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Western Sydney Emergency Triage of Acute Myocardial Infarction (ETAMI) Experience—Effect of Pre-Hospital Triage on 12 Month Mortality
329 Western Sydney Emergency Triage of Acute Myocardial Infarction (ETAMI) Experience—Effect of Pre-Hospital Triage on 12 Month Mortality G. Sivagangabalan 1,∗ , A. Ong 1 , A. Gerke 1 , A. Narayan 1 , N. Sadick 1 , S.P. Thomas 1 , D.L. Ross 1 , G. Nelson 2 , M. Flynn 3 , C. Lees 3 , R. Edwards 1 , S. Boyages 1 , P. Kovoor 1 1 Departments
of Cardiology and Emergency Medicine, Westmead Hospital, NSW, Australia; 2 Department of Cardiology, Royal North Shore Hospital, NSW, Australia; 3 NSW Ambulance Service, Australia The aim of the ETAMI project is to provide pre-hospital triage of patients with chest pain to expedite revascularisation. During the first 22 months of the trial, the Regional Heart Centre (RHC) in Western Sydney treated 300 patients with acute ST elevation myocardial infarction. We divided these patients into 3 groups: 96 presented to the RHC, 128 to the 3 district hospitals (DH), and 76 were triaged pre-hospital to the cardiac catheterisation laboratory using the ETAMI model. There was a median reduction in door to table time in the ETAMI group of 71 min compared to the DH patients, and 32 min compared to the RHC patients (p < 0.01). Table to open artery (TIMI-3) times were similar. Left ventricular ejection fraction (LVEF) was measured by Gated Isotope Scanning at a mean of 4 days post infarct. The median LVEF was 54% in the ETAMI group, 51% in the RHC group and 48.5% in the DH group (p = 0.02). There was a difference in all cause mortality at 30 days, with 7 deaths in the RHC group, 5 deaths in the DH group, and no deaths in the ETAMI group (p = 0.015). At 12 months follow up there were 11 deaths in the RHC group, 7 deaths in the DH group, and 4 deaths in the ETAMI group (p = 0.19). The combined 12 month mortality for the 3 groups was 7.3%. The ETAMI model is safe, reduces revascularisations times, and improves LV function and mortality in an Australian metropolitan population with RHC and DH structure. doi:10.1016/j.hlc.2007.06.334 330 Relationship of QRS Duration at Baseline and Changes Over 60 min After Fibrinolysis to 30-Day Mortality with Different Locations of ST Elevation Myocardial Infarction: Results from the HERO-2 Trial C.-K. Wong 1,2,∗ , H. White 1,2 , for the HERO-2 investigators 1 Dunedin
School of Medicine, University of Otago; Dunedin, New Zealand; 2 Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand Background: QRS duration prolongation with a ST elevation AMI may be due to either intraventricular conduction delay or RBBB. Perfusion of the interventricular septum where the right bundle branch traverses is more often jeopardized with anterior AMI than with inferior AMI.
Abstracts
S133
Whether a longer QRS duration portends higher mortality in anterior AMI not accompanied by RBBB is unknown. Methods: This study was done on patients with serial ECG collections at randomization and at 60 min after fibrinolysis, including 12,456 patients with normal conduction at both time points and 510 with RBBB at both time points. Results: On the baseline ECG, there was a positive association between QRS duration and 30-day mortality with anterior AMI (P < 0.0001 for those with normal conduction and = 0.007 for those with RBBB) but not with inferior AMI (P = 0.295 and 0.321 respectively). For anterior AMI, with or without RBBB, a 20 msec increase in QRS duration predicted a significant 30–40% relative increase in 30-day mortality both before and after adjusting for clinical variables including age, haemodynamics, Killip class and ECG variables including baseline ST elevation and presence of Q wave. The association was not present for inferior AMI. Changes in QRS duration over 60 min after fibrinolytic therapy were uncommon and unrelated to mortality. Conclusion: Baseline QRS duration independently stratify 30-day outcome in patients with anterior AMI even when unaccompanied by RBBB, but it does not stratify inferior AMI. For anterior AMI, there is a 30–40% increase in mortality risk per each 20 ms QRS duration increase. doi:10.1016/j.hlc.2007.06.335 331 The Use of Different Evidence-Based Medications and 5-Year Survival After an Acute Coronary Syndrome: An Observational Study C.-K. Wong 1,∗ , E. Tang 1 , P. Herbison 2 1 Department
of Cardiology (Statistics Division), Dunedin School of Medicine, University of Otago, New Zealand; 2 Department of Preventive and Social Medicine, Statistics Division, Dunedin School of Medicine, University of Otago, New Zealand Background: The use of different evidence based medications (EBMs) in hospital survivors of acute coronary syndrome (ACS) may be associated with different longterm survival. Methods: In 1025 consecutive survivors receiving aspirin, we analysed the associations between statins (prescribed in 59.5%), beta blockers (76.8%) and ACE-inhibitors (52.2%) and 5-year all-cause mortality as the endpoint, adjusting to the baseline risk using the GRACE hospital discharge risk score. Results: The use of beta-blockers and statins (but not ACE-inhibitors) was associated with reduced mortality. Significant reduction was observed from 6 months for statins, and from 2 years for beta-blockers. Results were similar after further adjustment for concomitant use of other EBMs. When interaction terms between different EBMs were tested, the only significant interaction was between statins and beta-blockers (P = 0.010). This interaction persisted (P = 0.018) when the 1025 patients were sub-grouped regardless of the use of ACE-inhibitors. The use of beta-blockers was associated with reduced mor-
ABSTRACTS
Heart, Lung and Circulation 2007;16:S1–S201
of Cardiology and Emergency Medicine, Westmead Hospital, NSW, Australia; 2 Department of Cardiology, Royal North Shore Hospital, NSW, Australia; 3 NSW Ambulance Service, Australia The aim of the ETAMI project is to provide pre-hospital triage of patients with chest pain to expedite revascularisation. During the first 22 months of the trial, the Regional Heart Centre (RHC) in Western Sydney treated 300 patients with acute ST elevation myocardial infarction. We divided these patients into 3 groups: 96 presented to the RHC, 128 to the 3 district hospitals (DH), and 76 were triaged pre-hospital to the cardiac catheterisation laboratory using the ETAMI model. There was a median reduction in door to table time in the ETAMI group of 71 min compared to the DH patients, and 32 min compared to the RHC patients (p < 0.01). Table to open artery (TIMI-3) times were similar. Left ventricular ejection fraction (LVEF) was measured by Gated Isotope Scanning at a mean of 4 days post infarct. The median LVEF was 54% in the ETAMI group, 51% in the RHC group and 48.5% in the DH group (p = 0.02). There was a difference in all cause mortality at 30 days, with 7 deaths in the RHC group, 5 deaths in the DH group, and no deaths in the ETAMI group (p = 0.015). At 12 months follow up there were 11 deaths in the RHC group, 7 deaths in the DH group, and 4 deaths in the ETAMI group (p = 0.19). The combined 12 month mortality for the 3 groups was 7.3%. The ETAMI model is safe, reduces revascularisations times, and improves LV function and mortality in an Australian metropolitan population with RHC and DH structure. doi:10.1016/j.hlc.2007.06.334 330 Relationship of QRS Duration at Baseline and Changes Over 60 min After Fibrinolysis to 30-Day Mortality with Different Locations of ST Elevation Myocardial Infarction: Results from the HERO-2 Trial C.-K. Wong 1,2,∗ , H. White 1,2 , for the HERO-2 investigators 1 Dunedin
School of Medicine, University of Otago; Dunedin, New Zealand; 2 Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand Background: QRS duration prolongation with a ST elevation AMI may be due to either intraventricular conduction delay or RBBB. Perfusion of the interventricular septum where the right bundle branch traverses is more often jeopardized with anterior AMI than with inferior AMI.
Abstracts
S133
Whether a longer QRS duration portends higher mortality in anterior AMI not accompanied by RBBB is unknown. Methods: This study was done on patients with serial ECG collections at randomization and at 60 min after fibrinolysis, including 12,456 patients with normal conduction at both time points and 510 with RBBB at both time points. Results: On the baseline ECG, there was a positive association between QRS duration and 30-day mortality with anterior AMI (P < 0.0001 for those with normal conduction and = 0.007 for those with RBBB) but not with inferior AMI (P = 0.295 and 0.321 respectively). For anterior AMI, with or without RBBB, a 20 msec increase in QRS duration predicted a significant 30–40% relative increase in 30-day mortality both before and after adjusting for clinical variables including age, haemodynamics, Killip class and ECG variables including baseline ST elevation and presence of Q wave. The association was not present for inferior AMI. Changes in QRS duration over 60 min after fibrinolytic therapy were uncommon and unrelated to mortality. Conclusion: Baseline QRS duration independently stratify 30-day outcome in patients with anterior AMI even when unaccompanied by RBBB, but it does not stratify inferior AMI. For anterior AMI, there is a 30–40% increase in mortality risk per each 20 ms QRS duration increase. doi:10.1016/j.hlc.2007.06.335 331 The Use of Different Evidence-Based Medications and 5-Year Survival After an Acute Coronary Syndrome: An Observational Study C.-K. Wong 1,∗ , E. Tang 1 , P. Herbison 2 1 Department
of Cardiology (Statistics Division), Dunedin School of Medicine, University of Otago, New Zealand; 2 Department of Preventive and Social Medicine, Statistics Division, Dunedin School of Medicine, University of Otago, New Zealand Background: The use of different evidence based medications (EBMs) in hospital survivors of acute coronary syndrome (ACS) may be associated with different longterm survival. Methods: In 1025 consecutive survivors receiving aspirin, we analysed the associations between statins (prescribed in 59.5%), beta blockers (76.8%) and ACE-inhibitors (52.2%) and 5-year all-cause mortality as the endpoint, adjusting to the baseline risk using the GRACE hospital discharge risk score. Results: The use of beta-blockers and statins (but not ACE-inhibitors) was associated with reduced mortality. Significant reduction was observed from 6 months for statins, and from 2 years for beta-blockers. Results were similar after further adjustment for concomitant use of other EBMs. When interaction terms between different EBMs were tested, the only significant interaction was between statins and beta-blockers (P = 0.010). This interaction persisted (P = 0.018) when the 1025 patients were sub-grouped regardless of the use of ACE-inhibitors. The use of beta-blockers was associated with reduced mor-
ABSTRACTS
Heart, Lung and Circulation 2007;16:S1–S201