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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 7  |  Issue : 2  |  Page : 52-56

Cardiac catheterization laboratory activation by social media reduces reperfusion time of patients transferred for primary percutaneous coronary intervention in community hospital


Department of Cardiology, Beijing Luhe Hospital of Capital Medical University, Beijing, China

Date of Submission11-Feb-2022
Date of Decision25-Apr-2022
Date of Acceptance28-Apr-2022
Date of Web Publication30-Jun-2022

Correspondence Address:
Guozhong Wang
Department of Cardiology, Beijing Luhe Hospital of Capital Medical University, Beijing
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ed.ed_7_22

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  Abstract 


Objective: The objective of the study is to evaluate the impact of cardiac catheterization laboratory (CCL) activation by WeChat in community hospitals transfer for primary percutaneous coronary intervention (PCI) bypassing emergency department (ED) on time delay in ST-segment elevation myocardial infarction (STEMI) patients.
Methods: This was a retrospective, cohort study of STEMI patients who were transferred from community hospitals to Luhe Hospital for primary PCI. Patients were divided into two groups: in CCL group, electrocardiogram (ECG) was transmitted through WeChat in the community hospital and the patients were transferred directly to CCL by emergency medical services (EMS) (n = 43); in control group, patients without ECG transmission were transferred by EMS to ED before CCL arrival (n = 57). The primary endpoint was median first medical contact (FMC)-to-device (FMC2D) times. The secondary endpoint was door-to-device (D2D) times.
Results: The baseline clinical data and angiographic features among the two groups were similar (all P > 0.05. There was no difference in the symptom onset-to-FMC time (median interquartile range [IQR] min, 100.00 [74.50–247.00] vs. 105.00 [70.00–180.00], P > 0.05) between the two groups. Compared to control group, CCL group had shortened FMC2D times (median IQR min, 95.00 [72.60–160.58] vs. 160.79 [124.72–205.50], P < 0.001) and shortened D2D time (median IQR min, 17.18 [13.77–21.15] vs. 49.27 [40.26–64.90], P < 0.001). Achievement of the FMC2D time goal of <120 min rose from 29.82% in the control group to 76.74% in the CCL group (P < 0.001).
Conclusion: CCL activated by WeChat can reduce reperfusion time of STEMI patients who are transferred for PCI from community hospitals.

Keywords: Myocardial infarction, percutaneous coronary intervention, transfer


How to cite this article:
Wang G. Cardiac catheterization laboratory activation by social media reduces reperfusion time of patients transferred for primary percutaneous coronary intervention in community hospital. Environ Dis 2022;7:52-6

How to cite this URL:
Wang G. Cardiac catheterization laboratory activation by social media reduces reperfusion time of patients transferred for primary percutaneous coronary intervention in community hospital. Environ Dis [serial online] 2022 [cited 2022 Aug 12];7:52-6. Available from: http://www.environmentmed.org/text.asp?2022/7/2/52/349541




  Introduction Top


An important parameter to evaluate regional treatment and prognosis of patients with ST-segment elevation myocardial infarction (STEMI) is first medical contact (FMC)-to-device (FMC2D) time. Building up the regional collaborative network and prehospital activation of cardiac catheterization laboratory (CCL) are two effective methods to shorten the FMC2D time.[1] However, the regional collaborative network based on wireless Internet of Things and cloud technology has only been implemented in a small number of medical centers in China for the reason of the high cost and equipment requirements.[2],[3] WeChat is a free social communication application that the Chinese company Tencent launched in January 2011 to provide instant messaging services. WeChat sends free voice messages, videos, pictures, and text through the network. The aim of this study was to evaluate the impact of CCL activation by WeChat on reperfusion time in STEMI patients initially seen in community hospitals without percutaneous coronary intervention (PCI) capability.


  Methods Top


Study population

One hundred consecutive STEMI patients who initially present to community hospitals without ambulance and who are transferred from community hospitals to our hospital for primary PCI by emergency medical services (EMS) between July 2015 and July 2016 were enrolled. Eligibility for enrollment included the following: the symptoms of STEMI occurred within 12 h and ST-segment elevation of at least 2 mm in 2 contiguous precordial leads or 1 mm in 2 adjacent limb leads on electrocardiogram (ECG). The exclusion criteria were as follows: thrombolysis, coronary artery bypass grafting history, and contraindications for antiplatelet and anticoagulant therapy.

Patients were divided into two groups: the CCL group comprised 43 patients whose ECG was transmitted through WeChat by a doctor on duty in the community hospital and confirmed by an interventional cardiologist in our hospital. The interventional doctor is responsible for notifying the transfer and activating CCL. The patient was then transferred bypassing emergency department (ED) to the CCL by EMS. At the same time, the interventional cardiologist arrived at CCL and prepared for PCI; the control group comprised 57 patients without ECG transmission through WeChat who were transferred from community hospitals to the ED of our hospital by EMS. The patients were evaluated by a doctor in ED and then a cardiologist on duty was called for consultation and activated CCL [Figure 1]. This study was approved by the local institutional ethics committees. Informed consent was given by patients.
Figure 1: Study flowchart. CCL: Cardiac catheterization laboratory, ED: Emergency department, PCI: Percutaneous coronary intervention

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Percutaneous coronary intervention procedure

All patients were given 300 mg of aspirin at no charge and ticagrelor (180 mg loading dose), which was donated by the “A Pack of Medicine” Project (sponsored by the Chinese Red Cross Foundation and AstraZeneca) after STEMI was diagnosed in the community hospital. The right radial artery was the default arterial access. Unfractionated heparin (UFH; 100 IU/kg) was used as an anticoagulant agent. Intra-aortic balloon pump was used for patients with hemodynamic instability. After coronary angiography of non-infarct related artery (IRA) confirmed by ECG, IRA coronary angiography and PCI were performed with a guiding catheter. Device selection was at the operator's discretion. After procedure, arterial sheaths were withdrawn immediately, and a TR band (Terumo, Tokyo, Japan) was used for hemostasis for 6 h. If the PCI was performed through the femoral artery, the sheath was removed 4 h later and a bandage was applied to assure hemostasis for 12 h. All patients were discharged from the hospital on dual antiplatelet agents (aspirin and clopidogrel or ticagrelor), unless contraindicated, for at least 12 months.

Endpoints and definitions

The symptom onset-to-FMC time, FMC2D, the rate of FMC2D <120 min, and door-to-device (D2D) time were recorded. FMC2D was defined as the time from FMC to the first device (balloon, aspiration catheter, or stent) use. D2D was defined as the time from the patient arrived at our hospital to the first device use.

Statistical analysis

All statistical tests were performed using SPSS 17.0 (SPSS, Inc., Chicago, IL). Continuous variables were expressed as the mean ± standard deviation or median (interquartile range) and compared between groups using a t-test or Mann–Whitney test, where appropriate. Categorical data were indicated as the absolute number and percentages and were compared using the Chi-square or Fisher's exact test. A two-tailed P < 0.05 was considered statistically significant.


  Results Top


Baseline characteristics

A total of 100 consecutive patients presented with STEMI were analyzed. There were 82 males and 18 females. The average age was 57.10 ± 13.80 years. There were no significant differences in the baseline clinical characteristics between the two groups [Table 1].
Table 1: Demographics and baseline characteristics

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Angiographic and procedural characteristics

The angiographic and procedural characteristics were similar between groups [Table 2] and [Table 3]. There were no significant differences between the two groups, including access crossover rate, number of diseased vessels, and stents implanted.
Table 2: Angiographic characteristics

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Table 3: Procedural characteristics

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Treatment times and clinical outcome

[Table 4] shows the treatment times and clinical outcome of the two groups. The symptom onset-to-FMC time was similar (median IQR min, 100.00 [74.50–247.00] vs. 105.00 [70.00–180.00], P > 0.05) between the two groups. Compared to the control group, the CCL group has shorter FMC2D (median IQR min, 95.00 [72.60–160.58] vs. 160.79 [124.72–205.50], P < 0.001) and D2D times (median IQR min, 17.18 [13.77–21.15] vs. 49.27 [40.26–64.90], P < 0.001). Achieving the FMC2D time goal of <120 min increased from 29.82% in the control group to 76.74% in the CCL group (P < 0.001).
Table 4: Treatment times and clinical outcome

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No significant differences were noted in creatine kinase-MB peak value, left ventricular ejection fraction, and hospital mortality rate between the two groups (P > 0.05).


  Discussion Top


This study demonstrated that CCL activation by physicians with WeChat in a community hospital and transfer of patients with STEMI directly to the CCL in a PCI-capable hospital can significantly shorten the FMC2D time by 65.80 min and shorten the D2D time by 32.10 min. Achieving the FMC2D time goal of <120 min increased from 29.80% in the control group to 76.70% in the CCL group.

According to the European and American guidelines for STEMI,[1],[4] patients who are initially admitted to a hospital that cannot perform PCI should be transferred immediately to the hospital which has the ability to perform primary PCI, and the FMC2D time should be within 120 min. Several strategies, including the use of prehospital ECGs, prehospital activation of the CCL, and directly transport to CCL bypassing the ED, are recommended to reduce reperfusion time.[5],[6],[7]

Recent studies have shown that prehospital CCL activation by a regional collaborative network based on wireless Internet of Things reduced the FMC2D time by 10–35 min.[8],[9],[10],[11] However, the effectiveness may be limited by the cost of dedicated equipment, physician training, and technical limitations.[12]

Our hospital is the only PCI center in Tongzhou district of Beijing, which can provide primary PCI 24 h/day and 7 day/week. When CCL was activated, interventional doctors can arrive at CCL within 20 min. Our hospital has established WeChat groups with EMS and half of the community hospitals in Tongzhou district since July 2015. In the CCL group, CCL can be activated earlier. EMS staff can communicate with interventional cardiologist during transferring a patient. When the transferred patient was on road, the interventional doctors had received information and prepared for PCI in CCL.

There may be some concerns about confidentiality of patients. Both community hospitals and our hospital have established patient information protection policies. The doctor on duty in community hospital obtained informed consent before transmission of ECG. There are several WeChat groups and people who were not in the group will not see the information.

WeChat is often used in daily life in China, which can deliver texts and multimedia content.[13] The WeChat characteristics of convenience, promptness, and cross-platform support simplify telecommunication and teleconsultation between physicians in a non-PCI-capable hospital and interventional team in a PCI-capable hospital. WeChat can also activate the CCL earlier, reduce interhospital delays, and improve the FMC2D time.

In the present study, ECG transmission by WeChat to a PCI center for consultation with an interventional doctor may be an effective method to reduce FMC2D time. We found that bypassing the ED was associated with a 65.80 min (95.00 min vs. 160.80 min) reduction in the FMC2D time and a 32.10 min (17.20 min vs. 49.30 min) reduction in the D2D time compared with the control group. There was a 40.90% absolute increase in achieving a FMC2D <120 min. This finding is consistent with the Astarcioglu et al.'s study,[14] which reported a 21-min shorter FMC2D time (109 min vs. 130 min, P < 0.001) using a smartphone and the WhatsApp messenger for interhospital transfer of STEMI patients. The basis for the prolonged FMC2D in the control group included examination and evaluation in ED, consultation of cardiologists, and delays in CCL activation.[12]

In addition, inappropriate activation of the CCL was decreased with WeChat conveying of the ECG for consultation with a cardiologist.

Limitations

Several potential limitations should be considered. First, this was a retrospective study; the sample size is relatively small. Second, several key factors which were thought to contribute to the FMC2D time, including social background, family structure, variability of ED providers, and selection bias by EMS, were not included in the study. Finally, our study originated from a single primary PCI center of Tongzhou District of Beijing. As such, our findings may not be applicable to other cities with different geographic features or infrastructure.


  Conclusion Top


CCL activation through WeChat bypassing the ED was associated with more rapid FMC2D time and D2D time in STEMI patients who were transferred from a community hospital and an increase in the proportion of patients meeting guideline recommendations. Further researches in larger number of patients may be needed to evaluate the impact of this strategy on clinical outcomes.

Financial support and sponsorship

This study was supported by Tongzhou District Health Development Research (TWKY-2016-ZD-01-08).

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Steg PG, James SK, Atar D, Badano LP, Blömstrom-Lundqvist C, et al. Task Force on the management of ST-segment elevation acute myocardial infarction of the European society of cardiology (ESC), ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J 2012;33:2569-619.  Back to cited text no. 1
    
2.
Duan T, Xiang D, Qin W, Peng Y, Li R, Peng H, et al. Impact of establishing regional collaborative network on reperfusion time and prognosis of patients with ST-segment elevated myocardial infarction admitting to community hospitals without percutaneous coronary intervention capacity. Zhonghua Xin Xue Guan Bing Za Zhi 2014;42:641-5.  Back to cited text no. 2
    
3.
Liang Y, Xu L, Yan J, Liu P, Yuan W, Chen X, et al. Impact of new regional cooperative rescue model on first medical contact to balloon time and outcome in patients with ST-segment elevation myocardial infarction. Zhonghua Xin Xue Guan Bing Za Zhi 2014;42:646-9.  Back to cited text no. 3
    
4.
O'Gara PT, Kushner FG, Ascheim DD, Casey DE Jr, Chung MK, de Lemos JA, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013;61:e78-140.  Back to cited text no. 4
    
5.
Kahlon TS, Barn K, Akram MM, Blankenship JC, Bower-Stout C, Carey DJ, et al. Impact of pre-hospital electrocardiograms on time to treatment and one year outcome in a rural regional ST-segment elevation myocardial infarction network. Catheter Cardiovasc Interv 2017;89:245-51.  Back to cited text no. 5
    
6.
Bata A, Quraishi AU, Love M, Title L, Beydoun H, Lee T, et al. Initial experience with pre-activation of the cardiac catheterization lab and emergency room bypass for patients with ST-elevation myocardial infarction in Halifax, Nova Scotia. Int J Cardiol 2016;222:645-7.  Back to cited text no. 6
    
7.
Roswell RO, Greet B, Parikh P, Mignatti A, Freese J, Lobach I, et al. From door-to-balloon time to contact-to-device time: Predictors of achieving target times in patients with ST-elevation myocardial infarction. Clin Cardiol 2014;37:389-94.  Back to cited text no. 7
    
8.
Bagai A, Jollis JG, Dauerman HL, Peng SA, Rokos IC, Bates ER, et al. 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;128:352-9.  Back to cited text no. 8
    
9.
Ducas RA, Labos C, Allen D, Golian M, Jeyaraman M, Lys J, et al. Association of pre-hospital ecg administration with clinical outcomes in ST-segment myocardial infarction: A systematic review and meta-analysis. Can J Cardiol 2016;32:1531-41.  Back to cited text no. 9
    
10.
Mumma BE, Kontos MC, Peng SA, Diercks DB. Association between prehospital electrocardiogram use and patient home distance from the percutaneous coronary intervention center on total reperfusion time in ST-segment-elevation myocardial infarction patients: A retrospective analysis from the national cardiovascular data registry. Am Heart J 2014;167:915-20.  Back to cited text no. 10
    
11.
Wang B, Wang Y, Ye T, Xiao G, Chang H, Wen H, et al. Integrated regional network construction for ST-segment elevation myocardial infarction care. Zhonghua Xin Xue Guan Bing Za Zhi 2014;42:650-4.  Back to cited text no. 11
    
12.
Bagai A, Al-Khalidi HR, Muñoz D, Monk L, Roettig ML, Corbett CC, et al. Bypassing the emergency department and time to reperfusion in patients with prehospital ST-segment-elevation: findings from the reperfusion in acute myocardial infarction in Carolina emergency departments project. Circ Cardiovasc Interv 2013;6:399-406.  Back to cited text no. 12
    
13.
Zeng F, Deng G, Wang Z, Liu L. WeChat: A new clinical teaching tool for problem-based learning. Int J Med Educ 2016;7:119-21.  Back to cited text no. 13
    
14.
Astarcioglu MA, Sen T, Kilit C, Durmus HI, Gozubuyuk G, Kalcik M, et al. Time-to-reperfusion in STEMI undergoing interhospital transfer using smartphone and WhatsApp messenger. Am J Emerg Med 2015;33:1382-4.  Back to cited text no. 14
    


    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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