NIHR Cardiovascular Biomedical Research Unit, Royal Brompton & Harefield NHS Foundation Trust, London, United Kingdom.
EuroIntervention. 2015 Sep;11(5):511-7. doi: 10.4244/EIJV11I5A103.
We aimed to investigate why many patients with ST-segment elevation myocardial infarction (STEMI) initially present to non-primary percutaneous coronary intervention (PPCI) equipped hospitals in a region that offers a 24-hour direct access Heart Attack Centre.
A retrospective stratified consecutive case analysis was performed for 180 inter-hospital transfer (IHT) and 201 direct access PPCI patients. IHT and direct patients had similar age (61±1.8 years vs. 62±1.9 years, p=0.42), gender (76% vs. 78% male, p=0.64), and cardiovascular risk profile (hypertension 53% vs. 46%, p=0.18; hypercholesterolaemia 32% vs. 25%, p=0.22; and smoking 38% vs. 35%, p=0.56), though there were more diabetic patients in the IHT group (15% vs. 8%, p<0.05). The IHT group had longer symptom-call times 104 mins (42 mins-195 mins) vs. 46 mins (19 mins-114 mins), p<0.0001), lower ECG ST-elevation scores (3.0 mm [1.0-6.0] vs. 5.0 mm [3.0-9.0], p<0.0001), and more protocol negative ECGs at presentation (31.6% vs. 9.4%, p<0.0001). Peak CK was similar for the two groups (628 IU/L [191-1,144] vs. 603 IU/L [280-1,238], p=0.61), as was in-hospital (1.7% vs. 1.5%, p=0.89) and 30-day mortality (2.8% vs. 2.0%, p=0.61).
This study suggests that reperfusion delays in PPCI due to IHT are not always simply "system failures". IHT patients appear to be a different patient cohort in which symptoms and early ECG changes may be less clear. In many cases, initial triage to a non-PPCI centre may be justifiable due to diagnostic uncertainty, and guideline time metrics should be amended appropriately.
我们旨在研究为什么在一个提供 24 小时直接接入心脏急救中心的地区，许多 ST 段抬高型心肌梗死（STEMI）患者最初会前往非经皮冠状动脉介入治疗（PPCI）的医院就诊。
对 180 例院际转院（IHT）和 201 例直接 PPCI 患者进行了回顾性分层连续病例分析。IHT 和直接患者的年龄（61±1.8 岁 vs. 62±1.9 岁，p=0.42）、性别（76% vs. 78%男性，p=0.64）和心血管风险特征（高血压 53% vs. 46%，p=0.18；高胆固醇血症 32% vs. 25%，p=0.22；吸烟 38% vs. 35%，p=0.56）相似，但 IHT 组的糖尿病患者更多（15% vs. 8%，p<0.05）。IHT 组的症状呼叫时间更长，为 104 分钟（42 分钟-195 分钟），而直接 PPCI 组为 46 分钟（19 分钟-114 分钟），p<0.0001），心电图 ST 段抬高评分较低（3.0 毫米[1.0-6.0] vs. 5.0 毫米[3.0-9.0]，p<0.0001），就诊时心电图阴性的比例更高（31.6% vs. 9.4%，p<0.0001）。两组的肌酸激酶峰值相似（628IU/L [191-1144] vs. 603IU/L [280-1144]，p=0.61），住院期间（1.7% vs. 1.5%，p=0.89）和 30 天死亡率（2.8% vs. 2.0%，p=0.61）也相似。
本研究表明，由于 IHT，PPCI 中的再灌注延迟并不总是简单的“系统故障”。IHT 患者似乎是一个不同的患者群体，其症状和早期心电图变化可能不太明显。在许多情况下，由于诊断不确定，最初分诊至非 PPCI 中心可能是合理的，并且应适当修改指南时间指标。
