Baylor College of Medicine, Houston, Texas.
Division of Cardiology, McAllister Heart Institute, University of North Carolina at Chapel Hill.
JAMA Cardiol. 2018 Jun 1;3(6):527-531. doi: 10.1001/jamacardio.2017.5356.
In-hospital ST-segment elevation myocardial infarction (STEMI) is a unique clinical entity with epidemiology, incidence, and outcomes distinct from that of out-of-hospital STEMI and has only within the past 10 years begun to receive increased attention and research. Patients with in-hospital STEMI are older, have more comorbidities, and more frequently have coagulopathies and contraindications for anticoagulation and fibrinolytic therapy. A standardized clinical definition of in-hospital STEMI is lacking. The objectives of this special communication are to (1) summarize the knowledge base regarding in-hospital STEMI; (2) review the challenges of diagnosis and treatment of patients with in-hospital STEMI; (3) present a standardized clinical definition for in-hospital STEMI; and (4) provide a quality improvement protocol to improve diagnosis, triage, and treatment of patients with in-hospital STEMI.
Patients with in-hospital STEMI less frequently present with typical angina symptoms, and an electrocardiogram is often obtained owing to changes in clinical status, changes on telemetry, or a finding of elevated cardiac biomarker. The frequent nontypical presentations often lead to substantial delays in the diagnosis of STEMI. Only 34% to 71% of patients with in-hospital STEMI undergo diagnostic catheterization, and only 22% to 56% undergo percutaneous coronary intervention. Even in contemporary reports, some studies report in-hospital mortality in the range of 31% to 42%. Three areas of delay in the treatment of patients with in-hospital STEMI that merit particular attention are (1) delays in electrocardiogram acquisition, (2) delays in electrocardiogram interpretation, and (3) delays in activation of existing STEMI systems of care.
Treatment of patients with in-hospital STEMI is more complex and challenging than treatment of patients who develop out-of-hospital STEMI, leading to delays in diagnosis and triage and less frequent use of reperfusion therapy. Quality improvement programs targeted at decreasing delays and streamlining treatment of such patients may improve treatment and outcome.
院内 ST 段抬高型心肌梗死（STEMI）是一种独特的临床实体，具有与院外 STEMI 不同的流行病学、发病率和结局，仅在过去 10 年才开始受到越来越多的关注和研究。院内 STEMI 患者年龄较大，合并症更多，经常出现凝血异常，并存在抗凝和溶栓治疗的禁忌证。目前缺乏对院内 STEMI 的标准化临床定义。本专题通讯的目的是：（1）总结有关院内 STEMI 的知识基础；（2）回顾诊断和治疗院内 STEMI 患者的挑战；（3）提出院内 STEMI 的标准化临床定义；（4）提供一个质量改进方案，以改善院内 STEMI 患者的诊断、分诊和治疗。
院内 STEMI 患者较少出现典型胸痛症状，心电图通常因临床状态改变、遥测变化或心脏生物标志物升高而获得。不典型表现频繁导致 STEMI 的诊断出现大量延迟。仅有 34%71%的院内 STEMI 患者接受诊断性冠状动脉造影，仅有 22%56%的患者接受经皮冠状动脉介入治疗。即使在当代报告中，一些研究报告的院内死亡率也在 31%~42%范围内。院内 STEMI 患者治疗中存在三个值得特别关注的延迟领域：（1）心电图获取延迟，（2）心电图解释延迟，（3）现有 STEMI 治疗系统激活延迟。
与发生院外 STEMI 的患者相比，院内 STEMI 患者的治疗更为复杂和具有挑战性，导致诊断和分诊延迟，再灌注治疗的应用频率更低。针对减少此类患者的治疗延迟和简化治疗的质量改进方案可能会改善治疗和结局。
