Coronary artery disease
Prehospital Delay in Patients With Acute Coronary Syndromes (from the Global Registry of Acute Coronary Events [GRACE])

https://doi.org/10.1016/j.amjcard.2008.10.038Get rights and content

Duration of delay in seeking medical care in persons with symptoms of evolving acute myocardial infarction (AMI) is of current interest given the time-dependent benefits associated with early use of coronary reperfusion approaches. The objectives of this multinational study were to describe geographic variation in the extent of and factors associated with prehospital delay in patients enrolled in the GRACE study. Data were collected from 44,695 patients hospitalized with an acute coronary syndrome in 14 countries from 2000 to 2006. The regions under study included Argentina and Brazil (n = 8,203), United States/Canada (n = 12,810), Europe (n = 19,354), and Australia/New Zealand (n = 4,328). Patients with ST-segment elevation AMI, non–ST-segment elevation AMI, and unstable angina comprised the study population. There were marked geographic differences in extent of prehospital delay in patients with ST-segment elevation AMI and those with non–ST-segment elevation AMI/unstable angina. In patients with ST-segment elevation AMI, the shortest duration of prehospital delay was observed in patients from Australia/New Zealand (median 2.2 hours), whereas patients from Argentina and Brazil delayed the longest (median 4.0 hours). Median duration of prehospital delay was shortest (2.5 hours) in patients with ST-segment elevation AMI, whereas patients with non–ST-segment elevation AMI/unstable angina showed considerably longer prehospital delay (3.1 hours). Several demographic and clinical characteristics were associated with prolonged delay overall and in the different geographic locations under study. In conclusion, results of this large multinational registry provided insights into contemporary patterns of care-seeking behavior in patients with acute coronary disease.

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Methods

Full details of the methods of this study have been published and are briefly described.1, 2 The Global Registry of Acute Coronary Events (GRACE) project is designed to reflect an unselected population of patients with ACS irrespective of geographic region. A total of 113 hospitals organized into 18 cluster sites in 14 countries in North and South America, Europe, Australia, and New Zealand are currently collaborating in the GRACE project. Patients with ST-segment elevation myocardial

Results

Overall, there were marked differences in durations of prehospital delay in patients with an ACS according to geographic region (Figure 1). The shortest duration of prehospital delay was observed in patients from study sites in Australia/New Zealand, whereas the longest delays were observed in patients from participating medical centers in Argentina and Brazil. In patients with ST-segment elevation acute MI (AMI), median duration of prehospital delay (3.1 hours) was longest in patients from

Discussion

Results of this large multinational study suggested there was wide geographic variation in care-seeking behavior in patients experiencing an ACS, delay patterns were shortest in those with ST-segment elevation AMI, and a number of factors distinguished patients seeking medical care in a more timely manner compared with those seeking medical care after more prolonged delay, both within and across the different geographic strata under study.

Although considerable success has been achieved in

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    Prehospital delay is the largest factor in delayed treatment for ACS (Moser et al., 2006). While population-based studies such as GRACE (Goldberg et al., 2009) and the Worcester Heart Attack Study (Saczynski et al., 2008) found median delay times ranging from 2.2–4.6 h, clinical studies have shown median delay times in presentation to the ED ranging from 1 to 24.4 h (Banks & Dracup, 2007; DeVon et al., 2010; Gorelik et al., 2007; Rosenfeld, 2004). In addition, mortality increases by 7.5% for each 30-min delay in treatment (De Luca et al., 2004; Levine et al., 2015; Mackay et al., 2014; McKee et al., 2013).

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The GRACE project was supported by an unrestricted educational grant from Sanofi-Aventis, Paris, France, to the Center for Outcomes Research, University of Massachusetts Medical School, Worcester, Massachusetts.

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