐Franciscan Healthcare La Crosse WI
                [ 4 ] Division of Cardiology Mayo Clinic Rochester MN
                Author notes
                [* ] Correspondence to: Amish N. Raval, MD, FACC, FSCAI, FAHA, Division of Cardiovascular Medicine, Department of Medicine, University of Wisconsin School of Medicine and Public Health, University of Wisconsin Hospital and Clinics (site of research), CSC H4/568, 600 Highland Ave, Madison, WI 53792. E‐mail: anr@ 123456medicine.wisc.edu
                Article
                JAH31987
                10.1161/JAHA.116.004936
                5523778
                28154162
                © 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.

                This is an open access article under the terms of the Creative Commons Attribution‐NonCommercial‐NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.

                Page count
                Figures: 0, Tables: 5, Pages: 6, Words: 4815
                Product
                Funding
                Funded by: University of Wisconsin Institute for Clinical and Translational Research
                Funded by: NIH Clinical and Translational Science Award
                Award ID: 1 UL1 TR000427
                Funded by: Herman and Gwendolyn Shapiro Summer Research Program
                Funded by: University of Wisconsin School of Medicine
                Funded by: Public Health Department of Medicine
                Categories
                Original Research
                Original Research
                Coronary Heart Disease
                Custom metadata
                2.0
                jah31987
                February 2017
                Converter:WILEY_ML3GV2_TO_NLMPMC version:5.1.3 mode:remove_FC converted:11.07.2017

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