impact of guidelines on the evolution of reperfusion strategies in acute stemi

Impact of Guidelines on the Evolution of Reperfusion Strategies in Acute STEMI A 6-Year Study on 4376 Patients from e-MUST Registry N. Karam 1 , M. Tafflet 1 , S. Bataille 2 , C. Lapandry 3 , H. Auger 4 , A. Greffet 5 , S. Dubourdieu 6 , F. Dupas 7 , X. Jouven 1 , Y. Lambert 8 (1) Inserm U970 - Paris Cardiovascular Research Center (PARCC), Cardiovascular Epidemiology-Sudden Death, Paris, France (2) Service des registres ARS Ile-de-France (3) Avicenne Hospital (4) Henri Mondor Hospital (5) Necker Hospital (6) Brigade des sapeurs pompiers de Paris (7) Pontoise Hospital (8) Versailles Hospital Our data were taken between 2003 and 2008 from e-MUST, a prospective multicenter registry that includes all acute STEMI patients managed by mobile intensive care units in Greater Paris Area. Patients presenting within two hours of pain onset were included in the analysis. Greater Paris Area ( 11.7 million inhabitants) was divided into 3 regions: Paris city, small ring, and large ring, each having different characteristics regarding their sizes and the density of cath labs, emergency units, and population. Prompt reperfusion is the cornerstone in the management of acute STEMI. When available within 90 min of first medical contact for patients presenting within two hours of pain onset, primary percutaneous intervention (pPCI) is the preferred revascularization strategy. We assessed the consequences of guidelines application on daily practice in Greater Paris Area, France. Among the 4376 patients included in the analysis, 1695 patients (39%) had pre-hospital thrombolysis, 1266 patients (29%) had pPCI within 90 min of first medical contact, and 1415 patients (32%) had pPCI beyond 90 min. Over the 6 years, there was a sharp increase in pPCI performed < 90 min in all regions, balanced by a sharp decrease in the use of thrombolysis. The proportion of pPCI > 90 min, which is associated with the highest mortality (6.5%), failed to decrease globally: it did decrease in Paris city, remained constant in the small ring, but increased in the large ring, where the density of cath labs is lowest. In this study, the attempt to apply guidelines regarding revascularization resulted in a drastic decrease in the use of thrombolysis, an increase in primary PCI performed within 90 minutes of first medical contact in regions with good resources, but also in an increase in primary PCI performed beyond 90 minutes in regions with limited resources, with a loss of chance for the patients. Accordingly, recommendation should probably be tailored to local resources. Purpose Methods Results Conclusion 2003 2004 2005 2006 2007 2008 0 20 40 60 80 Paris % per year 2003 2004 2005 2006 2007 2008 0 20 40 60 80 Small ring % per year 2003 2004 2005 2006 2007 2008 0 20 40 60 80 Overall % per year 2003 2004 2005 2006 2007 2008 0 20 40 60 80 Large ring % per year

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Page 1: Impact of Guidelines on the Evolution of Reperfusion Strategies in Acute STEMI

Impact of Guidelines on the Evolution of Reperfusion Strategies in Acute STEMI A 6-Year Study on 4376 Patients from e-MUST Registry

N. Karam1, M. Tafflet1, S. Bataille2, C. Lapandry3, H. Auger4, A. Greffet5, S. Dubourdieu6, F. Dupas7, X. Jouven1, Y. Lambert8 (1) Inserm U970 - Paris Cardiovascular Research Center (PARCC), Cardiovascular Epidemiology-Sudden Death, Paris, France

(2) Service des registres ARS Ile-de-France (3) Avicenne Hospital (4) Henri Mondor Hospital (5) Necker Hospital (6) Brigade des sapeurs pompiers de Paris (7) Pontoise Hospital (8) Versailles Hospital

Our data were taken between 2003 and 2008 from e-MUST, a prospective multicenter registry that includes all acute STEMI patients managed by mobile intensive care units in Greater Paris Area. Patients presenting within two hours of pain onset were included in the analysis. Greater Paris Area (11.7 million inhabitants) was divided into 3 regions: Paris city, small ring, and large ring, each having different characteristics regarding their sizes and the density of cath labs, emergency units, and population.

Prompt reperfusion is the cornerstone in the management of acute STEMI. When available within 90 min of first medical contact for patients presenting within two hours of pain onset, primary percutaneous intervention (pPCI) is the preferred revascularization strategy. We assessed the consequences of guidelines application on daily practice in Greater Paris Area, France.

Among the 4376 patients included in the analysis, 1695 patients (39%) had pre-hospital thrombolysis, 1266 patients (29%) had pPCI within 90 min of first medical contact, and 1415 patients (32%) had pPCI beyond 90 min. Over the 6 years, there was a sharp increase in pPCI performed < 90 min in all regions, balanced by a sharp decrease in the use of thrombolysis. The proportion of pPCI > 90 min, which is associated with the highest mortality (6.5%), failed to decrease globally: it did decrease in Paris city, remained constant in the small ring, but increased in the large ring, where the density of cath labs is lowest.

In this study, the attempt to apply guidelines regarding revascularization resulted in a drastic decrease in the use of thrombolysis, an increase in primary PCI performed within 90 minutes of first medical contact in regions with good resources, but also in an increase in primary PCI performed beyond 90 minutes in regions with limited resources, with a loss of chance for the patients. Accordingly, recommendation should probably be tailored to local resources.

Purpose Methods Results

Conclusion

2003 2004 2005 2006 2007 20080

Paris

% p

er y

ear

2003 2004 2005 2006 2007 20080

Small ring

% p

er y

ear