Open Access e-Journal Cardiometry - No.15 November 2019

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Table 3. In-hospital echocardiographic parametersMR grade(n, %)ESV (ml)EDV (ml)EF (%)WMSIVariables Group-1 (N=100) Group-2 (N=100) Group-3 (N=100) pMR (n, %) 14 (14.0%) a 12 (12.0%) a 3 (3.0%) b #0.020*Mild 11 (78.6%) 10 (83.3%) 3 (100.0%)Moderate 3 (21.4%) 2 (16.7%) 0 (0.0%)&1.000Mean ±SD 85.2±4.1 a 84.3±3.8 a 74.8±4.1b ^Range 77.9–93.0 78.1–92.8 60.6–81.7<0.001Mean ±SD 163.2±3.3 a 163.4±3.3 a 159.8±3.9b ^Range 154.7–171.2 154.5–170.0 148.4–169.6<0.001Mean ±SD 47.8±2.4a 48.4±1.9a 53.2±1.8b ^Range 40.0–51.0 41.0–51.0 51.0–60.0<0.001Mean ±SD 1.8±0.08a 1.8±0.06a 1.6±0.07b ^Range 1.70–2.00 1.70–2.00 1.40–1.70<0.001^ANOVA test with post hoc Bonferroni test. #Chi square test with post hoc Bonferroni test & Fisher's exact test. Homogenousgroups had the same letter "a, b") *SignificantEDV= End-diastolic volume, EF= Ejection fraction, ESV= End-systolic volume, , MR= Mitral regurgitation, WMSI= Wall motionscore indexFigure 1. Key time intervals among study groups.D2B= Door-to-balloon , ED= Emergency departmentDiscussion“Time is muscle” when it comes to emergent reperfusionof patients presenting with STEMI. Therefore,recent guidelines still recommend strict time framesfor primary PCI in the setting of STEMI (with a D2Btime of < 90 minutes) [1]. In recent years, the focushas shifted towards reduction of out-of-hospital componentof the total ischemic time, but these efforts arefaced with some difficulties related to public awareness,traffic infrastructure, etc. [11]. One of the componentsof the D2B time is the ED waiting time, whichcan be reduced by a strategy of pre-activation of theCCL team before patient arrival [5]. This requires acommunication between non-PCI capable and PCIcapable centers through an established system. Constructionof such a system in many developing countrieswith burdened economies (including Egypt)may not be ready for the prime time. Accordingly,we set out to test the hypothesis that utilizing freesmartphone messaging applications that are used bymillions all over the world such as WhatsApp for inter-hospitaltransfer for primary PCI in STEMI couldtranslate into reduction of D2B times through avoidingED waiting.Our main finding is that using WhatsApp forpre-activation of CCL teams during inter-hospitaltransfer for primary PCI in STEMI was associatedwith a significant reduction in ED waiting times andhence D2B times and total ischemic time as well. Tothe best of our knowledge, data on using smartphonemessaging applications for facilitating inter-hospitaltransfer for primary PCI in STEMI are scarce and thisis the 1st study on a national base and may be in theArab world evaluating this issue.Astarcioglu et al [12] evaluated 108 patients withSTEMI in a rural hospital with emergency departmentbut without PCI capability to determine the impact ofWhatsApp triage and activation of the CCL team onD2B time. They found that this strategy was associatedwith shorter D2B time (109±31 minutes in theintervention group vs. 130±46 minutes in the controlgroup, p<0.001) and results in a greater proportion ofpatients achieving guideline recommendations. Anotherstudy [13] showed that smartphone-based Tele-ECG support for primary care physicians reduced thehospital-to-Aspirin time in acute coronary syndromesignificantly (p<0.0001). Another unpublished workpresented at the Argentine Congress of Cardiology(SAC 2017) [14] concluded that among 900 STEMI60 | Cardiometry | Issue 15. November 2019
patients, symptom-onset-to-treatment time was significantlylower for those in the WhatsApp groupcompared with the other patients 150 vs 200 minutes(P < 0.001).The novelty of the current study (apart from beingthe 1st on a national base and may be in the Arabworld) emerges from the fact that we not only evaluatedthe impact of WhatsApp transfer on key timeintervals, but also we discussed in details its impact onvarious important echocardiographic parameters andselected in-hospital outcomes (namely, hospital stayand all-cause in-hospital mortality). Notably, the D2Btimes in the current study were exceedingly higherthan what’s recommended in the guidelines (this wastrue even among the group with the best-case-scenario‘group 3’). Taking the observational nature of thecurrent study into consideration, this might representa call for action, that much effort is still needed to theclose the gap between the real situation in a developingcountry like Egypt and the guideline-recommendedtime frames.Two main limitations deserve mention, first, therelatively small sample size did not allow the power forcalculation of the full spectrum of in-hospital clinicaloutcomes. Second, no formal calculation of the doorin-door-out(DIDO) time was done. This is becausepatients in groups 1 and 2 were mixed population (includingthose who were transferred from a non-PCIcapable centers and those who presented directly tothe PCI centers included in the study).ConclusionsUsing smartphone messaging applications suchas WhatsApp for pre-activation of CCL teams duringinter-hospital transfer for STEMI primary PCI is associatedwith scientifically shorter ED waiting andD2B times. This might be relevant for develop-ingcountries lacking inter-hospital robust communicationsystems. Adequately powered randomized trial isneeded to evaluate the impact of such a strategy onclinical outcomes.Statement on ethical issuesResearch involving people and/or animals is in fullcompliance with current na-tional and internationalethical standards.Conflict of interestNone declared.Author contributionsThe authors read the ICMJE criteria for authorshipand approved the final manuscript.References1. Ibanez B, James S, Agewall S, et al. 2017 ESC Guidelinesfor the management of acute myocardial infarctionin patients presenting with ST-segment elevation:The Task Force for the management of acute myocardialinfarction in patients presenting with ST-segmentelevation of the European Society of Cardiology(ESC). European heart journal. 2017; 39: 119-77. Doi:10.1093/eurheartj/ehx3932. Stone GW, Dixon SR, Grines CL, et al. Predictorsof infarct size after primary coronary angioplasty inacute myocardial infarction from pooled analysisfrom four contemporary trials. The American journalof cardiology. 2007; 100: 1370-5. Doi: 10.1016/j.amjcard.2007.06.0273. Brodie BR, Stone GW, Cox DA,et al. Impact oftreatment delays on outcomes of primary percutaneouscoronary intervention for acute myocardialinfarction: analysis from the CADILLAC trial. Americanheart journal. 2006; 15: 1231-8. Doi: 10.1016/j.ahj.2005.07.0164. Menees DS, Peterson ED, Wang Y, et al. Door-toballoontime and mortality among patients undergoingprimary PCI. New England Journal of Medicine.2013; 369: 901-9. Doi: 10.1056/NEJMoa12082005. Fordyce CB, Al-Khalidi HR, Jollis JG, et al. Associationof rapid care process implementation on reperfusiontimes across multiple ST-segment–elevationmyocardial infarction networks. Circulation: CardiovascularInterventions. 2017; 10: e004061. Doi: 10.1161/CIRCINTERVENTIONS.116.0040616. Bagai A, Jollis JG, Dauerman HL, et al. Emergencydepartment bypass for ST-segment–elevation myocardialinfarction patients identified with a prehospitalelectrocardiogram: a report from the AmericanHeart Association Mission: Lifeline Program. Circulation.2013; 128: 352-9. Doi: 10.1161/CIRCULATIO-NAHA.113.0023397. Helal AM, Shaheen SM, Elhammady WA, et al. PrimaryPCI versus pharma-coinvasive strategy for STelevation myocardial infarction. IJC heart & vascu-lature.2018; 21: 87-93. Doi: 10.1016/j.ijcha.2018.10.0068. Bendary A, Tawfek W, Mahros M, et al. PrimaryPCI versus Pharmaco-Invasive Strategy in Patientswith ST-Elevation Myocardial Infarction; a Random-Issue 15. November 2019 | Cardiometry | 61
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