Original article
Patient education after acute myocardial infarction: cardiologists should adapt their message – French registry of acute ST-elevation or non-ST-elevation myocardial infarction 2010 registry Etienne Puymirata,b, Nelson Teixeiraa, Tabassome Simonc,d, Philippe G. Stege,f,g, Franc¸ois Schieleh, Nicolas Lamblini, Vincent Probstj, Yves Juillie`rek, Jean Ferrie`resl, Nicolas Danchina, for the FAST-MI investigators Aims A shorter time delay between onset of symptoms and first call for medical attention would be expected in patients with a history of ischemic heart disease (IHD). We aimed to determine whether time to first call for an ST-elevation myocardial infarction (STEMI) differed between patients with or without history of coronary artery disease from the French registry of acute ST-elevation or non-ST-elevation myocardial infarction (FAST-MI) 2010 registry. Methods FAST-MI 2010 is a nationwide French registry that included 4169 patients with acute myocardial infarction (AMI, 2193 STEMI) at the end of 2010 in 213 centers. Factors correlated with time to first call were assessed, with a specific emphasis on previous history of IHD (IHDR; n U 402), compared with patients without history of IHD (IHDS; n U 1791). Results Time from onset to first call was 222 W 420 min (median time 68 min) in IHDR patients versus 240 W 4423 min (median time 75 min) in IHDS patients (P U 0.28). In multivariate analysis, only a few factors were significantly related to a shorter time from onset to first call (< — 75min); time of onset during the day (7:00 a.m. to 11:00 p.m.), upper socioeconomic class, anterior MI, cardiac arrest as the initial symptom, whereas history of IHD was not associated with a shorter time delay (odds ratio 0.86; 95% confidence interval 0.70–1.05). Similar results
Introduction Time from symptom onset to myocardial reperfusion is a major determinant of outcome in ST-elevation myocardial infarction (STEMI) patients.1,2 A shorter time delay between onset of symptoms and first call for medical attention would be expected in patients with a history of ischemic heart disease (IHD), compared with patients not known to have IHD, either because they have already experienced the symptoms of acute myocardial infarction (AMI) or because their general practitioners or cardiologists have educated them to recognize the symptoms of AMI. The aim of this study was to 1558-2027 Copyright ß 2015 Wolters Kluwer Health, Inc. All rights reserved.
were found between patients with previous AMI and IHDS patients. Conclusion Patients with a history of IHD do not call earlier than IHD-naı¨ve patients when they are confronted with symptoms of AMI. Cardiologists should spend more time educating their coronary patients to recognize symptoms of AMI. Clinicaltrials.gov identifier: NCT01237418 J Cardiovasc Med 2015, 16:761–767 Keywords: acute myocardial infarction, coronary artery disease, education, ST-elevation myocardial infarction a
Assistance Publique-Hoˆpitaux de Paris (AP-HP), Hoˆpital Europe´en Georges Pompidou, Department of Cardiology, Paris, Universite´ Paris-Descartes, INSERM U-970, cAP-HP, Hoˆpital Saint Antoine, Department of Clinical Pharmacology and Unite´ de Recherche Clinique (URCEST), dUniversite´ Pierre et Marie Curie (UPMC-Paris 06), eAP-HP, Hoˆpital Bichat, fParis, France, Universite´ Paris-Diderot, Sorbonne Paris-Cite´, gINSERM U-698, Paris, hUniversity Hospital Jean Minjoz, Department of Cardiology, Besanc¸on, iUniversity Hospital of Lille, Department of Cardiology, Lille, jUniversity hospital of Nantes, Nantes, kUniversity hospital of Nancy, Nancy and lToulouse Rangueil University Hospital, Department of Cardiology, UMR1027, INSERM, Toulouse, France b
Correspondence to Etienne Puymirat, MD, Hoˆpital Europe´en Georges Pompidou, Department of Cardiology, 20 rue Leblanc, 75015 Paris, France Tel: +33 1 56 09 28 51; fax: +33 1 56 09 38 10; e-mail: [email protected] Received 13 October 2013 Revised 27 February 2014 Accepted 27 February 2014
determine whether time to first call for a STEMI differed between patients with or without history of coronary artery disease (CAD) from the FAST-MI 2010 registry.
Methods Patient population
We selected patients with STEMI and known time delays between symptom onset and first call, from the French registry of acute ST-elevation or non-STelevation myocardial infarction (FAST-MI) 2010, the methodology of which has been previously described in detail.3 Briefly, the primary objective was to evaluate DOI:10.2459/JCM.0000000000000092
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
762 Journal of Cardiovascular Medicine 2015, Vol 16 No 11
practices for MI management in real life and to measure their impact on the medium- and long-term prognosis in patients admitted to the intensive care unit (ICU) with AMI (within 48 h). This registry results from a prospective multicenter (213 centers) study, including 4169 patients. Patients were recruited consecutively from ICUs over a period of 1 month (from October 2010), with a possible extension of recruitment up to one additional month. Participation in the study was offered to all French institutions, university teaching hospitals, general and regional hospitals, and private clinics with ICUs with the capacity to receive acute coronary syndrome emergencies. We included men or women aged over 18 years, who were admitted within 48 h after symptom onset for an AMI characterized by the elevation of troponin or creatine phosphokinase myocardial band associated with at least one of the following elements: symptoms compatible with myocardial ischemia, ECG abnormalities such as new pathological Q waves, ST-T changes compatible with myocardial ischemia, and who agreed to take part in the study. The main exclusion criteria were iatrogenic MI, defined as MI occurring within 48 h of a therapeutic procedure (bypass surgery, coronary angioplasty, or any other medical or surgical intervention), acute coronary syndrome diagnosis changed in favor of another diagnosis, and patients with unstable angina and no increase in cardiac biomarkers. Participating in the registry was not supposed to change the therapeutic approach of the cardiologist in any way. The registry was conducted in compliance with Good Clinical Practice guidelines, French law, and the French data protection law. The protocol was reviewed by the Committee for the Protection of Human Subjects in Biomedical Research of Saint-Antoine University Hospital and the data file of FAST-MI was declared to the Commission Nationale Informatique et Liberte´. Clinicaltrials.gov identifier: NCT01237418 Definition of ST-elevation myocardial infarction and ischemic heart disease
STEMI was diagnosed when ST elevation of at least 1 mm was seen in at least two contiguous leads in any location on the index or qualifying ECG. IHD was defined as a history of CAD with either previous angina treated by medication or coronary angiography documenting the presence of coronary artery disease, previous MI, and percutaneous coronary intervention (PCI) or coronary artery bypass surgery (CABG). As the presence of major risk factors implying a regular medical follow-up might have an impact on time to call, we also compared patients without any history of atherosclerotic disease (CAD, peripheral artery disease, carotid artery disease, stroke, or transient ischemic attack), or risk
factors (diabetes mellitus, hypertension, hypercholesterolemia), and who did not receive cardiovascular medications to the group of patients having at least one of these conditions. Data collection
Baseline characteristics were prospectively collected. Besides clinical management and outcome data, data characterizing the patients’ way of life were also collected; these comprised socioeconomic class, based on current or former employment (for upper socioeconomic class: high level executives, physicians, lawyers, engineers, professors and so forth, representing 17% of the overall STEMI population), living conditions (living alone versus not alone), or employment status (employed, retired, unemployed, never worked). All data were recorded on computerized case record forms by dedicated research technicians sent into each of the centers at least once a week. The research technicians were also asked to ensure that recruitment was consecutive. Delay between symptom onset to first call was defined as time from onset to first call (TOFC). Initial pathways and place of admission were also recorded according to previous IHD. Statistical analysis
Statistical analysis was performed using SPSS software (version 20.0, IBM). For quantitative variables, means (SDs) were calculated. In addition, medians with interquartile ranges (IQR) were calculated when appropriate. Discrete variables are presented as percentages. Comparisons were made with Chi-square or Fisher exact tests for discrete variables; continuous variables were compared using unpaired Student’s t-tests, or one-way analyses of variance, and when appropriate, nonparametric tests (Mann–Whitney or Kruskal–Wallis tests). Correlates of time to call of less than 75 min were determined using a multivariate backward stepwise multiple logistic regressions. Variables listed in Table 1 were included in the models. For all analyses, a P value of 0.05 was considered significant.
Results Of the 4169 patients included in the registry, 2193 had a STEMI and time from onset of pain to first call available. Of those, 402 had a history of IHD (IHDþ, 18%), with 212 (10%) having a previous MI and 190 (9%) with other manifestations of IHD but no previous AMI. Patient population
Baseline clinical characteristics are described in Table 1; 402 patients (18%) presented as IHDþ at admission. Overall, these patients were older, had a more severe cardiovascular risk profile, with more risk factors and comorbidities compared with patients with no history of IHD (IHD); IHDþ patients had significantly more
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Education after acute myocardial infarction Puymirat et al. 763
Table 1
Baseline characteristics according to history of ischemic heart disease
Age, years Female BMI, kg/m2 Previous MI Previous PCI Previous CABG Hypertension Diabetes Hyperlipidemiaa Smoking Family history of CADb Prior stroke/TIA CKDc PVD Aspirin Clopidogrel Statin Beta-blocker ACE-I or ARB CCB Clinical presentation Typical chest pain Cardiac arrest Signs of heart failure EMS as first contact Direct admission to catheterization laboratory
No IHD (n ¼ 1791)
History of IHD (n ¼ 402)
P value
62 14 458 (26%) 26.7 4.4 0 (0%) 0 (0%) 0 (0%) 785 (44%) 211 (12%) 634 (35%) 796 (44%) 488 (27%) 60 (3%) 31 (1.7) 61 (3%) 128 (7%) 30 (2%) 256 (14%) 217 (12%) 400 (22%) 203 (11.3)
66 15 95 (24%) 26.9 4.7 212 (53%) 201 (50%) 101 (25%) 232 (58%) 104 (26%) 225 (56%) 142 (35%) 93 (23%) 20 (5%) 15 (4%) 40 (10%) 195 (48.5%) 105 (26%) 201 (50%) 175 (43.5%) 181 (45%) 84 (20.9)
Patient education after acute myocardial infarction: cardiologists should adapt their message – French registry of acute ST-elevation or non-ST-elevation myocardial infarction 2010 registry Etienne Puymirata,b, Nelson Teixeiraa, Tabassome Simonc,d, Philippe G. Stege,f,g, Franc¸ois Schieleh, Nicolas Lamblini, Vincent Probstj, Yves Juillie`rek, Jean Ferrie`resl, Nicolas Danchina, for the FAST-MI investigators Aims A shorter time delay between onset of symptoms and first call for medical attention would be expected in patients with a history of ischemic heart disease (IHD). We aimed to determine whether time to first call for an ST-elevation myocardial infarction (STEMI) differed between patients with or without history of coronary artery disease from the French registry of acute ST-elevation or non-ST-elevation myocardial infarction (FAST-MI) 2010 registry. Methods FAST-MI 2010 is a nationwide French registry that included 4169 patients with acute myocardial infarction (AMI, 2193 STEMI) at the end of 2010 in 213 centers. Factors correlated with time to first call were assessed, with a specific emphasis on previous history of IHD (IHDR; n U 402), compared with patients without history of IHD (IHDS; n U 1791). Results Time from onset to first call was 222 W 420 min (median time 68 min) in IHDR patients versus 240 W 4423 min (median time 75 min) in IHDS patients (P U 0.28). In multivariate analysis, only a few factors were significantly related to a shorter time from onset to first call (< — 75min); time of onset during the day (7:00 a.m. to 11:00 p.m.), upper socioeconomic class, anterior MI, cardiac arrest as the initial symptom, whereas history of IHD was not associated with a shorter time delay (odds ratio 0.86; 95% confidence interval 0.70–1.05). Similar results
Introduction Time from symptom onset to myocardial reperfusion is a major determinant of outcome in ST-elevation myocardial infarction (STEMI) patients.1,2 A shorter time delay between onset of symptoms and first call for medical attention would be expected in patients with a history of ischemic heart disease (IHD), compared with patients not known to have IHD, either because they have already experienced the symptoms of acute myocardial infarction (AMI) or because their general practitioners or cardiologists have educated them to recognize the symptoms of AMI. The aim of this study was to 1558-2027 Copyright ß 2015 Wolters Kluwer Health, Inc. All rights reserved.
were found between patients with previous AMI and IHDS patients. Conclusion Patients with a history of IHD do not call earlier than IHD-naı¨ve patients when they are confronted with symptoms of AMI. Cardiologists should spend more time educating their coronary patients to recognize symptoms of AMI. Clinicaltrials.gov identifier: NCT01237418 J Cardiovasc Med 2015, 16:761–767 Keywords: acute myocardial infarction, coronary artery disease, education, ST-elevation myocardial infarction a
Assistance Publique-Hoˆpitaux de Paris (AP-HP), Hoˆpital Europe´en Georges Pompidou, Department of Cardiology, Paris, Universite´ Paris-Descartes, INSERM U-970, cAP-HP, Hoˆpital Saint Antoine, Department of Clinical Pharmacology and Unite´ de Recherche Clinique (URCEST), dUniversite´ Pierre et Marie Curie (UPMC-Paris 06), eAP-HP, Hoˆpital Bichat, fParis, France, Universite´ Paris-Diderot, Sorbonne Paris-Cite´, gINSERM U-698, Paris, hUniversity Hospital Jean Minjoz, Department of Cardiology, Besanc¸on, iUniversity Hospital of Lille, Department of Cardiology, Lille, jUniversity hospital of Nantes, Nantes, kUniversity hospital of Nancy, Nancy and lToulouse Rangueil University Hospital, Department of Cardiology, UMR1027, INSERM, Toulouse, France b
Correspondence to Etienne Puymirat, MD, Hoˆpital Europe´en Georges Pompidou, Department of Cardiology, 20 rue Leblanc, 75015 Paris, France Tel: +33 1 56 09 28 51; fax: +33 1 56 09 38 10; e-mail: [email protected] Received 13 October 2013 Revised 27 February 2014 Accepted 27 February 2014
determine whether time to first call for a STEMI differed between patients with or without history of coronary artery disease (CAD) from the FAST-MI 2010 registry.
Methods Patient population
We selected patients with STEMI and known time delays between symptom onset and first call, from the French registry of acute ST-elevation or non-STelevation myocardial infarction (FAST-MI) 2010, the methodology of which has been previously described in detail.3 Briefly, the primary objective was to evaluate DOI:10.2459/JCM.0000000000000092
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
762 Journal of Cardiovascular Medicine 2015, Vol 16 No 11
practices for MI management in real life and to measure their impact on the medium- and long-term prognosis in patients admitted to the intensive care unit (ICU) with AMI (within 48 h). This registry results from a prospective multicenter (213 centers) study, including 4169 patients. Patients were recruited consecutively from ICUs over a period of 1 month (from October 2010), with a possible extension of recruitment up to one additional month. Participation in the study was offered to all French institutions, university teaching hospitals, general and regional hospitals, and private clinics with ICUs with the capacity to receive acute coronary syndrome emergencies. We included men or women aged over 18 years, who were admitted within 48 h after symptom onset for an AMI characterized by the elevation of troponin or creatine phosphokinase myocardial band associated with at least one of the following elements: symptoms compatible with myocardial ischemia, ECG abnormalities such as new pathological Q waves, ST-T changes compatible with myocardial ischemia, and who agreed to take part in the study. The main exclusion criteria were iatrogenic MI, defined as MI occurring within 48 h of a therapeutic procedure (bypass surgery, coronary angioplasty, or any other medical or surgical intervention), acute coronary syndrome diagnosis changed in favor of another diagnosis, and patients with unstable angina and no increase in cardiac biomarkers. Participating in the registry was not supposed to change the therapeutic approach of the cardiologist in any way. The registry was conducted in compliance with Good Clinical Practice guidelines, French law, and the French data protection law. The protocol was reviewed by the Committee for the Protection of Human Subjects in Biomedical Research of Saint-Antoine University Hospital and the data file of FAST-MI was declared to the Commission Nationale Informatique et Liberte´. Clinicaltrials.gov identifier: NCT01237418 Definition of ST-elevation myocardial infarction and ischemic heart disease
STEMI was diagnosed when ST elevation of at least 1 mm was seen in at least two contiguous leads in any location on the index or qualifying ECG. IHD was defined as a history of CAD with either previous angina treated by medication or coronary angiography documenting the presence of coronary artery disease, previous MI, and percutaneous coronary intervention (PCI) or coronary artery bypass surgery (CABG). As the presence of major risk factors implying a regular medical follow-up might have an impact on time to call, we also compared patients without any history of atherosclerotic disease (CAD, peripheral artery disease, carotid artery disease, stroke, or transient ischemic attack), or risk
factors (diabetes mellitus, hypertension, hypercholesterolemia), and who did not receive cardiovascular medications to the group of patients having at least one of these conditions. Data collection
Baseline characteristics were prospectively collected. Besides clinical management and outcome data, data characterizing the patients’ way of life were also collected; these comprised socioeconomic class, based on current or former employment (for upper socioeconomic class: high level executives, physicians, lawyers, engineers, professors and so forth, representing 17% of the overall STEMI population), living conditions (living alone versus not alone), or employment status (employed, retired, unemployed, never worked). All data were recorded on computerized case record forms by dedicated research technicians sent into each of the centers at least once a week. The research technicians were also asked to ensure that recruitment was consecutive. Delay between symptom onset to first call was defined as time from onset to first call (TOFC). Initial pathways and place of admission were also recorded according to previous IHD. Statistical analysis
Statistical analysis was performed using SPSS software (version 20.0, IBM). For quantitative variables, means (SDs) were calculated. In addition, medians with interquartile ranges (IQR) were calculated when appropriate. Discrete variables are presented as percentages. Comparisons were made with Chi-square or Fisher exact tests for discrete variables; continuous variables were compared using unpaired Student’s t-tests, or one-way analyses of variance, and when appropriate, nonparametric tests (Mann–Whitney or Kruskal–Wallis tests). Correlates of time to call of less than 75 min were determined using a multivariate backward stepwise multiple logistic regressions. Variables listed in Table 1 were included in the models. For all analyses, a P value of 0.05 was considered significant.
Results Of the 4169 patients included in the registry, 2193 had a STEMI and time from onset of pain to first call available. Of those, 402 had a history of IHD (IHDþ, 18%), with 212 (10%) having a previous MI and 190 (9%) with other manifestations of IHD but no previous AMI. Patient population
Baseline clinical characteristics are described in Table 1; 402 patients (18%) presented as IHDþ at admission. Overall, these patients were older, had a more severe cardiovascular risk profile, with more risk factors and comorbidities compared with patients with no history of IHD (IHD); IHDþ patients had significantly more
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Education after acute myocardial infarction Puymirat et al. 763
Table 1
Baseline characteristics according to history of ischemic heart disease
Age, years Female BMI, kg/m2 Previous MI Previous PCI Previous CABG Hypertension Diabetes Hyperlipidemiaa Smoking Family history of CADb Prior stroke/TIA CKDc PVD Aspirin Clopidogrel Statin Beta-blocker ACE-I or ARB CCB Clinical presentation Typical chest pain Cardiac arrest Signs of heart failure EMS as first contact Direct admission to catheterization laboratory
No IHD (n ¼ 1791)
History of IHD (n ¼ 402)
P value
62 14 458 (26%) 26.7 4.4 0 (0%) 0 (0%) 0 (0%) 785 (44%) 211 (12%) 634 (35%) 796 (44%) 488 (27%) 60 (3%) 31 (1.7) 61 (3%) 128 (7%) 30 (2%) 256 (14%) 217 (12%) 400 (22%) 203 (11.3)
66 15 95 (24%) 26.9 4.7 212 (53%) 201 (50%) 101 (25%) 232 (58%) 104 (26%) 225 (56%) 142 (35%) 93 (23%) 20 (5%) 15 (4%) 40 (10%) 195 (48.5%) 105 (26%) 201 (50%) 175 (43.5%) 181 (45%) 84 (20.9)
