胸痛中心持续改进对急性ST段抬高型心肌梗死院内救治效率及预后的影响

目的探讨胸痛中心持续改进的救治体系对急性ST段抬高型心肌梗死(STEMI)患者救治效率及预后的影响。方法回顾性分析2014年11月至2016年10月以及2017年11月至2018年10月于南京医科大学附属无锡人民医院胸痛中心确诊为STEMI的398例患者的临床资料。将2014年11月至2015年10月确诊患者作为胸痛中心成立前的对照组(A组,102例),2015年11月至2016年10月确诊患者作为胸痛中心成立初期的观察组(B组,144例),2017年11月至2018年10月确诊患者作为胸痛中心持续改进后的观察组(C组,152例)。比较三组患者首次医疗接触至首份心电图(FMC-to-ECG)时间、入门至球囊扩张(D-to-B)时间、心肌肌钙蛋白I报告时间(从抽血到获取报告时间)、首次医疗接触至球囊扩张(FMC-to-B)时间、导管室激活时间、院前心电图传输比例、住院期间心力衰竭发生率、心律失常发生率,以及院内死亡率。对病程1年主要不良心脑血管事件(MACCE)发生的影响因素进行分析。结果胸痛中心成立后D-to-B时间、心肌肌钙蛋白I报告时间、FMC-to-ECG时间中位数呈下降趋势,三组间比较差异均有统计学意义(均P<0.05)。FMC-to-B时间中位数明显下降,达到质控标准,但仅A组与B、C组比较差异有统计学意义(均P<0.001)。三组导管室激活时间均在30 min以内,差异无统计学意义(P>0.05)。三组院前心电图传输比例逐年增加,从32.43%上升至95.78%,但仅C组与B、C组比较差异有统计学意义(均P<0.001)。此外,胸痛中心持续改进后院内死亡率及出院后1年总MACCE发生率均较前显著降低,其中C组的死亡率较B组显著下降[1.97%(3/152)比9.03%(13/144),P<0.0167],其余组间比较差异无统计学意义(P>0.0167)。C组总MACCE发生率较A组[2.63%(4/152)比10.78%(11/102),P<0.0167]、B组[2.63%(4/152)比8.33%(12/144),P<0.0167]显著降低,差异均有统计学意义,但A、B两组比较差异无统计学意义(P>0.0167)。三组患者院内恶性心律失常、院内心力衰竭、院内出血以及出院后1年心原性死亡、靶血管血运重建、再发心肌梗死、卒中比较,差异均无统计学意义(均P>0.05)。三组患者急诊经皮冠状动脉介入治疗(PCI)比例逐年递增,三组间比较差异有统计学意义(P<0.05)。在急诊PCI亚组分析中发现,三组患者院内并发症及出院后1年MACCE发生率比较差异均无统计学意义(均P>0.05)。logistic多因素回归模型分析显示,年龄≥75岁是STEMI患者PCI术后1年全因死亡率(OR 6.116,95%CI 1.794~20.842,P=0.004)及出院后1年MACCE发生(OR 4.987,95%CI 1.759~14.138,P=0.003)的危险因素。发生症状到首次医疗接触(SO-to-FMC)时间≥5 h也是PCI患者出院后1年MACCE发生的危险因素(OR 4.957,95%CI 1.064~23.093,P=0.041)。结论胸痛中心持续改进可提高STEMI患者的院内救治效率,增加急诊PCI比例,降低院内病死率及出院后1年总MACCE发生率,但胸痛中心持续改进尚未降低SO-to-FMC时间、院内并发症发生率以及出院后1年死亡率,因而减少院前延误及转诊时间、加强患者胸痛急救意识是胸痛中心持续改进的主要方向。

Eff ect of continuous improvement of chest pain center on the treatment effi ciency within hospital and prognosis of patients with acute ST-segment elevation myocardial infarction

Objective To investigate the effect of continuous improvement on the treatment efficiency and effectiveness of patients with acute ST-segment elevation myocardial infarction after the chest pain center certifi cation.Methods The clinical data of 398 patients with acute ST-segment elevation myocardial infarction diagnosed at Chest Pain Center of Wuxi People’s Hospital from November 2014 to October 2016 and November 2017 to October 2018 were retrospectively analyzed.Confirmed patients were devided into chest pain center pre-existing control group(102 cases in group A)from November 2014 to October 2015,the initial observation group of the chest pain center(144 cases in group B)from November 2015 to October 2016,the observation group after continuous improvement of chest pain center(152 cases in group C)from November 2017 to October 2018.The time of first medical contact to the first electrocardiogram(FMC-to-ECG),door-to-balloon(D-to-B),blood sampling to acquisition of report,fi rst medical contact to balloon dilation(FMC-to-B),as well as catheter lab activation time,prehospital electrocardiogram transmission ratio,incidence of heart failure during hospitalization,incidence of arrhythmia,and hospital mortality were compared among the groups.The factors aff ecting the occurrence of main adverse cardiovascular and cerebrovascular events(MACCE)in 1 year were analyzed by logistic regression.Results The median time of D-to-B,the troponin reporting time and FMC-to-ECG time among three groups showed a decreasing trend,with statistically signifi cant diff erences(all P<0.05).The median time of FMC-to-B met quality control standards,but only group A and the rest were statistically significant(P<0.001).In all three groups the catheter labs were activated within 30 minutes,there was no statistically significant difference among three groups(P>0.05).The proportion of prehospital ECG transmission increased year by year in three groups(from 32.43%to 95.78%),but only group C and the rest were statistically significant(P<0.001).In addition,the in-hospital mortality rate and the total MACCE incidence in one year after discharge were signifi cantly lower than before due to continuous improvement of chest pain center.The mortality of group C was signifi cantly lower than that in group B[1.97%(3/152)vs.9.03%(13/144),P<0.0167],there was no statistical signifi cance between other groups(P>0.0167).The incidence of total MACCE in group C was signifi cantly higher than that in group A[2.63%(4/152)vs.10.78%(11/102),P<0.0167]and B[2.63%(4/152)vs.8.33%(12/144),P<0.0167],but there was no statistically significant difference between group A and group B(P>0.0167).There were no signifi cant diff erences in malignant arrhythmia,heart failure,hemorrhage and death in hospital,revascularization of target vessel,recurrence of myocardial infarction and stroke among the three groups(all P>0.05).The percentage of emergency PCI in three groups increased year by year,the difference among three groups was statistically significant(P<0.05).By the subgroup analysis of emergency PCI patients,hospital complications and the incidence of MACCE 1 year after discharge were not statistically signifi cant among three groups(P>0.05).Multivariate logistic regression model analysis showed that age≥75 years was a risk factor for the 1-year mortality rate of STEMI patients after PCI(OR 6.116,95%CI 1.794 to 20.842,P=0.004)and the 1-year MACCE incidence rate after discharge(OR 4.987,95%CI 1.759 to 14.138,P=0.003).SO-to-FMC≥5 h was also a risk factor MACCE 1 year after discharge(OR 4.957,95%CI 1.064 to 23.093,P=0.041).Conclusions Continuous improvement of chest pain center can improve the effi ciency of hospital treatment in patients with acute ST elevation myocardial infarction.The mortality rate in hospital and the incidence of total MACCE in 1 year after discharge are reduced by increasing the proportion of primary PCI.Nevertheless,continuous improvement in chest pain center has not reduced the time from symptom onset-to-fi rst medical contact,the incidence of in-hospital complications,and the mortality rate one year after discharge.Therefore,reducing pre-hospital delay and referral time,and strengthening patients'awareness of chest pain emergency is the main direction of continuous improvement of chest pain center.