Summary
Background
Myocardial infarction with ST-segment elevation (STEMI) is a medical emergency requiring specific management, with the main aim of achieving reperfusion as quickly as possible. Guidelines from medical societies have defined optimal management, with proven efficacy on morbi-mortality.
Aims
Our study aimed to evaluate trends in practices between 2002 and 2010 in the emergency management of STEMI in a single French department, namely Cote d’Or.
Methods
All patients admitted with a first STEMI to one of the six participating coronary care units (private or public) in Cote d’Or since January 2001 were included in a prospective registry (obseRvatoire des Infarctus de Côte d’Or [RICO]). Based on these data, we analysed trends in prehospital times between 2002 and 2010.
Results
A total of 4114 patients were included in this analysis. Between 2002 and 2010, there was an increase in the proportion of patients who contacted the emergency services (by dialling 15) as first medical contact; however, the time from onset of symptoms to first medical contact remained stable over the study period. Overall, there was little change in prehospital management times but we noted a slight reduction in time to reperfusion.
Conclusion
Despite some improvement in prehospital management practices between 2002 and 2010 in Cote d’Or, there is still significant room for improvement to achieve earlier reperfusion in STEMI patients.
Résumé
Contexte
L’infarctus du myocarde avec sus-décalage du segment ST (STEMI) nécessite une prise en charge en urgence reposant sur une filière de soins spécifique dont le but est une reperfusion précoce. Les recommandations définissent une stratégie de prise en charge optimale qui a montré une efficacité sur la morbi-mortalité.
Objectifs
L’objectif de notre étude a été d’évaluer l’évolution des pratiques entre 2002 et 2010 dans la prise en charge en urgence des STEMI au niveau d’un département français.
Méthodes
Ont été inclus tous les patients admis dans une unité de soins intensifs cardiologiques public ou privée de Côte d’Or pour un STEMI dans la base de données de l’observatoire des Infarctus de Côte d’Or (RICO) entre 2002 et 2010. À partir de ces données, nous avons étudié l’évolution des pratiques de prise en charge préhospitalière des STEMI.
Résultats
Notre étude a inclus 4114 STEMI. Entre 2002 et 2010, les malades ont appelé davantage le centre 15, mais les délais d’appel à un recours médical par rapport au début de leurs symptômes ne se sont pas améliorés. Les délais de prise en charge préhospitalière ont peu évolué, mais les délais de reperfusion se sont raccourcis.
Conclusions
Les pratiques des professionnels de santé dans le cadre de la filière préhospitalière des STEMI se sont améliorées entre 2002 et 2010 en Côte d’Or, mais des progrès restent à faire, notamment dans les délais de prise en charge.
Introduction
Myocardial infarction, including ST-segment elevation myocardial infarction (STEMI), is one of the leading causes of morbi-mortality worldwide . Management of STEMI presents a medical emergency, with the main objective being to urgently reopen the occluded artery, in order to minimize necrosis size and subsequent disabling complications. One of the prerequisites for timely and efficacious management is that the first medical contact be made early in case of suspected acute myocardial infarction .
In France, in patients with chest pain, optimal management recommended by the National Authority for Health (Haute Autorité de Santé [HAS]) since 2006 comprises a systematic call to the emergency medical system followed by intervention by a mobile intensive care unit from the Service mobile d’urgence et de réanimation with doctors on board, who perform an early prehospital electrocardiogram to enable direct admission to the catheterization laboratory within a time period that should not exceed 45 minutes from the time of first medical contact .
Since 2001, Cote d’Or, an eastern department of France, has had an ongoing registry (obseRvatoire des Infarctus de la Cote d’Or [RICO]) to record data, including time to treatment for all myocardial infarctions, for all patients hospitalized for an acute myocardial infarction in any of the coronary care units in the department.
Our study, based on the data from this registry, aimed to evaluate temporal trends in time to treatment in patients with STEMI between 2002 and 2010.
Methods
The study included all patients with a confirmed diagnosis of STEMI admitted to the coronary care units in the six participating centres (the general hospitals of Beaune, Châtillon-sur-Seine, Montbard and Semur-en-Auxois, the private clinic of Fontaine-lès-Dijon and the University Hospital Bocage, Dijon) between 1st January 2002 and 31st December 2010, and treated in one of the two centres equipped with interventional cardiology facilities (catheterization laboratory). For each patient, standardized data collection was performed using the RICO registry case report form.
For the purposes of this report, we analysed baseline demographic and clinical characteristics of the patients, times to treatment, the medical and paramedical staff involved in prehospital management, reperfusion strategies and the existence of any prior admissions to other hospitals for cardiovascular causes. Data on major in-hospital cardiac events, including cardiogenic shock, recurrent myocardial infarction and cardiovascular death, were collected. The study complied with the Declaration of Helsinki and was approved by the ethics committee of the Centre hospitalier universitaire de Dijon. Each patient gave written informed consent before participation.
Statistical analysis
Data recorded in the RICO case report form were transcribed into a dedicated computer programme to facilitate archiving and statistical analysis. All statistical analyses were performed using SPSS software, version 12.0 (IBM Corp., Armonk, NY, USA).
Quantitative data are described as mean ± standard deviation and qualitative data as number (percentage). For continuous variables, the normality of distribution was checked by the Kolmogorov–Smirnov test. We performed either the Kruskal–Wallis one-way analysis of variance by rank for non-normally distributed values or one-way analysis of variance for normally distributed values. Categorical data were compared using the χ 2 test, as appropriate. A two-sided P value of 0.05 was considered statistically significant.
Results
Between 1st January 2002 and 31st December 2010, 4114 patients were admitted for STEMI in the participating centres. The distribution of STEMIs per year over the study period is shown in Fig. 1 (1162 women; 2952 men). Among these, 2387 were admitted directly to one of the two coronary referral centres equipped with angioplasty facilities, while the remaining 1727 were first admitted to a peripheral hospital.
First medical contact
Over the study period, the number of patients who made first medical contact with their local general practitioner (GP) decreased, with a corresponding increase in the number who contacted the emergency services by telephone (i.e. by dialling 15) as first medical contact. In 2002, 246 (57.1%) contacted the GP first versus 107 (24.8%) who dialled the emergency services, compared with 184 (34.2%) and 212 (39.4%), respectively, in 2010. In addition, 5 to 10% of patients called the fire brigade as first medical contact each year (by dialling 18). Other recipients of first calls included private practice cardiologists, hospital emergency rooms and hospital units other than the emergency department or the coronary care unit.
There was a significant difference in time to first medical contact according to age, with patients aged less than 50 years getting help on average 40 to 100 minutes earlier than patients aged over 50 years ( P = 0.019). There were no differences in time to first medical contact according to sex, diabetes or history of myocardial infarction.
Time to reperfusion
The average time to reperfusion from first medical contact over the entire study period was 312 minutes (median 165 minutes). The time to treatment varied considerably depending on who was first contacted (GP, emergency services, fire brigade, etc.). Calling the emergency services (by dialling 15) as first medical contact significantly reduced the average time between the first call and reperfusion (218 minutes [median 120 minutes] compared with 397 minutes [median 225 minutes] when the GP was first to be contacted; P = 0.005). If the patient contacted the GP first but subsequently contacted the emergency services, the average time to reperfusion decreased to 283 minutes (median 180 minutes). The later the emergency services were contacted, the longer the time to reperfusion, with an average time to reperfusion of 482 minutes in patients who did not contact the emergency services at all.
Over the study period, the average time from onset of symptoms to first medical contact increased slightly, but not significantly, from 307 minutes in 2002 to 340 minutes in 2010, with some fluctuation over the study period.
Reperfusion therapy
In 2002, 151 (35%) STEMI patients underwent revascularization at the acute phase of STEMI by thrombolytic therapy, 100 (23.1%) underwent primary percutaneous coronary intervention (pPCI) and 181 (41.9%) had no reperfusion at all. The proportion of patients treated by pPCI increased over the study period and, since 2007, has exceeded the proportion treated by thrombolytic therapy. Accordingly, in 2010, 197 patients (36.7%) were treated by pPCI and 145 (27%) were treated by thrombolytic therapy. The number of patients without any reperfusion strategy decreased steadily over the study period, reaching 36.3% ( n = 196) in 2010. The evolution of the types of reperfusion over the course of the study is shown in Fig. 2 .
