Elsevier

American Heart Journal

Volume 166, Issue 3, September 2013, Pages 457-465
American Heart Journal

Clinical Investigation
Acute Ischemic Heart Disease
A prospective regional registry of ST-elevation myocardial infarction in Central Romania: Impact of the Stent for Life Initiative recommendations on patient outcomes

https://doi.org/10.1016/j.ahj.2013.03.033Get rights and content

Background

Reperfusion therapy is the treatment of choice in patients with ST-elevation myocardial infarction (STEMI) presenting within 12 hours after the onset of symptoms. However, a significant number of patients do not benefit from it because of the lack of access to well-organized emergency care. We aimed to investigate the evolution of STEMI treatment and mortality between 2004 and 2011 in an unselected population from central Romania and to demonstrate the role of a regional network in increasing the rates of reperfusion therapy with associated reduction of STEMI-related mortality in a region with very low primary percutaneous coronary intervention (pPCI) rates at baseline.

Methods

We analyzed the data of 5,899 consecutive patients with STEMI enrolled in this prospective study since 2004, after the initiation of an STEMI network in Central Romania and with continuous support of the Stent for Life Initiative.

Results

Introduction of the network was associated with an absolute change in the use of reperfusion therapy from 2004 to 2011 (26.94% vs 87.15%, P < .001) and of pPCI (10.88% vs 78.64%, P < .001) for patients presenting within 12 hours after the onset of symptoms, with a decrease of inhospital mortality from 20.73% to 6.35% (P < .001). In addition, the global inhospital mortality of all the STEMI population showed a significant decrease (23.18% vs 13.39%, P < .001).

Conclusions

Reduction of STEMI-related mortality was possible via implementation of pPCI, even in a region with low health care expenditures. The organization of an STEMI network led to a significant decrease in STEMI-related mortality, revealing the significant impact of the Stent for Life Initiative recommendations on patient outcomes.

Section snippets

Background

European Society of Cardiology (ESC) guidelines recommend primary percutaneous coronary intervention (pPCI), if available, as the first-option therapy for patients with ST-elevation myocardial infarction (STEMI) within 90 to 120 minutes of the first medical contact, especially for those presenting earlier than 12 hours after the onset of symptoms.1 When PCI is not available within 90 to 120 minutes of the first medical contact, thrombolysis is the alternative strategy for reperfusion and should

Logistic network

An STEMI network was initiated in 2004 in a central Romanian territory of 1,133,307 people, encompassing 1 pPCI academic center with an emergency hospital and 13 territorial urban hospitals without catheterization facilities (11 municipal hospitals and 2 county hospitals) located in the surrounding area, distributed in 3 zones according to the distance between them and the pPCI center (zone 1, maximum 60 km; zone 2, 60-120 km; zone 3, 120-200 km) (Figure 1).

To facilitate the early transport of

Results

Between January 1, 2004, and December 31, 2011, 5,899 patients with STEMI were enrolled in the registry. Baseline characteristics of the study population in relation to the treatment strategy are listed in Table I.

Multivariate logistic regression analysis for predictors of not receiving reperfusion therapy in a population with STEMI showed that besides presentation outside the recommended 12-hour time frame, presentation to a territorial hospital instead of a pPCI center (odds radio 3.9, 95% CI

Discussion

Many prior studies (ASSENT, DANAMI, TRANSFER-AMI) have proven that reperfusion therapy, when initiated within 12 hours after the onset of symptoms, is the treatment of choice in patients with STEMI and should be started as soon as possible.4., 5., 6., 7. However, the effectiveness of these therapies depends on the access to well-organized emergency care.1., 2. Many registries have demonstrated that, in the real world, a significant number of patients do not benefit from reperfusion therapy

Conclusions

This study shows that a reduction of STEMI-related mortality by implementing pPCI in a territory of 1 million people was possible even in a country with very low health care expenditures.

The intervention of the appropriate logistic measures in the network had a significant impact and led to a more substantial increase in the total number of patients treated for STEMI.

The major progress of pPCI rates in our experience was recorded after 5 years of intervention in the community, when the most

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