Management of acute ST-elevation myocardial infarction in the coronary care units of Piedmont in 2005: results from the PRIMA regionwide survey

Abstract

In Piedmont (north-western Italy) a network for emergency treatment of acute ST-elevation myocardial infarction is being implemented. To provide a baseline for care assessment and quality improvement, a regionwide survey was conducted. We describe the clinical characteristics, treatment and outcomes of patients admitted to the coronary care units (CCUs) of the Regional Health System. All patients with acute ST-elevation myocardial infarction <12 h of symptom onset, admitted to any of the 31 CCUs (13 with full-time interventional facilities) between February and May 2005, were enrolled in the study. Of 818 patients (28.1% female, mean age 66 +/- 12 years), 14.3% had diabetes mellitus and 39.7% anterior myocardial infarction; 77% had their first medical contact within 3 h of symptom onset, and 53% reached full-time interventional CCUs. The 118 emergency medical system was used by 50% of patients. Median door-to-electrocardiogram time was 9 min (<10 min in 60%). Reperfusion treatment was attempted in 682 patients (83.4%) as follows: lysis in 254 (31.1%), lysis-angioplasty in 95 (11.6%), and primary angioplasty in 333 (40.7%); 136 patients (16.6%) received no reperfusion treatment. Median door-to-needle time was 35 min (<30 min in 43%). Emergency angioplasty was performed on site in 356 patients, with a median door-to-balloon time of 84 min (<90 min and <60 min in 50% and 23%, respectively). Emergency transfer to a full-time interventional centre was required in 93 patients (24% of candidates), regardless of their risk profile, with median decision-to-door out and travel times of 45 min and 52 min, respectively. In-hospital death, reinfarction and stroke occurred in 62 (7.6%), 13 (1.6%) and 10 patients (1.2%), respectively. Mortality was 5.9% and 16.7% in patients with and without reperfusion treatment, respectively. At multivariate analysis, the type of reperfusion treatment was not a predictor of mortality, whereas this was the case for the absence of reperfusion treatment (odds ratio 2.16; 95% confidence interval 1.17-4.02), TIMI risk index >33 (odds ratio 6.78; 95% confidence interval 3.70-12.40), and chronic renal failure (odds ratio 4.96; 95% confidence interval 1.82-13.55). In Piedmont, candidates for myocardial reperfusion treatment admitted to the CCUs of the Regional Health System are about 600 per million inhabitants/year. The 118 emergency medical system is used by about half of them, and medical contact occurs within 3 h of symptom onset in most cases. Use of reperfusion treatment is frequent, the choice is related to on-site availability rather than to risk profile, and door-to-treatment times can be improved. Use of emergency transfer is limited, poorly selected, and slow.