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Editorial| Volume 73, P27-29, March 2020

Impact of mobile intensive care units on STEMI delays and outcomes–Is it simply a matter of time?

Published:February 05, 2020DOI:https://doi.org/10.1016/j.ejim.2020.01.022
Impact of mobile intensive care units on STEMI delays and outcomes–Is it simply a matter of time?
Previous ArticleDeath from, with, and without pulmonary embolism
Next ArticleOverlooked cases of HIV infection: An Italian tale of missed diagnostic opportunities
      Ischemic heart disease (IHD) remains the leading cause of death worldwide [
      • Nowbar A.N.
      • Gitto M.
      • Howard J.P.
      • Francis D.P.
      • Al-Lamee R
      Mortality from ischemic heart disease.
      Circulation. 2019; 12e005375https://doi.org/10.1161/CIRCOUTCOMES.118.005375
      ], regardless of the income level of the country [
      • Roth G.A.
      • Johnson C.
      • Abajobir A.
      • Abd-Allah F.
      • Abera S.F.
      • Abyu G.
      • Ahmed M.
      • Aksut B.
      • Alam T.
      • Alam K.
      • Alla F.
      • Alvis-Guzman N.
      • Amrock S.
      • Ansari H.
      • Ärnlöv J.
      • Asayesh H.
      • Atey T.M.
      • Avila-Burgos L.
      • Awasthi A.
      • Banerjee A.
      • Barac A.
      • Bärnighausen T.
      • Barregard L.
      • Bedi N.
      • Belay Ketema E.
      • Bennett D.
      • Berhe G.
      • Bhutta Z.
      • Bitew S.
      • Carapetis J.
      • Carrero J.J.
      • Malta D.C.
      • Castañeda-Orjuela C.A.
      • Castillo-Rivas J.
      • Catalá-López F.
      • Choi J.-.Y.
      • Christensen H.
      • Cirillo M.
      • Cooper Jr., L.
      • Criqui M.
      • Cundiff D.
      • Damasceno A.
      • Dandona L.
      • Dandona R.
      • Davletov K.
      • Dharmaratne S.
      • Dorairaj P.
      • Dubey M.
      • Ehrenkranz R.
      • El Sayed Zaki M.
      • Faraon E.J.A.
      • Esteghamati A.
      • Farid T.
      • Farvid M.
      • Feigin V.
      • Ding E.L.
      • Fowkes G.
      • Gebrehiwot T.
      • Gillum R.
      • Gold A.
      • Gona P.
      • Gupta R.
      • Habtewold T.D.
      • Hafezi-Nejad N.
      • Hailu T.
      • Hailu G.B.
      • Hankey G.
      • Hassen H.Y.
      • Abate K.H.
      • Havmoeller R.
      • Hay S.I.
      • Horino M.
      • Hotez P.J.
      • Jacobsen K.
      • James S.
      • Javanbakht M.
      • Jeemon P.
      • John D.
      • Jonas J.
      • Kalkonde Y.
      • Karimkhani C.
      • Kasaeian A.
      • Khader Y.
      • Khan A.
      • Khang Y.-.H.
      • Khera S.
      • Khoja A.T.
      • Khubchandani J.
      • Kim D.
      • Kolte D.
      • Kosen S.
      • Krohn K.J.
      • Kumar G.A.
      • Kwan G.F.
      • Lal D.K.
      • Larsson A.
      • Linn S.
      • Lopez A.
      • Lotufo P.A.
      • El Razek H.M.A.
      • Malekzadeh R.
      • Mazidi M.
      • Meier T.
      • Meles K.G.
      • Mensah G.
      • Meretoja A.
      • Mezgebe H.
      • Miller T.
      • Mirrakhimov E.
      • Mohammed S.
      • Moran A.E.
      • Musa K.I.
      • Narula J.
      • Neal B.
      • Ngalesoni F.
      • Nguyen G.
      • Obermeyer C.M.
      • Owolabi M.
      • Patton G.
      • Pedro J.
      • Qato D.
      • Qorbani M.
      • Rahimi K.
      • Rai R.K.
      • Rawaf S.
      • Ribeiro A.
      • Safiri S.
      • Salomon J.A.
      • Santos I.
      • Santric Milicevic M.
      • Sartorius B.
      • Schutte A.
      • Sepanlou S.
      • Shaikh M.A.
      • Shin M.-.J.
      • Shishehbor M.
      • Shore H.
      • Silva D.A.S.
      • Sobngwi E.
      • Stranges S.
      • Swaminathan S.
      • Tabarés-Seisdedos R.
      • Tadele Atnafu N.
      • Tesfay F.
      • Thakur J.S.
      • Thrift A.
      • Topor-Madry R.
      • Truelsen T.
      • Tyrovolas S.
      • Ukwaja K.N.
      • Uthman O.
      • Vasankari T.
      • Vlassov V.
      • Vollset S.E.
      • Wakayo T.
      • Watkins D.
      • Weintraub R.
      • Werdecker A.
      • Westerman R.
      • Wiysonge C.S.
      • Wolfe C.
      • Workicho A.
      • Xu G.
      • Yano Y.
      • Yip P.
      • Yonemoto N.
      • Younis M.
      • Yu C.
      • Vos T.
      • Naghavi M.
      • Murray C
      Global, regional, and national burden of cardiovascular diseases for 10 causes, 1990 to 2015.
      J Am Coll Cardiol. 2017; 70 (Epub 2017/05/17PubMed PMID: 28527533): 1-25https://doi.org/10.1016/j.jacc.2017.04.052
      ]. Mortality trends for IHD slowly but progressively declined over the last decades [
      • Nowbar A.N.
      • Gitto M.
      • Howard J.P.
      • Francis D.P.
      • Al-Lamee R
      Mortality from ischemic heart disease.
      Circulation. 2019; 12e005375https://doi.org/10.1161/CIRCOUTCOMES.118.005375
      ]. This gradual decrease may be explained by a reduced impact of some conditions including smoking and hypertension, by the generally more effective treatment of cardiovascular risk factors, and finally, by the improvement in the management of acute coronary syndromes [
      • Nowbar A.N.
      • Gitto M.
      • Howard J.P.
      • Francis D.P.
      • Al-Lamee R
      Mortality from ischemic heart disease.
      Circulation. 2019; 12e005375https://doi.org/10.1161/CIRCOUTCOMES.118.005375
      ]. Since the release of 2004 Guidelines for the management of patients with ST-elevation myocardial infarction (STEMI) [
      • Antman E.M.
      • Anbe D.T.
      • Armstrong P.W.
      • Bates E.R.
      • Green L.A.
      • Hand M.
      • Hochman J.S.
      • Krumholz H.M.
      • Kushner F.G.
      • Lamas G.A.
      • Mullany C.J.
      • Ornato J.P.
      • Pearle D.L.
      • Sloan M.A.
      • Smith Jr., S.C.
      • Alpert J.S.
      • Anderson J.L.
      • Faxon D.P.
      • Fuster V.
      • Gibbons R.J.
      • Gregoratos G.
      • Halperin J.L.
      • Hiratzka L.F.
      • Hunt S.A.
      • Jacobs A.K.
      American college of cardiology/American heart association task force on practice G. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction–executive summary: a report of the American college of Cardiology/American heart association task force on practice guidelines (Writing committee to revise the 1999 guidelines for the management of patients with acute myocardial infarction).
      Circulation. 2004; 110 (Epub 2004/08/04PubMed PMID: 15289388): 588-636https://doi.org/10.1161/01.CIR.0000134791.68010.FA
      ], primary percutaneous coronary intervention (PCI) have been chosen as the preferred reperfusion strategy over fibrinolysis, provided that it could be performed in a timely fashion: 120 min is the maximum allowed from the diagnosis of STEMI to primary PCI [
      • Ibanez B.
      • James S.
      • Agewall S.
      • Antunes M.J.
      • Bucciarelli-Ducci C.
      • Bueno H.
      • Caforio A.L.P.
      • Crea F.
      • Goudevenos J.A.
      • Halvorsen S.
      • Hindricks G.
      • Kastrati A.
      • Lenzen M.J.
      • Prescott E.
      • Roffi M.
      • Valgimigli M.
      • Varenhorst C.
      • Vranckx P.
      • Widimsky P
      2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: the task force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European society of Cardiology (ESC).
      Eur Heart J. 2018; 39 (Epub 2017/09/10PubMed PMID: 28886621): 119-177https://doi.org/10.1093/eurheartj/ehx393
      ].
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      References

        • Nowbar A.N.
        • Gitto M.
        • Howard J.P.
        • Francis D.P.
        • Al-Lamee R
        Mortality from ischemic heart disease.
        Circulation. 2019; 12e005375https://doi.org/10.1161/CIRCOUTCOMES.118.005375
        View in Article
        • Roth G.A.
        • Johnson C.
        • Abajobir A.
        • Abd-Allah F.
        • Abera S.F.
        • Abyu G.
        • Ahmed M.
        • Aksut B.
        • Alam T.
        • Alam K.
        • Alla F.
        • Alvis-Guzman N.
        • Amrock S.
        • Ansari H.
        • Ärnlöv J.
        • Asayesh H.
        • Atey T.M.
        • Avila-Burgos L.
        • Awasthi A.
        • Banerjee A.
        • Barac A.
        • Bärnighausen T.
        • Barregard L.
        • Bedi N.
        • Belay Ketema E.
        • Bennett D.
        • Berhe G.
        • Bhutta Z.
        • Bitew S.
        • Carapetis J.
        • Carrero J.J.
        • Malta D.C.
        • Castañeda-Orjuela C.A.
        • Castillo-Rivas J.
        • Catalá-López F.
        • Choi J.-.Y.
        • Christensen H.
        • Cirillo M.
        • Cooper Jr., L.
        • Criqui M.
        • Cundiff D.
        • Damasceno A.
        • Dandona L.
        • Dandona R.
        • Davletov K.
        • Dharmaratne S.
        • Dorairaj P.
        • Dubey M.
        • Ehrenkranz R.
        • El Sayed Zaki M.
        • Faraon E.J.A.
        • Esteghamati A.
        • Farid T.
        • Farvid M.
        • Feigin V.
        • Ding E.L.
        • Fowkes G.
        • Gebrehiwot T.
        • Gillum R.
        • Gold A.
        • Gona P.
        • Gupta R.
        • Habtewold T.D.
        • Hafezi-Nejad N.
        • Hailu T.
        • Hailu G.B.
        • Hankey G.
        • Hassen H.Y.
        • Abate K.H.
        • Havmoeller R.
        • Hay S.I.
        • Horino M.
        • Hotez P.J.
        • Jacobsen K.
        • James S.
        • Javanbakht M.
        • Jeemon P.
        • John D.
        • Jonas J.
        • Kalkonde Y.
        • Karimkhani C.
        • Kasaeian A.
        • Khader Y.
        • Khan A.
        • Khang Y.-.H.
        • Khera S.
        • Khoja A.T.
        • Khubchandani J.
        • Kim D.
        • Kolte D.
        • Kosen S.
        • Krohn K.J.
        • Kumar G.A.
        • Kwan G.F.
        • Lal D.K.
        • Larsson A.
        • Linn S.
        • Lopez A.
        • Lotufo P.A.
        • El Razek H.M.A.
        • Malekzadeh R.
        • Mazidi M.
        • Meier T.
        • Meles K.G.
        • Mensah G.
        • Meretoja A.
        • Mezgebe H.
        • Miller T.
        • Mirrakhimov E.
        • Mohammed S.
        • Moran A.E.
        • Musa K.I.
        • Narula J.
        • Neal B.
        • Ngalesoni F.
        • Nguyen G.
        • Obermeyer C.M.
        • Owolabi M.
        • Patton G.
        • Pedro J.
        • Qato D.
        • Qorbani M.
        • Rahimi K.
        • Rai R.K.
        • Rawaf S.
        • Ribeiro A.
        • Safiri S.
        • Salomon J.A.
        • Santos I.
        • Santric Milicevic M.
        • Sartorius B.
        • Schutte A.
        • Sepanlou S.
        • Shaikh M.A.
        • Shin M.-.J.
        • Shishehbor M.
        • Shore H.
        • Silva D.A.S.
        • Sobngwi E.
        • Stranges S.
        • Swaminathan S.
        • Tabarés-Seisdedos R.
        • Tadele Atnafu N.
        • Tesfay F.
        • Thakur J.S.
        • Thrift A.
        • Topor-Madry R.
        • Truelsen T.
        • Tyrovolas S.
        • Ukwaja K.N.
        • Uthman O.
        • Vasankari T.
        • Vlassov V.
        • Vollset S.E.
        • Wakayo T.
        • Watkins D.
        • Weintraub R.
        • Werdecker A.
        • Westerman R.
        • Wiysonge C.S.
        • Wolfe C.
        • Workicho A.
        • Xu G.
        • Yano Y.
        • Yip P.
        • Yonemoto N.
        • Younis M.
        • Yu C.
        • Vos T.
        • Naghavi M.
        • Murray C
        Global, regional, and national burden of cardiovascular diseases for 10 causes, 1990 to 2015.
        J Am Coll Cardiol. 2017; 70 (Epub 2017/05/17PubMed PMID: 28527533): 1-25https://doi.org/10.1016/j.jacc.2017.04.052
        View in Article
        • Antman E.M.
        • Anbe D.T.
        • Armstrong P.W.
        • Bates E.R.
        • Green L.A.
        • Hand M.
        • Hochman J.S.
        • Krumholz H.M.
        • Kushner F.G.
        • Lamas G.A.
        • Mullany C.J.
        • Ornato J.P.
        • Pearle D.L.
        • Sloan M.A.
        • Smith Jr., S.C.
        • Alpert J.S.
        • Anderson J.L.
        • Faxon D.P.
        • Fuster V.
        • Gibbons R.J.
        • Gregoratos G.
        • Halperin J.L.
        • Hiratzka L.F.
        • Hunt S.A.
        • Jacobs A.K.
        American college of cardiology/American heart association task force on practice G. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction–executive summary: a report of the American college of Cardiology/American heart association task force on practice guidelines (Writing committee to revise the 1999 guidelines for the management of patients with acute myocardial infarction).
        Circulation. 2004; 110 (Epub 2004/08/04PubMed PMID: 15289388): 588-636https://doi.org/10.1161/01.CIR.0000134791.68010.FA
        View in Article
        • Ibanez B.
        • James S.
        • Agewall S.
        • Antunes M.J.
        • Bucciarelli-Ducci C.
        • Bueno H.
        • Caforio A.L.P.
        • Crea F.
        • Goudevenos J.A.
        • Halvorsen S.
        • Hindricks G.
        • Kastrati A.
        • Lenzen M.J.
        • Prescott E.
        • Roffi M.
        • Valgimigli M.
        • Varenhorst C.
        • Vranckx P.
        • Widimsky P
        2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: the task force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European society of Cardiology (ESC).
        Eur Heart J. 2018; 39 (Epub 2017/09/10PubMed PMID: 28886621): 119-177https://doi.org/10.1093/eurheartj/ehx393
        View in Article
        • Gersh B.J.
        • Antman E.M.
        Selection of the optimal reperfusion strategy for STEMI: does time matter?The opinions expressed in this article are not necessarily those of the editors of the European heart journal or of the European society of cardiology.
        Eur Heart J. 2006; 27: 761-763https://doi.org/10.1093/eurheartj/ehi775
        View in Article
        • Luca G.D.
        • Suryapranata H.
        • Ottervanger J.P.
        • Antman E.M
        Time delay to treatment and mortality in primary angioplasty for acute myocardial infarction.
        Circulation. 2004; 109: 1223-1225https://doi.org/10.1161/01.CIR.0000121424.76486.20
        View in Article
        • Zijlstra F.
        • Patel A.
        • Jones M.
        • Grines C.L.
        • Ellis S.
        • Garcia E.
        • Grinfeld L.
        • Gibbons R.J.
        • Ribeiro E.E.
        • Ribichini F.
        • Granger C.
        • Akhras F.
        • Weaver W.D.
        • Simes R.J
        Clinical characteristics and outcome of patients with early (<2h), intermediate (2–4h) and late (>4h) presentation treated by primary coronary angioplasty or thrombolytic therapy for acute myocardial infarction.
        Eur Heart J. 2002; 23 (Epub 2002/04/02PubMed PMID: 11922645): 550-557https://doi.org/10.1053/euhj.2001.2901
        View in Article
        • De Luca G.
        • Suryapranata H.
        • Zijlstra F.
        • van't Hof A.W.J.
        • Hoorntje J.C.A.
        • Gosselink A.T.M.
        • Dambrink J.-.H.
        • de Boer M.-.J
        Symptom-onset-to-balloon time and mortality in patients with acute myocardial infarction treated by primary angioplasty.
        J Am Coll Cardiol. 2003; 42: 991-997https://doi.org/10.1016/S0735-1097(03)00919-7
        View in Article
        • Terkelsen C.J.
        • Sorensen J.T.
        • Maeng M.
        • Jensen L.O.
        • Tilsted H.H.
        • Trautner S.
        • Vach W.
        • Johnsen S.P.
        • Thuesen L.
        • Lassen J.F
        System delay and mortality among patients with stemi treated with primary percutaneous coronary intervention.
        JAMA. 2010; 304 (Epub 2010/08/19PubMed PMID: 20716739): 763-771https://doi.org/10.1001/jama.2010.1139
        View in Article
        • Rosselló X.
        • Huo Y.
        • Pocock S.
        • Van de Werf F.
        • Chin C.T.
        • Danchin N.
        • Lee S.W.L.
        • Medina J.
        • Vega A.
        • Bueno H
        Global geographical variations in ST-segment elevation myocardial infarction management and post-discharge mortality.
        Int J Cardiol. 2017; 245: 27https://doi.org/10.1016/j.ijcard.2017.07.039
        View in Article
        • Viejo-Moreno R.
        • Cabrejas-Aparicio A.
        • Arriero-Fernández N.
        • Quintana-Díaz M.
        • Galván-Roncero E.
        • Gálvez-Marco MdlN
        • Carriedo-Scher C.
        • Balaguer-Recena J.
        • Marian-Crespo C
        Mobile intensive care unit versus hospital walk-in patients, in the treatment of first episode ST- elevation myocardial infarction.
        Eur. J Int Med. 2019; https://doi.org/10.1016/j.ejim.2019.12.005
        View in Article
        • Pedersen F.
        • Butrymovich V.
        • Kelbaek H.
        • Wachtell K.
        • Helqvist S.
        • Kastrup J.
        • Holmvang L.
        • Clemmensen P.
        • Engstrom T.
        • Grande P.
        • Saunamaki K.
        • Jorgensen E
        Short- and long-term cause of death in patients treated with primary PCI for STEMI.
        J Am Coll Cardiol. 2014; 64 (Epub 2014/12/03PubMed PMID: 25457398): 2101-2108https://doi.org/10.1016/j.jacc.2014.08.037
        View in Article
        • Ducas R.A.
        • Labos C.
        • Allen D.
        • Golian M.
        • Jeyaraman M.
        • Lys J.
        • Mann A.
        • Copstein L.
        • Vokey S.
        • Rabbani R.
        • Zarychanski R.
        • Abou-Setta A.M.
        • Menkis A.H
        Association of pre-hospital ECG administration with clinical outcomes in ST-Segment myocardial infarction: a systematic review and meta-analysis.
        Can J Cardiol. 2016; 32 (Epub 2016/10/07PubMed PMID: 27707525): 1531-1541https://doi.org/10.1016/j.cjca.2016.06.004
        View in Article
        • Pedersen S.H.
        • Galatius S.
        • Hansen P.R.
        • Mogelvang R.
        • Abildstrom S.Z.
        • Sorensen R.
        • Davidsen U.
        • Galloe A.
        • Abildgaard U.
        • Iversen A.
        • Bech J.
        • Madsen J.K.
        • Jensen J.S
        Field triage reduces treatment delay and improves long-term clinical outcome in patients with acute ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention.
        J Am Coll Cardiol. 2009; 54 (Epub 2009/12/05PubMed PMID: 19958965): 2296-2302https://doi.org/10.1016/j.jacc.2009.06.056
        View in Article
        • Bagai A.
        • Jollis J.G.
        • Dauerman H.L.
        • Peng S.A.
        • Rokos I.C.
        • Bates E.R.
        • French W.J.
        • Granger C.B.
        • Roe M.T
        Emergency department bypass for ST-Segment-elevation myocardial infarction patients identified with a prehospital electrocardiogram: a report from the American heart association mission: lifeline program.
        Circulation. 2013; 128 (Epub 2013/06/22PubMed PMID: 23788525): 352-359https://doi.org/10.1161/circulationaha.113.002339
        View in Article
        • Menees D.S.
        • Peterson E.D.
        • Wang Y.
        • Curtis J.P.
        • Messenger J.C.
        • Rumsfeld J.S.
        • Gurm H.S
        Door-to-balloon time and mortality among patients undergoing primary PCI.
        N Engl J Med. 2013; 369 (Epub 2013/09/06PubMed PMID: 24004117): 901-909https://doi.org/10.1056/NEJMoa1208200
        View in Article
        • de Boer M.J.
        • Zijlstra F
        STEMI time delays: a clinical perspective: editorial comment on the article by Verweij et al.
        Neth Heart J. 2015; 23 (PubMed PMID: 26187608): 415-419https://doi.org/10.1007/s12471-015-0728-z
        View in Article
        • Swaminathan R.V.
        • Wang T.Y.
        • Kaltenbach L.A.
        • Kim L.K.
        • Minutello R.M.
        • Bergman G.
        • Wong S.C.
        • Feldman D.N
        Nonsystem reasons for delay in door-to-balloon time and associated in-hospital mortality: a report from the national cardiovascular data registry.
        J Am Coll Cardiol. 2013; 61 (Epub 2013/03/19PubMed PMID: 23500264): 1688-1695https://doi.org/10.1016/j.jacc.2012.11.073
        View in Article
        • Kontos M.C.
        • Wang Y.
        • Chaudhry S.I.
        • Vetrovec G.W.
        • Curtis J.
        • Messenger J
        Lower hospital volume is associated with higher in-hospital mortality in patients undergoing primary percutaneous coronary intervention for ST-segment-elevation myocardial infarction: a report from the NCDR.
        Circ Cardiovasc Qual Outcomes. 2013; 6 (Epub 2013/11/07PubMed PMID: 24192572): 659-667https://doi.org/10.1161/circoutcomes.113.000233
        View in Article
        • Santucci A.
        • Gargiulo G.
        • Ariotti S.
        • Marino M.
        • Magnani G.
        • Baldo A.
        • Piccolo R.
        • Franzone A.
        • Valgimigli M
        Radial versus femoral approach in STEMI: what do we know so far?.
        Minerva Cardioangiol. 2016; 64 (Epub 2016/03/05. PubMed PMID: 26934660): 219-237
        View in Article
        • Ndrepepa G.
        • Tiroch K.
        • Fusaro M.
        • Keta D.
        • Seyfarth M.
        • Byrne R.A.
        • Pache J.
        • Alger P.
        • Mehilli J.
        • Schomig A.
        • Kastrati A
        5-year prognostic value of no-reflow phenomenon after percutaneous coronary intervention in patients with acute myocardial infarction.
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      Article info

      Publication history

      Published online: February 05, 2020
      Accepted: January 29, 2020
      Received: January 19, 2020

      Identification

      DOI: https://doi.org/10.1016/j.ejim.2020.01.022

      Copyright

      © 2020 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.

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