Aplin Richard, Tiede Daniel, Lovitz Cheryl, Gartner Mark, Robinson David, Xu Hui, Martin Philip, Erickson Bernard, Schmidt Wade, Pelzel Jamie, Wendt David, Mahowald John
Central Minnesota Heart Center at St. Cloud Hospital, MN 56303, USA.
J Invasive Cardiol. 2009 Dec;21(12):639-44.
Strategies of emergency care in the treatment of ST-segment elevation myocardial infarction (STEMI) have evolved rapidly over the past two decades to include primary percutaneous coronary intervention (PPCI) when possible. Most U.S.-based transfer programs still use complicated protocols that include fibrinolytic therapy often resulting in transfer delays, inappropriately applied therapy (wrong diagnosis) and bleeding and stroke complications. These protocols are often emphasized in low-volume centers. We implemented a program absent fibrinolytic therapy and applied it to a network of 25 participating hospitals over a 100-mile radius in central Minnesota.
One-thousand consecutive patients ages 21 to 90 who presented within 12 hours of the onset of symptoms consistent with MI from April, 2004 to January, 2008 were included in this registry. Prior to transfer to the cardiac catheterization laboratory, patients received aspirin and heparin. Clopidogrel was added to the protocol in January, 2007. Glycoprotein (GP) IIb/IIIa inhibitors were typically utilized after diagnostic catheterization and prior to PPCI. Median door-to-balloon time was 56 minutes at the PCI Center and 110 minutes from referral sites (RS). Of the transfer patients, 71% underwent helicopter transfer. The success rate for PPCI was 99.4%. Despite inherent transfer delays, there was no difference in mortality between the PCI Center and RS. Overall mortality rates in-hospital, at 30 days, at 6 months, and 1 year were 2.1%, 2.9%, 3.8% and 4.5%, respectively, with follow up on 998 of 1,000 patients. In-hospital stroke, reinfarction and major bleeding were 0.7%, 2.0% and 2.7%, respectively.
Despite increasing trends toward a pharmacoinvasive approach in transfer patients with STEMI, a protocol which stresses rapid transfer and PPCI results in excellent outcomes, with very low complication rates without fibrinolytic therapy.
在过去二十年中，ST段抬高型心肌梗死（STEMI）治疗中的急诊护理策略迅速发展，尽可能包括直接经皮冠状动脉介入治疗（PPCI）。大多数美国的转运项目仍采用复杂的方案，其中包括纤维蛋白溶解疗法，这常常导致转运延迟、治疗应用不当（诊断错误）以及出血和中风并发症。这些方案在低容量中心经常被强调。我们实施了一个不包括纤维蛋白溶解疗法的项目，并将其应用于明尼苏达州中部半径100英里范围内的25家参与医院组成的网络。
该登记研究纳入了2004年4月至2008年1月期间出现症状后12小时内就诊、年龄在21至90岁之间且症状符合心肌梗死的1000例连续患者。在转运至心脏导管实验室之前，患者接受阿司匹林和肝素治疗。2007年1月，氯吡格雷被纳入该方案。糖蛋白（GP）IIb/IIIa抑制剂通常在诊断性导管插入术后和PPCI之前使用。在PCI中心，门到球囊的中位时间为56分钟，从转诊地点（RS）为110分钟。在转运患者中，71%通过直升机转运。PPCI的成功率为99.4%。尽管存在固有的转运延迟，但PCI中心和RS之间的死亡率没有差异。在1000例患者中，对998例进行了随访，住院、30天、6个月和1年时的总体死亡率分别为2.1%、2.9%、3.8%和4.5%。住院期间中风、再梗死和大出血的发生率分别为0.7%、2.0%和2.7%。
尽管在STEMI转运患者中采用药物侵入性方法的趋势不断增加，但强调快速转运和PPCI的方案可产生优异的结果，在不使用纤维蛋白溶解疗法的情况下并发症发生率非常低。
