Management of acute ST-elevation myocardial infarction in the coronary care units of Piedmont in 2005: results from the PRIMA regionwide survey

Abstract

Objective: In Piedmont (north-western Italy) a network for emergency treatment of acute ST-elevation myocardial infarction is being implemented. To provide a baseline for care assessment and quality improvement, a regionwide survey was conducted. We describe the clinical characteristics, treatment and outcomes of patients admitted to the coronary care units (CCUs) of the Regional Health System.

Methods: All patients with acute ST-elevation myocardial infarction <12 h of symptom onset, admitted to any of the 31 CCUs (13 with full-time interventional facilities) between February and May 2005, were enrolled in the study.

Results: Of 818 patients (28.1% female, mean age 66 +/- 12 years), 14.3% had diabetes mellitus and 39.7% anterior myocardial infarction; 77% had their first medical contact within 3 h of symptom onset, and 53% reached full-time interventional CCUs. The 118 emergency medical system was used by 50% of patients. Median door-to-electrocardiogram time was 9 min (<10 min in 60%). Reperfusion treatment was attempted in 682 patients (83.4%) as follows: lysis in 254 (31.1%), lysis-angioplasty in 95 (11.6%), and primary angioplasty in 333 (40.7%); 136 patients (16.6%) received no reperfusion treatment. Median door-to-needle time was 35 min (<30 min in 43%). Emergency angioplasty was performed on site in 356 patients, with a median door-to-balloon time of 84 min (<90 min and <60 min in 50% and 23%, respectively). Emergency transfer to a full-time interventional centre was required in 93 patients (24% of candidates), regardless of their risk profile, with median decision-to-door out and travel times of 45 min and 52 min, respectively. In-hospital death, reinfarction and stroke occurred in 62 (7.6%), 13 (1.6%) and 10 patients (1.2%), respectively. Mortality was 5.9% and 16.7% in patients with and without reperfusion treatment, respectively. At multivariate analysis, the type of reperfusion treatment was not a predictor of mortality, whereas this was the case for the absence of reperfusion treatment (odds ratio 2.16; 95% confidence interval 1.17-4.02), TIMI risk index >33 (odds ratio 6.78; 95% confidence interval 3.70-12.40), and chronic renal failure (odds ratio 4.96; 95% confidence interval 1.82-13.55).

Conclusions: In Piedmont, candidates for myocardial reperfusion treatment admitted to the CCUs of the Regional Health System are about 600 per million inhabitants/year. The 118 emergency medical system is used by about half of them, and medical contact occurs within 3 h of symptom onset in most cases. Use of reperfusion treatment is frequent, the choice is related to on-site availability rather than to risk profile, and door-to-treatment times can be improved. Use of emergency transfer is limited, poorly selected, and slow.