Ferlini Marco, De Ferrari Gaetano Maria, Moroni Giuseppe, Roversi Paolo, Potenza Antonella, Leonardi Sergio, Repetto Alessandra, Camporotondo Rita, Alessandrino Giuseppe, Gnecchi Massimiliano, Marinoni Barbara, Guerci Manuela, Crimi Gabriele, Ferrario Maurizio, Bressan Maria Antonietta, Raimondi Maurizio, De Servi Stefano, Visconti Luigi Oltrona
S.C. Cardiologia, Fondazione IRCCS Policlinico San Matteo, Pavia.
UTIC LSR Cardiologia Sperimentale, Fondazione IRCCS Policlinico San Matteo, Università degli Studi, Pavia.
G Ital Cardiol (Rome). 2016 Jan;17(1):51-7. doi: 10.1714/2140.23192.
Primary percutaneous coronary intervention (pPCI) is the treatment of choice in patients with ST-elevation myocardial infarction (STEMI) if performed by an experienced team within 120 min of first medical contact. The door to balloon time (DTB) has become a performance measure and is the focus of local, regional and national quality improvement initiatives. The primary objective of the present study was to evaluate whether the implementation of reperfusion strategies could result in shorter DTB times.
In 2007, at the cath lab of the IRCCS Policlinico San Matteo (a hub of a network including 7 spoke centers), 245 pPCI were performed with a median DTB time of 116 (25th-75th percentile, 96-155) min, and <90 min only in 20% of cases. To improve time to reperfusion, the following strategies were adopted in 2010 and 2011: direct access to the cath lab without initial coronary care unit admission; activation of the cath lab based on pre-hospital ECG; a faster triage with ECG performed within 10 min and use of a dedicated ambulance for patients presenting directly to the emergency room (ER) of the hub.
Overall, 226 and 258 pPCI were performed in 2010 and 2011, respectively, with no differences in type of hospital admission (emergency medical service, ER, or spoke) compared with 2007. A significant DTB reduction was observed (2007 vs 2010 vs 2011: 116 [96-155] vs 99 [77-129] vs 97 [80-125] min, p<0.0001), with a significant improvement in the number of patients treated within 90 min (20 vs 41 vs 40%, p<0.0001) as a result of a significant reduction in the time from first medical contact to cath lab (86 [64-124] vs 66 [50-93] vs 62 [46-93] min, p<0.0001). By analyzing only data from 2010 and 2011, median DTB was 88 (73-104) min for patients arriving through the emergency medical service, 139 (116-179) min for patients presenting to spoke centers, and 96 (75-126) min for patients presenting to the ER, with pPCI performed within 90 min in 55%, 8% e 42% of cases, respectively. The longer DTB time of the spoke centers was solely due to transportation to the hub (emergency medical service vs spoke: 56 [42-68] vs 106 [86-147] min, p<0.0001), with no differences in time to reperfusion once the cath lab was reached.
Based on our strategies and experience including 729 STEMI patients treated with pPCI in 2007, 2010 and 2011, a significant improvement in DTB time was achieved. The main factor affecting our results is transportation to the cath lab for patients with direct access to spoke centers. Further exploration and advocacy for DTB implementation in these patients are warranted.
对于ST段抬高型心肌梗死（STEMI）患者，若由经验丰富的团队在首次医疗接触后120分钟内进行，直接经皮冠状动脉介入治疗（pPCI）是首选治疗方法。门球时间（DTB）已成为一项绩效指标，是地方、区域和国家质量改进举措的重点。本研究的主要目的是评估再灌注策略的实施是否能缩短DTB时间。
2007年，在IRCCS圣马泰奥综合医院（一个包括7个分支中心的网络的中心）的导管室，进行了245例pPCI，DTB时间中位数为116（第25百分位数-第75百分位数，96-155）分钟，仅20%的病例在90分钟内完成。为了缩短再灌注时间，2010年和2011年采取了以下策略：直接进入导管室，无需先入住冠心病监护病房；根据院前心电图启动导管室；10分钟内完成心电图进行更快的分诊，并为直接前往中心急诊室（ER）的患者使用专用救护车。
总体而言，2010年和2011年分别进行了226例和258例pPCI，与2007年相比，医院入院类型（紧急医疗服务、急诊室或分支中心）无差异。观察到DTB显著缩短（2007年 vs 2010年 vs 2011年：116 [96-155] vs 99 [77-129] vs 97 [80-125]分钟，p<0.0001），90分钟内接受治疗的患者数量显著增加（20% vs 41% vs 40%，p<0.0001），这是由于从首次医疗接触到导管室的时间显著缩短（86 [64-124] vs 66 [50-93] vs 62 [46-93]分钟，p<0.0001）。仅分析2010年和2011年的数据，通过紧急医疗服务到达的患者DTB中位数为88（73-104）分钟，前往分支中心的患者为139（116-179）分钟，前往急诊室的患者为96（75-126）分钟，pPCI在90分钟内完成的病例分别为55%、8%和42%。分支中心DTB时间较长完全是由于转运至中心（紧急医疗服务 vs 分支中心：56 [42-68] vs 106 [86-147]分钟，p<0.0001），到达导管室后再灌注时间无差异。
基于我们的策略和经验，包括2007年、2010年和2011年接受pPCI治疗的729例STEMI患者，DTB时间有显著改善。影响我们结果的主要因素是直接前往分支中心的患者转运至导管室的时间。有必要对这些患者进一步探索和倡导实施DTB。
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