Patient and System-Related Delays of Emergency Medical Services Use in Acute ST-Elevation Myocardial Infarction: Results from the Third Gulf Registry of Acute Coronary Events (Gulf RACE-3Ps)

Abstract

Background: Little is known about Emergency Medical Services (EMS) use and pre-hospital triage of patients with acute ST-elevation myocardial infarction (STEMI) in Arabian Gulf countries.

Methods: Clinical arrival and acute care within 24 h of STEMI symptom onset were compared between patients transferred by EMS (Red Crescent and Inter-Hospital) and those transferred by non-EMS means. Data were retrieved from a prospective registry of 36 hospitals in 6 Arabian Gulf countries, from January 2014 to January 2015.

Results: We enrolled 2,928 patients; mean age, 52.7 (SD ±11.8) years; 90% men; and 61.7% non-Arabian Gulf citizens. Only 753 patients (25.7%) used EMS; which was mostly via Inter-Hospital EMS (22%) rather than direct transfer from the scene to the hospital by the Red Crescent (3.7%). Compared to the non-EMS group, the EMS group was more likely to arrive initially at a primary or secondary health care facility; thus, they had longer median symptom-onset-to-emergency department arrival times (218 vs. 158 min; p˂.001); they were more likely to receive primary percutaneous coronary interventions (62% vs. 40.5%, p = 0.02); they had shorter door-to-needle times (38 vs. 42 min; p = .04); and shorter door-to-balloon times (47 vs. 83 min; p˂.001). High EMS use was independently predicted mostly by primary/secondary school educational levels and low or moderate socioeconomic status. Low EMS use was predicted by a history of angina and history of percutaneous coronary intervention. The groups had similar in-hospital deaths and outcomes.

Conclusion: Most acute STEMI patients in the Arabian Gulf region did not use EMS services. Improving Red Crescent infrastructure, establishing integrated STEMI networks, and launching educational public campaigns are top health care system priorities.

Fig 1. Number of hospitals with percutaneous coronary intervention capability (PCI H.) versus without (Non-PCI H.) that enrolled acute STEMI patients in the study per each Arabian Gulf country.

Fig 2. Evidence-based treatments administered in the first 24 hours of hospital admission in acute STEMI patients that arrived to the hospital by an emergency medical service (EMS) versus not (non-EMS).

Other aniplatelets, clopidogrel, prasugrel, ticagrelor; BB, beta-blockers; ACE-I/ARB, angiotensin-converting enzyme inhibitors/Angiotensin-receptor blockers, Heparins, unfractionated or low-molecular weight heparin; GP 2b/3a-I, glycoprotein 2bb/3a inhibitors.

Fig 3. Median time-line of events from symptoms-onset to the administration of reperfusion therapies (total ischemic time) in acute STEMI patients that arrived to the hospital by an emergency medical service (EMS) versus not (non-EMS).

SO, symptoms-onset, FMC, first medical contact; ED, Emergency Department arrival, ECG, electrocardiogram; TT/PPCI, thrombolytic therapy/primary percutaneous coronary intervention.