266 Performance assessment of French guidelines for the management of STEMI patients out of cardiac critical care unit on clinical practices: insights from the e-MUST registry

Abstract

Objective In 2006 evidence based guidelines for STEMI reperfusion strategies out of cardiac critical care unit were published in France. The objective of this program is to assess the performance of these guidelines to improve reperfusion strategies for STEMI within 2 h from onset of symptoms, thrombolysis versus primary PCI, using the e-MUST registry data in the greater Paris area. Methods The e-MUST registry is a regional prospective prehospital database supported by the hospital governmental agency (ARHIF). It began tracking practice patterns for STEMI prehospital reperfusion strategies in 2000 in the greater Paris area. All STEMI with clinical and ECG features suggestive of less than 24 h duration, managed by prehospital medical team, are collected. The evidence based guidelines for STEMI patients managed out of cardiac critical care unit, including prehospital setting, were established in 2006 to stratify reperfusion strategies according to the presumed delay to cath lab. If the presumed door to cathlab delay is over 45 min and onset of symptom delay less than 12 h thrombolysis is recommended before transferring to a PCI capability hospital. Reperfusion strategies for STEMI within 2 h of onset of symptoms, either thrombolysis or primary PCI were compared in the registry through the years 2002, before guidelines, 2006, and 2008, after guidelines publication. Two groups of patients were studied according to the elected reperfusion strategy, Two subgroups of patients elected for primary PCI were distinguished according to the 45 min door to cathlab delay cut off. The onset of symptom to treatment mean delays, either lytic infusion or balloon inflation, were documented for each group and subgroup of patients. Results Discussion The ratio of patients managed within 2 h of onset of symptoms has increased from 57% in 2002 to 62% in 2008. The rate of prehospital reperfusion decision has also increased from 91% in 2002 to 95% in 2008. Mean delays from onset of symptom to treatment were not significantly different from 2002 through 2008, either for thrombolysis, or for the primary PCI elected strategy within or over the 45 min door to cathlab delay cut off. Prehospital thrombolytic therapy was significantly less frequently elected, from 44% in 2002 to 21% in 2008. The ratio of primary PCI with over 45 min door to cathlab delay has significantly increased from 42% in 2002 to 53% in 2008. Conclusion The e-MUST registry helps to assess the performance of guidelines on clinical practices and prehospital management of STEMI within 2 h of onset of symptoms. This improvement study highlights an everyday earlier management of STEMI patients and a very high rate of prehospital reperfusion decision. These are the main benefits of the registry program. Nevertheless most of physicians underestimate the door to cathlab delay. The registry should initiate a brain storming on delays and elected strategies to optimise the ratio of reperfusion within the guidelines recommended delays especially for STEMI patients fitting with the golden hour delay. Objectif(s), contexte L9objectif de ce programme est de mesurer en Ile-de-France, par le registre e-MUST, l9evolution des strategies de reperfusion coronaire (thrombolyse pre-hospitaliere versus angioplastie primaire) des syndrome coronaires aigus ST+ Programme Le registre e-MUST est un registre de pratiques prospectif, developpe par l9Agence regionale de l9hospitalisation en Ile-de-France depuis 2000. Il recense tous les SCA ST+ La conference de consensus sur la prise en charge des IDM aigus en dehors des services de cardiologie a ete publiee en 2006. Les recommandations portent sur la strategie de desobstruction coronaire en fonction du delai estime d9arrivee en salle de catheterisme cardiaque pour realiser une angioplastie primaire. Si l9estimation du delai porte-porte cardio est superieure a 45 min et que le debut de la douleur thoracique est inferieur a 12h et a fortiori inferieur a 2h il est recommande de thrombolyser le patient et de l9adresser dans un centre de cardiologie interventionnelle. Nous avons compare pour les annees 2002 (avant la conference), 2006 (pendant) et 2008 (apres), les SCA ST+ 45 min. Pour chaque sous-groupe, le delai median entre le debut de la douleur thoracique et le traitement (injection du thrombolytique ou passage du guide) ont ete calcules. Resultats Discussion La proportion de SCA ST+ pris en charge en moins de 2h augmente de 57% en 2002 a 62% en 2008. Le taux de decision de desobstruction en pre-hospitalier augmente de 91% en 2002 a 95% en 2008. Les delais medians « debut de la douleur thoracique-traitement » sont stables pour l9angioplastie primaire. La thrombolyse pre-hospitaliere diminue de 44% en 2002 a 21% en 2008. La proportion de SCA ST+ Conclusion Le registre e-MUST permet de mesurer l9impact clinique des recommandations de la conference de consensus sur la prise en charge pre-hospitaliere des SCA ST+