Le May Michel R, So Derek Y, Dionne Richard, Glover Chris A, Froeschl Michael P V, Wells George A, Davies Richard F, Sherrard Heather L, Maloney Justin, Marquis Jean-François, O'Brien Edward R, Trickett John, Poirier Pierre, Ryan Sheila C, Ha Andrew, Joseph Phil G, Labinaz Marino
University of Ottawa Heart Institute, Ottawa, ON, Canada.
N Engl J Med. 2008 Jan 17;358(3):231-40. doi: 10.1056/NEJMoa073102.
If primary percutaneous coronary intervention (PCI) is performed promptly, the procedure is superior to fibrinolysis in restoring flow to the infarct-related artery in patients with ST-segment elevation myocardial infarction. The benchmark for a timely PCI intervention has become a door-to-balloon time of less than 90 minutes. Whether regional strategies can be developed to achieve this goal is uncertain.
We developed an integrated-metropolitan-area approach in which all patients with ST-segment elevation myocardial infarction were referred to a specialized center for primary PCI. We sought to determine whether there was a difference in door-to-balloon times between patients who were referred directly from the field by paramedics trained in the interpretation of electrocardiograms and patients who were referred by emergency department physicians.
Between May 1, 2005, and April 30, 2006, a total of 344 consecutive patients with ST-segment elevation myocardial infarction were referred for primary PCI: 135 directly from the field and 209 from emergency departments. Primary PCI was performed in 93.6% of patients. The median door-to-balloon time was shorter in patients referred from the field (69 minutes; interquartile range, 43 to 87) than in patients needing interhospital transfer (123 minutes; interquartile range, 101 to 153; P<0.001). Door-to-balloon times of less than 90 minutes were achieved in 79.7% of patients who were transferred from the field and in 11.9% of those transferred from emergency departments (P<0.001).
Guideline door-to-balloon-times were more often achieved when trained paramedics independently triaged and transported patients directly to a designated primary PCI center than when patients were referred from emergency departments.
对于ST段抬高型心肌梗死患者，如果能迅速进行直接经皮冠状动脉介入治疗（PCI），该治疗在恢复梗死相关动脉血流方面优于溶栓治疗。及时进行PCI干预的基准已成为门球时间少于90分钟。是否可以制定区域策略来实现这一目标尚不确定。
我们制定了一种大都市地区综合方法，即所有ST段抬高型心肌梗死患者均被转诊至专门中心进行直接PCI。我们试图确定，由经过心电图解读培训的护理人员直接从现场转诊的患者与由急诊科医生转诊的患者之间，门球时间是否存在差异。
在2005年5月1日至2006年4月30日期间，共有344例连续的ST段抬高型心肌梗死患者被转诊进行直接PCI：135例直接从现场转诊，209例从急诊科转诊。93.6%的患者接受了直接PCI。从现场转诊的患者中位门球时间较短（69分钟；四分位间距，43至87分钟），短于需要院间转运的患者（123分钟；四分位间距，101至153分钟；P<0.001）。从现场转诊的患者中，79.7%实现了门球时间少于90分钟，而从急诊科转诊的患者中这一比例为11.9%（P<0.001）。
与患者由急诊科转诊相比，当经过培训的护理人员独立进行分诊并将患者直接转运至指定的直接PCI中心时，更常能达到指南规定的门球时间。
