Short- and long-term mortality in patients with ST-elevation myocardial infarction treated with different therapeutic strategies. Results from WIelkopolska REgional 2002 Registry (WIRE Registry)
ABSTRACT Although primary coronary angioplasty seems to be the best treatment in acute myocardial infarction (MI), thrombolytic therapy still remains the most common reperfusion strategy particularly in smaller centers. Nowadays, different regional networks are developed to improve the treatment of patients with MI.
To analyse the effects of different therapeutic strategies on 30-day and long-term mortality (median time 18.3 months) after ST-elevation MI (STEMI) in a population of 3 350 000 people from the Wielkopolska Region.
In 2002, 3780 patients with STEMI entered the registry. Complete data were available for 3564 (94.3%) patients. Depending on therapeutic strategies, patients were divided into five groups: the PCI group--direct percutaneous coronary angioplasty (PCI) in small cathlab, 'selected patients', n=381 (10.7%); the PA group--aged <70, treated with tissue plasminogen activator (rt-PA) up to 4 hours from the onset of chest pain, n=479 (13.4%); the IS group - invasive strategy in every patient, 24-hour duty, setting of unselected patients with STEMI, n=989 (27.7%); the SK group--patients receiving standard streptokinase treatment up to 12 hours from the onset of chest pain, n=584 (16.4%); the NR group--no reperfusion therapy, n=1131 (31.7%).
The 30-day mortality rate in the groups above was: 3.15, 4.38, 4.54, 9.25, and 12.5% respectively (p <0.001). Long-term mortality rate was: 4.2, 9.4, 9.4, 14.4, and 18.50% respectively (p <0.001). The rate of urgent PCI in the PA group was 25% and in the SK group--11% (p <0.001).
Treatment with rt-PA in patients under 70 years of age and up to 4 hours from pain onset may be an alternative to an invasive strategy. However, a quarter of those patients require urgent PCI. In long-term observation the mortality benefit can be clearly seen only in patients with early PCI.
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ABSTRACT: ST-segment elevation myocardial infarction (STEMI) is one of the greatest medical emergencies, for which organization of care has a determinant impact on patient outcomes. The purpose of this paper is to review systems of care for STEMI patients. Although primary percutaneous coronary intervention (PCI) is the preferred option for patients with STEMI, offering easy and emergent access to this procedure often remains difficult because of geographic and diverse structural difficulties. intravenous fibrinolysis, especially when administered early after symptom onset and as part of a pharmacoinvasive strategy (i.e., followed by rapid coronary angiography with PCI when necessary), offers a reasonable therapeutic option in selected cases and has yielded satisfactory clinical results. Network organization is central for optimizing patient care at the acute stage of myocardial infarction. This review describes different clinical experiences with network implementation both in Europe and in North America. In all instances, early recognition of STEMI and, particularly in the pre-hospital setting, shortening time delays is central for the achievement of optimal clinical results. Overall, the encouraging results described in the models presented here, as diverse as they might be, should be an encouragement to promote and implement regional protocols according to the specific local constraints and to monitor their effectiveness by recording simple quality indicators in ongoing registries.JACC. Cardiovascular Interventions 10/2009; 2(10):901-8. DOI:10.1016/j.jcin.2009.05.025 · 7.35 Impact Factor
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ABSTRACT: Detailed data on patients admitted for acute myocardial infarction (AMI) on a European-wide basis are lacking. The Euro Heart Survey 2009 Snapshot was designed to assess characteristics, management, and hospital outcomes of AMI patients throughout European Society of Cardiology (ESC) member countries in a contemporary 'real-world' setting, using a methodology designed to improve the representativeness of the survey. Member countries of the ESC were invited to participate in a 1-week survey of all patients admitted for documented AMI in December 2009. Data on baseline characteristics, type of AMI, management, and complications were recorded using a dedicated electronic form. In addition, we used data collected during the same time period in national registries in Sweden, England, and Wales. Data were centralized at the European Heart House. Overall, 4236 patients (mean age 66±13 years; 31% women) were included in the study in 47 countries. Sixty per cent of patients had ST-segment elevation myocardial infarction, with 50% having primary percutaneous coronary intervention and 21% fibrinolysis. Aspirin and thienopyridines were used in >90%. Unfractionated and low-molecular-weight heparins were the most commonly used anticoagulants. Statins, beta-blockers, and angiotensin-converting enzyme inhibitors were used in >80% of the patients. In-hospital mortality was 6.2%. Regional differences were observed, both in terms of population characteristics, management, and outcomes. In-hospital mortality of patients admitted for AMI in Europe is low. Although regional variations exist in their presentation and management, differences are limited and have only moderate impact on early outcomes.12/2013; 2(4):359-70. DOI:10.1177/2048872613497341
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ABSTRACT: Todas las guías recomiendan la intervención coronaria percutánea primaria como estrategia por defecto para el tratamiento de reperfusión de pacientes con infarto agudo de miocardio con elevación del segmento ST. Estas recomendaciones se basan en ensayos aleatorizados en los que se ha comparado la intervención coronaria percutánea primaria con la fibrinolisis intravenosa sola. Sin embargo, desde la época en que se llevaron a cabo esos ensayos, se han realizado otros estudios que han puesto de manifiesto que usar la intervención coronaria percutánea de rescate en pacientes que no presentan signos de reperfusión después del tratamiento lítico y la angiografía coronaria sistemática en las primeras 24 h tras la administración de dicho tratamiento para todos los demás pacientes mejora los resultados del tratamiento fibrinolítico intravenoso. Esto ha llevado a proponer la estrategia farmacoinvasiva como alternativa a la intervención coronaria percutánea primaria. De hecho, no es infrecuente que las circunstancias concretas impidan la intervención coronaria percutánea primaria dentro de los límites temporales recomendados en las guías. En tales casos, el uso de una estrategia farmacoinvasiva puede ser una alternativa válida. Tanto el ensayo aleatorizado STREAM como la experiencia de la práctica clínica real, y en especial los resultados a largo plazo del registro FAST-MI, indican que la estrategia farmacoinvasiva, cuando se utiliza en una población adecuada, puede compararse favorablemente con la intervención coronaria percutánea primaria. Así pues, la puesta en práctica de un protocolo de estrategia farmacoinvasiva puede ser un complemento importante para compensar las posibles limitaciones de las redes de tratamiento del infarto agudo de miocardio con elevación del segmento ST.Revista Espanola de Cardiologia 08/2014; 67(8). DOI:10.1016/j.recesp.2014.04.006 · 3.34 Impact Factor