Summary
Background
Guidelines emphasize the implementation of local networks with prehospital emergency medical systems to improve the management of patients with ST-segment elevation myocardial infarction (STEMI); they also define the choice of reperfusion strategies and adjunctive treatments.
Aim
To assess the compliance of STEMI emergency care with current French guidelines in a large area of France and to identify predictors of compliance with guidelines.
Method
The RESCA+31 registry was a 2-year, multicentre, prospective, multidisciplinary study, including 512 consecutive patients with STEMI evolving within 12 hours managed by emergency physicians in the prehospital system or emergency department. Data were recorded during the emergency phase and after admission to cardiology.
Results
First medical contact (FMC) was prehospital emergency care for 80% of patients; 97% received reperfusion treatment and 98% were admitted to a cardiology intensive care unit (CICU) with a catheterization laboratory. The mortality rate was 5%. Guidelines were complied with in 41% of patients for reperfusion strategies, in 47% for adjunctive treatments and in 23% for both. The only factor independently associated with guideline compliance was FMC by prehospital emergency system. In 52% of cases, emergency physicians underestimated the delay between FMC and admission to a CICU.
Conclusion
Despite the implementation of a network, compliance with guidelines for reperfusion strategies and adjunctive treatments was insufficient in our area. However, very few patients did not receive reperfusion therapy and the mortality rate was low. Efforts should be made to improve the estimation of delay before primary percutaneous coronary intervention.
Résumé
Contexte
Les recommandations insistent pour développer des réseaux locaux avec les systèmes préhospitaliers pour améliorer la prise en charge des patients avec un infarctus du myocarde avec sus-décalage du segment ST (IDM ST+). Elles définissent le choix des stratégies de reperfusion et des traitements adjuvants.
Objectif
Évaluer le suivi des recommandations françaises dans un département pour la prise en charge en urgences des IDM ST+ et identifier les facteurs prédictifs de suivi des recommandations.
Méthodes
Le registre RESCA+31 est une étude multicentrique, multidisciplinaire menée pendant deux ans et incluant 512 patients avec un IDM ST+ évoluant depuis moins de 12 heures et pris en charge par des urgentistes préhospitaliers ou des urgences. Les données ont été recueillies pendant la phase d’urgence et après l’admission en cardiologie.
Résultats
Le premier contact médical (PCM) était préhospitalier pour 80 % des patients, 97 % recevaient un traitement de reperfusion et 98 % étaient admis en cardiologie interventionnelle (CI). La mortalité était de 5 %. Les stratégies de reperfusion étaient mises en œuvre en accord avec les recommandations pour 41 % des patients, les traitements adjuvants pour 47 % et les deux pour 21 %. Le seul facteur indépendant de suivi des recommandations était le PCM par le système préhospitalier. Le délai PCM admission en CI était sous-estimé dans 52 % des cas.
Conclusion
Malgré le développement de réseaux, le suivi des recommandations pour le choix des stratégies de reperfusion et les traitements adjuvants a été insuffisant dans notre département. Toutefois, très peu de patients n’ont pas bénéficié d’un traitement de reperfusion et la mortalité a été faible. Des efforts doivent être faits pour estimer les délais permettant une angioplastie primaire.
Background
European and American societies of cardiology and emergency care have defined recommendations for the management of ST-segment elevation myocardial infarction (STEMI) . Delay in receipt of reperfusion therapy strongly correlates with mortality, regardless of the reperfusion strategy chosen–thrombolysis or primary percutaneous coronary intervention (PCI) . The guidelines therefore emphasize the implementation of an emergency medical system (EMS) to reduce delay to reperfusion. In this network, the prehospital organization has a key role in the initial diagnosis, risk stratification and reperfusion treatment of patients with STEMI . In Europe, a statement from the European Society of Cardiology Working Group on Acute Cardiac Care emphasized that guidelines and recommendations should be translated, taking into consideration the diversity of healthcare systems in Europe, and that their implementation should be adapted to, and evaluated in, local and national circumstances . In France in 2007, recommendations were developed by the French Societies of Emergency and Cardiology, under the auspices of the Haute Autorité de santé (Health Authority) , for the emergency care of STEMI before care by the cardiology team. The treatment delays, reperfusion strategies and adjunctive treatments recommended were specific to the emergency phase.
The French emergency healthcare system benefits from a high level of medicalization at all levels of management . Public health campaigns advocate telephoning an emergency medical dispatch centre when someone presents with acute chest pain. After assessing for the probability of acute coronary syndrome, the emergency physician in the emergency centre can dispatch a medical intensive care unit (MICU) with a physician on board if a myocardial infarction is suspected. If a diagnosis of STEMI is confirmed, treatment is initiated immediately and the patient is usually transferred to a cardiology intensive care unit (CICU) with a catheterization laboratory (cath-lab). However, some patients fall outside of this system and arrive directly at an emergency department. In this case, the emergency physicians rapidly transfer the patient to a CICU with a cath-lab after beginning reperfusion treatment. Collaboration between cardiologists and emergency physicians is very important in this system and strategies are planned jointly. One step of the recommendation concerns the assessment of quality of care and compliance with guidelines.
The aim of this study was to assess the compliance of STEMI emergency care with current French guidelines in a large area of France. The secondary objective was to identify predictors of guideline compliance.
Methods
Study design and setting
The RESCA+31 registry was a multicentre, prospective, multidisciplinary study carried out between January 2008 and January 2010 in a 6309 km 2 area of France–Haute Garonne–which has 1,046,532 habitants. In this area, one university hospital, one emergency medical dispatch centre, two MICUs, eight emergency departments and five CICUs (each with a cath-lab) in public or private hospitals are operational; all participated in the RESCA+31 registry. All CICU cath-labs had a high volume of primary PCI procedures . The study was conducted by the Regional Observatory of Emergency Medicine in Midi-Pyrénées, in accordance with the principles outlined in the Declaration of Helsinki. Patients were informed of study participation; as this was an observational study, prior written consent was not necessary.
Selection of patients
Patients with STEMI managed by emergency physicians in the MICU or emergency department were included prospectively by the treating physician. Patients admitted directly to a cardiology department without receiving emergency medical care were not enrolled in the study.
Inclusion criteria were: age greater or equal to 18 years; chest pain for more than 20 minutes and less than 12 hours; and management in an emergency department or MICU. According to the guidelines, ST-segment elevation on a 17-lead electrocardiogram was defined as more than 0.1 mV in at least two peripheral leads and in V4–V9, V3R and V4R precordial leads and more than 0.2 mV in V1–V3 precordial leads.
Data collection and processing
Demographic, clinical, electrocardiographic and delay data were collected prospectively by the emergency physician and recorded on a case report form (CRF). The treatments, reperfusion strategies and adjunctive treatments implemented by the emergency physician were also recorded, along with data on whether the physician intended to manage the patient according to the 2007 guidelines . For patients admitted to a CICU, the results of coronary angiography and angioplasty, and data on clinical outcomes occurring during hospitalization in the CICU were collected by the treating cardiologist. A research assistant checked the completeness of the data in the CRF.
Compliance with guidelines
The guidelines concerned the emergency care of patients with STEMI, before they were transferred to the cardiology team. An algorithm was developed to choose reperfusion therapy (primary PCI or thrombolysis) according to time from first medical contact (FMC) to balloon, and time between onset of symptoms and FMC. Specifically, an emergency time was identified: from FMC to admission to the CICU. This time is half the duration of the FMC to balloon time (i.e. 45 minutes). After admission to a CICU with cath-lab, the cardiologist has 45 minutes in which to perform primary PCI.
For reperfusion strategies, patients were considered to have been managed according to the guidelines if they followed the algorithm in Fig. 1 : all patients received reperfusion therapy; patients with a delay from FMC to CICU admission of less than 45 minutes and a time since onset of symptoms of less than 3 hours could receive thrombolysis or have primary PCI; patients with a time from FMC to CICU admission of less than 45 minutes and a time since onset of symptoms of more than 3 hours should have primary PCI; patients with a time from FMC to CICU admission of more than 45 minutes should receive thrombolytic treatment, unless contraindicated.
For adjunctive treatments, the choice depends on the reperfusion strategy and the patient’s age ( Fig. 2 ): all patients received aspirin; patients who had undergone primary PCI and were less than 75 years of age received clopidogrel 300 mg or prasugrel 60 mg and an intravenous infusion of unfractionated heparin (UFH) 60 IU/kg intravenously; patients who had a primary PCI and were more than 75 years received clopidogrel 75 mg or prasugrel 60 mg and a intravenous infusion of UFH of 60 IU/kg intravenously; patients treated with a thrombolytic agent and who were less than 75 years received clopidogrel 300 mg, an intravenous bolus of enoxaparin 30 mg and enoxaparin 1 mg/kg subcutaneously; patients treated with a thrombolytic agent and age more than 75 years received clopidogrel 75 mg and UFH 60 IU/kg intravenously.
Patients were considered to have been managed according to the guidelines for reperfusion strategies and adjunctive treatments if they fulfilled both conditions described above.
Primary data analysis
Statistical analyses were conducted using STATA10 software (StataCorp LP, College Station, TX, USA). Statistics are reported as means with standard deviations, and medians with interquartile ranges (IQRs) for delays. Means were compared using Student’s t test for normally distributed data or the non-parametric two-sample Mann-Whitney rank sum test for data not fitting the assumption of parametric testing. Percentages were compared using Pearson’s Chi-square test and Fisher’s exact test.
Univariate analyses were performed to identify factors associated with guideline compliance for reperfusion therapies, adjunctive treatments or both. We introduced all variables with a P -value < 0.20 in the univariate analyses into a stepwise multivariable logistic regression analysis. Odds ratios (ORs) were reported with 95% confidence intervals (CIs).
Results
Characteristics of the study population
During the 2 years of recruitment, 512 consecutive patients with a final diagnosis of STEMI were included in our study. The FMC was by the MICU in 411 patients (80%). The demographic, clinical, electrocardiographic and delay in care management data are reported in Table 1 . Reperfusion strategies and adjunctive treatments are presented in Table 2 . Reperfusion strategies were performed for 97% of patients; only 14 patients failed to receive some form of reperfusion therapy, 11 of whom were elderly. Thrombolytic therapy was contraindicated in 51 patients. Primary PCI was the most common reperfusion strategy used (68%), particularly in elderly patients (81%). The FMC to balloon time was less than 90 minutes for 21% of patients and less than 120 minutes for 44% of patients.
| Variable | |
|---|---|
| Men | 390 (76) |
| Age (years) | 62 ± 15 |
| Age ≤ 75 years | 136 (26) |
| Risk factors | |
| Diabetes | 71 (14) |
| Hyperlipidaemia | 174 (3) |
| Smoker | 229 (45) |
| Hypertension | 201 (39) |
| Family history of CAD | 93 (18) |
| More than one risk factor | 449 (88) |
| Previous CAD | 87 (17) |
| Killip class ≤ 1 | 382 (82) |
| Anterior site STEMI | 199 (39) |
| MICU FMC | 411 (80) |
| Period of initial management 8–20 hours | 295 (60) |
| Delays (minutes) | |
| Time since symptom onset | 92 (82–183) |
| Time since symptom onset < 180 minutes | 349 (74) |
| FMC to arrival in cardiology | 84 (59–129) |
| FMC to arrival in cardiology < 45 minutes | 48 (11) |
| FMC to balloon | 127 (92–190) |
| FMC to balloon < 90 minutes | 50 (21) |
| FMC to needle | 20 (10–24) |
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