Journal Information
Vol. 40. Issue 2.
Pages 81-90 (February 2021)
Share
Share
Download PDF
More article options
Visits
...
Vol. 40. Issue 2.
Pages 81-90 (February 2021)
Original Article
DOI: 10.1016/j.repce.2020.05.023
Open Access
Five years of Stent for Life in Portugal
Cinco anos da Iniciativa Stent for Life em Portugal
Visits
...
Hélder Pereiraa,
Corresponding author
hhpereira@gmail.com

Corresponding author.
, Rita Caléb, Ernesto Pereirac, Sofia Mellod, Sílvia Vitorinob, Pedro Jerónimo de Sousae, Sílvia Monteirof, Fausto J. Pintog, Raquel Ramosh, Pedro Coelho dos Santosh, João Ferreirai, João Silveiraj, João Moraisk, on behalf of the centers participating in the 'Stent for Life' Initiative Portugal
a Cardiology Department, Hospital Garcia de Orta, Almada, CCUL, CAML, University of Lisbon, Portugal
b Cardiology Department, Hospital Garcia de Orta, Almada, Portugal
c Cardiology Department, Hospital Garcia de Orta, Almada; Escola Superior de Saude da Cruz Vermelha Portuguesa, Lisboa, Portugal
d SFL Project Manager, Portugal
e Cardiology Department, Centro Hospitalar de Lisboa Ocidental, Lisboa, Portugal
f Cardiology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
g Cardiology Department, CCUL, CAML, University of Lisbon, Portugal
h National Institute of Medical Emergency (INEM), Portugal
i Portuguese Society of Cardiology, Lisbon, Portugal
j Cardiology Department, Centro Hospitalar do Porto, Porto, Portugal
k Cardiology Department, Santo André Hospital, Leiria, Portugal
Article information
Abstract
Full Text
Bibliography
Download PDF
Statistics
Figures (6)
Show moreShow less
Tables (3)
Table 1. Demographic characteristics and medical history of the population included in the Time Points.
Table 2. Comparison of reperfusion times in patients who directly attended a center with primary percutaneous coronary intervention by their own means and those transported by the emergency medical services.
Table 3. Reperfusion times before and after five years of activity of Stent for Life in Portugal.
Show moreShow less
Abstract
Objective

To analyze changes in performance indicators five years after Portugal joined the Stent for Life (SFL) initiative.

Methods

National surveys were carried out annually over one-month periods designated as study Time Points between 2011 (Time Zero) and 2016 (Time Five). In this study, 1340 consecutive patients with suspected ST-elevation myocardial infarction (STEMI) who underwent coronary angiography, admitted to 18 24/7 primary percutaneous coronary intervention (PCI) centers, were enrolled.

Results

There was a significant reduction in the proportion of patients who attended primary healthcare centers (20.3% vs. 4.8%, p<0.001) and non-PCI-capable centers (54.5% vs. 42.5%, p=0.013). The proportions of patients who called 112, the national emergency medical services (EMS) number (35.2% vs. 46.6%, p=0.022) and of those transported via the EMS to a PCI-capable center (13.1% vs. 30.5%, p<0.001) increased. The main improvement observed in timings for revascularization was a trend toward a reduction in patient delay (114 min in 2011 vs. 100 min in 2016, p=0.050). System delay and door-to-balloon time remained constant, at a median of 134 and 57 min in 2016, respectively.

Conclusion

During the lifetime of the SFL initiative in Portugal, there was a positive change in patient delay indicators, especially the lower proportion of patients who attended non-PCI centers, along with an increase in those who called 112. System delay did not change significantly over this period. These results should be taken into consideration in the current Stent – Save a Life initiative.

Keywords:
Myocardial infarction
Primary percutaneous coronary intervention
Stent for Life
Resumo
Objetivo

Avaliar a evolução dos indicadores de desempenho da Iniciativa Stent for Life (SFL) durante os cinco anos de atividade em Portugal.

Métodos

Inquéritos nacionais foram feitos anualmente, por períodos de um mês, designados por «Momentos», entre 2011 (Momento Zero) e 2016 (Momento Cinco). Neste estudo, foram incluídos 1340 doentes consecutivos com suspeita de enfarte agudo do miocárdio com supradesnivelamento de ST (STEMI) submetidos a angiografia coronária, admitidos em 18 centros de angioplastia primária (P-PCI) 24/7.

Resultados

Observou-se uma redução significativa da percentagem de doentes que recorreram aos cuidados primários (20,3% versus 4,8%, p<0,001) e centros não PCI (54,5% versus 42,5%, p=0,013). A percentagem de doentes que ligaram para o 112 (INEM) (35,2% versus 46,6%, p=0,022) e transporte de doentes através do INEM para um centro com capacidade de PCI (13,1% versus 30,5%, p<0,001) aumentou. A principal melhoria observada nos intervalos de tempo para a revascularização foi uma tendência à redução do «atraso do doente» (114 minutos em 2011 versus 100 minutos em 2016, p=0,050). O «atraso do sistema» e tempo «porta-balão» (D2B) permaneceram constantes, registando uma mediana de 134 e 57 minutos em 2016, respetivamente.

Conclusão

Durante o período de vigência da iniciativa SFL em Portugal, houve uma evolução positiva dos indicadores de «atraso do doente», nomeadamente a redução da percentagem de pacientes que recorreram a centros não PCI, juntamente com um aumento daqueles que ligaram para o INEM. O «atraso do sistema» ainda não sofreu alterações significativas ao longo deste período, devendo estes resultados ser considerados na estratégia atual do Stent Save a Life (SSL).

Palavras-chave:
Enfarte agudo do miocárdio
Angioplastia primária
Stent for Life
Full Text
Introduction

The Stent for Life (SFL) initiative was implemented in Europe in 2008.1 Its main objective was to increase timely access to primary percutaneous coronary intervention (P-PCI), in order to reduce mortality and morbidity in patients with ST-segment elevation myocardial infarction (STEMI).

The SFL initiative supported processes that aimed to improve the organization of existing regional systems and to create new systems that enable better implementation of European Society of Cardiology (ESC) guidelines for STEMI treatment. SFL was initially implemented in five countries2 and in 2011, Portugal also joined the initiative.3 There are few projects in medicine with the ambitious goal to reduce mortality. Instead of new drugs or medical devices, this SFL goal was achieved by improving the efficiency and availability of P-PCI, a treatment that had been performed for more than a decade.

SFL set out to increase the number of patients with STEMI treated with P-PCI, aiming to perform 600 P-PCI procedures/year/million population. However, the incidence of STEMI is not the same in all European countries and the goals had to be adjusted according to the national incidence. According to data published by the Portuguese Directorate-General of Health (DGS), the P-PCI/year/million population ratio improved threefold in a decade, increasing from 106 in 2002 to 338 in 2013.4

At the same time, the SFL initiative also aimed to improve the quality of STEMI treatment, by reducing reperfusion time. The difficulties hampering good P-PCI performance vary among countries, so the action plans to implement the initiative were adjusted according to the specific needs and current situation of each country. Considering that the timing variable is one of the main elements affecting mortality and the complexity of the overall process, both educational and logistical, this was a very ambitious project that simultaneously involved patients, their relatives, healthcare professionals and health authorities.

This work aims to describe the action plan defined by the SFL initiative, the programs that were developed within its scope, and the reporting of the main results obtained five years after Portugal joined the initiative.

Methods

In 2011, a task force was created to discuss the main difficulties hampering good P-PCI performance in Portugal. This group identified three different areas that needed specific interventions: (1) patient population: patients were unable to recognize the symptoms of myocardial infarction (MI), took too long to ask for help and went to the hospital by their own means, instead of calling 112, the national emergency medical services (EMS) number; (2) EMS: the EMS did not directly contact interventional cardiology centers and did not systematically send electrocardiograms (ECGs) to these centers; and (3) hospitals: the performance of hospital networks presented long system delays and the national network included regions that had no 24/7 P-PCI.

In order to overcome these difficulties, various programs were created within each sector. Programs aimed at the patient population were developed under the international SFL slogan ‘Act now. Save a life’. With the help of a communications agency, informative materials, including flyers, posters and videos, were produced to support the campaign. Public figures were invited to be ambassadors and partnerships were set up with the Portuguese Pharmaceutical Society, major national companies in different business areas (energy, entertainment, supermarkets, etc.) and local government bodies. During the five-year period, SFL maintained an ongoing campaign in the press and on radio and television.

Programs targeting the EMS firstly aimed to enable the EMS to directly contact centers with P-PCI facilities, send ECGs, and manage secondary transport between hospitals with and without P-PCI facilities. Additionally, an educational program on acute coronary syndromes (ACS) was developed (STEMINEM) that targeted EMS healthcare professionals.

Regarding hospitals, besides meetings aiming to facilitate the implementation of a national 24/7 P-PCI network, an educational program on ACS (STEMICARE), as well as the discussion platform Stent Network Meeting, were introduced targeting emergency department healthcare professionals.

To evaluate the success of this initiative, specific methods were established to enable qualitative assessment of patient and system delays, as well as market and economic assessment studies.

In this study, we analyze the results of SFL activities in Portugal in the five years of the initiative, using a series of annual study Time Points, in which a prospective cross-sectional study was conducted in all P-PCI-capable hospitals in mainland Portugal that were included in the Via Verde Coronária (the national coronary fast-track system). Data on 1340 patients with suspected STEMI of less than 12 hours duration and referred for P-PCI, admitted to 18 Portuguese cardiology centers, were collected during a one-month period each year from 2011 to 2016. All enrolled patients gave their informed consent for P-PCI and data collection by the National Center for Data Collection in Cardiology (CNCDC) of the Portuguese Society of Cardiology (SPC).5

This study aims to compare the results from 2011 (Time 0) and from 2016 (Time 5), in order to assess the evolution of the SFL initiative during the five years of its activities in Portugal.

Timings

First medical contact (FMC) was defined as the time of arrival of medical and/or paramedical staff to assist the patient for prehospital care or the time of arrival at a hospital. Patient delay was defined as the time between symptom onset and FMC; it was considered a continuous variable and expressed in min. System delay was defined as the time from FMC to the beginning of reperfusion therapy, with balloon, wiring or mechanical thrombectomy, and was considered a continuous or categorical variable (cut-off value 90 min).

Door-to-balloon time was defined as the time from admission to a P-PCI-capable hospital to reperfusion therapy, and was analyzed as a continuous or categorical variable (cut-off value 60 min). Total ischemic time was defined as the time between symptom onset and reperfusion and was analyzed as a continuous or categorical variable (cut-off value 120 min).

Statistical analysis

Continuous variables were presented as means ± standard deviation. Normality of data was assessed by the Kolmogorov-Smirnov test, and equality of variances was assessed by the Levene test. The Student's t test was used to compare the mean of variables presenting normal distribution or equality of variances (e.g. age). Categorical variables were presented as percentages and proportions were compared by the chi-square test or Fisher's exact test. Continuous variables that were not normally distributed, including patient delay and system delay, were presented as median and interquartile range (IQR) and compared with the Mann-Whitney U test for two independent samples or the Kruskal-Wallis test for more than two samples.

Two-sided p-values <0.05 were considered statistically significant. All statistical analyses were performed using IBM SPSS software for Windows version 21.

ResultsData from study Time Points

Between 2011 and 2016, 1340 patients (mean age 62±13 years, 74.9% male), from 18 national interventional cardiology centers, were enrolled in the Time Points. The demographic data and medical history of these patients are presented in Table 1. There was a trend for an increase in the proportion of diabetic patients since the beginning of the study (16.2% in 2011 vs. 23.2% in 2016, p=0.088). The proportion of patients that called 112, the EMS number, increased significantly (35.2% in 2011 vs. 46.6% in 2016, p=0.022) (Figure 1). A significant reduction was also observed in the proportion of patients who attended healthcare centers without P-PCI (54.5% in 2011 vs. 42.5% in 2016, p=0.013), as well as those who attended primary care centers (20.3% in 2011 vs. 4.8% in 2016, p<0.001) (Figure 2).

Table 1.

Demographic characteristics and medical history of the population included in the Time Points.

Variable  Time 0 (n=187)  Time 1(n=187)  Time 2 (n=223)  Time 3 (n=256)  Time 4 (n=220)  Time 5 (n=267) 
Region, %
North  43.9  40.6  33.6  35.5  39.5  34.1  <0.001 
Center  13.4  7.0  5.8  5.5  13.2  11.6   
LVT  37.4  44.4  45.7  50.0  40.0  39.3   
Algarve  5.3  6.4  7.6  3.9  4.1  6.4   
Alentejo  1.6  7.2  5.1  3.2  8.6   
Female gender, %  21.9  17.9  27.7  20.6  26.9  25.2  0.129 
Age, years, mean (SD)  62.1 (13.7)  61.5 (13.2)  62.6 (13.6)  60.8 (13.8)  64.5 (12.3)  62.7 (13.4)  0.074 
Age>75 years, %  18.4  18.4  20.4  17.1  25.5  20.5  0.313 
Past medical history, %
PCI  9.9  9.9  11.7  10.8  10.3  13.1  0.877 
CABG  0.6  1.1  0.5  2.0  2.3  1.5  0.491 
MI  9.7  10.5  13.5  12.4  9.9  10.8  0.789 
Diabetes  16.2  22.1  21.2  17.6  29.1  23.2  0.025 
Diagnosis of STEMI after team activation, %  92.0  93.5  87.3  87.2  91.3  90.1  0.164 

CABG: coronary artery bypass graft; LVT: Lisbon and Tagus Valley; MI: myocardial infarction; PCI: percutaneous coronary intervention; STEMI: ST-segment elevation myocardial infarction.

Figure 1.

The use of prehospital transport by emergency medical services (EMS) after symptom onset in patients with myocardial infarction before and after five years of activity of Stent for Life in Portugal.

(0.1MB).
Figure 2.

Attendance at a healthcare center without primary percutaneous coronary intervention facilities after symptom onset in patients with myocardial infarction before and after five years of activity of Stent for Life in Portugal. FMC: first medical contact; P-PCI: primary percutaneous coronary intervention.

(0.08MB).

A significant increase was also observed in the proportion of patients whose primary transport was by EMS (13.1% in 2011 vs. 30.5% in 2016, p<0.001), as well as of those whose secondary transport was by EMS (0.5% in 2011 vs. 8.1% in 2016, p<0.001) (Figure 1). Figure 3 presents changes in primary and secondary transport performed by EMS throughout all the Time Points, showing a positive trend over time, except for the percentage of secondary transport in Time 5 (2016).

Figure 3.

Changes in primary and secondary transport by the emergency medical services (EMS) throughout the Time Points.

(0.13MB).

Moreover, patients who called 112 and who were transported to P-PCI facilities by the EMS more often presented delays within the limits set by the ESC and the American College Cardiology/American Heart Association guidelines than other patients: FMC-ECG time ≤10 min (68.7% vs. 35.4%, p<0.001); door-to-balloon time ≤60 min (61.5% vs. 52.2%, p=0.012); system delay ≤90 min (32.3% vs. 23.6%, p=0.009); and total ischemic time ≤120 min (17.2% vs. 5.4%, p<0.001) (Figure 4).

Figure 4.

Proportions of patients within the recommendations of the European Society of Cardiology and American College of Cardiology/American Heart Association guidelines for reperfusion delays. The graphic compares the ideal scenario (calling 112 and primary transport to a center with primary percutaneous coronary intervention) with other scenarios. ECG: electrocardiogram; EMS: emergency medical services; FMC: first medical contact.

(0.12MB).

Among patients who directly attended healthcare centers with P-PCI facilities, the proportion of patients who arrived by their own means of transport fell (49.4% in 2011 vs. 32.8% in 2016, p=0.016). While the proportion of patients who were transported by the EMS (22.4% in 2011 vs. 48.0% in 2016, p<0.001) rose, the proportion being transported by basic life support ambulance decreased (28.2% in 2011 vs. 15.3% in 2016; p=0.025). Table 2 shows that patient delay and door-to-balloon time, and consequently total ischemic time, were longer in patients who went directly to P-PCI-capable centers by their own means than in those who were transported by the EMS.

Table 2.

Comparison of reperfusion times in patients who directly attended a center with primary percutaneous coronary intervention by their own means and those transported by the emergency medical services.

Variable  Own means (n=241)  EMS (n=284) 
Symptom onset-FMC (patient delay), min  132.0 (71.0-255.0)  60.0 (35.0-115.0)  <0.001 
FMC-ECG, min  16.0 (9.0-32.0)  6.0 (2.0-13.8)  <0.001 
Admission to P-PCI hospital-reperfusion (door-to-balloon time), min  104.0 (75.0-164.0)  52.0 (30.0-79.0)  <0.001 
FMC-reperfusion (system delay), min  104.0 (75.0-164.0)  103.0 (82.0-135.0)  0.764 
Symptom onset-reperfusion (total ischemic time), min  257.5 (172.8-445.0)  180.0 (140.0-256.5)  <0.001 

Results are presented as median and interquartile range.

ECG: electrocardiogram; EMS: emergency medical services; FMC: first medical contact; P-PCI: primary percutaneous coronary intervention.

Concerning the Manchester triage system, which attributes clinical priority for attendance of patients admitted to a hospital unit, the proportion of patients who did not receive a red or orange code (needing immediate or very urgent assistance) within 10 min of admission remained constant throughout the Time Points (16.1% of patients received a yellow or green code in 2011 vs. 17.7% in 2016) (Figure 5).

Figure 5.

Proportions of patients assigned different priorities according to the Manchester triage system, before and after five years of activity of Stent for Life in Portugal. Red: emergency, requires immediate intervention; orange: very urgent, needing an intervention within 10 min; yellow or other: urgent or less urgent, can wait 60 min or more for an intervention.

(0.07MB).

During the study, no significant change was observed in patient delay, system delay or door-to-balloon time (Table 3 and Figure 6). Although there was a trend for a reduction in patient delay (114 min in 2011 vs. 100 min in 2016, p=0.050), a trend was also observed for longer system delay (115 min in 2011 vs. 134 min in 2016, p=0.059).

Table 3.

Reperfusion times before and after five years of activity of Stent for Life in Portugal.

Variable  Statistic  Time 0 (n=187)  Time 5 (n=267) 
Symptom onset-FMC (patient delay), min  Median (IQR)  113.5 (63.5-211.5)  100.0 (50.5-190.0)  0.050 
FMC-ECG, min  Median (IQR)  16.0 (8.0-39.0)  15.0 (6.0-36.5)  0.482 
Time from FMC to ECG ≤10 min  32.7  40.6  0.128 
Admission to P-PCI hospital-reperfusion (door-to-balloon time), min  Median (IQR)  54.0 (30.0-99.5)  54.0 (30.0-95.0)  0.812 
Door-to-balloon ≤60 min  55.7  57.0  0.834 
FMC-reperfusion (system delay), min  Median (IQR)  115.0 (79.0-179.5)  133.5 (95.0-188.0)  0.059 
System delay ≤90 min  31.6  21.8  0.041 
Symptom onset-reperfusion (total ischemic time), min  Median (IQR)  250.0 (178.0-430.0)  270.0 (182.0-408.0)  0.844 
Total ischemic time ≤120 min  8.2  7.8  1.000 

ECG: electrocardiogram; FMC: first medical contact; IQR: interquartile range; P-PCI: primary percutaneous coronary intervention.

Figure 6.

Changes in patient and system delay over the five years of Stent for Life (2011-2016).

(0.14MB).
Discussion

Although at the beginning of the millennium the distribution of P-PCI centers and road networks in Portugal were acceptable, the country had one of the lowest rates of P-PCI implementation in Europe,6 which led the SPC to join the SFL initiative.3 Subsequently, between 2001 and 2013, the rate of P-PCI/million population tripled.7

The aim of the SFL initiative was quantitative, with the aim that ideally 600 P-PCI/year/million population would be performed.8 The SFL Portugal task force also added a qualitative aim, as it considered that treating a larger number of patients with P-PCI was as important as treating them faster. To monitor these objectives, the Time Points analysis was introduced, aiming to assess changes in quality indicators over time.3

Total ischemic time is the sum of patient delay (from symptom onset to FMC) and system delay (from FMC to P-PCI). A total ischemic time longer than four hours has been identified as an independent indicator of mortality within a year of STEMI.9,10 Although the initial focus was on door-to-balloon time, patient delay has been recently given more importance, as it is during the first two hours that the highest incidence of fatal arrhythmias is recorded. Reducing patient delay is not dependent on the direct action of healthcare professionals, but rather depends mainly on the implementation of educational campaigns and on the support of the bodies that oversee healthcare services.

Considering hard endpoints (patient delay, system delay and door-to-balloon time) throughout the five years of this study, it could be said that the SFL initiative in Portugal was unsuccessful, because there were no significant changes in any of these endpoints. However, for a short- to medium-term evaluation of the initiative, these endpoints are not good indicators. More specific indicators, such as the proportions of patients who called the EMS number, went to healthcare centers without P-PCI facilities by their own means or were primarily and/or secondarily transported by EMS, are more sensitive ways to assess whether the SFL initiative led to positive changes.

It is also important to understand why the hard endpoints did not improve during the first years of the initiative. As stated above, in less than ten years the number of P-PCI/year/million population in Portugal tripled,4 meaning that patients living in peripheral regions with less access to hospitals were also included. Inevitably, these patients will have a longer total ischemic time than those who live in large cities closer to hospitals, which will worsen the mean patient delay. At the same time, improvements in prehospital management and patient transport mean that system delay also worsens, because it is timed starting from FMC, even though it may also mean a substantial improvement in the system itself.

If Portugal's performance in the mid-2000s6 is compared with the current situation, there has been a very positive development, as the country had very poor indicators and now is within the European average, alongside Spain, France, Belgium, and the UK11. In addition to the increase in P-PCI procedures, there was also significant progress in the indicators that demonstrate a positive effect of the SFL initiative. The proportion of patients requesting medical assistance by calling 112 increased significantly (by 11.4% in five years). A 12% reduction was also observed in the proportion of patients who attended healthcare without P-PCI facilities by their own means.

It is worth mentioning that, even for patients who directly attended P-PCI-capable hospitals, those who were transported by the EMS were treated significantly earlier than those who arrived by their own means. Door-to-balloon time was significantly shorter in patients who were transported by EMS (a median of 52.0 min less than for patients who arrived by their own means) and this is reflected in earlier P-PCI. These data highlight the less efficient response that emergency services are able to provide for patients that arrive by their own means.

It is important to note the proportion of patients who received a yellow or green Manchester triage code (16.1% in 2011 vs. 17.7% in 2016). This problem is not exclusive to Portugal12 but is also seen in other countries.13 It should be remembered that our study population consisted of patients suspected of having STEMI with less than 12 hours duration and referred for P-PCI. The SFL initiative recommended that a cardiopulmonary technician should always be available at hospital emergency departments to ensure that all patients with thoracic or upper abdominal pain undergo an ECG, to diagnose all STEMI cases that are not immediately detected by the Manchester protocol.

Prehospital transport plays an essential part in the performance of the coronary fast-track system. Between 2011 and 2016, there were significant increases in the proportions of patients who were primarily transported by the EMS (13.1% in 2011 vs. 30.5% in 2016; p=0.001) and in secondary transport, which barely existed in 2011 (0.5%) but increased to 15.2% in 2015. The EMS are responsible for prehospital emergency transport. During the SFL initiative, the EMS were also responsible for the secondary transport of patients in the coronary fast-track system. In 2014, the Ministry of Health reviewed this arrangement and decided that hospitals would be primarily responsible for managing secondary transport and the EMS were only to be used in situations in which hospitals could not carry out this function. Thus, in 2016, there was a decrease in secondary transport performed directly by the EMS (15.2% in 2015 vs. 8.1% in 2016). Currently, hospitals are facing difficulties in organizing and managing an efficient transport system, which is one of the barriers that the SFL task force brought to the attention of the responsible authorities.

Although a public educational campaign was conducted to increase awareness of the symptoms of MI and the need to ask for help by calling 112 (the SFL initiative ‘Act Now. Save a Life’),14 patient delay did not decrease significantly during the five years of the campaign. As mentioned above, these numbers were obtained in patients who had progressively better access to P-PCI. At all events, there was no significant progress in reducing time before FMC, and it is important to analyze the factors that were most strongly associated with this delay and to try and design campaigns and actions targeting these populations. Previous studies showed that older age and symptom onset at night were associated with longer patient delay.14 On the other hand, asking for help by calling 112 and transport by the EMS were associated with shorter patient delay.14

Although door-to-balloon time is associated with mortality,15,16 this indicator is only a small part of total ischemic time. In Portugal, door-to-balloon time is within the range recommended by the guidelines,17–19 but most patients were registered in the healthcare system earlier, as half of them attended hospitals without P-PCI facilities and needed secondary transport, which inevitably meant longer total ischemic times.20

For a long time, door-to-balloon time was one of the main indicators of quality of P-PCI programs. However, in recent years it has been observed that shorter door-to-balloon time is not followed by decreased mortality,21–23 and the US Department of Health and Human Services has decided to remove door-to-balloon time from Value-Based Purchasing algorithms, as hospitals currently report essentially equal performance on door-to-balloon time without room for significant improvement, so it has no value for estimating financing metrics.24 In addition, after observing that more than 75% of non-transferred patients were treated in less than 90 min, the Door-to-Balloon Alliance25 in the US launched a new program, Sustain the Gain, which aimed to maintain the good performance of hospitals treating STEMI.26,27

It has been pointed out that focusing on reducing door-to-balloon time may lead to misdiagnoses, increasing the number of false positives, which may negatively impact efficiency, cause burn-out of hospital teams, consume resources that may be needed in other sectors, and increase costs.28 Some authors report that false positive rates vary between 24% and 36%.29–31 In Portugal, the false positive rate was approximately 10% in the Time Points, which is markedly lower than reported values.

Door-to-balloon time, one of the components of total ischemic time, may not be a good quality indicator. The reason that decreasing it is not followed by reductions in mortality may be because patients often wait before asking for help, which may lead to their death before P-PCI. Since this important factor is not used in the estimation of door-to-balloon time, the effect of door-to-balloon time on reducing mortality may be misinterpreted. The latest ESC guidelines also removed door-to-balloon time as a quality indicator.19

System delay also remained high, with no significant reduction being observed over the years. This was to be expected during the implementation phase of the initiative, as with an increasing proportion of patients calling the EMS number and receiving a prompt response, total ischemic time started earlier. Reductions in system delay are only to be expected at a more mature stage of the SFL initiative. Currently, the factors associated with longer system delay are age >75 years, attendance at a hospital without P-PCI facilities, not calling 112, and patient origin from the Center region.32 For cases in which P-PCI is not possible within 120 min after FMC, fibrinolysis continues to have an important role. Based on randomized studies, the guidelines recommend coronary angiography and possibly angioplasty 3-24 hours after fibrinolysis.33–35

Data collected during the SFL initiative helped in the implementation of various educational programs targeting patients and healthcare professionals, aiming to improve overall system performance.

Under the aegis of the Stent Network Meeting platform, centers with P-PCI met with referral centers, general practitioners, representatives of the EMS and local authorities to discuss and present specific proposals for their centers. These meetings took place in most national centers and enabled the SFL task force to better understand the overall national situation and centers to gain a clearer idea of their own conditions.

In our opinion, educational programs for healthcare professionals have been one of the most important tools, not only to improve knowledge of ACS, but also to facilitate exchange of experiences among the different professionals who are part of the system. STEMINEM targets EMS professionals and STEMICARE targets those working in emergency departments.

To promote preventive and educational actions targeting the young, a partnership was established with the Portuguese Pharmaceutical Society, to teach the main aims of the SFL to elementary school students, through the Healthy Generation program.

The studies that have been conducted are based on patients diagnosed with STEMI admitted to hospitals with P-PCI facilities and do not reflect the overall picture of patients with MI, particularly those who have no access to P-PCI.36 Ideally, patients should be treated with P-PCI, but system times must be assessed and monitored to enable the best treatment to be provided to each patient and to determine whether P-PCI is being performed after the period during which this treatment has proved to be better than fibrinolysis.

Now that the SFL initiative has ended, its replacement, Stent – Save a Life (SSL), will extend monitoring to centers without P-PCI facilities, aiming to improve assessment of STEMI patients and to include patients with high-risk non-STEMI.37 SPC registries may be important tools for this goal.

Conclusion

During the lifetime of the SFL initiative in Portugal, there were positive changes in indicators of patient delay, including lower proportions of patients who resorted to primary health centers and local hospitals without P-PCI facilities, along with an increase in the proportion of those who called the EMS number. System delay did not significantly change over this period. These results should be taken into consideration in the future strategy of the SSL, particularly in strengthening current educational programs aiming to shorten system delays.

Centers participating in the Stent for Life initiative, Portugal, sponsored by the Portuguese Association of Cardiovascular Intervention (APIC):

Hospital Vila Real (Henrique Cyrne Carvalho, MD and Paulino Sousa), Hospital Braga (João Costa, MD), Hospital S. João (João Carlos Silva, MD), Hospital Santo António (Henrique Cyrne Carvalho, MD), Centro Hospitalar Vila Nova de Gaia (Vasco Gama Fernandes, MD), Hospital de Viseu (João Pipa, MD), Centro Hospitalar de Coimbra (Marco Costa, MD and Vitor Matos, MD), Hospital de Leiria (João Morais, MD), Hospital Fernando da Fonseca (Pedro Farto e Abreu, MD), Hospital de Santa Maria (Pedro Canas da Silva, MD), Hospital Santa Cruz (Manuel Almeida, MD), Hospital de Santa Marta (Rui Ferreira, MD), Hospital Curry Cabral (Luis Morão, MD), Hospital Pulido Valente (Pedro Cardoso, MD), Hospital Garcia de Orta (Hélder Pereira, MD), Hospital Setúbal (Ricardo Santos, MD), Hospital de Évora (Lino Patrício, MD and Renato Fernandes, MD), Hospital de Faro (Victor Brandão, MD).

Funding

The authors state that they have no funding to declare.

Conflicts of interest

The authors have no conflicts of interest to declare.

References
[1]
P. Widimsky, J. Fajadet, N. Danchin, “Stent 4 Life” targeting PCI at all who will benefit the most: a joint project between EAPCI, Euro-PCR, EUCOMED and the ESC Working Group on Acute Cardiac Care, et al.
EuroIntervention, 4 (2009), pp. 555-557
[2]
J. Knot, P. Widimsky, W. Wijns, et al.
How to set up an effective national primary angioplasty network: Lessons learned from five European countries.
EuroIntervention, 5 (2009), pp. 299-309
[3]
H. Pereira, F.J. Pinto, R. Calé, et al.
Stent for life in Portugal: this initiative is here to stay.
Rev Port Cardiol, 33 (2014), pp. 363-370
[4]
Directorate-General of Health. Programa Nacional para as Doenças Cérebro-Cardiovasculares. Programa Nacional para as Doenças Cérebro-Cardiovasculares. Available at: https://www.dgs.pt/pns-e-programas/programas-de-saude-prioritarios/doencas-cerebro-cardiovasculares.aspx [accessed 12.02.18]
[5]
Sociedade Portuguesa de Cardiologia. Centro Nacional de Colecção de Dados em Cardiologia. Available at: http://www.spc.pt/CNCDC [accessed 12.02.18]
[6]
P. Widimsky, W. Wijns, J. Fajadet, et al.
Reperfusion therapy for ST elevation acute myocardial infarction in Europe: description of the current situation in 30 countries.
Eur Heart J, 31 (2010), pp. 943-957
[7]
H. Pereira, R.C. Teles, M. Costa, et al.
Trends in percutaneous coronary intervention from 2004 to 2013 according to the Portuguese National Registry of Interventional Cardiology.
Rev Port Cardiol (English Ed), 34 (2015), pp. 673-681
[8]
P. Widimsky, W. Wijns, Z. Kaifoszova.
Stent for Life: How this initiative began?.
EuroIntervention, 8 (2012), pp. P8-P10
[9]
L.K. Newby, W.R. Rutsch, R.M. Califf, et al.
Time from symptom onset to treatment and outcomes after thrombolytic therapy. GUSTO-1 Investigators.
J Am Coll Cardiol, 27 (1996), pp. 1646-1655
[10]
G. De Luca, M.T. Dirksen, C. Spaulding, et al.
Time course, predictors and clinical implications of stent thrombosis following primary angioplasty: Insights from the DESERT cooperation.
Thromb Haemost, 110 (2013), pp. 826-833
[11]
S.D. Kristensen, K.G. Laut, J. Fajadet, et al.
Reperfusion therapy for ST elevation acute myocardial infarction 2010/2011: current status in 37 ESC countries.
Eur Heart J, 35 (2014), pp. 1957-1970
[12]
M.W. Cooke, S. Jinks.
Does the Manchester triage system detect the critically ill?.
J Accid Emerg Med, 16 (1999), pp. 179-181
[13]
M.L. Wong, R.M. Eisenstein.
An evaluation of the accuracy of emergency physician activation of the cardiac catheterization laboratory for patients with suspected ST-segment elevation myocardial infarction.
Ann Emerg Med, 56 (2010), pp. 705-706
[14]
H. Pereira, R. Calé, F. Pinto, et al.
Factors influencing patient delay before primary percutaneous coronary intervention in ST-segment elevation myocardial infarction: the Stent for Life initiative in Portugal.
Rev Port Cardiol, 37 (2018), pp. 409-421
[15]
E.L. Hannan, Y. Zhong, A.K. Jacobs, et al.
Effect of onset-to-door time and door-to-balloon time on mortality in patients undergoing percutaneous coronary interventions for ST-segment elevation myocardial infarction.
Am J Cardiol, 106 (2010), pp. 143-147
[16]
B.R. Brodie, C. Hansen, T.D. Stuckey, et al.
Door-to-balloon time with primary percutaneous coronary intervention for acute myocardial infarction impacts late cardiac mortality in high-risk patients and patients presenting early after the onset of symptoms.
J Am Coll Cardiol, 47 (2006), pp. 289-295
[17]
P.G. Steg, S.K. James, D. Atar, et al.
ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation.
Eur Heart J, 33 (2012), pp. 2569-2619
[18]
The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS).
2014 ESC/EACTS Guidelines on myocardial revascularization.
Eur Heart J, 35 (2014), pp. 2541-2619
[19]
B. Ibanez, S. James, S. Agewall, et al.
2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation.
Eur Heart J, 39 (2018), pp. 119-177
[20]
H. Pereira.
Primary angioplasty in Portugal: door-to-balloon time is not a good performance index.
EuroIntervention, 8 (2012), pp. P121-P125
[21]
A.E. Denktas, H.V. Anderson, J. McCarthy, et al.
Total ischemic time: the correct focus of attention for optimal ST-segment elevation myocardial infarction care.
JACC Cardiovasc Interv, 4 (2011), pp. 599-604
[22]
D.S. Menees, E.D. Peterson, Y. Wang, et al.
Door-to-balloon time and mortality among patients undergoing primary PCI.
N Engl J Med, 369 (2013), pp. 901-909
[23]
A. Flynn, M. Moscucci, D. Share, et al.
Trends in door-to-balloon time and mortality in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention.
Arch Intern Med, 170 (2010), pp. 1842-1849
[24]
S. Askandar, T. Bob-Manuel, P. Singh, et al.
Shorter door-to-balloon ST-elevation myocardial infarction time: should there be a minimum limit?.
Curr Probl Cardiol, 42 (2017), pp. 175-187
[25]
H.M. Krumholz, E.H. Bradley, B.K. Nallamothu, et al.
A campaign to improve the timeliness of primary percutaneous coronary intervention. Door-to-balloon: an alliance for quality.
JACC Cardiovasc Interv, 1 (2008), pp. 97-104
[26]
B.K. Nallamothu, H.M. Krumholz, E.D. Peterson, et al.
Door-to-balloon times in hospitals within the get-with-the-guidelines registry after initiation of the door-to-balloon (D2B) alliance.
Am J Cardiol, 103 (2009), pp. 1051-1055
[27]
E.H. Bradley, B.K. Nallamothu, J. Herrin, et al.
National efforts to improve door-to-balloon time: results from the door-to-balloon alliance.
J Am Coll Cardiol, 54 (2009), pp. 2423-2429
[28]
G.D. Barnes, A. Katz, J.S. Desmond, et al.
False activation of the cardiac catheterization laboratory for primary PCI.
Am J Manag Care, 19 (2013), pp. 671-675
[29]
M.C. Kontos, M.C. Kurz, C.S. Roberts, et al.
An evaluation of the accuracy of emergency physician activation of the cardiac catheterization laboratory for patients with suspected ST-segment elevation myocardial infarction.
Ann Emerg Med, 55 (2010), pp. 423-430
[30]
T.A. Mixon, E. Suhr, G. Caldwell, et al.
Retrospective description and analysis of consecutive catheterization laboratory st-segment elevation myocardial infarction activations with proposal, rationale, and use of a new classification scheme.
Circ Cardiovasc Qual Outcomes, 5 (2012), pp. 62-69
[31]
J.M. McCabe, E.J. Armstrong, A. Kulkarni, et al.
Prevalence and factors associated with false-positive ST-segment elevation myocardial infarction diagnoses at primary percutaneous coronary intervention-capable centers: a report from the activate-SF registry.
Arch Intern Med, 172 (2012), pp. 864-871
[32]
H. Pereira, F.C.R. Pinto, R. Cale, et al.
The Stent for Life initiative: factors predicting system delay in patients with ST-segment elevation myocardial infarction.
Rev Port Cardiol, 37 (2018), pp. 681-690
[33]
C. Di Mario, D. Dudek, F. Piscione, et al.
Immediate angioplasty versus standard therapy with rescue angioplasty after thrombolysis in the Combined Abciximab REteplase Stent Study in Acute Myocardial Infarction (CARESS-in-AMI): an open, prospective, randomised, multicentre trial.
[34]
W.J. Cantor, D. Fitchett, B. Borgundvaag, et al.
Routine early angioplasty after fibrinolysis for acute myocardial infarction.
N Engl J Med, 360 (2009), pp. 2705-2718
[35]
E. Bøhmer, P. Hoffmann, M. Abdelnoor, et al.
Efficacy and safety of immediate angioplasty versus ischemia-guided management after thrombolysis in acute myocardial infarction in areas with very long transfer distances. results of the NORDISTEMI (NORwegian study on DIstrict treatment of ST-Elevation Myocardial Infarction).
J Am Coll Cardiol, 55 (2010), pp. 102-110
[36]
H. Pereira, R. Calé, PE., et al.
Hospitais sem cardiologia de intervenção: evolução do acesso à angioplastia primária durante uma década.
Rev Port Cardiol, 34 (2015), pp. 265-274
[37]
G. Morgado, H. Pereira, D. Caldeira.
Adopting an early invasive strategy for non-ST-elevation myocardial infarction: analysis of the Portuguese Registry on Acute Coronary Syndromes.
Idiomas
Revista Portuguesa de Cardiologia (English edition)

Subscribe to our newsletter

Article options
Tools
en pt

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos

By checking that you are a health professional, you are stating that you are aware and accept that the Portuguese Journal of Cardiology (RPC) is the Data Controller that processes the personal information of users of its website, with its registered office at Campo Grande, n.º 28, 13.º, 1700-093 Lisbon, telephone 217 970 685 and 217 817 630, fax 217 931 095, and email revista@spc.pt. I declare for all purposes that the information provided herein is accurate and correct.