Editorial comment
Early reperfusion in myocardial infarction requires widespread access to prehospital emergency care
A reperfusão precoce no enfarte agudo do miocárdio implica acesso generalizado à emergência pré-hospitalar
Jorge Ferreira
Serviço de Cardiologia, Hospital de Santa Cruz, Carnaxide, Portugal
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EMS: pre-hospital emergency medical service.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Inês Silveira, Maria João Sousa, Patrícia Rodrigues, Bruno Brochado, Raquel B. Santos, Maria Trêpa, André Luz, João Silveira, Aníbal Albuquerque, Henrique Carvalho, Severo Torres" "autores" => array:11 [ 0 => array:2 [ "nombre" => "Inês" "apellidos" => "Silveira" ] 1 => array:2 [ "nombre" => "Maria João" "apellidos" => "Sousa" ] 2 => array:2 [ "nombre" => "Patrícia" "apellidos" => "Rodrigues" ] 3 => array:2 [ "nombre" => "Bruno" "apellidos" => "Brochado" ] 4 => array:2 [ "nombre" => "Raquel B." "apellidos" => "Santos" ] 5 => array:2 [ "nombre" => "Maria" "apellidos" => "Trêpa" ] 6 => array:2 [ "nombre" => "André" "apellidos" => "Luz" ] 7 => array:2 [ "nombre" => "João" "apellidos" => "Silveira" ] 8 => array:2 [ "nombre" => "Aníbal" "apellidos" => "Albuquerque" ] 9 => array:2 [ "nombre" => "Henrique" "apellidos" => "Carvalho" ] 10 => array:2 [ "nombre" => "Severo" "apellidos" => "Torres" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "pt" => array:9 [ "pii" => "S0870255116303420" "doi" => "10.1016/j.repc.2017.02.013" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "pt" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255116303420?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204917302830?idApp=UINPBA00004E" "url" => "/21742049/0000003600000011/v1_201712190639/S2174204917302830/v1_201712190639/en/main.assets" ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial comment</span>" "titulo" => "Early reperfusion in myocardial infarction requires widespread access to prehospital emergency care" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "857" "paginaFinal" => "858" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Jorge Ferreira" "autores" => array:1 [ 0 => array:3 [ "nombre" => "Jorge" "apellidos" => "Ferreira" "email" => array:1 [ 0 => "jorge_ferreira@netcabo.pt" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Serviço de Cardiologia, Hospital de Santa Cruz, Carnaxide, Portugal" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "A reperfusão precoce no enfarte agudo do miocárdio implica acesso generalizado à emergência pré-hospitalar" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Time to reperfusion in ST-elevation myocardial infarction (STEMI) is critical to maximizing the benefit of reperfusion therapy in maintaining the viability of jeopardized myocardium and preserving left ventricular systolic function, and thus affects short- and long-term survival.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">1</span></a> The importance of this factor was established in the era of pharmacological reperfusion with fibrinolytic agents, subsequently superseded by primary percutaneous coronary intervention (PPCI), which is more effective in delivering reperfusion and hence improves survival,<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">2</span></a> with apparently less dependence on time to reperfusion than with fibrinolysis.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">However, as the indications for PPCI were extended to higher-risk patients, it soon became clear that its benefits are also significantly affected by time to reperfusion,<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">4</span></a> and a system delay (measured from first medical contact to reperfusion) of ≤60 min for high-risk patients presenting within two hours of symptom onset and ≤90 min for other patients is now recommended.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">5</span></a> Nevertheless, these times are not achieved in a significant proportion of patients undergoing PPCI, particularly those who do not use the pre-hospital emergency medical system (EMS), and the situation is even worse for centers without PPCI facilities.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">System delay is thus an important quality indicator in myocardial infarction (MI)<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">7</span></a> and as such should be continuously monitored and used as the basis for measures to help achieve the goals set in the guidelines.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In the current issue of the <span class="elsevierStyleItalic">Journal</span>, Silveira et al.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">8</span></a> analyze system and total delays in reperfusion times in 764 patients with STEMI undergoing PPCI in their center between January 2008 and July 2015, as well as in-hospital and one-year clinical outcomes. Median total time to reperfusion was 240 min and median system delay was 85 min. With regard to compliance with the guidelines, the authors report that system delay was ≤60 min in 39% of patients and ≤90 min in 61%. In-hospital mortality was 9.2% and one-year mortality was 3.3%.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Most of the study population arrived at the hospital by their own means (46%) or by non-EMS ambulance (7%). A third were transported by the EMS and the others were transferred from other institutions (14%). Those who used the EMS had significantly shorter times to reperfusion (195 vs. 286 min, p<0.001) and system delay (61 vs. 90 min, p<0.001) than those who did not, which was reflected in the proportion of patients reperfused with a system delay of ≤60 min (50% vs. 34%, p<0.001) and ≤90 min (74% vs. 55%, p<0.001). One-year mortality was lower in patients transported by the EMS, but this was not statistically significant. However, reductions in mortality due to access to the EMS in MI patients have been demonstrated by other studies in Portugal.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">9</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Analysis of changes over time showed that the proportion of patients using the EMS increased from 30% in 2008 to around 50% in 2015, with a corresponding decrease in the proportion of those traveling by their own means. Although the authors did not analyze changes in reperfusion times, these can be expected to have improved, given the favorable impact of access to the EMS on time to PPCI. At the national level, access to the EMS increased from 2.1% in 2002 to 38% in 2012,<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">10,11</span></a> and access to PPCI trebled between 2002 and 2013, from 106 to 338 procedures per million population.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">12</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">This progress in management of patients with MI is based on information on the situation in Portugal that has been collected since the 1990s, firstly with the establishment of fibrinolysis registries, followed in 2002 by the creation of the National Center for Data Collection in Cardiology, which enabled the formation of the National Registries of Acute Coronary Syndromes and of Interventional Cardiology<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">10,12</span></a> and the implementation of referral networks with continuous monitoring such as Stent for Life.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">11</span></a> The contributions of single-center series<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">8,9</span></a> should also be noted, the results of which are in agreement with those of multicenter national registries<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">6,11,12</span></a> and demonstrate unequivocally that early reperfusion for MI in Portugal requires more widespread access to the EMS.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Ferreira J. A reperfusão precoce no enfarte agudo do miocárdio implica acesso generalizado à emergência pré-hospitalar. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 1 | 2 | 3 |
| 2024 October | 26 | 28 | 54 |
| 2024 September | 32 | 21 | 53 |
| 2024 August | 24 | 22 | 46 |
| 2024 July | 24 | 29 | 53 |
| 2024 June | 22 | 24 | 46 |
| 2024 May | 22 | 17 | 39 |
| 2024 April | 19 | 25 | 44 |
| 2024 March | 31 | 22 | 53 |
| 2024 February | 20 | 21 | 41 |
| 2024 January | 17 | 20 | 37 |
| 2023 December | 21 | 26 | 47 |
| 2023 November | 19 | 22 | 41 |
| 2023 October | 16 | 18 | 34 |
| 2023 September | 21 | 20 | 41 |
| 2023 August | 20 | 15 | 35 |
| 2023 July | 16 | 8 | 24 |
| 2023 June | 15 | 10 | 25 |
| 2023 May | 30 | 27 | 57 |
| 2023 April | 21 | 6 | 27 |
| 2023 March | 28 | 25 | 53 |
| 2023 February | 30 | 24 | 54 |
| 2023 January | 15 | 17 | 32 |
| 2022 December | 32 | 27 | 59 |
| 2022 November | 38 | 29 | 67 |
| 2022 October | 35 | 31 | 66 |
| 2022 September | 21 | 32 | 53 |
| 2022 August | 22 | 24 | 46 |
| 2022 July | 30 | 47 | 77 |
| 2022 June | 23 | 34 | 57 |
| 2022 May | 16 | 29 | 45 |
| 2022 April | 23 | 42 | 65 |
| 2022 March | 29 | 46 | 75 |
| 2022 February | 29 | 38 | 67 |
| 2022 January | 25 | 25 | 50 |
| 2021 December | 18 | 33 | 51 |
| 2021 November | 29 | 40 | 69 |
| 2021 October | 28 | 42 | 70 |
| 2021 September | 17 | 27 | 44 |
| 2021 August | 25 | 44 | 69 |
| 2021 July | 16 | 20 | 36 |
| 2021 June | 17 | 35 | 52 |
| 2021 May | 27 | 31 | 58 |
| 2021 April | 41 | 20 | 61 |
| 2021 March | 45 | 19 | 64 |
| 2021 February | 50 | 10 | 60 |
| 2021 January | 24 | 12 | 36 |
| 2020 December | 30 | 10 | 40 |
| 2020 November | 32 | 15 | 47 |
| 2020 October | 20 | 18 | 38 |
| 2020 September | 66 | 9 | 75 |
| 2020 August | 13 | 6 | 19 |
| 2020 July | 37 | 14 | 51 |
| 2020 June | 37 | 10 | 47 |
| 2020 May | 18 | 6 | 24 |
| 2020 April | 27 | 12 | 39 |
| 2020 March | 41 | 17 | 58 |
| 2020 February | 37 | 41 | 78 |
| 2020 January | 25 | 8 | 33 |
| 2019 December | 25 | 6 | 31 |
| 2019 November | 24 | 11 | 35 |
| 2019 October | 25 | 4 | 29 |
| 2019 September | 32 | 4 | 36 |
| 2019 August | 25 | 10 | 35 |
| 2019 July | 37 | 12 | 49 |
| 2019 June | 24 | 10 | 34 |
| 2019 May | 37 | 7 | 44 |
| 2019 April | 15 | 13 | 28 |
| 2019 March | 14 | 13 | 27 |
| 2019 February | 26 | 7 | 33 |
| 2019 January | 18 | 7 | 25 |
| 2018 December | 31 | 9 | 40 |
| 2018 November | 29 | 10 | 39 |
| 2018 October | 60 | 12 | 72 |
| 2018 September | 33 | 9 | 42 |
| 2018 August | 32 | 3 | 35 |
| 2018 July | 15 | 3 | 18 |
| 2018 June | 29 | 7 | 36 |
| 2018 May | 34 | 7 | 41 |
| 2018 April | 28 | 7 | 35 |
| 2018 March | 42 | 11 | 53 |
| 2018 February | 28 | 5 | 33 |
| 2018 January | 39 | 14 | 53 |
| 2017 December | 49 | 24 | 73 |
| 2017 November | 0 | 1 | 1 |
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