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Impact of a nationwide public campaign on delays and outcome in Swiss patients with acute coronary syndrome Barbara Naegeli, Dragana Radovanovic, Hans Rickli, Paul Erne, Burkhardt Seifert, Nicole Duvoisin, Giovanni Pedrazzini, Philip Urban and Osmund Bertel European Journal of Cardiovascular Prevention & Rehabilitation 2011 18: 297 originally published online 11 February 2011 DOI: 10.1177/1741826710389386 The online version of this article can be found at: http://cpr.sagepub.com/content/18/2/297

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EURO PEAN SO CIETY O F CARDIOLOGY ®

Original scientific paper

Impact of a nationwide public campaign on delays and outcome in Swiss patients with acute coronary syndrome

European Journal of Cardiovascular Prevention & Rehabilitation 18(2) 297–304 ! The European Society of Cardiology 2011 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1741826710389386 ejcpr.sagepub.com

Barbara Naegeli1, Dragana Radovanovic2, Hans Rickli3, Paul Erne4, Burkhardt Seifert5, Nicole Duvoisin2, Giovanni Pedrazzini6, Philip Urban7 and Osmund Bertel1

Abstract Background: To improve the outcome in patients with acute coronary syndrome (ACS), public campaigns have been launched aimed at shortening presentation delays and allowing more efficient treatment. Their impact is uncertain. Methods: Pre-hospital delays and outcome in patients with ACS included in the Swiss National AMIS Plus registry were assessed prospectively before and after a nationwide multimedia campaign (‘HELP’) by the Swiss Heart Foundation in 2007. The campaign aimed at better awareness of symptoms, increasing knowledge in laymen of resuscitation and more rapid access to medical services. The primary study endpoint was the time between onset of symptoms and hospital admission. Secondary endpoints were successful out-of-hospital resuscitation, symptoms upon admission, and outcome. Results: Between January 2005 and December 2008, 8906 ACS patients (61% ST-segment elevation myocardial infarction (STEMI), 39% non-ST-segment elevation myocardial infarction/unstable angina pectoris (NSTEMI/UAP), mean age 65  13 years, 75% males) admitted within 24 hours after onset of symptoms were enrolled. The median pre-hospital delay was reduced from 197 minutes during the pre-intervention period to 180 minutes during the post-intervention period (reduction 10% (95% confidence interval (CI) 6–14%); P < 0.001), in STEMI (reduction 10% (95% CI 5–14%); P < 0.001) and NSTEMI patients (reduction 11% (95% CI 4–17%); P ¼ 0.001), due to pronounced effects in males (reduction 12% (95% CI 7–16%); P < 0.001) and in patients 75 years (reduction 12% (95% CI 8–16%); P < 0.001). Out-of-hospital resuscitation increased (odds ratio (OR) 1.26 (95% CI 1.06–1.54); P ¼ 0.02). Overall outcome remained unchanged, however, the rate of re-infarction showed a decrease (OR 0.58 (95% CI 0.36–0.91); P ¼ 0.021). Conclusions: After a nationwide educational campaign, shorter pre-hospital delays were observed, and more patients were able to be treated promptly. These results may be useful in planning future health strategies to improve management and outcome of patients with ACS, especially in female and elderly patients.

Keywords Public campaign, acute coronary syndrome, pre-hospital delays, resuscitation, outcome Received 3 May 2010; accepted 28 July 2010

1

Introduction

HerzGefa¨ssZentrum, Klinik Im Park, Zu¨rich, Switzerland. AMIS Plus Data Center, Institute of Social and Preventive Medicine, Zu¨rich University, Switzerland. 3 Division of Cardiology, Kantonsspital, St.Gallen, Switzerland. 4 Division of Cardiology, Luzerner Kantonsspital, Switzerland. 5 Biostatistics Unit, Institute of Social and Preventive Medicine, Zu¨rich University, Switzerland. 6 Division of Cardiology, Cardiocentro Ticino, Lugano, Switzerland. 7 Cardiovascular Department, Hopital de la Tour, Switzerland. 2

Cardiovascular disease is a major cause of morbidity and mortality,1 accounting for 40% of deaths in Switzerland.2 The time between onset of symptoms and beginning treatment has a critical impact on morbidity and outcome in patients with acute coronary syndrome (ACS) and acute myocardial infarction (AMI).3–7 Furthermore, time is also a crucial factor in cases of sudden death, where patients die before they receive medical care or reach hospital. Therefore, public health strategies must aim to shorten patient

Corresponding author: Barbara Naegeli, HerzGefa¨ssZentrum, Klinik Im Park, Seestrasse 247, CH-8027 Zu¨rich, Switzerland Email: [email protected]

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and treatment delays and accommodate rapid access to acute care for ACS/AMI.8,9 Such interventions in several countries in trying to achieve these goals in the past have often been difficult to evaluate, and reports with widely differing results have been published.10–13 In many of these studies interventional methods and contents, duration of intervention, target populations and outcome measures have been poorly defined, explaining conflicting results. We report on a prospective outcome evaluation of a nationwide public campaign of the Swiss Heart Foundation (‘HELP campaign’) by using the nationwide AMIS (Acute Myocardial Infarction in Switzerland) Plus patient registry.14 To improve the final outcome of patients with ACS, the HELP campaign had three aims: (1) to improve knowledge and awareness of early symptoms of acute myocardial infarction (ischaemic pain and severe dyspnoea), (2) to speed up patient access to emergency medical services using a uniform phone number, and (3) to propagate skills for resuscitation and basic life support to the public.

Methods Intervention The nationwide HELP campaign of the Swiss Heart Foundation. Commencing January 2007, the Swiss Heart Foundation launched a nationwide public campaign aimed at improving outcome in patients with ACS and stroke. Information and detailed programme activities can be found at www.helpbyswissheart.ch. In short, for patients with ACS, the programme aimed at improved knowledge of symptoms, and focused on correct and rapid intervention in order to speed up patient access to emergency medical services (call for help, dial the national emergency number ‘144’). Moreover, simple instructions for resuscitation and use of automated external defibrillators (AED) were publicized widely. Throughout 2007, these issues were covered by a multimedia campaign including TV spots broadcast on Swiss public television before the daily evening news during early and late 2007 (from 18 January to 18 March 2007 and from 26 September to 4 November 2007). Media coverage was complemented by widely distributed fliers, promotions and public events throughout the country. National activities were brought to various regions by regional HELP committees. They organized group training for layman resuscitation and other regional events (www.helpzuerich.ch). After these activities in 2007, the HELP programme is ongoing, focusing on workplace resuscitation courses. Certification and further activities have been included in school curricula.

Patients: The AMIS Plus registry. The AMIS Plus registry, established in 1997, is a nationwide project initiated by the Swiss Societies of Internal Medicine, Cardiology and Intensive Care Medicine. Details and results of this registry have been previously published.14–16 It is an on-going national registry encompassing a national network between participating acute hospitals, and the AMIS Plus Data Center. Teaching and non-teaching hospitals all over Switzerland participate voluntarily and provide blind data of these patients to the Data Center via an online or written questionnaire with 150 items. The Data Center controls and checks the data for plausibility and crosschecks in case of queries. (The AMIS Plus questionnaire can be downloaded from the AMIS Plus website: www.amisplus.ch (documents).) Stored data on 33,000 patients are on file. Data of this registry representing Switzerland have been included in a recent survey on ST elevation acute myocardial infarction in Europe.16 Patients are enrolled in the registry on grounds of their final diagnosis, which must comply with one of the three earlier described ACS definitions (i.e. ST-segment elevation ACS, non-ST-segment elevation ACS or unstable angina (UAP)). Details and definitions of the registry have been published elsewhere.14 Cases with unclear or non-cardiac diagnoses were not included. Demographic data, clinical variables, procedures and events were collected at admission and during the hospital stay by physicians and dedicated nurses. The registry was approved by the Supraregional Ethical Committee for Clinical Studies and the Swiss Board for Data Security.

Outcome evaluation To investigate the potential impact of the HELP campaign on delay time and outcome, we analysed all patients included in the AMIS Plus registry between the years 2005 and 2006 (pre-intervention period), and between the years 2007 and 2008 (post-intervention period), respectively. Patients referred more than 24 hours after symptom onset and patients whose referral and treatment delays could not be analysed correctly due to transfer reasons between hospitals, as well as those who suffered their index ACS during hospitalization were excluded. Variables were measured and collected prospectively according to the questionnaire and definitions of the AMIS Plus registry. Primary endpoint of the study was the time between symptom onset and hospital admission (pre-hospital delay). Secondary endpoints were successful pre-hospital resuscitation, symptoms on admission, outcome including in-hospital mortality, re-infarction and stroke.

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Statistical methods Categorical variables are presented as numbers with percentages and compared between periods using the chi-square test. Odds ratios including 95% confidence intervals (CI) are computed using logistic regression. Continuous variables are presented as means  standard deviation or medians with interquartile range and compared using the Mann–Whitney U-test. As the variables delay and door-to-balloon time are approximately log-normally distributed, changes of these variables were calculated as ratios of geometric means and presented as percent change including 95% confidence interval (95% CI). All analyses were conducted using commercially available statistical software (SPSS version 15.0, SPSS Inc., Chicago, Illinois, USA). All P-values are two-sided and considered statistically significant if 0.05.

Results Patient characteristics Patient demographics and characteristics are presented in Table 1. A total of 8906 ACS patients (75% males) from 60 hospitals (which contributed to both observational periods) with a mean age of 65  13 years were included. During the pre-intervention period 5006, and during the post-intervention period 3900 eligible patients could be analysed. Both groups were comparable in age, gender, prior coronary artery

disease, risk factors, ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction/unstable angina pectoris (NSTEMI/UAP).

Pre-hospital delay (onset of symptoms to hospital admission) Time between onset of symptoms and hospital admission during the HELP campaign and post-intervention period was reduced by 10% (95% CI 6–14%) compared to the pre-intervention period. The median delay decreased from 197 minutes to 180 minutes (P < 0.001). This decrease could be observed in all ACS patients and in various subgroups as depicted in Table 2. Significant decreases in delay during the campaign period were found in STEMI and NSTEMI/UAP patients (180 minutes versus 161 minutes for STEMI during the campaign period (reduction 10% (95% CI 6–14%), P ¼ 0.001), and 240 minutes versus 218 minutes for NSTEMI/UAP during the campaign period (reduction 12% (95% CI 7–16%), P < 0.001, respectively), as well as in male patients, in patients younger than 75 years and also in patients with typical symptoms at admission (Table 2). In addition, the percentage of patients arriving within the first hour after symptom onset significantly increased during the HELP campaign period compared with the pre-intervention period (13.2% vs. 10.9%, OR 1.25 (95% CI 1.10–1.42), P ¼ 0.001; Figure 1).

Table 1. Baseline characteristics of the patients admitted with acute coronary syndrome according to HELP campaign periods

Number of patients Men Age mean years (SD) Cardiovascular risk factors History of CAD Diabetes Hypertension Dyslipidaemia Current smoker Obesity (BMI>30 kg/m2) Family history of early CAD STEMI NSTEMI UAP

Pre-intervention period (n/N)

Post-intervention period (n/N)

P-value

5006 74.7% (3737/5006) 65.7  13.4

3900 74.2% (2894/3900) 65.4  13.6

0.64 0.29

37.8% (1892/5002) 17.9% (856/4785) 59.1% (2805/4746) 55.3% (2416/4367) 38.3% (1807/4722) 20.1% (869/4315) 34.7% (1433/4126) 61.3% (3069/5006) 32.8% (1645/5006) 5.8% (292/5006)

36.8% (1434/3898) 18.3% (687/3745) 61.7% (2270/3677) 53.2% (1810/3403) 38.8% (1389/3582) 20.2% (661/3265) 33.4% (1107/3318) 60.2% (2348/3898) 34.3% (1337/3898) 5.5% (213/3898)

0.32 0.59 0.01 0.06 0.65 0.91 0.22 0.31 0.15 0.46

All acute coronary syndrome patients admitted within 24 hours after symptom onset. Pre-intervention period ¼ 2005/2006. Post-intervention period ¼ 2007/2008. SD, standard deviation; CAD, coronary artery disease; BMI, body mass index; STEMI, ST-segment elevation myocardial infarction; NSTEMI, non-ST-segment elevation myocardial infarction; UAP, unstable angina pectoris.

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Table 2. Median time between onset of symptoms and hospital admission for acute coronary syndrome (ACS) (pre-hospital delay in minutes) according to HELP campaign periods in all patients and in various subgroups (interquartile range 25, 75 percentile)

14%

p = 0.001

12%

10.9%

13.2%

10% 8%

PostPreintervention intervention Changea period period (95% CI) P-value All ACS patients N ¼ 5006 197 (105, 440) ACS type NSTEMI/UAP N ¼ 1937 240 (120, 613) STEMI N ¼ 3069 180 (101, 360) Gender Male N ¼ 3737 190 (105, 430) Female N ¼ 1269 220 (120, 480) Age 75 years N ¼ 3716 195 (105, 426) >75 years N ¼ 1290 210 (120, 480) Symptoms at admission Typical N ¼ 4267 195 (105, 421) Atypical N ¼ 405 205 (105, 603)

6% 4% 2%

N ¼ 3900 180 (90, 400)

10% (6–14%)