EVOLUTION OF A REGIONAL STEMI REPERFUSION MODEL: THE 6-YEAR VANCOUVER COASTAL HEALTH AUTHORITY EXPERIENCE

Abstract

BACKGROUND: Guidelines strongly recommend that regional systems of STEMI care include the assessment and continuous quality improvement of EMS and hospitalbased activities. We describe the evolution of the Vancouver Coastal Health Authority (VCHA) STEMI program, including the impact of individual care components on reperfusion times and clinical outcomes over a 75-month period. METHODS: All patients with confirmed STEMI presenting within the VCHA from June 2007 to September 2013 were included (n 1⁄4 2041). Primary analysis was performed by care component phase: Phase 1, regionalization of the STEMI program (n 1⁄4 278, June 2007 to May 2008); Phase 2, introduction of pre-hospital ECGs (n 1⁄4 979, May 2008 to May 2011); and Phase 3, implementation of an inter-facility transfer protocol for primary PCI (pPCI) (n 1⁄4 784, May 2011 to September 2013)). A total of 1353 patients received pPCI across all phases. RESULTS: Baseline clinical characteristics were similar between phases. Amongst patients receiving pPCI, median first medical contact-to-device times decreased over the 3 phases, whether the initial presentation was at a PCI capable hospital (116 min, 92 min, 95 min; p < 0.001 for trend) or PCI non-capable hospital (174 min, 146 min, 123 min; p < 0.001 for trend) (Figure). Moreover, the proportion of STEMI patients receiving successful pPCI increased across each phase (44.2%, 63.8%, 74.5%; p < 0.001). Overall in-hospital mortality was not significantly different across each phase (9.4%, 8.8%, 10.6%; p 1⁄4 0.44). However, overall rates of in-hospital congestive heart failure (15.8%, 19.7%, 23.9%; p 1⁄4 0.008) and major bleeding (9.0%, 16.0%, 14.8%; p 1⁄4 0.014) increased over time. CONCLUSION: Within a geographically defined cohort of STEMI patients, a phased roll out of regional pPCI significantly reduced reperfusion times and increased the proportion of patients receiving timely pPCI over a 6-year period. However, in-hospital mortality was unchanged during this same period despite improvements in pPCI performance and access, and both in-hospital congestive heart failure and major bleeding increased over this time period. This suggests that variables beyond receiving timely pPCI are important in determining clinical endpoints. Therefore, in addition to optimizing reperfusion strategies, further understanding and optimization of these variables will be critical to improve STEMI outcomes. 122 DELAYED EDUCATIONAL REMINDERS FOR LONG-TERM MEDICATION ADHERENCE IN ST-ELEVATION MYOCARDIAL INFARCTION (DERLA -STEMI)