The national Moroccan Registry of ST-elevation Myocardial Infarction (MR-MI)

The national Moroccan Registry of ST-elevation Myocardial Infarction (MR-MI) | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The national Moroccan Registry of ST-elevation Myocardial Infarction (MR-MI) Aida Soufiani, Hamza Chraibi, Ilyasse Asfalou, Noha El Ouafi, and 10 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2812111/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 24 Aug, 2023 Read the published version in BMC Cardiovascular Disorders → Version 1 posted 13 You are reading this latest preprint version Abstract Background MR-MI is the first national Moroccan ST-elevation myocardial infarction (STEMI) registry. Its objectives are to assess patient management modalities and highlight the clinical and therapeutic characteristics of this pathology in all cardiology centres on a national scale. Methods Adult patients presenting with STEMI within 5 days of symptoms onset were enrolled over a period of 18 weeks from April to August 2018. 57 cardiology centres distributed in 22 cities in Morocco participated in the study, including 5 university hospitals, representing 70% of Moroccan centres managing STEMI patients. A case report form was sent to the investigators in both electronic and paper forms. Sociodemographic, clinical, management, revascularization, and follow-up data were collected. Results A total of 809 patients were recruited. The population was mostly male (74.8%) with an average age of 62.6 ± 11.6 years. The most common risk factors were smoking (38.3%) arterial hypertension (30.7%), and diabetes (28%). 30% of patients were admitted within the first 6 hours of symptoms onset and 49.6% benefitted from early revascularization. Mortality rate was 5.2% in-hospital and 3.2% at the one-month follow-up. Conclusion MR-MI is the first Moroccan STEMI registry on a national scale. Relevant management delays are much longer than other countries, and less than 50% of the patients that present on time benefit from early revascularization. Efforts remain to be done on the optimal diagnosis and treatment of STEMI. acute coronary syndrome acute myocardial infarction STEMI Figures Figure 1 Figure 2 Figure 3 Background Despite global improvements in management, cardiovascular disease, and more specifically ischemic heart disease (IHD) still represents a substantial health burden, with major social and economic consequences [ 1 – 4 ]. In Morocco, IHD has become the number one cause of mortality, with a 31% rate according to the 2019 Global Burden of Diseases Study [ 1 ]. Among cardiovascular risk factors, a recent meta-analysis remarked that tobacco smoking (20 to 45%) and hypertension (25 to 30%) are the most prevalent in the Moroccan population [ 5 ]. Management of ST-elevation myocardial infarction (STEMI) remains far from optimal; in a study published in 2012 regrouping patients from Morocco, Tunisia, and Algeria, Moustaghfir et al. reported that almost half of the patients do not receive any reperfusion therapy, explaining the higher rate of 30-day mortality compared to other countries (4.1%) [ 6 ]. The 2018 MR-MI (Moroccan Registry of Myocardial Infarction) is a project of the Moroccan Society of Cardiology in partnership with the National College of Myocardial Infarction. Our goals were: to extensively characterize the clinical profile of STEMI patients throughout Morocco’s regions, and set up a reference database for future studies; to quantitatively and qualitatively assess the current state of STEMI management in Morocco, and consequences on short- and long-term patient outcomes; to study the implementation of relevant practice guidelines in a real-world setting. Large-scale descriptive studies are far and few in Morocco. The largest myocardial infarction registry is a city-wide effort from Fez, published in 2015 by Akoudad et al. and compiling 1835 patients [ 7 ]. To our knowledge, this is the first national scale STEMI registry in Morocco. Methods Study design This was a national prospective multicentre study, including all centres practicing invasive cardiac catheterization. Study population Data was collected over a period of 18 weeks, from April to August 2018. Inclusion criteria were: patients aged > 18 years; admitted for recent (less than 5 days) STEMI, defined as a rise of troponin or another cardiac enzyme, and at least one of the following: ST-segment elevation, new abnormal Q waves or new-onset bundle branch block. Exclusion criteria were: STEMI with symptom onset > 5 days; patients admitted for NSTE-ACS (non ST-elevation acute coronary syndrome); patients admitted in cardiac arrest, who died in transport or very early after admission. All patients gave informed concent to participate in the study. Study organization Participating centres 57 centres across 22 cities accepted to participate in the study, including university and provincial hospitals, military hospitals, and private clinics, and covering a large majority of the Moroccan territory (Fig. 1 ). 5 university hospitals were represented (Rabat, Casablanca, Fez, Oujda, Marrakech). Data collection Sociodemographic data such as mode of living and health coverage was collected. Clinical data included medical history and cardiovascular risk factors, STEMI symptoms and timing, vital constants and Killip class at admission, findings on the first ECG (electrocardiogram) and TTE (transthoracic echocardiography) such as wall motion abnormalities and LVEF (left ventricular ejection fraction). The speed and quality of management was thoroughly documented; revascularization modalities, angiographic findings, and relevant time delays (symptoms-to-first medical contact and symptoms-to-management) were precisely recorded. Follow-up data included in-hospital complication and mortality rates, and outcomes at one month. Statistical analysis Qualitative variables are reported as means ± standard deviations (SD), and median values were calculated when appropriate. Discrete variables are reported as percentages. Statistical analyses were performed using SPSS software. Comparisons were done using the chi-square test or Fisher’s exact test when the sample size was too small. Results Baseline characteristics A total of 809 STEMI patients was included, originating from 76 cities and 68 rural villages. The majority were admitted in university hospitals (52.9%), followed by regional hospitals (20.7%) and private centres (14.3%). 15% didn’t have any health coverage (Table 1 ). The mean age was 62.6 ± 11.6 years, and 42% of patients were younger than 60. The majority were men (74.8%). The most common modifiable cardiovascular risk factors were smoking (38.3%) and arterial hypertension (30.7%). 65% of patients had 3 or more risk factors. 63% had no cardiovascular medical history (Table 2 ). The main complaint was typical chest pain (56.4%), followed by heart failure symptoms (13.4%). The majority were Killip I at admission (73.2%). The mean heart rate and blood pressures were 85 ± 20 beats per minute and 131 ± 26 / 78 ± 17 mmHg, respectively. Prehospital ECG was obtained only in 0.9% of cases. The most common arrhythmias were premature ventricular contractions (4.5%) and atrial fibrillation (AF) or flutter (3.1%). The majority of STEMI were anterior (47.9%) or inferior (36%). Mean LVEF was 45 ± 10%, and 27% of patients had a reduced LVEF (< 40%). Table 1 Baseline characteristics of STEMI patients Variables Patients (N = 809) Centre University hospital (%) 52.3 Regional hospital (%) 20.7 Military hospital (%) 10.8 Private clinic (%) 14.3 Private practice (%) 1.9 Demographics Age (years) 62.6 ± 11.6 Women (%) 25.2 Urban origin (%) 76.5 Rural origin (%) 23.5 Health coverage (%) 85.0 Cardiovascular risk factors Diabetes (%) 28.0 Arterial hypertension (%) 30.7 Smoking (%) 38.3 Dyslipidaemia (%) 13.6 Body mass index 26.6 ± 4.1 Family history of CAD (%) 7.5 Cardiovascular history and comorbidities Angina (%) 74.2 Myocardial infarction (%) 16.6 PCI (%) 8.6 CABG (%) 1.0 Stroke (%) 3.0 Peripheral artery disease (%) 2.6 Chronic kidney disease (%) 8.6 Data are expressed as percentage (%) or mean ± SD. CABG: coronary artery bypass graft; CAD: coronary artery disease; PCI: percutaneous coronary intervention; STEMI: ST-segment-elevation myocardial infarction. Table 2 Initial presentation Variables Patients (N = 809) First medical contact Emergency department (%) 68.8 Private cardiology practice (%) 22.8 Private general practice (%) 8.4 EMS involvement (%) 3.2 Initial symptoms Typical chest pain (%) 56.4 Atypical chest pain (%) 6.1 Heart failure (%) 13.4 Syncope (%) 1.1 Cardiac arrest (%) 0.5 Others (%) 6.0 Initial Killip class I (%) 73.2 II (%) 20.2 III (%) 4.3 IV (%) 2.1 Admission parameters Heart rate (beats per minute) 85.6 ± 19.6 Systolic blood pressure (mmHg) 131.5 ± 26.4 Diastolic blood pressure (mmHg) 78.0 ± 16.7 Electrocardiographic findings Sinus rhythm (%) 80.4 Atrial fibrillation or flutter (%) 3.1 Ventricular arrythmia, including PVC (%) 4.9 ST-elevation (%) 63.8 Anterior leads (%) 43.3 Inferior leads (%) 32.5 Lateral leads (%) 11.9 Other leads (%) 2.6 Pathological Q waves (%) 32.4 LBBB or RBBB (%) 3.8 Echocardiographic findings TTE performed (%) 63.0 LVEF (%) 44.9 ± 10.8 Akinesia (%) 80.4 Hypokinesia (%) 88.2 Data are expressed as percentage (%) or mean ± SD. EMS: emergency medical services; LBBB: left bundle branch block; LVEF: left ventricular ejection fraction; PVC: premature ventricular contractions; LBBB: left bundle branch block; RBBB: right bundle branch block; TTE: transthoracic echocardiography. Management and reperfusion The median symptoms-to-first medical contact delay was 690 minutes and 50% of patients presented after the 12-hour mark (Fig. 2 ). The median symptoms-to-management delay was 815 minutes (Fig. 3 ). Regarding medical therapy, most patients received aspirin, clopidogrel and low molecular weight heparin. 23.4% of patients benefitted from fibrinolysis, with a median time delay of 6 hours, and the majority being performed in university hospitals. 98% of patients underwent coronary angiography, regardless of delay. 26.2% of patients underwent percutaneous coronary intervention (PCI), mostly in private centres and university hospitals, with a median delay of 3 hours. The most common culprit artery, in 81.2% of cases, was the left anterior descending (Table 3 ). Table 3 Initial management Variables Patients (N = 809) Procedures and revascularization Coronary angiography (%) 98 Vascular access Radial (%) 53.7 Femoral (%) 46.1 Culprit artery Left anterior descending (%) 81.2 Circumflex (%) 10.9 Right coronary (%) 7.1 PCI (%) 26.2 PCI < 24 hours from symptom onset (%) 14.3 Median delay (hours) 3 Drug-eluting stent (%) 21.5 Thrombus aspiration (%) 3.8 Fibrinolysis (%) 23.4 Median delay (hours) 6 Medication Aspirin (%) 80.3 Clopidogrel (%) 85.7 LMWH (%) 81.6 UFH (%) 9.3 Fondaparinux (%) 1.5 Glycoprotein IIb/IIIa inhibitor (%) 5.4 Data are expressed as percentage (%). LMWH: low molecular weight heparin; PCI: percutaneous coronary intervention; UFH: unfractionated heparin. Outcomes In-hospital evolution was marked by a 17.4% rate of complications, the most prevalent being arrhythmias and recurrent ischemia. Mortality rate was 5.2%, with a mean age of 61 ± 11 years (Table 4 ). Follow-up data was available for 42.4% of the cohort. At the 1-month check, 94.1% of available patients were asymptomatic; the re-hospitalization and mortality rates were 2.1% and 3.8%, respectively (Table 5 ). Table 4 In-hospital evolution and outcomes Variables Patients (N = 809) Complications (%) 17.4 Ischemic recurrence (%) 1.7 Stent thrombosis (%) 0.6 Arrhythmia (%) 7.1 Conduction disturbance (%) 2.9 Mechanical complication (%) 4.9 In-hospital mortality (%) 5.2 Data are expressed as percentage (%). Table 5 Follow-up results at one month Variables Patients (N = 343) Asymptomatic (%) 94.1 Rehospitalization (%) 2.1 Mortality (%) 3.8 Data are expressed as percentage (%). Discussion MR-MI aimed to answer two important questions. First, what are the main differences between the Moroccan STEMI patients and those from other countries? Second, does the management in Morocco adhere to current practice guidelines? To answer the first question, our results should be compared to other Mediterranean countries, such as Tunisia [ 8 ] and France [ 9 ]. Sociodemographic data is similar in all three countries, with a mean age of 60 to 63 years, and a clear male predominance (74.8% in Morocco and France, 81.5% in Tunisia). Smoking and arterial hypertension are the most common risk factors although hypercholesterolemia is more prevalent in France (36 vs 13.6%) and smoking is much more frequent in Tunisia (63.6 vs 38.3%). Smoking is a major health issue in Morocco; with a prevalence of 30 to 50% [ 5 , 10 ]. That rate is probably higher due to the social stigma associated with smoking in Morocco, and the increase among young men of other forms of tobacco usage such as water pipe-smoking, which are not reported in many studies [ 5 ]. The prevalence of arterial hypertension in the Moroccan population ranges from 26 to 29% in most major reports [ 11 – 13 ]. Arterial hypertension is also severely underdiagnosed and undertreated in Morocco; in the ETHNA study, 29% of patients were newly diagnosed, and in treated hypertensive patients, control rates range from 25 to 35% [ 13 , 14 ]. Hypercholesterolemia was probably underreported in our study as 29% of Moroccan patients suffer from this condition [ 13 ]. This discrepancy is probably explained by the fact that practicians are less likely to perform lipid panels in the emergency setting. In our study, 63% of patients had no cardiovascular medical history, which is lower than in France (84%). Typical chest pain was the most common presentation in all three countries, but heart failure was more frequent in Maghreb countries (13.4 and 11.4%) compared to France (3%), underlining the late presentation of patients in those countries. The prevalence of AF in our study was similar to the French one (3.1 vs. 4%). Anterior and inferior STEMI comprised about 90% of all localizations in the three countries. The mean LVEF was slightly increased in France compared to Morocco (50.2 vs. 45%). Overall, the clinical profile of STEMI patients remains similar between the three countries. To answer the second question, it is essential to review revascularization modalities used and the various management delays. The 2017 European guidelines on STEMI recommend that a patient undergoes primary PCI within 48 hours (but preferably 12 hours) after symptom onset. Fibrinolysis should be administered within 12 hours after symptom onset if PCI is not available within 2 hours [ 15 ]. Early presentation of the patient is therefore crucial for optimal diagnosis and management. In Morocco, the symptom-to-first medical contact delay is much longer than in France (690 vs 141 minutes). Half of the patients consult after the key 12-hour mark, which explains why two thirds of the patients do not receive thrombolytic agents even when they’re available. Fibrinolysis was used in 23.4% of cases; that rate is higher in Tunisia (31.8%) but much lower in France (6%), underlining the poor availability of cath labs especially in rural areas and provincial hospitals. Only 14.3% benefit from primary PCI, compared to 30% in the Tunisian cohort and 91% in the French registry. These longer delays explain in part the higher rate of complications in Moroccan patients compared to French patients, especially recurrent myocardial infarction (1.7 vs 0.3%) and in-hospitality death (5.2% vs 2.8%). The mortality rate reported in our study is slightly inferior to the Tunisian one (5.2 vs 5.5%). At the one-month follow-up, it remains stable at 3.8%. What are concrete solutions to improve the situation in Morocco? We need to take a look at the 1995 to 2010 period in France, when 30-day mortality fell from 13.7–4.4% [ 16 ]. In addition to the STEMI demographic shift (patients were younger by 3 years on average), this decrease was mostly explained by shorter management delays (120 to 74 min), a greater involvement of emergency medical services (EMS), whose rate of use grew from 23 to 49% and a higher rate of primary angioplasty (49 to 75%) [ 17 ]. EMS involvement rate was only 3.2% in our study. By increasing the awareness of the general public about STEMI and the need to call EMS as soon as symptoms begin, management delays would be tremendously reduced, allowing for more efficient revascularization and better outcomes. The availability of cath labs is also an issue, especially in provincial hospitals where the only recourse is fibrinolysis, which is known to be inferior to PCI [ 7 , 18 ]. These are the main areas that Morocco is developing in the present and the near future. Since 2018, the Moroccan government has made great strides in the construction of new PCI centres, both private and public, and the development of chest pain awareness programs. Conclusions MR-MI is the first national STEMI registry in Morocco with a total of 809 patients and draws some important conclusions. The clinical profile of our patients is similar to that of other Mediterranean countries, but management suffers from many inadequacies, especially long time delays and inefficient revascularization options. Concrete, proven solutions exist, such as the involvement of EMS and the democratization of urgent angiography and PCI. Since 2018, Moroccan practicians and health officials have been involved in the development of these areas and much progress has been made in the right direction. Abbreviations ECG electrocardiogram EMS emergency medical services IHD ischemic heart disease LVEF left ventricular ejection fraction PCI percutaneous coronary intervention STEMI ST-elevation myocardial infarction TTE transthoracic echocardiogram Declarations Ethics approval and consent to participate This study was approved by the Ethics Committee of Rabat’s Faculty of Medicine and Pharmacy and was conducted in accordance in accordance with the Declaration of Helsinki and Morocco’s laws and regulations on human research. Consent for publication Not applicable. Competing interests The authors declare no competing interests. Funding None. Availability of data and materials The datasets used and/or analyzed in this study are available from the corresponding author on reasonable request. Authors' contributions AS – Conceptualization, Methodology. HC – Writing. IA, NE, ME, RH, AC, RF, HA, AB, MC, RA, NB, SZ – Review and editing. All authors have read and approved the manuscript. Acknowledgements The authors are exceedingly grateful to all those involved for successfully conducting the study. We would like to acknowledge and thank Amine A., Abourazzak A., Achkari Begdouri A., Achoukhi S., Agoumy J., Aitbella S., Akhbour S., Amellal S., Aouad A., Aziz A., Balafrej K., Barrada D., Belayachi J., Belghiti H., Beloauchi F., Benfarji A., Benlamine S., Benyamna I., Benzagmout K., Benzeroual D., Berrada M., Bigane K., Boulaamayl S., Bousabniya R., Chaara A., Cherradi G., Chetoui A., Chniber R., Choukri A. H., Chtioui M., Darif A., Drissi S., El Beqqali H., El Fath S., El Hattab F., El Marjani H., El Ouali L., El Hamzaoui H., El Khlifi A., El Ouarradi A., El Younassi B., Es-sabbani S., Fassi O., Fennich N., Guelzim Y., Haddour L., Hara L., Ismaili N., Jalal H., Kamal A., Kendoussi T., Khatri D., Lakhal Z., Lididi Y., Louahabi T., Loubaris M., Maliki S., Mayoussi C., Mechti A., Moubarki H., Mouine N., Nouamou I., Oukerraj L., Oussibla F., Rahmouni A., Rami A., Sabry M., Saghi G., Saidi I., Scadi E., Sebbar S., Shimou I., Talhi F., Tamdy A., Tazi Mezalek A., Zaidi K., Zaimi A., Zaimi S., Zarzur J., Zbir E., Zouhair S. References Roth GA, Mensah GA, Johnson CO, Addolorato G, Ammirati E, Baddour LM, GBD-NHLBI-JACC Global Burden of Cardiovascular Diseases Writing Group. ;. Global Burden of Cardiovascular Diseases and Risk Factors, 1990–2019: Update From the GBD 2019 Study. J Am Coll Cardiol. 2020 Dec 22;76(25):2982–3021. Erratum in: J Am Coll Cardiol. 2021 Apr 20;77(15):1958–1959. Townsend N, Kazakiewicz D, Lucy Wright F, Timmis A, Huculeci R, Torbica A, Gale CP, Achenbach S, Weidinger F, Vardas P. Epidemiology of cardiovascular disease in Europe. Nat Rev Cardiol. 2022 Feb;19(2):133–43. Bauersachs R, Zeymer U, Brière JB, Marre C, Bowrin K, Huelsebeck M. Burden of Coronary Artery Disease and Peripheral Artery Disease: A Literature Review. Cardiovasc Ther. 2019 Nov 26;2019:8295054. Keates A, Mocumbi A, Ntsekhe M, Sliwa K, Stewart S. Cardiovascular disease in Africa: epidemiological profile and challenges. Nat Rev Cardiol. 2017;14:273–93. Elyamani R, Soulaymani A, Hami H. Epidemiology of Cardiovascular Diseases in Morocco: A systematic review. Rev Diabet Stud. 2021;17(2):57–67. Moustaghfir A, Haddak M, Mechmeche R. Management of acute coronary syndromes in Maghreb countries: The access (acute coronary events – a multinational survey of current management strategies) registry. Arch Cardiovasc Dis. 2012;105(11):566–77. Akoudad H, El Khorb N, Sekkali N, Mechrafi A, Zakari N, Ouaha L et al. L’infarctus du Myocarde au Maroc: Les Données du Registre Fes-Ami. Annales de Cardiologie et d'Angéiologie. 2015;64(6):434–8. Addad F, Mahdhaoui A, Gouider J, Boughzela E, Kamoun S, Boujnah MR et al. Management of patients with acute ST-elevation myocardial infarction: Results of the fast-mi tunisia registry. PLoS ONE. 2019;14(2). Belle L, Cayla G, Cottin Y, Coste P, Khalife K, Labèque J-N, et al. French registry on Acute ST-elevation and non – ST-elevation myocardial infarction 2015 (FAST-MI 2015). design and baseline data. Arch Cardiovasc Dis. 2017;110(6–7):366–78. Nejjari C, Benjelloun MC, Berraho M, El Rhazi K, Tachfouti N, Elfakir S, et al. Prevalence and demographic factors of smoking in Morocco. Int J Public Health. 2009;54(6):447–51. Tazi MA, Abir-Khalil S, Chaouki N, Cherqaoui S, Lahmouz F, Sraïri JE, et al. Prevalence of the main cardiovascular risk factors in Morocco: results of a National Survey, 2000. J Hypertens. 2003 May;21(5):897–903. Ministry of Health of Morocco. National survey of noncommunicable diseases risk factors 2017–2018. https://www.sante.gov.ma/Documents/2019/05/Rapport%20de%20l%20enqu%C3%AAte%20Stepwise.pdf . Nejjari C, Arharbi M, Chentir MT, Boujnah R, Kemmou O, Megdiche H, et al. Epidemiological Trial of Hypertension in North Africa (ETHNA): an international multicentre study in Algeria, Morocco and Tunisia. J Hypertens. 2013 Jan;31(1):49–62. Essayagh T, Essayagh M, El Rhaffouli A, Khouchoua M, Bukassa Kazadi G, Khattabi A et al. Prevalence of uncontrolled blood pressure in Meknes, Morocco, and its associated risk factors in 2017. PLoS One. 2019 Aug 9;14(8):e0220710. Ibanez B, James S, Agewall S, Antunes MJ, Bucciarelli-Ducci C, Bueno H et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2018 Jan 7;39(2):119 – 77. Puymirat E, Simon T, Cayla G, Cottin Y, Elbaz M, Coste P, Lemesle G, Motreff P, Popovic B, Khalife K, Labèque JN, Perret T, Le Ray C, Orion L, Jouve B, Blanchard D, Peycher P, Silvain J, Steg PG, Goldstein P, Guéret P, Belle L, Aissaoui N, Ferrières J, Schiele F, Danchin N, USIK. USIC 2000, and FAST-MI investigators. Acute Myocardial Infarction: Changes in Patient Characteristics, Management, and 6-Month Outcomes Over a Period of 20 Years in the FAST-MI Program (French Registry of Acute ST-Elevation or Non-ST-Elevation Myocardial Infarction) 1995 to 2015. Circulation. 2017 Nov 14;136(20):1908–1919. doi: 10.1161/CIRCULATIONAHA.117.030798 . Puymirat E, Simon T, Steg PG, Schiele F, Guéret P, Blanchard D, USIK USIC 2000 Investigators; FAST MI Investigators. ;. Association of changes in clinical characteristics and management with improvement in survival among patients with ST-elevation myocardial infarction. JAMA 2012; 308:998–1006. https://doi.org/10.1001/2012.jama.11348 PMID: 22928184. Widimsky P. Primary angioplasty vs. thrombolysis: the end of the controversy? Eur Heart J. 2010 Mar;31(6):634–6. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 24 Aug, 2023 Read the published version in BMC Cardiovascular Disorders → Version 1 posted Editorial decision: Major revision 25 Jul, 2023 Reviews received at journal 24 Jul, 2023 Reviews received at journal 03 Jul, 2023 Reviewers agreed at journal 29 Jun, 2023 Reviewers agreed at journal 23 Jun, 2023 Reviews received at journal 29 May, 2023 Reviewers agreed at journal 26 May, 2023 Reviewers agreed at journal 26 May, 2023 Reviewers invited by journal 26 May, 2023 Editor assigned by journal 26 May, 2023 Editor invited by journal 18 Apr, 2023 Submission checks completed at journal 18 Apr, 2023 First submitted to journal 13 Apr, 2023 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2812111","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":220482108,"identity":"e4c6ad67-1832-4c76-a6de-b67002fd00b1","order_by":0,"name":"Aida Soufiani","email":"","orcid":"","institution":"Ibn Sina Hospital University Centre, Mohammed V University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Aida","middleName":"","lastName":"Soufiani","suffix":""},{"id":220482109,"identity":"e6ad8352-1c6c-44fa-a418-a7ff70280d4c","order_by":1,"name":"Hamza Chraibi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABAUlEQVRIiWNgGAWjYBACAyidwMDA2MaQYMAmB+IdeEC8lgI+Y7CWBOK0MLAxMHyQS2yAcXEBc/bTyR9+MNjlmbcfbnvwwMAsfX7Y4YdAW+zkdBuwa7Hsyd1g2MOQXCxzJrHdIMEgLXfj7TQDoJZkY7MDOBx2IHdDAg/DgcQZDIltEgkGx3I3zk4AaTmQuA2XlvNvNxz8A9LC/xCk5X+64ez0D/i13Mjd2Ay2RQJsC1uCvHQOAVtuvN3MLGOQDNTyEOQXNsMN0jkFBxIM8PjlfO7mj28q7IAOS3/28McfNnn52embP3yosJPDpQWqESVA0EUIAvkGUlSPglEwCkbBSAAAsKhmTy72RIoAAAAASUVORK5CYII=","orcid":"","institution":"Ibn Sina Hospital University Centre, Mohammed V University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Hamza","middleName":"","lastName":"Chraibi","suffix":""},{"id":220482110,"identity":"40171779-4fc1-4054-8933-8cdad9f990a1","order_by":2,"name":"Ilyasse Asfalou","email":"","orcid":"","institution":"Mohammed V Military Instruction Hospital, Mohammed V University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ilyasse","middleName":"","lastName":"Asfalou","suffix":""},{"id":220482111,"identity":"434c625b-d964-4c51-9f31-552638751b89","order_by":3,"name":"Noha El Ouafi","email":"","orcid":"","institution":"Mohammed VI Hospital University Centre, Mohamed Premier University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Noha","middleName":"El","lastName":"Ouafi","suffix":""},{"id":220482112,"identity":"9f215543-a67e-4362-b21c-18a7b8a23ab5","order_by":4,"name":"Mustapha El Hattaoui","email":"","orcid":"","institution":"Mohammed VI Hospital University Centre, Cadi Ayyad University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Mustapha","middleName":"El","lastName":"Hattaoui","suffix":""},{"id":220482113,"identity":"16b2dca5-e7df-49f4-92d9-66296761944a","order_by":5,"name":"Rachida Habbal","email":"","orcid":"","institution":"Ibn Rochd Hospital University Centre, Hassan II University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Rachida","middleName":"","lastName":"Habbal","suffix":""},{"id":220482114,"identity":"8a9ec00f-e3c0-4be3-908a-5a71e816a308","order_by":6,"name":"Ali Chaib","email":"","orcid":"","institution":"Mohammed V Military Instruction Hospital, Mohammed V University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ali","middleName":"","lastName":"Chaib","suffix":""},{"id":220482115,"identity":"7cfc396b-7611-4ff2-9519-8811f557a598","order_by":7,"name":"Rokya Fellat","email":"","orcid":"","institution":"Ibn Sina Hospital University Centre, Mohammed V University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Rokya","middleName":"","lastName":"Fellat","suffix":""},{"id":220482116,"identity":"da69f833-8fd1-4d75-9cf2-08327670492b","order_by":8,"name":"Hafid Akoudad","email":"","orcid":"","institution":"Hassan II Hospital University Centre, Sidi Mohamed Ben Abdellah University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Hafid","middleName":"","lastName":"Akoudad","suffix":""},{"id":220482117,"identity":"2f35894e-713a-4b52-957c-34892ed119e5","order_by":9,"name":"Aatif Benyass","email":"","orcid":"","institution":"Mohammed V Military Instruction Hospital, Mohammed V University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Aatif","middleName":"","lastName":"Benyass","suffix":""},{"id":220482118,"identity":"440b154a-e848-4f22-b949-3220104cb26e","order_by":10,"name":"Mohamed Cherti","email":"","orcid":"","institution":"Ibn Sina Hospital University Centre, Mohammed V University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Mohamed","middleName":"","lastName":"Cherti","suffix":""},{"id":220482119,"identity":"435db05e-0ee6-45d0-a472-f5394057b7fb","order_by":11,"name":"Redouane Abouqal","email":"","orcid":"","institution":"Ibn Sina Hospital University Centre, Mohammed V University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Redouane","middleName":"","lastName":"Abouqal","suffix":""},{"id":220482120,"identity":"c1a2e216-9ffa-4ec3-b92a-f70812f39528","order_by":12,"name":"Nesma Bendagha","email":"","orcid":"","institution":"Ibn Sina Hospital University Centre, Mohammed V University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Nesma","middleName":"","lastName":"Bendagha","suffix":""},{"id":220482121,"identity":"bdeb8100-fd24-43b2-a91b-2d2d8278ba0c","order_by":13,"name":"Samir Ztot","email":"","orcid":"","institution":"Mohammed V Military Instruction Hospital, Mohammed V University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Samir","middleName":"","lastName":"Ztot","suffix":""}],"badges":[],"createdAt":"2023-04-13 09:59:24","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2812111/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2812111/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12872-023-03458-7","type":"published","date":"2023-08-24T15:02:13+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":40620382,"identity":"61c14596-aba5-437b-9dd7-24ebf91613b5","added_by":"auto","created_at":"2023-07-26 17:39:28","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":124743,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eGeographical map of participating centres\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-2812111/v1/9ebcd42ecc8b5a9b5a0dd06e.png"},{"id":40620168,"identity":"56c48799-498d-4e13-969e-2cbd66f19ee3","added_by":"auto","created_at":"2023-07-26 17:31:28","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":41065,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSymptoms to first medical contact delay\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-2812111/v1/838000aa807d1a0210d362d0.png"},{"id":40620170,"identity":"3ec8921c-4a96-48a7-a982-a4f4a80b4fe9","added_by":"auto","created_at":"2023-07-26 17:31:28","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":38359,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSymptoms to management delay\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-2812111/v1/9e5986c85a14f388b1a74e1e.png"},{"id":42781529,"identity":"5a8720d7-ff85-49c0-b030-198bd5db0895","added_by":"auto","created_at":"2023-09-07 15:10:02","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":581508,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2812111/v1/572f1888-1985-40ff-b01d-7b0c487f3a67.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The national Moroccan Registry of ST-elevation Myocardial Infarction (MR-MI)","fulltext":[{"header":"Background","content":"\u003cp\u003eDespite global improvements in management, cardiovascular disease, and more specifically ischemic heart disease (IHD) still represents a substantial health burden, with major social and economic consequences [\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn Morocco, IHD has become the number one cause of mortality, with a 31% rate according to the 2019 Global Burden of Diseases Study [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Among cardiovascular risk factors, a recent meta-analysis remarked that tobacco smoking (20 to 45%) and hypertension (25 to 30%) are the most prevalent in the Moroccan population [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Management of ST-elevation myocardial infarction (STEMI) remains far from optimal; in a study published in 2012 regrouping patients from Morocco, Tunisia, and Algeria, Moustaghfir et al. reported that almost half of the patients do not receive any reperfusion therapy, explaining the higher rate of 30-day mortality compared to other countries (4.1%) [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe 2018 MR-MI (Moroccan Registry of Myocardial Infarction) is a project of the Moroccan Society of Cardiology in partnership with the National College of Myocardial Infarction. Our goals were:\u003c/p\u003e \u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eto extensively characterize the clinical profile of STEMI patients throughout Morocco\u0026rsquo;s regions, and set up a reference database for future studies;\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eto quantitatively and qualitatively assess the current state of STEMI management in Morocco, and consequences on short- and long-term patient outcomes;\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eto study the implementation of relevant practice guidelines in a real-world setting.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e \u003cp\u003eLarge-scale descriptive studies are far and few in Morocco. The largest myocardial infarction registry is a city-wide effort from Fez, published in 2015 by Akoudad et al. and compiling 1835 patients [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. To our knowledge, this is the first national scale STEMI registry in Morocco.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eThis was a national prospective multicentre study, including all centres practicing invasive cardiac catheterization.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStudy population\u003c/h2\u003e \u003cp\u003eData was collected over a period of 18 weeks, from April to August 2018.\u003c/p\u003e \u003cp\u003eInclusion criteria were: patients aged\u0026thinsp;\u0026gt;\u0026thinsp;18 years; admitted for recent (less than 5 days) STEMI, defined as a rise of troponin or another cardiac enzyme, and at least one of the following: ST-segment elevation, new abnormal Q waves or new-onset bundle branch block.\u003c/p\u003e \u003cp\u003eExclusion criteria were: STEMI with symptom onset\u0026thinsp;\u0026gt;\u0026thinsp;5 days; patients admitted for NSTE-ACS (non ST-elevation acute coronary syndrome); patients admitted in cardiac arrest, who died in transport or very early after admission.\u003c/p\u003e \u003cp\u003eAll patients gave informed concent to participate in the study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStudy organization\u003c/h2\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003ch2\u003eParticipating centres\u003c/h2\u003e \u003cp\u003e 57 centres across 22 cities accepted to participate in the study, including university and provincial hospitals, military hospitals, and private clinics, and covering a large majority of the Moroccan territory (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). 5 university hospitals were represented (Rabat, Casablanca, Fez, Oujda, Marrakech).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003eSociodemographic data such as mode of living and health coverage was collected. Clinical data included medical history and cardiovascular risk factors, STEMI symptoms and timing, vital constants and Killip class at admission, findings on the first ECG (electrocardiogram) and TTE (transthoracic echocardiography) such as wall motion abnormalities and LVEF (left ventricular ejection fraction). The speed and quality of management was thoroughly documented; revascularization modalities, angiographic findings, and relevant time delays (symptoms-to-first medical contact and symptoms-to-management) were precisely recorded. Follow-up data included in-hospital complication and mortality rates, and outcomes at one month.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eQualitative variables are reported as means\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviations (SD), and median values were calculated when appropriate. Discrete variables are reported as percentages. Statistical analyses were performed using SPSS software. Comparisons were done using the chi-square test or Fisher\u0026rsquo;s exact test when the sample size was too small.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eBaseline characteristics\u003c/h2\u003e \u003cp\u003eA total of 809 STEMI patients was included, originating from 76 cities and 68 rural villages. The majority were admitted in university hospitals (52.9%), followed by regional hospitals (20.7%) and private centres (14.3%). 15% didn\u0026rsquo;t have any health coverage (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe mean age was 62.6\u0026thinsp;\u0026plusmn;\u0026thinsp;11.6 years, and 42% of patients were younger than 60. The majority were men (74.8%). The most common modifiable cardiovascular risk factors were smoking (38.3%) and arterial hypertension (30.7%). 65% of patients had 3 or more risk factors. 63% had no cardiovascular medical history (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe main complaint was typical chest pain (56.4%), followed by heart failure symptoms (13.4%). The majority were Killip I at admission (73.2%). The mean heart rate and blood pressures were 85\u0026thinsp;\u0026plusmn;\u0026thinsp;20 beats per minute and 131\u0026thinsp;\u0026plusmn;\u0026thinsp;26 / 78\u0026thinsp;\u0026plusmn;\u0026thinsp;17 mmHg, respectively. Prehospital ECG was obtained only in 0.9% of cases. The most common arrhythmias were premature ventricular contractions (4.5%) and atrial fibrillation (AF) or flutter (3.1%). The majority of STEMI were anterior (47.9%) or inferior (36%). Mean LVEF was 45\u0026thinsp;\u0026plusmn;\u0026thinsp;10%, and 27% of patients had a reduced LVEF (\u0026lt;\u0026thinsp;40%).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline characteristics of STEMI patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePatients (N\u0026thinsp;=\u0026thinsp;809)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eCentre\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUniversity hospital (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRegional hospital (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMilitary hospital (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrivate clinic (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrivate practice (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eDemographics\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62.6\u0026thinsp;\u0026plusmn;\u0026thinsp;11.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWomen (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrban origin (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e76.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRural origin (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth coverage (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e85.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eCardiovascular risk factors\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eArterial hypertension (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSmoking (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDyslipidaemia (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBody mass index\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26.6\u0026thinsp;\u0026plusmn;\u0026thinsp;4.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFamily history of CAD (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eCardiovascular history and comorbidities\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAngina (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e74.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMyocardial infarction (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePCI (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCABG (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStroke (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePeripheral artery disease (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChronic kidney disease (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eData are expressed as percentage (%) or mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD. CABG: coronary artery bypass graft; CAD: coronary artery disease; PCI: percutaneous coronary intervention; STEMI: ST-segment-elevation myocardial infarction.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eInitial presentation\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePatients (N\u0026thinsp;=\u0026thinsp;809)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eFirst medical contact\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmergency department (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e68.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrivate cardiology practice (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrivate general practice (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEMS involvement (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eInitial symptoms\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTypical chest pain (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAtypical chest pain (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeart failure (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSyncope (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCardiac arrest (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOthers (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eInitial Killip class\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e73.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eII (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIII (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIV (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eAdmission parameters\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeart rate (beats per minute)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e85.6\u0026thinsp;\u0026plusmn;\u0026thinsp;19.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSystolic blood pressure (mmHg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e131.5\u0026thinsp;\u0026plusmn;\u0026thinsp;26.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiastolic blood pressure (mmHg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e78.0\u0026thinsp;\u0026plusmn;\u0026thinsp;16.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eElectrocardiographic findings\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSinus rhythm (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e80.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAtrial fibrillation or flutter (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVentricular arrythmia, including PVC (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eST-elevation (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnterior leads (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInferior leads (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLateral leads (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther leads (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePathological Q waves (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLBBB or RBBB (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eEchocardiographic findings\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTTE performed (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLVEF (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44.9\u0026thinsp;\u0026plusmn;\u0026thinsp;10.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAkinesia (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e80.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypokinesia (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e88.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eData are expressed as percentage (%) or mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD. EMS: emergency medical services; LBBB: left bundle branch block; LVEF: left ventricular ejection fraction; PVC: premature ventricular contractions; LBBB: left bundle branch block; RBBB: right bundle branch block; TTE: transthoracic echocardiography.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eManagement and reperfusion\u003c/h2\u003e \u003cp\u003eThe median symptoms-to-first medical contact delay was 690 minutes and 50% of patients presented after the 12-hour mark (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The median symptoms-to-management delay was 815 minutes (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Regarding medical therapy, most patients received aspirin, clopidogrel and low molecular weight heparin. 23.4% of patients benefitted from fibrinolysis, with a median time delay of 6 hours, and the majority being performed in university hospitals. 98% of patients underwent coronary angiography, regardless of delay. 26.2% of patients underwent percutaneous coronary intervention (PCI), mostly in private centres and university hospitals, with a median delay of 3 hours. The most common culprit artery, in 81.2% of cases, was the left anterior descending (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eInitial management\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePatients (N\u0026thinsp;=\u0026thinsp;809)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eProcedures and revascularization\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCoronary angiography (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e98\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eVascular access\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRadial (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemoral (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eCulprit artery\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeft anterior descending (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e81.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCircumflex (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRight coronary (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePCI (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePCI\u0026thinsp;\u0026lt;\u0026thinsp;24 hours from symptom onset (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedian delay (hours)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDrug-eluting stent (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThrombus aspiration (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFibrinolysis (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedian delay (hours)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMedication\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAspirin (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e80.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClopidogrel (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e85.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLMWH (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e81.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUFH (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFondaparinux (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGlycoprotein IIb/IIIa inhibitor (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eData are expressed as percentage (%). LMWH: low molecular weight heparin; PCI: percutaneous coronary intervention; UFH: unfractionated heparin.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eOutcomes\u003c/h2\u003e \u003cp\u003eIn-hospital evolution was marked by a 17.4% rate of complications, the most prevalent being arrhythmias and recurrent ischemia. Mortality rate was 5.2%, with a mean age of 61\u0026thinsp;\u0026plusmn;\u0026thinsp;11 years (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Follow-up data was available for 42.4% of the cohort. At the 1-month check, 94.1% of available patients were asymptomatic; the re-hospitalization and mortality rates were 2.1% and 3.8%, respectively (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eIn-hospital evolution and outcomes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePatients (N\u0026thinsp;=\u0026thinsp;809)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eComplications (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIschemic recurrence (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStent thrombosis (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eArrhythmia (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConduction disturbance (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMechanical complication (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eIn-hospital mortality (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eData are expressed as percentage (%).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFollow-up results at one month\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePatients (N\u0026thinsp;=\u0026thinsp;343)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAsymptomatic (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e94.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRehospitalization (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMortality (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eData are expressed as percentage (%).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eMR-MI aimed to answer two important questions. First, what are the main differences between the Moroccan STEMI patients and those from other countries? Second, does the management in Morocco adhere to current practice guidelines?\u003c/p\u003e \u003cp\u003eTo answer the first question, our results should be compared to other Mediterranean countries, such as Tunisia [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] and France [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Sociodemographic data is similar in all three countries, with a mean age of 60 to 63 years, and a clear male predominance (74.8% in Morocco and France, 81.5% in Tunisia). Smoking and arterial hypertension are the most common risk factors although hypercholesterolemia is more prevalent in France (36 vs 13.6%) and smoking is much more frequent in Tunisia (63.6 vs 38.3%). Smoking is a major health issue in Morocco; with a prevalence of 30 to 50% [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. That rate is probably higher due to the social stigma associated with smoking in Morocco, and the increase among young men of other forms of tobacco usage such as water pipe-smoking, which are not reported in many studies [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The prevalence of arterial hypertension in the Moroccan population ranges from 26 to 29% in most major reports [\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Arterial hypertension is also severely underdiagnosed and undertreated in Morocco; in the ETHNA study, 29% of patients were newly diagnosed, and in treated hypertensive patients, control rates range from 25 to 35% [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Hypercholesterolemia was probably underreported in our study as 29% of Moroccan patients suffer from this condition [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. This discrepancy is probably explained by the fact that practicians are less likely to perform lipid panels in the emergency setting. In our study, 63% of patients had no cardiovascular medical history, which is lower than in France (84%). Typical chest pain was the most common presentation in all three countries, but heart failure was more frequent in Maghreb countries (13.4 and 11.4%) compared to France (3%), underlining the late presentation of patients in those countries. The prevalence of AF in our study was similar to the French one (3.1 vs. 4%). Anterior and inferior STEMI comprised about 90% of all localizations in the three countries. The mean LVEF was slightly increased in France compared to Morocco (50.2 vs. 45%). Overall, the clinical profile of STEMI patients remains similar between the three countries.\u003c/p\u003e \u003cp\u003eTo answer the second question, it is essential to review revascularization modalities used and the various management delays. The 2017 European guidelines on STEMI recommend that a patient undergoes primary PCI within 48 hours (but preferably 12 hours) after symptom onset. Fibrinolysis should be administered within 12 hours after symptom onset if PCI is not available within 2 hours [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Early presentation of the patient is therefore crucial for optimal diagnosis and management. In Morocco, the symptom-to-first medical contact delay is much longer than in France (690 vs 141 minutes). Half of the patients consult after the key 12-hour mark, which explains why two thirds of the patients do not receive thrombolytic agents even when they\u0026rsquo;re available. Fibrinolysis was used in 23.4% of cases; that rate is higher in Tunisia (31.8%) but much lower in France (6%), underlining the poor availability of cath labs especially in rural areas and provincial hospitals. Only 14.3% benefit from primary PCI, compared to 30% in the Tunisian cohort and 91% in the French registry. These longer delays explain in part the higher rate of complications in Moroccan patients compared to French patients, especially recurrent myocardial infarction (1.7 vs 0.3%) and in-hospitality death (5.2% vs 2.8%). The mortality rate reported in our study is slightly inferior to the Tunisian one (5.2 vs 5.5%). At the one-month follow-up, it remains stable at 3.8%.\u003c/p\u003e \u003cp\u003eWhat are concrete solutions to improve the situation in Morocco? We need to take a look at the 1995 to 2010 period in France, when 30-day mortality fell from 13.7\u0026ndash;4.4% [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In addition to the STEMI demographic shift (patients were younger by 3 years on average), this decrease was mostly explained by shorter management delays (120 to 74 min), a greater involvement of emergency medical services (EMS), whose rate of use grew from 23 to 49% and a higher rate of primary angioplasty (49 to 75%) [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. EMS involvement rate was only 3.2% in our study. By increasing the awareness of the general public about STEMI and the need to call EMS as soon as symptoms begin, management delays would be tremendously reduced, allowing for more efficient revascularization and better outcomes. The availability of cath labs is also an issue, especially in provincial hospitals where the only recourse is fibrinolysis, which is known to be inferior to PCI [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. These are the main areas that Morocco is developing in the present and the near future. Since 2018, the Moroccan government has made great strides in the construction of new PCI centres, both private and public, and the development of chest pain awareness programs.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eMR-MI is the first national STEMI registry in Morocco with a total of 809 patients and draws some important conclusions. The clinical profile of our patients is similar to that of other Mediterranean countries, but management suffers from many inadequacies, especially long time delays and inefficient revascularization options.\u003c/p\u003e \u003cp\u003eConcrete, proven solutions exist, such as the involvement of EMS and the democratization of urgent angiography and PCI. Since 2018, Moroccan practicians and health officials have been involved in the development of these areas and much progress has been made in the right direction.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eECG\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eelectrocardiogram\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eEMS\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eemergency medical services\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eIHD\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eischemic heart disease\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eLVEF\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eleft ventricular ejection fraction\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003ePCI\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003epercutaneous coronary intervention\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eSTEMI\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eST-elevation myocardial infarction\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eTTE\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003etransthoracic echocardiogram\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Ethics Committee of Rabat\u0026rsquo;s Faculty of Medicine and Pharmacy and was conducted in accordance in accordance with the Declaration of Helsinki and Morocco\u0026rsquo;s laws and regulations on human research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed in this study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAS \u0026ndash; Conceptualization, Methodology. HC \u0026ndash; Writing. IA, NE, ME, RH, AC, RF, HA, AB, MC, RA, NB, SZ \u0026ndash; Review and editing. All authors have read and approved the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors are exceedingly grateful to all those involved for successfully conducting the study. We would like to acknowledge and thank Amine A., Abourazzak A., Achkari Begdouri A., Achoukhi S., Agoumy J., Aitbella S., Akhbour S., Amellal S., Aouad A., Aziz A., Balafrej\u003c/p\u003e\n\u003cp\u003eK., Barrada D., Belayachi J., Belghiti H., Beloauchi F., Benfarji A., Benlamine S., Benyamna I., Benzagmout K., Benzeroual D., Berrada M., Bigane K., Boulaamayl S., Bousabniya R., Chaara A., Cherradi G., Chetoui A., Chniber R., Choukri A. H., Chtioui M., Darif A., Drissi S., El Beqqali H., El Fath S., El Hattab F., El Marjani H., El Ouali L., El Hamzaoui H., El Khlifi A., El Ouarradi A., El Younassi B., Es-sabbani S., Fassi O., Fennich N., Guelzim Y., Haddour L., Hara L., Ismaili N., Jalal H., Kamal A., Kendoussi T., Khatri D., Lakhal Z., Lididi Y., Louahabi T., Loubaris M., Maliki S., Mayoussi C., Mechti A., Moubarki H., Mouine N., Nouamou I., Oukerraj L., Oussibla F., Rahmouni A., Rami A., Sabry M., Saghi G., Saidi I., Scadi E., Sebbar S., Shimou I., Talhi F., Tamdy A., Tazi Mezalek A., Zaidi K., Zaimi A., Zaimi S., Zarzur J., Zbir E., Zouhair S.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eRoth GA, Mensah GA, Johnson CO, Addolorato G, Ammirati E, Baddour LM, GBD-NHLBI-JACC Global Burden of Cardiovascular Diseases Writing Group. ;. Global Burden of Cardiovascular Diseases and Risk Factors, 1990\u0026ndash;2019: Update From the GBD 2019 Study. J Am Coll Cardiol. 2020 Dec 22;76(25):2982\u0026ndash;3021. Erratum in: J Am Coll Cardiol. 2021 Apr 20;77(15):1958\u0026ndash;1959.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTownsend N, Kazakiewicz D, Lucy Wright F, Timmis A, Huculeci R, Torbica A, Gale CP, Achenbach S, Weidinger F, Vardas P. Epidemiology of cardiovascular disease in Europe. Nat Rev Cardiol. 2022 Feb;19(2):133\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBauersachs R, Zeymer U, Bri\u0026egrave;re JB, Marre C, Bowrin K, Huelsebeck M. Burden of Coronary Artery Disease and Peripheral Artery Disease: A Literature Review. Cardiovasc Ther. 2019 Nov 26;2019:8295054.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKeates A, Mocumbi A, Ntsekhe M, Sliwa K, Stewart S. Cardiovascular disease in Africa: epidemiological profile and challenges. Nat Rev Cardiol. 2017;14:273\u0026ndash;93.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eElyamani R, Soulaymani A, Hami H. Epidemiology of Cardiovascular Diseases in Morocco: A systematic review. Rev Diabet Stud. 2021;17(2):57\u0026ndash;67.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoustaghfir A, Haddak M, Mechmeche R. Management of acute coronary syndromes in Maghreb countries: The access (acute coronary events \u0026ndash; a multinational survey of current management strategies) registry. Arch Cardiovasc Dis. 2012;105(11):566\u0026ndash;77.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAkoudad H, El Khorb N, Sekkali N, Mechrafi A, Zakari N, Ouaha L et al. L\u0026rsquo;infarctus du Myocarde au Maroc: Les Donn\u0026eacute;es du Registre Fes-Ami. Annales de Cardiologie et d'Ang\u0026eacute;iologie. 2015;64(6):434\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAddad F, Mahdhaoui A, Gouider J, Boughzela E, Kamoun S, Boujnah MR et al. Management of patients with acute ST-elevation myocardial infarction: Results of the fast-mi tunisia registry. PLoS ONE. 2019;14(2).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBelle L, Cayla G, Cottin Y, Coste P, Khalife K, Lab\u0026egrave;que J-N, et al. French registry on Acute ST-elevation and non \u0026ndash; ST-elevation myocardial infarction 2015 (FAST-MI 2015). design and baseline data. Arch Cardiovasc Dis. 2017;110(6\u0026ndash;7):366\u0026ndash;78.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNejjari C, Benjelloun MC, Berraho M, El Rhazi K, Tachfouti N, Elfakir S, et al. Prevalence and demographic factors of smoking in Morocco. Int J Public Health. 2009;54(6):447\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTazi MA, Abir-Khalil S, Chaouki N, Cherqaoui S, Lahmouz F, Sra\u0026iuml;ri JE, et al. Prevalence of the main cardiovascular risk factors in Morocco: results of a National Survey, 2000. J Hypertens. 2003 May;21(5):897\u0026ndash;903.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMinistry of Health of Morocco. National survey of noncommunicable diseases risk factors 2017\u0026ndash;2018. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.sante.gov.ma/Documents/2019/05/Rapport%20de%20l%20enqu%C3%AAte%20Stepwise.pdf\u003c/span\u003e\u003cspan address=\"https://www.sante.gov.ma/Documents/2019/05/Rapport%20de%20l%20enqu%C3%AAte%20Stepwise.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNejjari C, Arharbi M, Chentir MT, Boujnah R, Kemmou O, Megdiche H, et al. Epidemiological Trial of Hypertension in North Africa (ETHNA): an international multicentre study in Algeria, Morocco and Tunisia. J Hypertens. 2013 Jan;31(1):49\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEssayagh T, Essayagh M, El Rhaffouli A, Khouchoua M, Bukassa Kazadi G, Khattabi A et al. Prevalence of uncontrolled blood pressure in Meknes, Morocco, and its associated risk factors in 2017. PLoS One. 2019 Aug 9;14(8):e0220710.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIbanez B, James S, Agewall S, Antunes MJ, Bucciarelli-Ducci C, Bueno H et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2018 Jan 7;39(2):119 \u0026ndash; 77.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePuymirat E, Simon T, Cayla G, Cottin Y, Elbaz M, Coste P, Lemesle G, Motreff P, Popovic B, Khalife K, Lab\u0026egrave;que JN, Perret T, Le Ray C, Orion L, Jouve B, Blanchard D, Peycher P, Silvain J, Steg PG, Goldstein P, Gu\u0026eacute;ret P, Belle L, Aissaoui N, Ferri\u0026egrave;res J, Schiele F, Danchin N, USIK. USIC 2000, and FAST-MI investigators. Acute Myocardial Infarction: Changes in Patient Characteristics, Management, and 6-Month Outcomes Over a Period of 20 Years in the FAST-MI Program (French Registry of Acute ST-Elevation or Non-ST-Elevation Myocardial Infarction) 1995 to 2015. Circulation. 2017 Nov 14;136(20):1908\u0026ndash;1919. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1161/CIRCULATIONAHA.117.030798\u003c/span\u003e\u003cspan address=\"10.1161/CIRCULATIONAHA.117.030798\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePuymirat E, Simon T, Steg PG, Schiele F, Gu\u0026eacute;ret P, Blanchard D, USIK USIC 2000 Investigators; FAST MI Investigators. ;. Association of changes in clinical characteristics and management with improvement in survival among patients with ST-elevation myocardial infarction. JAMA 2012; 308:998\u0026ndash;1006. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1001/2012.jama.11348\u003c/span\u003e\u003cspan address=\"10.1001/2012.jama.11348\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e PMID: 22928184.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWidimsky P. Primary angioplasty vs. thrombolysis: the end of the controversy? Eur Heart J. 2010 Mar;31(6):634\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-cardiovascular-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcar","sideBox":"Learn more about [BMC Cardiovascular Disorders](http://bmccardiovascdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcar/default.aspx","title":"BMC Cardiovascular Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"acute coronary syndrome, acute myocardial infarction, STEMI","lastPublishedDoi":"10.21203/rs.3.rs-2812111/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2812111/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eMR-MI is the first national Moroccan ST-elevation myocardial infarction (STEMI) registry. Its objectives are to assess patient management modalities and highlight the clinical and therapeutic characteristics of this pathology in all cardiology centres on a national scale.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eAdult patients presenting with STEMI within 5 days of symptoms onset were enrolled over a period of 18 weeks from April to August 2018. 57 cardiology centres distributed in 22 cities in Morocco participated in the study, including 5 university hospitals, representing 70% of Moroccan centres managing STEMI patients. A case report form was sent to the investigators in both electronic and paper forms. Sociodemographic, clinical, management, revascularization, and follow-up data were collected.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 809 patients were recruited. The population was mostly male (74.8%) with an average age of 62.6\u0026thinsp;\u0026plusmn;\u0026thinsp;11.6 years. The most common risk factors were smoking (38.3%) arterial hypertension (30.7%), and diabetes (28%). 30% of patients were admitted within the first 6 hours of symptoms onset and 49.6% benefitted from early revascularization. Mortality rate was 5.2% in-hospital and 3.2% at the one-month follow-up.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eMR-MI is the first Moroccan STEMI registry on a national scale. Relevant management delays are much longer than other countries, and less than 50% of the patients that present on time benefit from early revascularization. Efforts remain to be done on the optimal diagnosis and treatment of STEMI.\u003c/p\u003e","manuscriptTitle":"The national Moroccan Registry of ST-elevation Myocardial Infarction (MR-MI)","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-07-26 17:31:23","doi":"10.21203/rs.3.rs-2812111/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2023-07-25T05:12:59+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2023-07-24T12:21:45+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2023-07-03T08:47:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"066d5d96-ba62-4d82-9874-1d9a8678ee94","date":"2023-06-29T11:25:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"2f2ea829-05e9-4125-87fa-91c3953f1891","date":"2023-06-23T10:38:22+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2023-05-30T00:20:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"f45faf24-01c2-4d57-b043-371a445ae084_SNPRID","date":"2023-05-26T14:59:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"909fb05a-e331-4192-a76e-e74f57def7f9","date":"2023-05-26T14:06:32+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2023-05-26T13:44:01+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2023-05-26T13:23:27+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2023-04-18T09:55:55+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2023-04-18T09:52:35+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Cardiovascular Disorders","date":"2023-04-13T09:49:42+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-cardiovascular-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcar","sideBox":"Learn more about [BMC Cardiovascular Disorders](http://bmccardiovascdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcar/default.aspx","title":"BMC Cardiovascular Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1aadd79f-25b5-4fd6-b5be-df9e59335532","owner":[],"postedDate":"July 26th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2023-09-07T15:09:27+00:00","versionOfRecord":{"articleIdentity":"rs-2812111","link":"https://doi.org/10.1186/s12872-023-03458-7","journal":{"identity":"bmc-cardiovascular-disorders","isVorOnly":false,"title":"BMC Cardiovascular Disorders"},"publishedOn":"2023-08-24 15:02:13","publishedOnDateReadable":"August 24th, 2023"},"versionCreatedAt":"2023-07-26 17:31:23","video":"","vorDoi":"10.1186/s12872-023-03458-7","vorDoiUrl":"https://doi.org/10.1186/s12872-023-03458-7","workflowStages":[]},"version":"v1","identity":"rs-2812111","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2812111","identity":"rs-2812111","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}