Implementation of a pre-hospital network favoring primary angioplasty in STEMI to reduce mortality: The Algarve Project

Gomes, Veloso; Brandão, Victor; Mimoso, Jorge; Gago, Paula; Trigo, Joana; Santos, Walter; Marques, Nuno; Candeias, Rui; Pereira, Salomé; Marques, Vasco; Camacho, Ana; de Jesus, Ilídio

doi:10.1016/j.repce.2012.02.004

Article information

Abstract

Objective

To analyze the impact of reperfusion by either primary percutaneous coronary inter-vention (PPCI) or fibrinolysis, and mortality rates of a pre-hospital fast-track network for treating patients with ST-elevation myocardial infarction (STEMI).

Methods and Results

A pre-hospital network for STEMI patients, designated the Green Lane for Acute Myocardial Infarction (GL-AMI), has been implemented in the southern region of Portugal - the Algarve Project. We performed an observational study based on a prospective registry of 1338 patients admitted to Faro Hospital between 2004 and 2009, classified in two groups according to the method of admission: emergency department group (EDG) and GL-AMI group (GLG). More patients from GLG were reperfused (p<0.0001). PPCI was the preferred method of reperfusion, 73.1% in GLG and 45.3% in EDG. Time delays were significantly shorter in GLG, except for pre-hospital delay: pre-hospital delay (p=0.11); door-to-needle (p<0.0001); door-to-balloon (p<0.0001); and delay between symptoms and reperfusion (p<0.0001). In-hospital mortality (4.3% vs 9.2%, p=0.0007) and 6-month mortality (6.3% vs 13.8%, p<0.0001) were significantly lower in GLG.

Conclusions

The Algarve Project significantly reduced the time delay between onset of symp-toms and reperfusion, significantly increased the rate of reperfusion, and significantly reduced in-hospital and six-month mortality.

Keywords:

ST-elevation myocardial infarction

Treatment delays

Reperfusion therapy

Pre-hospital clinical network

Mortality

Resumo

Objetivo

Analisar o impacto nas taxas de reperfusão por intervenc¸ão coronária percutânea primária (PPCI) ou fibrinólise, e na mortalidade de uma rede pré-hospitalar para o tratamento de doentes com enfarte agudo do miocárdio com elevac¸ão do segmento ST.

Métodos e Resultados

A rede pré-hospitalar para doentes com enfarte agudo do miocárdio, designada Via Verde para o Enfarte Agudo do Miocárdio (GW-AMI), tem sido implementada na região sul de Portugal - O Projeto Algarve. Realizamos um estudo observacional, baseado num registo prospetivo de 1338 doentes internados no Hospital de Faro entre 2004 e 2009, classifica-dos em dois grupos de acordo com a forma de admissão: grupo do Servic¸o de Urgência (EDG) e grupo GW-AMI (GTG). Mais doentes do GTG foram reperfundidos (p<0,0001). PPCI foi o método preferencial de reperfusão, 73,1% no GTG e 45,3% no EDG. Os tempos de demora foram significa-tivamente inferiores no GTG, exceto o atraso pré-hospitalar: Tempo pré-hospitalar (p=0,11); Porta-agulha (p<0,0001); Porta-balão (p<0,0001); Tempo sintomas-reperfusão (p<0,0001). As taxas de mortalidade hospitalar (4,3% versus 9,2%, p=0,0007) e mortalidade aos 6 meses (6,3% versus 13,8%, p<0,0001) foram significativamente inferiores no GTG.

Conclusões

O Projeto Algarve reduziu significativamente os tempos de demora entre o iní-cio dos sintomas e reperfusão, aumentou significativamente a taxa de reperfusão e diminuiu significativamente as taxas de mortalidade hospitalar e aos seis meses.

Palavras-chave:

Enfarte agudo do miocárdio com elevação do segmento ST

Tempos de demora

Terapia de reperfusão

Rede pré-hospital

Mortalidade

Full text is only aviable in PDF

References

[1]

F. Van de Werf, J. Bax, A. Betriu, et al.

Management of acute myocardial infarction in patients presenting with persistent ST- segment elevation: The Task Force on the management of ST-segment elevation acute myocardial infarction of the Euro-pean Society of Cardiology.

Eur Heart J., 29 (2008), pp. 2909-2945

http://dx.doi.org/10.1093/eurheartj/ehn416 | Medline

[2]

G. De Luca, H. Suryapranata, J.P. Ottervanger, et al.

Time delay to treatment and mortality in primary angioplasty for acute myocardial infarction: every minute of delay counts.

Circula-tion., 109 (2004), pp. 1223-1225

[3]

B.K. Nallamothu, E.R. Bates, J. Herrin, et al.

NRMI Investigators. Times to treatment in transfer patients undergoing primary per-cutaneous coronary intervention in the United States: National Registry of Myocardial Infarction (NRMI)-3/4 analysis.

Circulation, 111 (2005), pp. 761-767

http://dx.doi.org/10.1161/01.CIR.0000155258.44268.F8 | Medline

[4]

M. Flesh, J. Hagemeister, H.J. Berger, et al.

Implementation of guidelines for the treatment of acute ST-elevation myocardial infarction: The Cologne Infarction Model Registry.

Circulation., 1 (2008), pp. 95-102

http://dx.doi.org/10.1161/CIRCINTERVENTIONS.108.768176 | Medline

[5]

J. Trigo, P. Gago, J. Mimoso, et al.

Tempo de demora intra-hospitalar após triagem de Manchester nos Enfartes Agu-dos do Miocárdio com elevac¸ão de ST.

Rev Port Cardiol., 27 (2008), pp. 1251-1259

Medline

[6]

J.H. Chesebro, G. Knatterud, R. Roberts, et al.

Thrombolysis In Myocardial Infarction (TIMI) Trial, phase I: a compari-son between intravenous tissue plasminogen activator and intravenous streptokinase: Clinical findings through hospital dis-charge.

Circulation., 76 (1987), pp. 142-154

Medline

[7]

F.A. Masoudi, R.O. Bonow, R.G. Brindis, et al.

ACC/AHA Task Force on Performance Measures. ACC/AHA 2008 statement on performance measurement and reperfusion therapy: a report of the ACC/AHA task force on performance measures (Work group to address the challenges of performance measure-ment and reperfusion therapy).

J Am Coll Cardiol., 52 (2008), pp. 2101-2112

[8]

P. Widimsky, J. Fajadet, N. Danchin, et al.

“Stent 4 Life” Targeting PCI at all who will benefit the most.

EuroInterv., 4 (2009), pp. 555-557

[9]

J. Knot, P. Widimsky, W. Wijns, et al.

How to set up an effective national primary angioplasty network: lessons learned from five European countries.

EuroInterv., 5 (2009), pp. 301-309

[10]

S. Carstensen, G.C. Nelson, P.S. Hansen, et al.

Field triage to pri-mary angioplasty combined with emergency department bypass reduces treatment delays and is associated with improved out-come.

Eur Heart J., 28 (2007), pp. 2113-2119

[11]

P. Widimsky, T. Budesinsky, D. Vorac, et al.

Long distance transport for primary angioplasty vs. thrombolysis in acute myocardial infarction. Final results of the randomized national multicentre trial: PRAGUE-2.

Eur Heart J., 24 (2003), pp. 94-104

Medline

[12]

P. Ortolani, A. Marzocchi, C. Marrozzini, et al.

Clinical impact of direct referral to primary percutaneous coronary interven-tion following pre-hospital diagnosis of ST-elevation myocardial infarction.

Eur Heart J., 27 (2006), pp. 1550-1557

http://dx.doi.org/10.1093/eurheartj/ehl006 | Medline

[13]

F.V. Aguirre, J.J. Varghese, M.P. Kelley, et al.

Stat Heart Investigators. Rural interhospital transfer of ST-elevation myocardial infarction patients for percutaneous coronary revascularization: the Stat Heart Program.

Circulation., 117 (2008), pp. 1145-1152

http://dx.doi.org/10.1161/CIRCULATIONAHA.107.728519Article | Medline

[14]

R.L. McNamara, Y. Wang, J. Herrin, et al.

NRMI Investigators. Effect of door-to-balloon time on mortality in patients with ST-segment elevation myocardial infarction.

J Am Coll Cardiol., 47 (2006), pp. 2180-2186

http://dx.doi.org/10.1016/j.jacc.2005.12.072 | Medline

[15]

R.L. McNamara, J. Herrin, Y. Wang, et al.

Impact of delay in door-to-needle time on mortality in patients with ST-segment elevation myocardial infarction.

Am J Cardiol., 100 (2007), pp. 1227-1232

http://dx.doi.org/10.1016/j.amjcard.2007.05.043 | Medline

[16]

A. Chakrabarti, H.M. Krumholz, Y. Wang, et al.

Time-to-reperfusion in patients undergoing interhospital transfer for primary percu-taneous coronary intervention in the U.S.: an analysis of 2005 and 2006 data from the National Cardiovascular Data Registry.

J Am Coll Cardiol., 51 (2008), pp. 2442-2443

http://dx.doi.org/10.1016/j.jacc.2008.02.071 | Medline

[17]

R.C. Welsh, J. Ornato, P.W. Armstrong.

Prehospital management of acute ST-elevation myocardial infarction: a time for reappraisal in North America.

Am Heart J., 145 (2003), pp. 1-8

http://dx.doi.org/10.1067/mhj.2003.47 | Medline

[18]

J.G. Canto, N.R. Every, D.J. Magid, et al.

The volume of primary angioplasty procedures and survival after acute myocardial infarction. National Registry of Myocardial Infarction 2 Inves-tigators.

N Engl J Med., 342 (2000), pp. 1573-1580

http://dx.doi.org/10.1056/NEJM200005253422106 | Medline

[19]

M. Moscucci, K.A. Fox, C.P. Cannon, et al.

for the GRACE Investiga-tors. Predictors of major bleeding in acute coronary syndromes: the Global Registry of Acute Coronary Events (GRACE).

Eur Heart J., 24 (2003), pp. 1815-1823

Medline

[20]

J. Marrugat, R. Elosua, H. Martí.

Epidemiology of ischaemic heart disease in Spain: estimation of the number of cases and trends from 1997 to 2005.

Rev Esp Cardiol., 55 (2002), pp. 337-346

Article | Medline

[21]

R.J. Goldberg, P.G. Steg, I. Sadiq, et al.

Extent of and factors associated with delay to hospital presentation in patients with acute coronary disease (the GRACE registry).

Am J Cardiol., 89 (2002), pp. 791-796

Medline

[22]

J.G. Canto, W.J. Rogers, L.J. Bowlby, et al.

The pre-hospital electro-cardiogram in acute myocardial infarction: is its full potential being realized?.

J Am Coll Cardiol., 29 (1997), pp. 498-505

Medline

[23]

Coordenac¸ão Nacional para Doenc¸as Cardiovasculares. Alto Comissariado da Saúde. Indicadores de Actividades, Julho 2009. Available from: http://www.acs.min-saude.pt/files/2009/07/indicadores-de-actividades-2009-final.pdf.

[24]

D.P. Chew, L.J. Blows.

Randomized trials of clinical networks in the management of ST-elevation MI: can they be performed?.

Curr Opin Cardiol., 24 (2009), pp. 301-306

http://dx.doi.org/10.1097/HCO.0b013e32832aabaf | Medline

Indexed in:

Follow us:

Indexed in:

Follow us:

Subscribe to our newsletter