Impact of the Type of First Medical Contact within a Guideline-Conform ST-Elevation Myocardial Infarction Network: A Prospective Observational Registry Study.

Roman Pfister,Guido Michels,Kathrin Kuhr,Wolfgang Fehske,Stephan Baldus,Hans-Wilhelm Hoepp,Samuel Lee,Frank Baer,Marc W Merx

doi:10.1371/journal.pone.0156769

Roman Pfister, Guido Michels + Show 7 more

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https://doi.org/10.1371/journal.pone.0156769

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Abstract

AimsThe impact of type of first medical contact (FMC) in the setting of a guideline conform metropolitan ST-elevation myocardial infarction (STEMI) network providing obligatory primary percutaneous coronary intervention (PCI) is unclear.Methods and Results3,312 patients were prospectively included between 2006 and 2012 into a registry accompanying the “Cologne Infarction Model” STEMI network, with 68.4% primarily presenting to emergency medical service (EMS), 17.6% to non-PCI-capable hospitals, and 14.0% to PCI-capable hospitals. Median contact-to-balloon time differed significantly by FMC with 89 minutes (IQR 72–115) for EMS, 107 minutes (IQR 85–148) for non-PCI- and 65 minutes (IQR 48–91) for PCI-capable hospitals (p < 0.001). TIMI-flow grade III and in-hospital mortality were 75.7% and 10.4% in EMS, 70.3% and 8.6% in non-PCI capable hospital and 84.4% and 5.6% in PCI-capable hospital presenters, respectively (p both < 0.01). The association of FMC with in-hospital mortality was not significant after adjustment for baseline characteristics, but risk of TIMI-flow grade < III remained significantly increased in patients presenting to non-PCI capable hospitals.ConclusionDespite differences in treatment delay by type of FMC in-hospital mortality did not differ significantly. The increased risk of TIMI-flow grade < III in patients presenting to non PCI-capable hospitals needs further study.

Highlights

For patients with acute ST-elevation myocardial infarction (STEMI) rapid reperfusion of the infarct related artery is the main therapeutic goal
We examined the association between the site of first medical contact (FMC) and delay to reperfusion, success of reperfusion by primary percutaneous coronary intervention (PCI) and in-hospital mortality in patients treated within the Cologne Infarction Model (‘Kölner Infarkt Modell’, KIM) from 2006 to 2012, a metropolitan STEMI network implemented to provide primary PCI to all patients presenting with STEMI within recommended treatment goals
Between January 1, 2006, and December 31, 2012, 3,381 patients with STEMI were recorded in the KIM registry (Fig 1) of whom 69 patients were excluded from the analysis due to missing or implausible record of FMC

Summary

Introduction

For patients with acute ST-elevation myocardial infarction (STEMI) rapid reperfusion of the infarct related artery is the main therapeutic goal. Primary percutaneous coronary intervention (PCI) represents the preferred treatment of reperfusion over fibrinolysis [3] It is a logistic challenge for regional health care systems to timely transfer STEMI patients to primary PCI since PCI is only beneficial compared with fibrinolysis when delay to reperfusion can be held below 120 minutes [4]. Current guidelines recommend keeping the time between first medical contact (FMC) to inflation of balloon to less than 90 minutes [5, 6] To achieve these treatment goals both metropolitan and rural communities are encouraged to establish regional systems of STEMI care that involve emergency medical services (EMS) and local hospitals with the aim of optimizing timely diagnosis of STEMI patients and direct transfer to PCI capable hospitals [7]

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