Duraffourg A, Yayehd K, Fourny M, Turk J, Massoutier M, Ageron F X, Debaty G, Ricard C, Vanzetto G, Belle L, Labarere J
Médecins de Montagne Rhône-Alpes, 256, rue de la République, 73000 Chambery, France.
Service de cardiologie, CHU Campus, 03 BP 30284, Lomé, Togo.
Ann Cardiol Angeiol (Paris). 2014 Nov;63(5):312-20. doi: 10.1016/j.ancard.2014.09.001. Epub 2014 Sep 19.
International guidelines have recommendations for selecting the type of reperfusion (fibrinolysis or angioplasty) in the setting of ST-segment elevation myocardial infarction (STEMI), and suggest that emergency-care networks adapt these recommendations according to the local environment.
To assess the proportions of STEMI patients treated with fibrinolysis or angioplasty in accordance with regional guidelines.
Observational study based on a permanent registry of patients with STEMI of <12h duration in an emergency network in the French North Alps (Isère, Savoie, Haute-Savoie) from January 2009 to December 2012.
The registry included 2620 patients. Reperfusion was given in 2425/2620 (93%) of patients. Reperfusion type was in accordance with recommendations in 1567/2620 (60%) patients. Guideline-recommended fibrinolysis and angioplasty were performed in 47% (656/1385) and 79% (911/1149) respectively, of patients. In multivariable analysis, variables independently associated with guideline-recommended reperfusion were: an age < 65 years (OR 1.60; 95%CI 1.33-1.90), being managed in Haute-Savoie versus Isère or Savoie (OR 1.38; 95%CI 1.12-1.71), an arterial tension < 100mmHg (OR 1.73; 95%CI 1.27-2.35), a cardiogenic shock (OR 0.50; 95%CI 0.30-0.84), a pacemaker or left bundle branch block (OR 0.49; 95%CI 0.28-0.88), and an initial management outside the network (followed by treatment in an interventional centre in the network) (OR 0.62; 95%CI 0.40-0.94). Patients initially treated by mobile intensive care units were more often reperfused in accordance with recommendations when admitted < 3 (versus ≥ 3) h following symptom onset (adjusted OR 2.05; 95% CI 1.61-2.59), while those initially treated by in-hospital emergency units were less often reperfused in accordance with recommendation when treated < 3h following symptom onset (adjusted OR 0.67; 95% CI 0.46-0.97). In-hospital major adverse cardiac events (9.1% vs. 8.5%) and in-hospital mortality (6.4% vs. 5.1%) were not significantly different between patients reperfused in accordance with (versus not) recommendations.
Forty percent of patients with STEMI were not reperfused with fibrinolysis or angioplasty in accordance with regional guidelines. Characterization of this population should allow us to improve guideline adherence.
国际指南对ST段抬高型心肌梗死（STEMI）情况下再灌注类型（纤溶治疗或血管成形术）的选择有相关建议，并建议急救网络根据当地情况调整这些建议。
评估按照地区指南接受纤溶治疗或血管成形术的STEMI患者比例。
基于2009年1月至2012年12月法国北阿尔卑斯地区（伊泽尔省、萨瓦省、上萨瓦省）一个急救网络中持续时间<12小时的STEMI患者永久登记册进行观察性研究。
登记册纳入了2620例患者。2425/2620（93%）的患者接受了再灌注治疗。1567/2620（60%）的患者再灌注类型符合建议。指南推荐的纤溶治疗和血管成形术分别在47%（656/1385）和79%（911/1149）的患者中进行。在多变量分析中，与指南推荐的再灌注独立相关的变量有：年龄<65岁（比值比[OR]1.60；95%置信区间[CI]1.33 - 1.90），在上萨瓦省接受治疗而非在伊泽尔省或萨瓦省（OR 1.38；95%CI 1.12 - 1.71），动脉血压<100mmHg（OR 1.73；95%CI 1.27 - 2.35），心源性休克（OR 0.50；95%CI 0.30 - 0.84），起搏器或左束支传导阻滞（OR 0.49；95%CI 0.28 - 0.88），以及在网络外开始治疗（随后在网络内的介入中心接受治疗）（OR 0.62；95%CI 0.40 - 0.94）。症状发作后<3小时（对比≥3小时）入院时，最初由移动重症监护病房治疗的患者更常按照建议进行再灌注治疗（调整后OR 2.05；95%CI 1.61 - 2.59），而症状发作后<3小时接受治疗时，最初由医院急诊科治疗的患者按照建议进行再灌注治疗的频率较低（调整后OR 0.67；95%CI 0.46 - 0.97）。符合（对比不符合）建议进行再灌注治疗的患者之间，院内主要不良心脏事件（9.1%对8.5%）和院内死亡率（6.4%对5.1%）无显著差异。
40%的STEMI患者未按照地区指南接受纤溶治疗或血管成形术再灌注。对这部分人群的特征描述应有助于我们提高指南依从性。
