Assessment of hospital arrival time and associated factors of patients with acute myocardial infarction (STEMI) to introduce thrombolytic therapy at Jimma Medical Center, Jimma, Ethiopia

doi:10.21203/rs.3.rs-3240624/v1

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Assessment of hospital arrival time and associated factors of patients with acute myocardial infarction (STEMI) to introduce thrombolytic therapy at Jimma Medical Center, Jimma, Ethiopia

https://doi.org/10.21203/rs.3.rs-3240624/v1

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Background

Acute cardiovascular emergencies, including ST-segment elevation myocardial infarction (STEMI) and acute ischemic stroke, are common conditions requiring timely medical intervention. Thrombolytic therapy is an important treatment option for these conditions, although its effectiveness depends on prompt hospital arrival. This study aimed to assess the arrival time and associated factors in patients with ACS-STEMI at the Jimma Medical Center, with the objective of determining the need and applicability of thrombolytic therapy.

Methodology

: This hospital-based cross-sectional study was conducted at the Jimma Medical Center between September 1st and January 30, 2023. All patients diagnosed with ACS-STEMI during the study period were included. Data were collected using structured questionnaires and were entered into Epi-data version 3.1 for analysis. Chi-square tests and logistic regression models were used to examine the relationships between the variables.

Results

Among 63 patients admitted with ACS-STEMI, males accounted for 57.1%, and 42,9% of all admissions were in the 55—64 age group. More than two-thirds of the participants did not attend formal education, and hence could not read and write, and most (68%) used public transport to reach the medical center. Most participants had a very low monthly income of less than 50 USD. Approximately 62% of the study participants arrived at the Medical Center 12 h after the onset of chest pain (average time of arrival was approximately 33 h and 21 min). The sudden onset of symptoms and proximity to the Medical Center (within 5 km) were related to a shorter time of arrival, while those with diabetes mellitus had a longer time of arrival.

Conclusion

The time of arrival was longer in the patients with ACS-STEMI. Level of education, misinterpretation of symptoms, and lack of public health insurance were the major correlates of prehospital delays. This emphasizes the need to improve public health literacy, health insurance coverage, and the availability of standby emergency public ambulances, which shortens the time-to-needle and leads to early medical intervention that reduces morbidity and mortality, while improving survival and quality of life.

Acute cardiovascular emergencies

ST-segment elevation myocardial infarction

time of arrival

thrombolytic therapy

Jimma Medical Center

Ethiopia

Acute cardiovascular emergencies include ST-segment– elevation myocardial infarction (ACS- STEMI), ACS-NSTEMI/unstable angina, out-of-hospital cardiac arrest (OHCA), acute aortic dissection (AAD), abdominal aortic aneurysm (AAA), stroke and acute decompensated heart failure with or without cardiogenic shock. ST-segment elevation myocardial infarction (ACS-STEMI) and acute ischemic stroke are treated with thrombolytic therapy or other reperfusion strategies, in addition to optimal medical treatment. ST-elevation myocardial infarction (STEMI) is a clinical syndrome characterized by the characteristic symptoms of acute myocardial infarction, resulting in persistent ST elevation and the release of biomarkers of myocardial necrosis. It is caused by acute near-total occlusion of the culprit artery, and is mostly diagnosed in the presence of ischemic chest pain ¹.

Thrombolytic agents are plasminogen activators that convert the proenzyme plasminogen into the active enzyme plasmin, which digests fibrin into soluble degradation products. Inhibition of the fibrinolytic system occurs at the level of plasminogen activator (mainly by plasminogen activator inhibitor-1, PAI-1) and plasmin (mainly by α2-antiplasmin). Thrombolytic therapy is particularly effective in the early hours of Acute Myocardial Infarction, and its benefits are well established. Thrombolytic therapy has been shown to reduce mortality, decrease infarct size, and improve left ventricular function ².

Several types of thrombolytic agents can be used in clinical practice, including alteplase, reteplase, tenecteplase, and streptokinase. Alteplase is the most commonly used thrombolytic agent for ACS-STEMI, as it has been shown to be safe and effective in multiple clinical trials ^3,4. In Ethiopia, Thrombolytic therapy has been used to treat ACS-STEMI patients since the early 2000s. However, the use of this therapy is still low in the country. A study conducted in 2015 reported that only 4.3% of ACS-STEMI patients in Ethiopia were treated with thrombolytic therapy (Gebremariam et al., 2015). According to a study conducted by the American Heart Association, approximately 30% of patients with ST-segment elevation myocardial infarction (STEMI) in the United States were treated with thrombolytic therapy.

Despite the well-established benefits of thrombolytic therapy, it has several potential risks. Bleeding, which is the main risk associated with thrombolytic therapy, can occur at the site of the infarct, as well as in other parts of the body. Therefore, careful patient selection is critical to ensure that the benefits of thrombolytic therapy outweigh their risks. Some patient profiles may indicate an increased risk of thrombolysis-related bleeding. These include recent surgery, active bleeding, uncontrolled hypertension, and a history of intracranial hemorrhage ⁵. Additionally, the time from symptom onset to treatment is an important factor to consider as the effectiveness of thrombolytic therapy decreases over time, although there are still complications. The greatest benefit occurs when thrombolysis is initiated within 6 hours of symptom onset, although it exerts a definite benefit when initiated within 12 hours. These benefits are independent of age, sex, and the presence of comorbid conditions such as diabetes mellitus, although the degree of benefit varies among patient groups ⁶.

Study Design and setting

A quantitative prospective observational hospital-based study was conducted at the Jimma Medical Center, Ethiopia, from September 1st to January 30, 2022. The Jimma Medical Center is a tertiary teaching hospital located in Jimma Town, the Oromia region of Ethiopia, which serves a population of over 20 million catchment areas. The medical center has over 1500 healthcare providers serving approximately 160,000 outpatients, 11,000 emergency cases, and more than 4700 deliveries per year. The hospital provides coronary care services, including outpatient follow-up Clinics, Emergency care services, especially for spectrums of acute coronary syndromes; inpatient services with Electrocardiogram, Echocardiography, and stress testing services for patients with heart failure; and other major facilities, including diabetes care and follow-up, dialysis, and higher imaging services including computed tomography and magnetic resonance imaging (MRI). The setup also has an installed catheterization machine, which is a brand new of its kind and can start both diagnostic and interventional angiography very soon.

Inclusion and exclusion criteria

Patients with ACS-STEMI as confirmed by ECG and/or cardiac biomarkers, admitted to the cardiac unit of the Jimma Medical Center within the study period, and willing to participate in the study were included. Patients diagnosed with ACS-STEMI who declined to participate or those who died in the hospital while having a presumptive diagnosis of ACS-STEMI, but relevant data could not be obtained, were excluded from the study.

Sample size determination:

A previous study conducted in a similar setting reported a prevalence of delayed arrival (defined as more than 2 hours after the onset of symptoms) in patients with ACS-STEMI of 60.5 [29]. To detect a significant difference with a power of 80% at the level of significance of 0.05, this formula was used:

n = [(Zα/2 + Zβ) ² * (P1 * (1 - P1) + p2 * (1 - p2))] / (P1 - P2) ²

Where:

Zα/2 is the z-score for the significance (1.96 for α = 0.05)

Zβ is the z-score for power in the study (0.84 for power = 0.8)

P1 was the prevalence of delayed arrival in a previous study (0.6).

P2 was the expected prevalence of delayed arrival in this study (0.4).

n = [(1.96 + 0.84) ² * (0.6 * 0.4 + 0.4 * 0.6)] / (0.6 − 0.4) ²

n = 95

Data collection:

A structured data collection format, which was tested for consistency prior to data collection, was used, including the Socio-demographic characteristics (age, sex, chart number, marital status, level of education, monthly income, and area of residence) and clinical profiles of the patients with ACS-STEMI, with special focus on the time of onset of their symptoms and time of arrival. The charts of the patients were collected and reviewed for additional data regarding previous patient care, type and type of medication the patients took, previous history of admission, and possible reasons and management provided in the current presentation. The data collectors used personal protective equipment, such as alcohol-based hand sanitizers and face masks, to reduce the risk of transmitting infections from patients to the data collectors and vice versa.

Data analysis:

Data were analyzed using Epidata manager version 3.1 and then transported to SPSS version 26 for analysis. Demographic characteristics of the study participants were descriptively analyzed. Categorical data were analyzed using frequencies (n) and percentages (%), and are represented in graphs and pie charts. Continuous data were analyzed using the mean (SD) for normally distributed data or the median (IQR) for skewed data. Chi-square, Fisher’s exact, and student data were used in bivariate analysis, while binary logistic analysis was used to conduct multivariate analysis. Fischer´s exact test was used when the cell frequency was less than five (n < 5), while the chi-square test was used for cell frequency (n > 5). The significance level was set at P < 0.05. The odds ratio was used to show the direction of the association between independent and dependent variables.

Study limitation:

As this was a cross-sectional study, it was impossible to analyze the causal relationship between the study variables. It also included only those patients admitted to the medical ward. In addition to the small sample size, it is difficult to identify factors associated with admitted cases compared with non-admitted patients who can be referred to another institution or even die at the time of arrival. In addition, this is a finding from a single institution, which affects generalizability.

Ethical consideration:

Ethical clearance was obtained from the Institutional Review Board (IRB) of the Institute of Health, Jimma University. Written informed consent was obtained from all study participants before data collection. All the patients were granted the right to withdraw from the study at any given time. Patient confidentiality and privacy were ensured throughout the study period by removing identifiers from the data collection tools by using different codes. Neither the data records nor the extracted data were used for any other purposes.

Socio-demographic characteristics

All 63 patients admitted to the Internal Medicine Wards of Jimma Medical Center, Ethiopia, with ACS-STEMI during the study period were interviewed and enrolled in the study, with a 100% response rate. Most of the study participants were male (57.1%, male to female ratio of 1:1.33), and most were between 55 and 64 years of age. Most of the patients (71.4%) had no formal education. The approximate yearly income of most study participants (52.4%) was less than 5000ETB (50 USD), while about one-third of them had a yearly income in the range of $50–100. Most patients (87.3%) were married and 79.4 of them were lived with their families. More than half of the study population (61.9%) needed to travel a minimum of 5 km to visit the Jimma Medical Center for better care, and more than two-thirds of the participants used general public transport to reach the Medical Center. The average times taken to arrive at the Medical Center were 33 h and 21 min, respectively (Table 1).

Table 1

*Sociodemographic characteristics of ACS-STEMI among adult patients admitted to f Jimma Medical Center,2022*
Variables		Frequency	Percent
Age category	< 45	2	3.2
	45–54	12	19.0
	55–64	27	42.9
	65–74	12	19.0
	75+	10	15.9
Gender	Male	36	57.1
Gender	Female	27	42.9
Marital status	Married	55	87.3
	Single	1	1.6
	Widowed	7	11.1
Living status	Alone	13	20.6
Living status	with family	50	79.4
Family income of the participant	lower < 5000	33	52.4
	middle 5000–10000	19	30.2
	higher > 10000	11	17.5
Educational status of the participant	Unable to read and write	45	71.4
	Able to read and write	4	6.3
	university graduate	14	22.2
Transport	Ambulance	11	17.5
	general transport	43	68.3
	horse or with bare foot	9	14.3
Distance	< 5km	39	61.9
Distance	> 5km	24	38.1

Time arrival and correlates of pre- hospital delay

Of the 63 patients with ACS-STEMI, 39 (61.9%) arrived 12 h after symptom onset, while 24 (38.1%) arrived within 12 h, with the average time taken for patients with ACS-STEMI to arrive at the Medical Center after 33 h and 21 min (SD plus or minus 41 h and 36 min). The first medical action after onset of symptoms (p = 0.000, cOR = 1.050), mode of transport to the Medical Center (p = 0.000, cOR = 0.013), distance from the hospital (p = 0.000), history of recurrent angina (p = 0.000, cOR = 0.131), status of health insurance (p = 0.005, cOR = 0.222), symptoms (p = 0.000, cOR = 0.031), obesity (p = 0.016, cOR = 0.250), history of diabetes (p = 0.000, cOR = 0.078), blood pressure (p = 0.010, cOR = 1.705), and cholesterol levels (p = 0.027, cOR = 0.277), and behavior after onset of symptoms (p = 0.002, cOR = 2.864; p = 0.002, cOR = 14.000; p = 0.002, cOR = 21.000 for misinterpreting the nature of the pain, not considering the symptoms to be serious, and waiting to see if symptoms would go away, respectively) were factors contributing to pre-hospital delays (Table 2).

Table 2

Association between related variables and pre-hospital delay among ACS-STEMI patients admitted to JUMC, 2022
Variables	Subgroups	< 12	> 4.5	Total	COR [CI]	p-value
Age Category	< 45	0	2	2		0.162
	45–54	3	12	15	1.286 [0.196–8.431]
	55–64	10	27	37	0.729 [0.153–3.474]
	65–74	8	12	20	0.214 [0.035–1.307]
	75+	3	10	13
Gender	Male	11	25	36	0.474 [0.168–1.335]	0.155
Gender	Female	13	14	27		0.155
Marital Status	Married	20	35	55	2.333 [0.474–11.495]	0.414
	Single	0	1	1
	Widowed	4	3	7
Living Status	Alone	5	8	13	0.981 [0.280–3.439]	0.976
Living Status	With Family	19	31	50		0.976
Family Income of The Participant	Lower < 5000	16	17	33	0.092 [0.044–1.264]	0.157
	Middle 5000–10000	6	13	19	0.429 [0.079–2.948]
	Higher > 10000	2	9	11
Educational Status of The Participant	Unable To Read and Write	16	29	45	1.813 [0.539–6.093]	0.534
	Able To Read and Write	1	3	4	3.000 [0.248–36.325]
	University Graduate	7	7	14
First Medical Action After Onset of Symptoms	No Measure	2	21	23	1.050 [0.085–12.995]	0.000
	Visiting Qualified Doctor	11	3	14	0.027 [0.002–0.307]
	Visiting Non-Qualified Practitioner	7	0	7
	Self-Medication	3	5	8	0.167 [0.014–2.040]
	Go To Spiritual Place	1	10	11
Mode of transport to Jimma Medical Center	Ambulance	10	1	11	0.013 [0.001–0.233]	0.000
	General Transport	13	30	43	0.288 [0.033–2.548]
	Horse Or with Bare Foot	1	8	9
Distance of Hospital from residence of the Participant	< 5km	24	15	39		0.000
Distance of Hospital from residence of the Participant	> 5km	0	24	24		0.000
Recurrent Angina Within 2 Weeks Before Admission	Yes	18	11	29	0.131 [0.041–0.417]	0.000
Recurrent Angina Within 2 Weeks Before Admission	No	6	28	34		0.000
Health Insurance	Yes	16	12	28	0.222 [0.075–0.659]	0.005
Health Insurance	No	8	27	35		0.005
Symptoms	Predominantly chest pain	14	2	16	0.031 [0.004–0.212]	0.000
	Predominantly other pain	7	23	30	0.704 [0.156–3.177]
	Symptoms other than pain predominated	3	14	17
Obesity	No	19	19	38	0.250 [0.078–0.804]	0.016
Obesity	Yes	5	20	25		0.016
History of Diabetes mellitus	No	22	18	40	0.078 [0.016–0.378]	0.000
History of Diabetes mellitus	Yes	2	21	23		0.000
Blood Pressure	Unknown	4	5	9	1.705 [0.370–7.854]	0.010
	Normal	5	23	28	6.273 [1.813–21.703]
	Hypertension	15	11	26
Smoker	No	20	30	50	0.667 [0.180–2.463]	0.541
Smoker	Yes	4	9	13		0.541
Cholesterol	Normal	19	20	39	0.277 [0.086–0.891]	0.027
Cholesterol	High	5	19	24		0.027
History of angina	No	10	17	27	1.082 [0.387–3.028]	0.55
History of angina	Yes	14	22	36		0.55
Behavior after onset of Symptoms	Misinterpreted the nature of the pain	2	9	11	2.864 [0.473–17.351]	0.002
	Did not consider the symptoms to be serious	4	16	20	14.000 [2.061–95.085]
	Waited to see symptoms would go away	2	12	14	21.000[2.397-183.986]
	Suspected as heart diseases	16	2	18

Furthermore, visiting a physician at the first point of care significantly lowered the odds of a longer hospital arrival time and first medical management. The odds of delayed arrival time and medical management were reduced by a factor of 0.011 (95% confidence interval:0.000–0.449). This means that patients who visited physicians at the first point of care were 91 times less likely to experience delayed hospital arrival and medical treatment than those who visited other health care providers.

Conversely, patients with a history of diabetes had significantly higher odds of having longer hospital arrival times than those without a history of diabetes. The odds of delayed arrival increased by a factor of 31.730 (95% CI,1.751–574.976). This may be because patients with diabetes mellitus present with atypical symptoms that delay the recognition of a cardiovascular emergency, leading to delayed hospital arrival (Table 3).

Table 3

Logistic regression results of pre-hospital delay among ACS-STEMI patients admitted to JUMC,2022
Variables	Sig.	AOR	95% C. I
Variables	Sig.	AOR	Lower	Upper
Visiting physician vs, no measure	0.017	0.011	0.000	0.449
History of diabetes vs no history of diabetes mellitus	0.019	31.730	1.751	574.976
Gender (female vs male)	0.269	0.250	0.021	2.922

Most of the study participants were male (57.1%, male to female ratio of 1:1.33), and most were between 55 and 64 years of age. This finding is similar to that of a study conducted in India, which showed that the majority of patients with ACS-STEMI were male in the age group–51–70 years ⁷. Another study conducted in the United States reported that Patients with ACS-STEMI were generally older, male, and had a higher prevalence of cardiovascular risk factors ⁸. The average time taken for the patients to arrive at the hospital in this study is prolonged, as compared to the study conducted in Nigeria and South Africa, which reported that the average pre-hospital delay was 8.1 hours among patients with ACS-STEMI ⁹ and 260 minutes, respectively ¹⁰. This was even much longer as compared to studies conducted in the United Kingdom and the United States that reported an average pre-hospital delay of 2.6 hours ⁹ and approximately 60 minutes, respectively ¹¹.

The presence of recurrent angina (OR = 0.078), lack of health insurance (OR = 0.101), and symptoms such as chest pain (OR,0.227), obesity (OR,0.261), history of diabetes mellitus (OR,0.277), high blood pressure (OR,0.211), and high cholesterol levels (OR,0.146) were associated with delayed hospital arrival. Furthermore, patients who visited a heart failure physician at the first point of care had significantly lower odds of a longer hospital arrival time and first medical management. The odds of delayed arrival time and medical management were reduced by a factor of 0.011 (95% confidence interval:0.000–0.449). This means that patients who visited physicians at the first point of care were 91 times less likely to experience delayed hospital arrival and medical treatment than those who visited other health care providers.

Conversely, patients with a history of diabetes mellitus had significantly higher odds of longer hospital arrival times than those without a history of diabetes mellitus. The odds of delayed arrival increased by a factor of 31.730 (95% CI,1.751–574.976). This may be because patients with diabetes mellitus present with atypical symptoms that delay the recognition of a cardiovascular emergency, leading to delayed hospital arrival.

Previous studies have consistently reported that delayed hospital arrival is a significant problem in patients with cardiovascular emergencies including ST-elevation myocardial infarction (ACS-STEMI) ¹². The average time taken for patients to arrive at the hospital ranges from less than 30 min to more than 3 hours ^13,14, which is much shorter than that found in this study. Patients who had delays in seeking medical attention were those with older age, female sex, lower socioeconomic status, and lack of knowledge about symptoms of heart attack ^15,16. However, patient age and sex did not significantly contribute to delayed hospital arrival in this study.

The time of arrival for patients with ACS-STEMI was longer. Level of education, misinterpretation of symptoms, and lack of public health insurance were major correlates of longer prehospital delays. Furthermore, the presence of diabetes mellitus as a comorbidity further prolongs the time of hospital arrival, leading to misinterpretation of symptoms. This emphasizes the need to improve public health literacy, health insurance coverage, and the availability of standby emergency public ambulances, which may shorten the time-to-needle and lead to early medical intervention that reduces morbidity and mortality, while improving survival and quality of life.

Data sharing Statement

All data are available within the article.

Ethical Approval

Ethical clearance was obtained from the Institutional Review Board (IRB) of the Institute of Health. A formal support letter was obtained from the respective administration. All study participants and their respective stakeholders were informed of the purpose of the study, and written informed consent was obtained from all participants. We used an impartial witness during the entire informed consent process and data collection period for participants who were unable to read or write. The study was conducted per the declaration of Helsinki. Confidentiality of participants’ information was kept using unique codes rather than personal identification.

Acknowledgment

We are grateful to the Jimma Medical Center Medical Ward staff and other healthcare professionals working in the ward for their kind cooperation throughout the study.

Author Contributions

KNT and YDB wrote the main document. ETA and EGA revied the manuscript. KNT, YDM done the analysis. All authors reviewed the manuscript.

Funding

This research received no specific grants from any funding agency in the public, commercial, or nonprofit sectors.

Disclosure

The authors report no conflicts of interest in this work.

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No competing interests reported.

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You are reading this latest preprint version

Assessment of hospital arrival time and associated factors of patients with acute myocardial infarction (STEMI) to introduce thrombolytic therapy at Jimma Medical Center, Jimma, Ethiopia

Status:

Version 1

Abstract

Background

Methodology

Results

Conclusion

Introduction

Material and methods

Inclusion and exclusion criteria

Sample size determination:

Data collection:

Data analysis:

Study limitation:

Ethical consideration:

Results

Socio-demographic characteristics

Time arrival and correlates of pre- hospital delay

Discussion

Conclusion

Declarations

Data sharing Statement

Ethical Approval

Acknowledgment

Author Contributions

Funding

Disclosure

References

Additional Declarations

Status:

Version 1