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Postconditioning with Lactate-enriched Blood for Cardioprotection in ST-segment Elevation Myocardial Infarction
Published on: May 28, 2019
[Reperfusion in ST elevation myocardial infarction. From the guidelines to practice]
A Duraffourg1, K Yayehd2, M Fourny3
1Médecins de Montagne Rhône-Alpes, 256, rue de la République, 73000 Chambery, France.
Insights
Forty percent of ST-segment elevation myocardial infarction (STEMI) patients did not receive guideline-recommended reperfusion therapy. Improving adherence to STEMI treatment guidelines is crucial for patient outcomes.
Area of Science:
- Cardiology
- Emergency Medicine
- Health Services Research
Background:
- International guidelines recommend reperfusion strategies (fibrinolysis or angioplasty) for ST-segment elevation myocardial infarction (STEMI).
- Emergency-care networks are advised to adapt these guidelines to local contexts.
- Adherence to these adapted guidelines in real-world settings requires evaluation.
Purpose of the Study:
- To evaluate the proportion of STEMI patients treated with fibrinolysis or angioplasty according to regional guidelines.
- To identify factors associated with adherence to reperfusion guidelines in a French emergency network.
Main Methods:
- An observational study utilizing a permanent registry of STEMI patients (duration <12h) in the French North Alps (2009-2012).
- Data collected on reperfusion type (fibrinolysis vs. angioplasty) and adherence to regional guidelines.
- Multivariable analysis to identify predictors of guideline-recommended reperfusion.
Main Results:
- Out of 2620 STEMI patients, 93% received reperfusion, with 60% treated in accordance with guidelines.
- Guideline-recommended fibrinolysis was used in 47% and angioplasty in 79% of eligible patients.
- Younger age (<65), management in Haute-Savoie, lower blood pressure, and initial treatment by mobile intensive care units were associated with higher adherence.
Conclusions:
- A significant proportion (40%) of STEMI patients did not receive reperfusion therapy aligned with regional guidelines.
- Understanding the characteristics of non-adherent patients is key to improving future guideline implementation.
- Further efforts are needed to enhance adherence to STEMI reperfusion protocols within emergency networks.
Background:
International guidelines have recommendations for selecting the type of reperfusion (fibrinolysis or angioplasty) in the setting of ST-segment elevation myocardial infarction (STEMI), and suggest that emergency-care networks adapt these recommendations according to the local environment.
Aim:
To assess the proportions of STEMI patients treated with fibrinolysis or angioplasty in accordance with regional guidelines.
Method:
Observational study based on a permanent registry of patients with STEMI of <12h duration in an emergency network in the French North Alps (Isère, Savoie, Haute-Savoie) from January 2009 to December 2012.
Results:
The registry included 2620 patients. Reperfusion was given in 2425/2620 (93%) of patients. Reperfusion type was in accordance with recommendations in 1567/2620 (60%) patients. Guideline-recommended fibrinolysis and angioplasty were performed in 47% (656/1385) and 79% (911/1149) respectively, of patients. In multivariable analysis, variables independently associated with guideline-recommended reperfusion were: an age < 65 years (OR 1.60; 95%CI 1.33-1.90), being managed in Haute-Savoie versus Isère or Savoie (OR 1.38; 95%CI 1.12-1.71), an arterial tension < 100mmHg (OR 1.73; 95%CI 1.27-2.35), a cardiogenic shock (OR 0.50; 95%CI 0.30-0.84), a pacemaker or left bundle branch block (OR 0.49; 95%CI 0.28-0.88), and an initial management outside the network (followed by treatment in an interventional centre in the network) (OR 0.62; 95%CI 0.40-0.94). Patients initially treated by mobile intensive care units were more often reperfused in accordance with recommendations when admitted < 3 (versus ≥ 3) h following symptom onset (adjusted OR 2.05; 95% CI 1.61-2.59), while those initially treated by in-hospital emergency units were less often reperfused in accordance with recommendation when treated < 3h following symptom onset (adjusted OR 0.67; 95% CI 0.46-0.97). In-hospital major adverse cardiac events (9.1% vs. 8.5%) and in-hospital mortality (6.4% vs. 5.1%) were not significantly different between patients reperfused in accordance with (versus not) recommendations.
Conclusions:
Forty percent of patients with STEMI were not reperfused with fibrinolysis or angioplasty in accordance with regional guidelines. Characterization of this population should allow us to improve guideline adherence.
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