院前心电图对ST段抬高型心肌梗死患者进门至再灌注时间的影响

目的观察院前12导联心电图对急性ST段抬高心肌梗死(STEMI)患者进门至再灌注时间的影响。方法多中心现况调查2006年1～12月期间就诊于北京市19所医院并接受再灌注治疗的急性STEMI患者。根据有无院前心电图分为有心电图组和无心电图组。结果 635例患者中,接受直接经皮冠脉介入治疗(PPCI)者506例(79.7%),其中有心电图者211例(41.7%),无心电图者295例(58.3%);接受溶栓者129例(20.3%),其中有心电图者46例(35.7%),无心电图者83例(64.3%)。院前心电图可显著缩短进门-球囊扩张时间(中位数,120 min比150 min;P0.01),而对进门-溶栓时间(中位数,74min比93min;P=0.168)无影响。有心电图组进门90min内完成球囊扩张的比例显著高于无心电图组(24.6%比15.9%,P=0.017)。无论接受何种再灌注治疗,院前心电图对住院病死率无影响。结论院前心电图可显著缩短STEMI患者的进门-球囊扩张时间。应进一步提高院前心电图完成率。     

节假日对ST段抬高心肌梗死院内再灌注延迟的影响

目的 多中心、前瞻性观察节假日对急性ST段抬高心肌梗死(ST-elevation myocardial infarction,STEMI)患者院内再灌注延迟的影响.方法 连续入选在北京市19个医疗中心自2005年11月至2006年7月至急诊室就诊并接受再灌注的STEMI患者共297例.分为节假日(春节、劳动节、国庆节、元旦、周末)和非节假日(星期一至星期五)再灌注治疗组.与非节假日再灌注治疗相比,分析节假日对进入医院门口(进门)-再灌注延迟的影响.结果 297例患者中,节假日再灌注治疗组94例(31.6%),其中26例患者接受溶栓治疗,68例患者接受急诊PCI;非节假日再灌注治疗组203例(68.4%),其中61例患者接受溶栓治疗,142例患者接受PCI.在校正患者的各项因素后,节假日与进门-球囊扩张时间中位数[162.2 min(95% CI 160.8,165.3)比141.8 min(95% CI137.8,144.1); P＜0.01]及进门-溶栓时间中位数[64.1 min(95% CI 61.9,66.5)比50.1 min(95% CI 48.3,54.5); P=0.03]延长显著相关.结论 北京市在节假日接受再灌注治疗的STEMI患者进门-再灌注时间延迟增加.     

急性ST段抬高心肌梗死患者急诊介入治疗门-囊时间及其影响因素

目的探讨急性ST段抬高心肌梗死(STEMI)患者直接介入治疗(PCI)门-囊(D2B)时间及其影响因素。方法回顾性分析潞河医院2005年1月至2008年8月连续收治的行直接PCI的STEMI患者的D2B时间及其组成成分,记录如下时间(中位数):院前时间、门-CCU时间、CCU-获得知情同意时间、知情同意-导管室时间,导管室-首次球囊扩张时间。将D2B时间分为两组:短D2B组(≤120min)和长D2B组(120min),应用Logistic回归分析影响D2B时间的因素。结果477例STEMI患者中,院前延迟时间125min,总的D2B时间120min,其中门-CCU时间19min,CCU-获得知情同意时间30min,知情同意-导管室时间30min,导管室-首次球囊扩张30min。D2B时间低于90min的患者占19.5%(93/477)。Logistic回归分析表明:与长D2B时间(120min)有关的因素是节假日住院(OR=1.85,95%CI1.19～2.85),门诊就医(OR=2.28,95%CI1.21～4.33),入CCU时无症状(OR=2.17,95%CI1.47～3.20)。而通过急救医疗服务系统(EMS)转运(OR=0.36,95%CI0.23～0.55),入CCU时间在6am～10pm(OR=0.48,95%CI0.30～0.74)预测短D2B时间(≤120min)。结论多数STEMI患者的D2B时间超过指南要求,临床因素和院内机制与长D2B时间相关,应当建立起有效的院内机制来降低院内延迟。     

无锡地区急性ST段抬高型心肌梗死治疗现状调查——一项多中心调查研究报告

目的 分析中国江苏省无锡地区急性ST段抬高型心肌梗死（ST-segment elevation myocardial infarction, STEMI）患者的基线特征及治疗现状.方法 2011年1月至2012年12月我们通过网络直报,入选无锡九家医院STEMI患者共1 410例,分析其基线特征及治疗现状.结果 院内发生患者诊治延迟时间（发病至就诊、发病至第一份心电图、发病至接受专科治疗时间）耗时最少,其次为呼叫“120”急救车入院患者,自行入院者耗时最多.“120”急救车入院患者发病至溶栓时间、就诊至溶栓时间短于自行入院患者.在直接经皮冠状动脉介入（percutaneous coronary intervention,PCI）治疗患者中,“120”急救车入院患者发病至球囊扩张时间、就诊至球囊扩张时间短于自行入院患者.在再灌注治疗患者中,就诊至溶栓、就诊至球囊扩张、发病至溶栓,发病至球囊扩张时间均短于自行入院患者.发病至就诊时间＜3 h组、3～6 h组、6～12 h组和≥12 h组的院内全因病死率（4.23％ vs.10.54％vs.18.67％vs.23.67％,x2=83.372,P＜0.01）和主要心血管事件发生率（4.47％ vs.13.24％ vs.18.98％ vs.34.63％,x2=116.325,P＜0.01）比较,差异有统计学意义.直接PCI治疗组、溶栓组及早期药物保守治疗组的院内全因病死率（1.50％ vs.10.00％ vs.18.20％,x2=50.896,P＜0.01）和主要心血管事件发生率（5.76％ vs.12.27％vs.20.86％,x239.934,P＜0.01）比较,差异有统计学意义.结论 无锡地区急性STEMI患者合并原发性高血压（高血压）最多;药物治疗基本规范化;再灌注治疗（PCI治疗和静脉溶栓）患者比例偏低;就诊后30 min内溶栓,90 min内球囊扩张患者比例偏低.PCI治疗院内全因病死率和主要心血管事件发生率最低,溶栓其次,早期保守治疗最高.院内发病患者的院前延迟时间最短,“120”急救车入院患者其次,自行入院患者最长.就诊时间延迟大于12 h后就诊,院内病死率和主要心血管     

不同转运方式对急性心肌梗死患者再灌注治疗延迟的影响

目的比较不同转运方式对ST段抬高心肌梗死(STEMI)患者再灌注治疗延迟的影响。方法单中心现况调查。入选2006年1月1日至2007年4月30日期间,于发病24h内就诊于北京安贞医院抢救中心的232例STEMI患者。根据转运方式分为救护车组和自行转运组,比较两组各时间间隔:(1)决定就医-首次医疗接触;(2)决定就医-进门;(3)决定就医-球囊扩张;(4)进门-球囊扩张;(5)发病-球囊扩张。结果 105例(45.3%)STEMI患者通过救护车转运到达医院,其余127例(54.7%)为自行转运。自行转运组决定就医-进门时间显著短于救护车组(中位数,35min比50min,P0.001)。而救护车组的决定就医-首次医疗接触(中位数,15min比35min,P0.001)、决定就医-球囊扩张(中位数,173min比193min,P=0.049)、进门-球囊扩张(中位数,102min比125min,P0.001)以及发病-球囊扩张时间(中位数,223min比300min,P0.001)均显著短于自行转运组。结论尽管自行转运可更快到达医院,但是救护车转运可更快获得再灌注治疗。     

导管室启动模式对ST段抬高心肌梗死患者进门至球囊扩张时间的影响

目的 探讨依据院前心电图和电话通知的导管室启动模式能否缩短ST段抬高心肌梗死患者进门至球囊扩张时间.方法 收集2006年1月至2008年12月期间就诊于北京安贞医院抢救中心并接受直接经皮冠状动脉介入的ST段抬高心肌梗死患者的临床资料.按不同导管室启动模式,即是否有院前心电图及院前电话,将患者分为3组:A组(无院前心电图)、B组(有院前心电图)和C组(根据院前心电图进行院前电话通知).主要分析指标为进门至球囊扩张时间.次要分析指标为临床终点,包括肌钙蛋白I峰值、左心室射血分数、住院天数、院内病死率及随访30 d病死率.结果 共入选患者506例,A、B和C组患者分别为168例、224例和114例.3组患者基础临床资料差异无统计学意义.与A组比较,B组和C组进门至球囊扩张时间显著缩短(110 min比94 min和85min,P均<0.01),B组与C组差异也有统计学意义(P<0.05).与A组比较,B组和C组进门至进导管室时间缩短(91 min比74 min和64 min,P均<0.01),B组与C组差异也有统计学意义(P<0.05).进门至球囊扩张时间小于90 min的比例C组显著高于B组和A组(59%比43%和32%,P均<0.01).结论 依据院前心电图和早期电话通知启动介入治疗显著缩短ST段抬高心肌梗死患者导管室启动和进门至球囊扩张时间,并使更多的患者进门至球囊扩张时间小于90 min.     

急性ST段抬高型心肌梗死患者救治效率和院内死亡率的性别差异性分析

目的分析成都地区ST段抬高型心肌梗死(STEMI)患者救治效率和院内全因死亡的性别差异。方法纳入2017年1月—2019年6月就诊于成都地区的11家医院的STEMI患者1 443例,其中369例(25.57%)是女性。比较不同性别患者的救治效率和院内全因死亡率,救治效率指标主要包括症状发作至球囊开通(S-to-B)时间、症状发作至首次医疗接触(S-to-FMC)时间和首次医疗接触至球囊开通(FMC-to-B)时间。结果女性患者更年长,合并高血压和糖尿病的比例更高,不典型胸痛/胸闷症状更常见(P0.01);不同性别患者接受经皮冠脉介入术(PCI)的比例相当(P0.05)。在行急诊PCI的STEMI患者中,女性患者的中位Sto-FMC时间(130 min vs 115 min,P=0.007)和S-to-B时间(300 min vs 265 min,P=0.001)更长,而FMC-to-B时间(123 min vs 114min,P=0.087)的延长无统计学意义。女性患者死亡率更高(13.3%vs 6.0%,P0.001),且多因素的logistic回归分析显示女性患者的院内全因死亡率显著高于男性患者(OR 1.792,95%CI 1.035～3.103,P=0.037)。结论 STEMI患者院内救治效率无性别差异,但女性患者更年长,胸痛症状更不典型,合并症更多,院前就诊延误更重,院内全因死亡率更高。     

空巢老人是ST段抬高型心肌梗死患者院前救治延误的首要危险因素

目的 探讨ST段抬高型心肌梗死(STEMI)患者院前救治延迟的影响因素。方法 连续纳入2020年6月1日至2021年12月31日睢宁县人民医院心血管内科住院的STEMI患者414例，根据出现症状至入院时间分为延迟组300例(>120 min),非延迟组114例(≤120 min)。比较2组基线资料和院内信息，采用logistic回归分析院前延迟的影响因素。结果 延迟组年龄、空巢老人、糖尿病、首诊非直接PCI医院比例明显高于非延迟组，非老人、非空巢老人、吸烟和使用救护车比例明显低于非延迟组，差异有统计学意义(P<0.05,P<0.01)。延迟组直接PCI、LVEF明显低于非延迟组，N末端B型钠尿肽前体、院内病死率明显高于非延迟组，差异有统计学意义(P<0.05,P<0.01)。多因素分析显示，空巢老人(OR=5.223,95%CI:2.702～10.095,P=0.001)、糖尿病(OR=2.045,95%CI:1.211～3.455,P=0.007)、首诊非直接PCI医院(OR=2.821,95%CI:1.656～4.804,P=0.001)与院前时间延迟...     

急性ST段抬高心肌梗死患者院前延迟的影响因素分析及对预后的影响

目的 调查北京通州区急性ST段抬高心肌梗死患者（STEMI）院前延迟的时间分布,探讨其影响因素及对预后的影响.方法 前瞻性分析2009年1月至2011年6月连续住院的383例STEMI患者,男性283例（73.9%）,女性100例（26.1%）,调查STEMI患者院前延迟的时间分布,根据院前延迟时间（PHD）分为两组：PHD≤6 h组和PHD＞6 h组,分析影响院前延迟的因素及对近期预后的影响.结果 383例患者PHD中位数165 min,患者延迟（PD）中位数72 min,转运延迟（TD）中位数58 min.PHD≤6 h组302例,PHD＞6 h组81例.多因素logistic回归分析预测院前延迟的独立变量是：年龄（2.412,1.244～4.678）、症状进展（0.281,0.145～0.545）、1 h内求助（0.300,0.117～0.770）、忍受（2.753,1.230～6.161）、因恐惧感就医（0.452,0.242～0.847）、求助EMS（0.234,0.115～0.478）、直接到医院（0.176,0.090～0.350）.PHD≤6 h组急诊再灌注治疗率明显高于PHD＞6 h组（90.4%比70.4%,P＜0.01）,PHD≤6 h组院内MACE事件发生率明显低于PHD＞6 h组（1.7%比7.4%,P＜0.05）.结论 ①STEMI患者院前延迟时间较长,患者延迟是院前延迟的主要原因.②年龄、症状进展、1 h内求助、忍受、因恐惧就医、求助EMS、直接到介入医院是预测院前延迟的独立变量.③院前延迟对治疗方案选择和预后有显著影响.     

急性ST段抬高型心肌梗死患者行急诊经皮冠状动脉介入治疗术后发生院内死亡的危险因素分析

目的评估接受直接经皮冠状动脉介入治疗(PPCI)的ST段抬高型心肌梗死(STEMI患者住院期间的死亡因素。方法回顾性分析2016年9月至2018年6月在河北省人民医院心脏中心接受PPCI的392例STEMI患者的临床资料,根据是否发生院内死亡分为存活组和死亡组。通过logistic回归分析筛选出与死亡相关的危险因素。结果 392例STEMI行PPCI的患者中27例(6.9%)发生院内死亡。logistic单因素回归分析显示,性别(女)、年龄≥65岁、收缩压140 mmHg(1 mmHg=0.133 kPa)、Killip心功能分级≥Ⅲ级、糖尿病、既往心房颤动史、院前应用他汀类药物、完全闭塞、多支病变、术后心肌梗死溶栓治疗试验(TIMI)血流≤Ⅱ级、术中心搏骤停、术中主动脉内球囊反搏、术后心搏骤停、术后心室颤动、术后心房颤动、术后室性心动过速、术后高度房室传导阻滞、术后消化道出血、白细胞计数、中性粒细胞计数、钙离子浓度、肌酐、尿酸、肌酸激酶同工酶(CK-MB)峰值、左心室射血分数(LVEF)≤40%是与死亡相关的危险因素,而术后使用血管紧张素转换酶抑制药/血管紧张素Ⅱ受体拮抗药、β阻滞药、他汀类、螺内酯药物是与患者生存相关的保护因素(均P0.05)。logistic多因素回归分析显示,年龄≥65岁(OR 3.552,95%CI 1.086～11.62,P=0.036)、LVEF≤40%(OR 6.754,95%CI 1.982～23.02,P=0.002)、CK-MB峰值25 U/L(OR 4.243,95%CI 1.219～14.77,P=0.023)、发病至球囊扩张时间≥195 min(OR3.490,95%CI 1.079～11.29,P=0.037)、术后TIMI血流分级≤Ⅱ级(OR 8.425,95%CI2.899～24.49,P0.001)为STEMI患者行急诊PPCI术后发生院内死亡的独立预测因素。结论高龄、心功能差、CK-MB峰值升高、发病至球囊扩张时间、PPCI术后慢血流为STEMI患者行PPCI术后发生院内死亡的危险因素。     

The pre-hospital electrocardiogram and time to reperfusion in patients with acute myocardial infarction, 2000-2002: findings from the National Registry of Myocardial Infarction-4.

OBJECTIVES: The aim of this study was to determine the use of pre-hospital electrocardiogram (ECG) in patients with ST-segment elevation myocardial infarction (STEMI) undergoing reperfusion therapy, and evaluate the effect of pre-hospital ECG on door-to-reperfusion times. BACKGROUND: Although national guidelines recommend the use of pre-hospital ECG, there is limited contemporary information about its current use and effectiveness. METHODS: Using data from the National Registry of Myocardial Infarction-4, we studied patients with STEMI or left bundle branch block who received acute reperfusion with either fibrinolytic therapy (n = 35,370) or primary percutaneous coronary intervention (PCI) (n = 21,277) within 6 h of admission. We determined the prevalence of pre-hospital ECG use, evaluated the association between pre-hospital ECG and door-to-reperfusion time, and estimated the incremental reduction in time to reperfusion using hierarchical models to adjust for differences in patient and hospital characteristics. RESULTS: A pre-hospital ECG was performed in 4.5% of the fibrinolytic therapy cohort and in 8.0% of the PCI cohort. After adjusting for patient and hospital characteristics, the use of pre-hospital ECG was associated with a significantly shorter geometric mean door-to-drug time: 24.6 min (95% confidence interval [CI]: 23.7 to 25.5) vs. 34.7 min (95% CI: 34.2 to 35.3; p < 0.0001), and a significantly shorter geometric mean door-to-balloon time (94.0 min [95% CI: 91.8 to 96.3] vs. 110.3 min [95% CI: 108.7 to 112.0]; p < 0.0001). CONCLUSIONS: The national use of pre-hospital ECG to diagnose and facilitate the treatment of STEMI remains low. When used, however, pre-hospital ECG is associated with a significantly shorter time to reperfusion.     

ST段抬高心肌梗死患者进门-球囊扩张时间达标情况及影响因素

目的 以进门-球囊扩张时间为主要指标评价ST段抬高心肌梗死(STEMI)临床指南的执行情况及其影响因素.方法 回顾性分析我院2004年1月至2005年12月急性STEMI行直接冠状动脉介入治疗成功患者的临床资料,包括一般人口学特征、合并冠心病危险因素情况、本次就诊时的多项体检与辅助检查指标以及症状开始、就诊和球囊扩张的精确时间等.结果 符合入选条件的患者219例,中位进门-球囊扩张时间135 min,进入医院90 min内开通冠状动脉患者占24.7%.经logistic回归分析,于非常规工作时间就诊为独立预测因子(P<0.001,OR=3.413,95%CI 1.805～6.452).结论 在对急性STEMI患者进行直接冠状动脉介入治疗中,进门-球囊扩张时间与临床指南的要求仍有较大差距,非常规工作时间就诊是进门-球囊扩张时间不达标的独立预测因子.     

Implementation of reperfusion therapy in acute myocardial infarction. A policy statement from the European Society of Cardiology.

Reperfusion therapy in ST-segment elevation myocardial infarction (STEMI) is the most important component of treatment, as it strongly influences short- and long-term patient outcome. The main objective of healthcare providers should be to achieve at least 75% of reperfusion therapy applied to patients suffering from STEMI in a timely manner, and preferably within the first 3 h after onset of symptoms. Establishing networks of reperfusion at regional and national level, implying close collaboration between all the actors involved in reperfusion therapy, namely hospitals, departments of cardiology, PCI centres, emergency medical systems (EMS), (para)medically staffed ambulances, private cardiologists, primary care physicians, etc., is a key issue. All forms of reperfusion, depending on local facilities, need to be available to patients. Protocols must be written and agreed for the strategy of reperfusion to be applied within a network. Early diagnosis of STEMI is essential and is best achieved by rapid ECG recording and interpretation at first medical contact, wherever this contact takes place (hospital or ambulance). Tele-transmission of ECG for immediate interpretation by experienced cardiologists is an alternative. Primary PCI is the preferred reperfusion option if it can be performed by experienced staff within 90 min after first medical contact. Thrombolytic treatment, administered if possible in the pre-hospital setting, is a valid option if PCI cannot be performed in a timely manner, particularly within the first 3 h following onset of symptoms. Thrombolysis is not the end of the reperfusion therapy. Rescue PCI must be performed in the case of thrombolysis failure. Next-day PCI after successful thrombolysis has been proven efficacious. Quality control is important for monitoring the efficacy of networks of reperfusion. All elements that influence time to reperfusion must be taken into account, particularly transfer delays, in-hospital delays, and door-to-balloon or door-to-needle times. The rate of reperfusion achieved must also be taken into consideration. Professional organizations such as the European Society of Cardiology (ESC) have the responsibility to impart this message to the cardiology community, and inform politicians and health authorities about the best possible strategy to achieve reperfusion therapy.     

Comparison of early mortality of paramedic-diagnosed ST-segment elevation myocardial infarction with immediate transport to a designated primary percutaneous coronary intervention center to that of similar patients transported to the nearest hospital

Speed of reperfusion is critical in ST-segment elevation myocardial infarction (STEMI). We assessed the safety and feasibility of an integrated metropolitan approach in which advanced-care paramedics interpret the prehospital electrocardiogram and independently refer patients with STEMI to a designated center for primary percutaneous coronary intervention (PCI). We developed and implemented a protocol in which paramedics trained in electrocardiographic interpretation bypassed the nearest emergency room and referred patients with suspected STEMI directly to a designated primary PCI center (paramedic-referred primary PCI). Outcomes of these patients were compared with those of a retrospective cohort of 225 consecutive patients with STEMI transported by ambulance to the nearest hospital emergency department. We treated 108 consecutive patients with STEMI using ambulance services according to the paramedic-referred primary PCI protocol. Primary PCI was performed in 93.5% versus 8.9% in the control group, and the median door-to-balloon time was 63 versus 125 minutes in the control group (p <0.0001 for 2 comparisons). Thrombolytic therapy was prescribed to 80.4% of the control group, with a median door-to-needle time of 41 minutes. In-hospital mortality was 1.9% in the paramedic-referred primary PCI group versus 8.9% in the control group (p = 0.017) and remained significantly lower after statistical adjustment for baseline risk. In conclusion, paramedic-referred primary PCI is a safe and feasible strategy for treating STEMI that is associated with rapid and effective reperfusion and very low in-hospital mortality.     

入院高血糖对急诊经皮冠状动脉介入后复流的影响

目的 评价入院血糖水平与ST段抬高型急性心肌梗死(AMI)患者急诊经皮冠状动脉(冠脉)介入治疗(PCI)后复流的相关性.方法 入选2007-2010年共1413例ST段抬高型AMI并在发病24 h内成功进行急诊PCI的患者,分为无复流组和复流正常组,收集所有患者的临床、冠脉造影和PCI相关的资料以评价复流现象,采用多元回归方法 评价无复流的独立预测因素.结果 1413例患者中发生无复流现象的患者为297例(21.0%),无复流患者入院血糖水平显著高于复流正常患者[(13.80±7.47)mmol/L比(9.67±5.79)mmol/L,P＜0.0001],多元回归分析发现吸烟、高脂血症、再灌注时间＞6 h、入院肌酐清除率＜90 ml/min、PCI前使用主动脉内气囊反搏和入院血糖水平＞13.0 mmol/L是ST段抬高型AMI患者急诊PCI后无复流的独立预测因素.随着入院血糖水平的逐渐增加,无复流发生率也显著增加,血糖水平为＜7.8 mmol/L和＞13.0 mmol/L时,无复流发生率分别为14.6%和36.7%(P=0.009).结论 入院血糖水平＞13.0 mmol/L是ST段抬高型AMI患者急诊PCI后无复流的独立预测因素.

Abstract：

Objective To assess the association between admission plasma glucose (APG) and noreflow during primary percutaneous coronary intervention (PCI) in patients with ST-elevation acute myocardial infarction (STEMI). Methods A total of 1413 patients with STEMI successfully treated with PCI were divided into no-reflow group and normal reflow group. Results The no-reflow was found in 297 patients (21.0%) of 1413 patients; their APG level was significantly higher than that of the normal reflow group [( 13.80 ±7.47) vs (9.67 ±5.79) mmol/L, P＜0.0001]. Multivariate logistic regression analysis revealed that current smoking ( OR 1.146, 95% CI 1.026-1. 839,P = 0.031), hyperlipidemia ( OR 1. 082,95% CI 1. 007-1. 162, P = 0. 032), long reperfusion ( ＞ 6 h, OR 1. 271, 95% CI 1. 158-1. 403, P =0. 001 ) , admission creatinine clearance ( ＜ 90 ml/min, OR 1.046, 95% CI 1. 007-1.086, P = 0.020 ) ,IABP use before PCI (OR 9.346, 95%CI 1.314-67. 199, P=0.026), and APG ( ＞ 13.0 mmol/L, OR1.269, 95% CI 1.156-1.402, P = 0.027) were the independent no-reflow predictors. The no-reflow incidence was increased as APG increased ( 14. 6% in patients with APG ＜ 7. 8 mmol/L and 36. 7% in patients with APG ＞ 13.0 mmol/L, P = 0.009 ). Conclusion APG ＞ 13.0 mmol/L is an independent noreflow predictor in patients with STEMI and PPCI.     

建立胸痛中心对不同来院方式ST段抬高急性心肌梗死患者进门-球囊时间的影响

目的探讨胸痛中心（CPC）对不同来院方式接受直接经皮冠状动脉介入治疗（PPCI）的ST段抬高急性心肌梗死（STEMI）患者进门-球囊（D-to-B）时间的影响。方法根据来院方式不同将CPC成立前、后接受PPCI的STEMI患者分别分为自行来院组[A1组（52例）和A2组（65例）]、呼叫＂120＂组[B1组（31例）和B2组（92例）]、非经皮冠状动脉介入治疗（PCI）医院转诊组[C1组（23例）和C2组（552例）],比较同一来院方式的两组间D-to-B时间和D-to-B达标率的变化,分析延迟原因。结果 A1、A2组平均D-to-B时间分别是（123±78）min和（140±123）min,达标率分别为44.2%和46.2%,两组间比较,差异均无统计学意义（P〉0.05）;B2组平均D-to-B时间显著短于B1组[（89±66）min比（155±115）min,P〈0.05],而达标率显著高于B1组（69.6%比32.3%,P〈0.05）;C2组平均D-to-B时间显著短于C1组[（77±43）min比（337±662）min,P〈0.05],达标率显著高于C1组（75.7%比21.7%,P〈0.05）。自行来院组的主要延迟原因是签署知情同意书时间过长,呼叫＂120＂组和非PCI医院转诊组的主要延迟原因是导管室占台。结论区域协同救治模式CPC显著缩短了呼叫＂120＂和转诊入院患者的D-to-B时间,但需加强对自行来院途径的院内流程优化。     

Predictors of reperfusion delay in patients with acute myocardial infarction undergoing primary percutaneous coronary intervention from the HORIZONS-AMI trial

Primary percutaneous coronary intervention (PCI) is the optimal method of reperfusion when performed expeditiously. Factors contributing to delays in PCI for ST-segment elevation myocardial infarction (STEMI) have not been thoroughly characterized or quantified. We sought to identify the factors associated with the delays to reperfusion in patients with STEMI undergoing primary PCI. Primary PCI was performed in 3,340 patients with STEMI in the international, multicenter Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction trial. Multivariate analysis was used to identify independent predictors of delay in achieving reperfusion from 38 baseline and procedural variables. A total of 905 patients (27.1%) presented to non-PCI hospitals and were subsequently transferred; the remainder presented to PCI hospitals. The most powerful independent predictor of the interval from symptom onset to arrival at the PCI hospital and the first door-to-balloon time was an initial presentation at a non-PCI hospital (median incremental 58- and 54-minute delay, respectively, both p < 0.001). Other independent predictors of prolonged door-to-balloon times included presentation with respiratory failure (42-minute incremental delay, p = 0.003), presentation during off-work hours (11-minute incremental delay, p < 0.001), and co-morbid conditions such as diabetes and heart failure. In conclusion, among patients undergoing primary PCI, presentation to a non-PCI hospital was the variable associated with the greatest delay to reperfusion. Systems of care that encourage ambulance diagnosis and direct delivery of patients with STEMI to a PCI hospital might shorten the overall door-to-balloon times and improve the clinical outcomes.     

Clinical impact of direct referral to primary percutaneous coronary intervention following pre-hospital diagnosis of ST-elevation myocardial infarction.

AIMS: Treatment delay is a powerful predictor of survival in ST-elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI). We investigated effectiveness of pre-hospital diagnosis of STEMI with direct referral to PCI, alongside more conventional referral strategies. METHODS AND RESULTS: From January 2003 to December 2004, 658 STEMI patients were referred for primary PCI at our intervention laboratory. Three predefined referral routes were compared: (1) for patients within 90 min drive of the PCI centre, pre-hospital diagnosis and direct transportation (n=166), (2) diagnosis at the interventional hospital emergency department (n=316), (3) diagnosis at local hospitals before transportation (n = 176). Pre-hospital diagnosis was associated with more than 45 min reduction in treatment delay (P = 0.001). No significant difference in in-hospital mortality was apparent in the overall study population. In the cardiogenic shock subgroup (n = 80), pre-hospital diagnosis was associated with a two-thirds reduction in in-hospital mortality (P = 0.019); mortality was only 6.2% in shock patients who underwent PCI in < 2 h. CONCLUSION: This study shows that pre-hospital diagnosis can provide a reduction in primary PCI treatment delay, and suggests the hypothesis that this referral strategy might provide survival benefits to patients with cardiogenic shock.     

Field triage to primary angioplasty combined with emergency department bypass reduces treatment delays and is associated with improved outcome.

AIMS: We investigated the net benefit in the outcome of reducing treatment delay through field triage and emergency department (ED) bypass in patients with ST-elevation myocardial infarction (STEMI) treated with primary angioplasty. METHODS AND RESULTS: In a prospective registry study, consecutive patients with suspected STEMI were assigned to: (i) pre-hospital ECG and triage or (ii) ECG and triage at the closest ED, solely based on ambulance availability. Four district hospitals and one regional heart centre serviced the 890,000 population metropolitan area and primary angioplasty was the only reperfusion strategy employed. Baseline characteristics were similar in STEMI patients triaged in the field (108) and the EDs (193). Symptom onset to balloon times: 154 [inter-quartile range (IQR) 120-233) vs. 249 (IQR 184-405) min (P<0.001) and peak creatine kinase in early presenters (<2 h): 1435 (95 %CI: 904-1966) U/L vs. 2320 (95% CI: 1881-2762) U/L (P=0.009) were lower in field- than in ED-triaged patients. Mortality in the PCI treated were 1.1 and 8.2% [P=0.025, RR 0.14 (95% CI: 0.01-1.08)] and overall mortality were 1.9 and 7.3% [P=0.046, RR 0.26 (95% CI: 0.05-1.11)]. CONCLUSION: Field-triage and ED bypass were feasible means of reducing treatment delay in patients with suspected STEMI and resulted in smaller infarct size in early presenters and a trend towards a reduction in mortality.