Clinical Research - Coronary Artery Disease Management
Bridging the Gap for Nonmetropolitan STEMI Patients Through Implementation of a Pharmacoinvasive Reperfusion Strategy

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Abstract

Background

Timely primary percutaneous coronary intervention (PCI) is the preferred reperfusion strategy in ST-elevation myocardial infarction (STEMI). However, universal access is limited outside metropolitan centres and portends worse outcomes for rural patients. This study evaluates the outcomes of STEMI patients treated in a metropolitan and nonmetroplitan setting within Vital Heart Response, an integrated reperfusion program developed to reduce reperfusion delay in Central and Northern Alberta.

Methods

From October 2006 to March 2011, data on consecutive STEMI patients was prospectively recorded. Clinical characteristics, in-hospital management, and outcomes grouped by site of presentation are described.

Results

There were 1990 metropolitan and 1602 nonmetropolitan STEMI patients. Metropolitan were older (62.7 vs 60.4 years; P < 0.001) and had more: angina (21.2% vs 16.5%; P < 0.001), dyslipidemia (45.3% vs 39.6%; P = 0.001), and hypertension (49.9% vs 46.6%; P = 0.047). The reperfusion strategy for metropolitan and nonmetropolitan: primary PCI (57.4% vs 22.9%; P < 0.001), fibrinolysis (26.3% vs 61.2%; P < 0.001), and no reperfusion (16.3% vs 15.9%; P = 0.855). First medical contact to reperfusion was delayed in nonmetropolitan with fibrinolysis and PCI, 8 and 125 minutes. A rescue PCI or coronary angiography within 24 hours was completed in 41.4% and 46.2%, respectively. Nonmetropolitan patients had fewer deaths (4.1% vs 6.8%; P = 0.001) with no difference in the composite outcome (death, reinfraction, congestive heart failure, cardiogenic shock) (16.8% vs 15.1%; P = 0.161) or major bleeding (7.9% vs 8.0%; P = 0.951).

Conclusions

Systematic application of a pharmacoinvasive strategy appears to be safe and effective for patients in whom a delay in mechanical reperfusion is anticipated.

Résumé

Introduction

L’intervention coronarienne percutanée (ICP) primaire en temps opportun est la stratégie de reperfusion de prédilection lors d’infarctus du myocarde (IM) avec sus-décalage du segment ST. Cependant, l’accès universel est limité en dehors des centres métropolitains et laisse présager les pires résultats pour les patients vivant en milieu rural. Cette étude évalue les résultats des patients ayant subi un IM avec sus-décalage du segment ST traités en milieu métropolitain et en milieu non métropolitain dans le cadre de la Vital Heart Response, un programme intégré de reperfusion mis en place pour réduire le délai d’attente en reperfusion dans le centre et le nord de l’Alberta.

Méthodes

D’octobre 2006 à mars 2011, les données de patients consécutifs ayant subi un IM avec sus-décalage du segment ST ont été enregistrées de manière prospective. Les caractéristiques cliniques, la prise en charge des patients hospitalisés et les résultats regroupés par site d’admission sont décrits.

Résultats

Il y a eu 1990 patients en milieu métropolitain ayant un IM avec sus-décalage du segment ST et 1602 patients en milieu non métropolitain ayant un IM avec sus-décalage du segment ST. Les patients vivant en milieu métropolitain étaient plus âgés (62,7 vs 60,4 ans; P < 0,001) et manifestaient plus d’angine (21,2 % vs 16,5 %; P < 0,001), de dyslipidémie (45,3 % vs 39,6 %; P = 0,001) et d’hypertension (49,9 % vs 46,6 %; P = 0,047). La stratégie de reperfusion en milieu métropolitain et en milieu non métropolitain se présentait comme suit : l’ICP primaire (57,4 % vs 22,9 %; P < 0,001), la fibrinolyse (26,3 % vs 61,2 %; P < 0,001) et aucune reperfusion (16,3 % vs 15,9 %; P = 0,855). Le premier contact médical à la reperfusion chez les patients en milieu non métropolitain ayant reçu une fibrinolyse et ayant subi une ICP a été respectivement retardé de 8 et de 125 minutes. Une ICP urgente ou une coronarographie dans les 24 heures ont été respectivement réalisées dans 41,4 % et 46,2 % des cas. Les patients vivant en milieu non métropolitain risquaient moins de mourir (4,1 % vs 6,8 % : P = 0,001) et ne montraient aucune différence dans les critères de jugement combinés (mort, nouvel infarctus, insuffisance cardiaque congestive, choc cardiogénique) (16,8 % vs 15,1 %; P = 0,161) ou l’hémorragie majeure (7,9 % vs 8,0 %; P = 0,951).

Conclusions

L’application systématique d’une stratégie pharmaco-effractive semble être sécuritaire et efficace chez les patients dont un délai d’attente pour la reperfusion mécanique est anticipé.

Section snippets

Geographical data

Alberta, Canada covers an area of 661,848 m2 with an estimated population of 3.7 million. For the purposes of this study, the 5 centres in metropolitan Edmonton with 2 primary PCI centres were considered to be metropolitan, and the remainder of Central and Northern Alberta referral area were considered nonmetropolitan. The estimated catchment area for the population in this study is approximately 440,000 km2 serving 1.8 million inhabitants.

Prehospital care

Vital Heart Response (VHR) is a regional reperfusion

Patient characteristics

Over a 5-year period, 1990 and 1602 STEMI patients were recruited from the metropolitan and nonmetropolitan pools respectively. Baseline patient characteristics are presented in Table 1. The nonmetropolitan population was younger, and on FMC, had higher heart rates compared with the urban group. Metropolitan patients had a higher proportion of traditional cardiovascular risk factors, with more pre-existing coronary artery disease (CAD) and chronic aspirin use, hypercholesterolemia,

Discussion

This study is distinct in providing real world information about outcome of STEMI patients with an index presentation either to a metropolitan or nonmetropolitan facility in Canada. It attempts to compare outcomes of patients first presenting at geographically distinct (metropolitan and nonmetropolitan) facilities within an organized system of care, with protocols directed at shortening delays for an optimal reperfusion strategy. With the majority of nonmetropolitan patients receiving a

Conclusion

STEMI patients presenting to nonmetropolitan facilities receiving a pharmacoinvasive reperfusion approach within an organized system of care do not appear to be exposed to an increased risk of adverse clinical outcomes, and seems an equally safe and effective strategy, compared with metropolitan patients principally receiving primary PCI. Despite this, substantial reperfusion delay occurs in nonmetropolitan patients and efforts to reduce this are required to further improve clinical outcomes.

Acknowledgements

The authors acknowledge the VHR clinicians (Drs R. Leung, B. Tyrrell) and the staff at the Epidemiology Coordinating and Research Centre at the University of Alberta for their dedication to quality data.

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