IMPACT OF PROVINCIAL ST ELEVATION MYOCARDIAL INFARCTION GUIDELINE IMPLEMENTATION ON TIMELINESS OF DIAGNOSIS, REPERFUSION THERAPY, SUBSEQUENT INVASIVE ASSESSMENT AND OUTCOMES - ANALYSIS FROM CARDIOVASCULAR HEALTH NOVA SCOTIA DATABASE

Abstract

Provincial guidelines for the management of acute ST elevation myocardial infarction (STEMI) were implemented in Nova Scotia in 2008. These emphasized the importance of rapid diagnosis after first medical contact, timely reperfusion therapy (fibrinolysis or primary percutaneous coronary intervention (PPCI) as appropriate) and pre-discharge cardiac catheterization for most STEMI patients treated initially with fibrinolysis. Guideline adoption was accompanied by the development and implementation of multiple local and provincial protocols and quality improvement strategies across the province. The Cardiovascular Health Nova Scotia database was interrogated to determine the impact of guideline implementation on the timeliness of diagnosis, utilization of reperfusion therapy/cardiac catheterization and clinical outcomes in patients with acute STEMI. Data on EKG time, door to needle time (DTNT) for fibrinolytic treated patients, cardiac catheterization rates, PCI rates, one year cardiac readmission rate and one year mortality following admission with acute STEMI were obtained. These data were compared for a three year period prior to provincial guideline implementation (2004-6) against a three year period following guideline implementation (2010-12). The two time periods were compared using the chi-squared test. The rates of EKG within 10 minutes of first medical contact and DTNT less than 30 minutes showed significant improvement between the two time periods. The rate of cardiac catheterization, P-PCI and delayed PCI increased significantly between the two time periods. One year cardiac readmission and one year mortality were significantly lower during the post guideline period. Patients managed with P-PCI had a significantly lower one year mortality than STEMI patients treated with fibrinolytic therapy. Although there have been significant improvements in STEMI management and outcomes in Nova Scotia, there are still considerable room for improvement. Further analysis is needed to understand more clearly the contribution of provincial guideline implementation to the improvements in STEMI treatment in Nova Scotia and the recent drop in readmissions and mortality. More detailed analysis of P-PCI and fibrinolytic treated patients is planned as well as comparison of treatment and outcome in other Canadian jurisdictions.