Cardiovascular Medicine, Mayo Clinic Arizona, Phoenix, Arizona, USA.
Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.
Open Heart. 2024 Jan 30;11(1):e002505. doi: 10.1136/openhrt-2023-002505.
Patients who experience in-hospital ST-segment elevation myocardial infarction (iSTEMI) represent a uniquely high-risk cohort owing to delays in diagnosis, prolonged time to reperfusion and increased mortality. Quality initiatives aimed at improving the care of this vulnerable, yet understudied population are needed.
This study included consecutive patients with iSTEMI treated with percutaneous coronary intervention (PCI) between 1 January 2011 and 15 July 2019 at a single, tertiary referral centre. A comprehensive iSTEMI protocol (CSP) was implemented on 15 July 2014, incorporating: (1) cardiology fellow activation of the catheterisation lab using standardised criteria, (2) nursing chest pain protocol, (3) improved electronic access to electrocardiographic studies, (4) checklist for initial triage and management, (5) 24/7/365 catheterisation lab readiness and (6) radial-first PCI approach. Key metrics and clinical outcomes were compared before and after CSP implementation.
Among 125 total subjects, the post-CSP cohort (n=81) was younger, had more males and were more likely to be hospitalised for cardiac-related reasons relative to the pre-CSP cohort (n=44) who were more likely hospitalised for operative-related aetiologies. After CSP adoption, median ECG-to-first-device-activation time decreased from 113 min to 64 min (p<0.001), goal ECG-to-first-device-activation time increased from 36% to 76% of patients (p<0.001), administration of guideline-directed medical therapy prior to PCI increased from 27.3% to 65.4% (p<0.001), trans-radial access increased from 16% to 70% (p<0.001) and rates of discharge home increased from 56.8% to 76.5% (p=0.04). Statistically insignificant numerical reductions were observed post-CSP in in-hospital mortality (18.2% vs 9.9%, p=0.30), 30-day mortality (15.9% vs 12.3%, p=0.78) and 1-year mortality (27.3% vs 21.0%, p=0.57).
The implementation of a CSP was associated with marked enhancements in key care metrics among patients with iSTEMI. Among a larger cohort, the use of a CSP yielded a significant reduction in ECG-to-first-device-activation time in a particularly vulnerable population at high risk of death.
因诊断延迟、再灌注时间延长和死亡率增加，院内 ST 段抬高型心肌梗死（iSTEMI）患者属于高危人群。需要采取旨在改善这一脆弱但研究不足的人群护理的质量举措。
这项研究纳入了 2011 年 1 月 1 日至 2019 年 7 月 15 日期间在一家单中心三级转诊中心接受经皮冠状动脉介入治疗（PCI）的连续 iSTEMI 患者。2014 年 7 月 15 日实施了综合 iSTEMI 方案（CSP），其中包括：（1）心脏病学研究员使用标准化标准激活导管实验室，（2）护理胸痛方案，（3）改善对心电图研究的电子访问，（4）初始分诊和管理检查表，（5）24/7/365 导管实验室就绪，（6）桡动脉优先 PCI 方法。比较了 CSP 实施前后的关键指标和临床结局。
在 125 名受试者中，CSP 后队列（n=81）较 CSP 前队列（n=44）更年轻，男性更多，因心脏相关原因住院的可能性更大，而 CSP 前队列因手术相关病因而住院的可能性更大。CSP 采用后，中位心电图至首次设备激活时间从 113 分钟缩短至 64 分钟（p<0.001），目标心电图至首次设备激活时间从 36%增加到 76%（p<0.001），PCI 前指南指导的药物治疗的使用率从 27.3%增加到 65.4%（p<0.001），经桡动脉入路从 16%增加到 70%（p<0.001），出院回家的比例从 56.8%增加到 76.5%（p=0.04）。CSP 后，院内死亡率（18.2% vs 9.9%，p=0.30）、30 天死亡率（15.9% vs 12.3%，p=0.78）和 1 年死亡率（27.3% vs 21.0%，p=0.57）均呈数值下降但无统计学意义。
实施 CSP 后，iSTEMI 患者的关键护理指标明显改善。在更大的队列中，CSP 的使用显著缩短了高危死亡风险的脆弱人群的心电图至首次设备激活时间。
