Evolution and Impact of a Regional Reperfusion System for ST-Elevation Myocardial Infarction

• Published in: Canadian journal of cardiology 2016-10, Vol.32 (10), p.1222-1230
• Main Authors: Fordyce, Christopher B., MD, MSc, Cairns, John A., MD, Singer, Joel, PhD, Lee, Terry, PhD, Park, Julie E., MMath, Vandegriend, Richard A., MD, Perry, Michele, BScN, MHA, Largy, Wendy, RN, Gao, Min, MD, PhD, Ramanathan, Krishnan, MBChB, Wong, Graham C., MD, MPH
• Format: Article
• Language: English
• Subjects: Aged; Algorithms; Canada - epidemiology; Cardiovascular; Coronary Artery Bypass - statistics & numerical data; Electrocardiography; Emergency Medical Services; Female; Fibrinolytic Agents - therapeutic use; Hemorrhage - epidemiology; Hospital Mortality; Humans; Male; Patient Transfer; Percutaneous Coronary Intervention; Regional Medical Programs - organization & administration; Retrospective Studies; Shock, Cardiogenic - epidemiology; ST Elevation Myocardial Infarction - epidemiology; ST Elevation Myocardial Infarction - therapy; Telemetry; Time-to-Treatment
• ISSN: 0828-282X; 1916-7075
• DOI: 10.1016/j.cjca.2015.11.026

Abstract Background We describe the evolution of a regional system designed to provide primary percutaneous coronary intervention (pPCI) as the preferred method of revascularization for ST-elevation myocardial infarction (STEMI) and its impact on first medical contact (FMC)-to-device times and in-hospital outcomes. Methods Patients with STEMI presenting to the Vancouver Coastal Health Authority between June 2007 and January 2015 (N = 2503) were categorized according to 3 sequential phases: phase 1 = standardization of reperfusion algorithms; phase 2 = use of prehospital electrocardiograms; phase 3 = expedited interfacility transfer for pPCI. In-hospital outcomes by phase and hospital type were analyzed using multivariable logistic regression techniques. Results Regional pPCI use increased across phases (55.0% vs 72.5% vs 86.7%; P < 0.001) and median FMC-to-device times shortened between phase 1 and later phases at both PCI-capable (117 minutes vs 92 minutes vs 97 minutes, respectively; P < 0.001) and non-PCI–capable hospitals (174 minutes vs 146 minutes vs 123 minutes, respectively; P < 0.001). Overall in-hospital mortality (9.4% vs 8.9% vs 10.3%, respectively; P  = 0.54) and congestive heart failure (CHF) (15.8% vs 19.7% vs 22.0%, respectively; P  = 0.056) were unchanged across phases. A trend toward increased mortality (9.0% vs 9.3% vs 12.9%, respectively; P  = 0.079) and higher rates of CHF (15.7% vs 21.5% vs 25.9%, respectively; P  = 0.014) were seen in PCI-capable hospitals. Conclusions Our regional STEMI model increased access to pPCI and reduced median reperfusion times. However, FMC-to-device times remained prolonged in many patients and overall clinical outcomes were not improved—in particular at PCI-capable hospitals. A strategy of pPCI as the preferred method of reperfusion may not benefit all patients in a regional model of STEMI care.