Optimizing the early treatment of a threatening myocardial infarction

Acute myocardial infarction is the single most common cause of death for both women and men in Sweden. Great efforts have, over the years, been made to improve immediate treatment and care of acute coronary syndromes. Through fast and efficient chest pain care we know that we can minimize myocardial damage and improve outcome and prognosis. In this thesis we have focused on the early chain of care in patients with a threatening myocardial infarction. In five papers we describe chest pain care in our community with regard to the gender-, the foreign-, the age and the comorbidity perspective. We have also investigated predictors of direct admittance to a coronary care unit and predictors of mortality. Regarding the gender perspective, women with chest pain were older as compared to men. Women were not admitted to a coronary care unit as often as men and there were longer delays to the right level of care and to performance of coronary angiography among women. However, a final acute coronary syndrome diagnosis was more common in the male group. Among women, who actually had an acute coronary syndrome and were admitted to a coronary care unit, gender differences were minor or even non-existent. In non-Swedish speaking chest pain patients we found a higher prevalence of diabetes and previous stroke, placing them at increased risk also for coronary heart disease. Poorer language proficiency was associated with longer delay time from arrival in hospital to admission to a coronary care unit or catheterization laboratory. Maybe this prolonged delay is due to communication difficulties and there could be room for improvements by increased use of interpreters. The strongest predictor for admittance to a coronary care unit was a prehospital ECG suggesting acute occlusion of a coronary vessel. Interestingly, these patients had lower 1-year mortality. The future challenge is to improve early cardiac care for the large infarction-group with poor prognosis but without such alarming ECG signs. In the municipality of Gothenburg there are three hospitals offering emergency care for chest pain patients. In our studies we found differences between these hospitals especially with regard to delays to coronary angiography in presumed acute coronary syndrome patients. Our data highlight logistical problems that our health care system has to deal with in order to improve chest pain care and to follow current guidelines. Hopefully our findings will improve the early treatment of a threatening myocardial infarction and hopefully other communities can learn from our experience. Our goal is an efficient and equitable chest pain care despite age, gender, ethnicity and geographical belongings.