TY - JOUR
AU1 - El Khoury, Carlos
AU2 - Bochaton, Thomas
AU3 - Flocard, Elodie
AU4 - Serre, Patrice
AU5 - Tomasevic, Danka
AU6 - Mewton, Nathan
AU7 - Bonnefoy-Cudraz, Eric
AU8 - on behalf of the Observatoire des Syndromes Coronaires Aigus dans RESCUe (OSCAR) Research Team
AB - Abstract Aim To assess 5-year evolutions in reperfusion strategies and early mortality in patients with ST-segment elevation myocardial infarction. Methods and results Using data from the French RESCUe network, we studied patients with ST-segment elevation myocardial infarction treated in mobile intensive care units between 2009 and 2013. Among 2418 patients (median age 62 years; 78.5% male), 2119 (87.6%) underwent primary percutaneous coronary intervention and 299 (12.4%) pre-hospital thrombolysis (94.0% of whom went on to undergo percutaneous coronary intervention). Use of primary percutaneous coronary intervention increased from 78.4% in 2009 to 95.9% in 2013 (Ptrend<0.001). Median delays included: first medical contact to percutaneous coronary intervention centre 48 minutes; first medical contact to balloon inflation 94 minutes; and percutaneous coronary intervention centre to balloon inflation 43 minutes. Times from symptom onset to first medical contact and first medical contact to thrombolysis remained stable during 2009–2013, but times from symptom onset to first balloon inflation, and first medical contact to percutaneous coronary intervention centre to first balloon inflation decreased (P<0.001). Among patients with known timings, 2146 (89.2%) had a first medical contact to percutaneous coronary intervention centre delay ⩽90 minutes, while 260 (10.8%) had a longer delay, with no significant variation over time. Primary percutaneous coronary intervention use increased over time in both delay groups, but was consistently higher in the ⩽90 versus >90 minutes delay group (83.0% in 2009 to 97.7% in 2013; Ptrend<0.001 versus 34.1% in 2009 to 79.2% in 2013; Ptrend<0.001). In-hospital (4–6%) and 30-day (6–8%) mortalities remained stable from 2009 to 2013. Conclusion In the RESCUe network, the use of primary percutaneous coronary intervention increased from 2009 to 2013, in line with guidelines, but there was no evolution in early mortality. ST-segment elevation myocardial infarction, primary percutaneous coronary intervention, thrombolysis, mobile intensive care units, mortality Introduction European guidelines emphasise the importance of primary percutaneous coronary intervention (PPCI) in ST-segment elevation myocardial infarction (STEMI) – if it is available – within 2 hours following first medical contact (FMC).1–3 However, thrombolysis may be preferred if balloon inflation would occur beyond 2 hours, especially in patients presenting early after symptom onset.1 Although emergency physicians cannot know the exact time balloon inflation will take after arrival at the percutaneous coronary intervention (PCI) centre, they can generally predict the transfer delay, and hence can base their treatment decision on this variable. To help physicians in their choice of treatment, strategies should be developed as part of a network cooperation between cardiologists and emergency physicians.2 Network development should optimise the start of the patient on the right path, permit the introduction of new therapeutics and facilitate access to primary angioplasty. The aim of the current analysis was to assess the evolutions in reperfusion strategies and early mortality in an organised network through a real-life registry. We describe pre-hospital management, in-hospital care, and early mortality of patients admitted for STEMI between 2009 and 2013. Methods Setting In 2005, we established a regional emergency cardiovascular network (RESCUe network) that covers a population of 3 million inhabitants across five administrative counties, including urban and rural territories. Our area has 10 large-volume centres (>400 PCI cases/year), offering a 24-hour PPCI service. Two of these are within academic hospitals, four are in general hospitals and four are in private clinics. The RESCUe network is funded by the Regional Agency for Health (Agence Régionale de Santé). All mobile intensive care units (MICUs) responsible for out-of-hospital emergencies, emergency departments and PCI centres in our territory share a written STEMI management protocol. In addition to the use of evidence-based treatments, the RESCUe network recommends PPCI if the transfer time to the PCI centre will be less than 90 minutes, which leaves 30 minutes for the cardiologist to achieve balloon inflation. The RESCUe guidelines are regularly updated according to European guidelines. The deployment of the protocol and its updates are accompanied by a doctors’ training programme to improve its enforcement. Admission to all catheterisation laboratories of public hospitals and private clinics is available around the clock. The decision regarding thrombolysis or PPCI is the responsibility of the emergency physician. The impact of the protocol is evaluated through the observational RESCUe registry that collects epidemiological, clinical and therapeutic data. All 19 MICUs, five medical dispatch centres (commonly called centres 15 or services d’aide médicale urgente (SAMUs)) and 10 catheterisation laboratories participate in the registry. It aims to evaluate management by emergency physicians involved in MICUs and interventional cardiologists of patients with STEMI, their characteristics and their outcomes as seen in real life. The registry received approval of the National Commission for Liberties and Data Protection (Commission Nationale de l’Informatique et des Libertés). Patients All patients with persistent chest pain and ST-segment elevation of ⩾2 mm in two contiguous leads were included, with no age or delay limitations. Patients received written information about the registry objectives. Patients for whom a final diagnosis of STEMI was not retained were excluded, as were patients who were not reperfused because of care limitations (e.g. dementia, bedridden, active cancer). Evidence of STEMI, established at catheterisation laboratory discharge, was based on a rise of cardiac troponin associated with at least one of the following: symptoms of ischaemia, significant ST-segment T-wave changes or new left bundle branch block, presence of pathological Q waves, or intracoronary thrombus.4 Data collection Data collected during 2009–2013 were included in the analysis. Data from MICU medical records were transferred into standardised case report forms (CRFs). The RESCUe CRF meets the requirements of an out-of-hospital emergency medical system and is structured according to the progress of STEMI care. The CRF, in which data were recorded by emergency physicians and cardiologists, accompanied the patient until catheterisation laboratory admission. A nurse was responsible for establishing a list of all patients who met the registry criteria. Data collected included: baseline clinical characteristics, history, pre-hospital treatment, reperfusion strategy, initial and final thrombolysis in myocardial infarction (TIMI) flow grade (0, no perfusion; 1, penetration without perfusion; 2, partial reperfusion; 3, normal flow) and discharge therapies. In-hospital and 30-day mortality were also recorded in the CRF. Thirty-day mortality was ascertained by telephone contact. All data were entered into a secured database located at the RESCUe coordination centre, where follow-up was also centralised. Monitoring and recovery of missing data were ensured by two clinical research assistants dedicated to the registry full time. Regular quality control consisted of the assessment of randomly chosen records by a different clinical research assistant in order to identify errors or inconsistencies. The completeness of the database is regularly tested by cross-checking it with regional Programme de Médicalisation des Systèmes d’Information data. Since 2009, the data in the registry have been at least 85% complete. Statistical analysis Baseline population characteristics are described by medians and interquartile ranges (IQRs) for continuous variables and numbers and percentages for qualitative variables. Temporal trends were tested using the χ2 test for binary variables and Kruskal–Wallis analysis of variance for continuous variables. The difference was considered to be significant when the P value was <0.05. All tests were two-tailed. In line with the RESCUe network protocol ‘early transferred patients’ were those whose delay from FMC to PCI centre admission was ⩽90 minutes, while ‘late transferred patients’ were those whose delay was >90 minutes. All analyses were conducted with R 2.14.1. Results Patient characteristics Between January 2009 and December 2013, the RESCUe registry recorded 4212 cases of chest pain and ST-segment elevation, of whom 2656 (63.1%) received pre-hospital care in MICUs. This percentage remained stable each year. Among these 2656 patients, PPCI was chosen for 2348 and thrombolysis for 308; and 2119 and 299 of these patients, respectively, retained STEMI as a final diagnosis and are included in this analysis (Figure 1). Baseline characteristics, overall and by year, of these patients are shown in Table 1. Of note, 281 (94.0%) thrombolysis patients went on to receive PCI. Study flow. Patients with a final diagnosis other than STEMI were excluded from this analysis. The timing of treatment was not known for 10 PPCI and two thrombolysis patients. *A total of 281 thrombolysis patients went on to undergo PCI Figure 1. Open in new tabDownload slide STEMI: ST-segment elevation myocardial infarction; ED: emergency department; MICU: mobile intensive care unit; PCI: percutaneous coronary intervention; PPCI: primary percutaneous coronary intervention. Baseline characteristics of patients with confirmed STEMI in the RESCUe registry Table 1. Baseline characteristics of patients with confirmed STEMI in the RESCUe registry . All (n=2418) . 2009 (n=462) . 2010 (n=470) . 2011 (n=404) . 2012 (n=542) . 2013 (n=540) . Ptrend . Age (years), median (IQR) 62 (52–75) 64 (54–77) 62 (52–74) 63 (51–74) 62 (51–74) 62 (52–74) 0.006 Male, n (%) 1899 (78.5) 351 (76.0) 358 (76.2) 324 (80.2) 435 (80.3) 431 (79.8) 0.36 BMI (kg/m2), median (IQR) 26 (24–29) 26 (24–29) 26 (24–29) 26 (24–28) 26 (24–29) 26 (24–29) 0.34 Risk factors, n (%)  Hypertension 1070 (44.7) 223 (48.3) 198 (42.2) 180 (45.5) 235 (44.4) 234 (43.7) 0.43  Hypercholesterolaemia 937 (39.1) 185 (40.0) 172 (36.6) 162 (40.6) 207 (38.7) 211 (39.6) 0.76  Diabetes mellitus (type I or II) 347 (14.4) 72 (15.6) 66 (14.0) 51 (12.6) 79 (14.6) 79 (14.6) 0.80  Current smoking 978 (40.4) 167 (36.1) 183 (38.9) 167 (41.3) 242 (44.6) 219 (40.6) 0.09  Obesity (BMI ⩾30 kg/m2) 443 (19.8) 83 (19.3) 85 (19.1) 69 (18.2) 90 (18.1) 116 (23.8) 0.16 Cardiovascular history, n (%)  Myocardial infarction 276 (11.4) ND 37 (7.9) 60 (14.9) 78 (14.4) 101 (18.7) <0.001  Stroke 29 (1.3) 1 (0.2) 1 (0.3) 11 (2.8) 10 (1.9) 6 (1.1) 0.003 Pre-STEMI medications, n (%)  Aspirin 313 (17.7) ND 47 (14.6) 67 (16.6) 92 (17.0) 107 (19.8) 0.27  Statin 379 (21.4) ND 52 (18.1) 83 (20.5) 111 (20.5) 133 (24.6) 0.13  β-blocker 288 (16.2) ND 46 (16.0) 66 (16.3) 88 (16.2) 88 (16.3) 0.99  ACEI 219 (12.4) ND 30 (10.5) 49 (12.1) 70 (12.9) 70 (13.0) 0.72 Clinical status  Heart rate (bpm), median (IQR) 75 (64–90) 75 (64–90) 75 (64–90) 76 (60–90) 77 (65–90) 77 (65–91) 0.60  SBP <100 mmHg, n (%) 145 (6.1) 27 (5.9) 29 (6.2) 20 (5.0) 39 (7.3) 30 (5.6) 0.66  Killip status, n (%)   1 2081 (90.7) 404 (88.2) 402 (91.2) 343 (91.5) 471 (91.3) 461 (91.3) 0.39   2 125 (5.4) 28 (6.1) 26 (5.9) 21 (5.6) 25 (4.8) 25 (5.0) 0.88   3 40 (1.7) 5 (1.1) 6 (1.4) 10 (2.7) 9 (1.7) 10 (2.0) 0.47   4 49 (2.1) 21 (4.6) 7 (1.6) 1 (0.3) 11 (2.1) 9 (1.8) <0.001 Anterior wall MI 1099 (45.5) 199 (43.1) 221 (47.0) 182 (45.0) 246 (45.4) 251 (46.5) 0.78 Inferior wall MI 1231 (50.9) 234 (50.6) 243 (51.7) 215 (53.2) 281 (51.8) 258 (47.8) 0.51 . All (n=2418) . 2009 (n=462) . 2010 (n=470) . 2011 (n=404) . 2012 (n=542) . 2013 (n=540) . Ptrend . Age (years), median (IQR) 62 (52–75) 64 (54–77) 62 (52–74) 63 (51–74) 62 (51–74) 62 (52–74) 0.006 Male, n (%) 1899 (78.5) 351 (76.0) 358 (76.2) 324 (80.2) 435 (80.3) 431 (79.8) 0.36 BMI (kg/m2), median (IQR) 26 (24–29) 26 (24–29) 26 (24–29) 26 (24–28) 26 (24–29) 26 (24–29) 0.34 Risk factors, n (%)  Hypertension 1070 (44.7) 223 (48.3) 198 (42.2) 180 (45.5) 235 (44.4) 234 (43.7) 0.43  Hypercholesterolaemia 937 (39.1) 185 (40.0) 172 (36.6) 162 (40.6) 207 (38.7) 211 (39.6) 0.76  Diabetes mellitus (type I or II) 347 (14.4) 72 (15.6) 66 (14.0) 51 (12.6) 79 (14.6) 79 (14.6) 0.80  Current smoking 978 (40.4) 167 (36.1) 183 (38.9) 167 (41.3) 242 (44.6) 219 (40.6) 0.09  Obesity (BMI ⩾30 kg/m2) 443 (19.8) 83 (19.3) 85 (19.1) 69 (18.2) 90 (18.1) 116 (23.8) 0.16 Cardiovascular history, n (%)  Myocardial infarction 276 (11.4) ND 37 (7.9) 60 (14.9) 78 (14.4) 101 (18.7) <0.001  Stroke 29 (1.3) 1 (0.2) 1 (0.3) 11 (2.8) 10 (1.9) 6 (1.1) 0.003 Pre-STEMI medications, n (%)  Aspirin 313 (17.7) ND 47 (14.6) 67 (16.6) 92 (17.0) 107 (19.8) 0.27  Statin 379 (21.4) ND 52 (18.1) 83 (20.5) 111 (20.5) 133 (24.6) 0.13  β-blocker 288 (16.2) ND 46 (16.0) 66 (16.3) 88 (16.2) 88 (16.3) 0.99  ACEI 219 (12.4) ND 30 (10.5) 49 (12.1) 70 (12.9) 70 (13.0) 0.72 Clinical status  Heart rate (bpm), median (IQR) 75 (64–90) 75 (64–90) 75 (64–90) 76 (60–90) 77 (65–90) 77 (65–91) 0.60  SBP <100 mmHg, n (%) 145 (6.1) 27 (5.9) 29 (6.2) 20 (5.0) 39 (7.3) 30 (5.6) 0.66  Killip status, n (%)   1 2081 (90.7) 404 (88.2) 402 (91.2) 343 (91.5) 471 (91.3) 461 (91.3) 0.39   2 125 (5.4) 28 (6.1) 26 (5.9) 21 (5.6) 25 (4.8) 25 (5.0) 0.88   3 40 (1.7) 5 (1.1) 6 (1.4) 10 (2.7) 9 (1.7) 10 (2.0) 0.47   4 49 (2.1) 21 (4.6) 7 (1.6) 1 (0.3) 11 (2.1) 9 (1.8) <0.001 Anterior wall MI 1099 (45.5) 199 (43.1) 221 (47.0) 182 (45.0) 246 (45.4) 251 (46.5) 0.78 Inferior wall MI 1231 (50.9) 234 (50.6) 243 (51.7) 215 (53.2) 281 (51.8) 258 (47.8) 0.51 Data are among patients with non-missing data. ACEI: angiotensin-converting enzyme inhibitor; bpm: beats per minute; BMI: body mass index; IQR: interquartile range; MI: myocardial infarction; ND: no data; SBP: systolic blood pressure; STEMI: ST-segment elevation myocardial infarction. Open in new tab Table 1. Baseline characteristics of patients with confirmed STEMI in the RESCUe registry . All (n=2418) . 2009 (n=462) . 2010 (n=470) . 2011 (n=404) . 2012 (n=542) . 2013 (n=540) . Ptrend . Age (years), median (IQR) 62 (52–75) 64 (54–77) 62 (52–74) 63 (51–74) 62 (51–74) 62 (52–74) 0.006 Male, n (%) 1899 (78.5) 351 (76.0) 358 (76.2) 324 (80.2) 435 (80.3) 431 (79.8) 0.36 BMI (kg/m2), median (IQR) 26 (24–29) 26 (24–29) 26 (24–29) 26 (24–28) 26 (24–29) 26 (24–29) 0.34 Risk factors, n (%)  Hypertension 1070 (44.7) 223 (48.3) 198 (42.2) 180 (45.5) 235 (44.4) 234 (43.7) 0.43  Hypercholesterolaemia 937 (39.1) 185 (40.0) 172 (36.6) 162 (40.6) 207 (38.7) 211 (39.6) 0.76  Diabetes mellitus (type I or II) 347 (14.4) 72 (15.6) 66 (14.0) 51 (12.6) 79 (14.6) 79 (14.6) 0.80  Current smoking 978 (40.4) 167 (36.1) 183 (38.9) 167 (41.3) 242 (44.6) 219 (40.6) 0.09  Obesity (BMI ⩾30 kg/m2) 443 (19.8) 83 (19.3) 85 (19.1) 69 (18.2) 90 (18.1) 116 (23.8) 0.16 Cardiovascular history, n (%)  Myocardial infarction 276 (11.4) ND 37 (7.9) 60 (14.9) 78 (14.4) 101 (18.7) <0.001  Stroke 29 (1.3) 1 (0.2) 1 (0.3) 11 (2.8) 10 (1.9) 6 (1.1) 0.003 Pre-STEMI medications, n (%)  Aspirin 313 (17.7) ND 47 (14.6) 67 (16.6) 92 (17.0) 107 (19.8) 0.27  Statin 379 (21.4) ND 52 (18.1) 83 (20.5) 111 (20.5) 133 (24.6) 0.13  β-blocker 288 (16.2) ND 46 (16.0) 66 (16.3) 88 (16.2) 88 (16.3) 0.99  ACEI 219 (12.4) ND 30 (10.5) 49 (12.1) 70 (12.9) 70 (13.0) 0.72 Clinical status  Heart rate (bpm), median (IQR) 75 (64–90) 75 (64–90) 75 (64–90) 76 (60–90) 77 (65–90) 77 (65–91) 0.60  SBP <100 mmHg, n (%) 145 (6.1) 27 (5.9) 29 (6.2) 20 (5.0) 39 (7.3) 30 (5.6) 0.66  Killip status, n (%)   1 2081 (90.7) 404 (88.2) 402 (91.2) 343 (91.5) 471 (91.3) 461 (91.3) 0.39   2 125 (5.4) 28 (6.1) 26 (5.9) 21 (5.6) 25 (4.8) 25 (5.0) 0.88   3 40 (1.7) 5 (1.1) 6 (1.4) 10 (2.7) 9 (1.7) 10 (2.0) 0.47   4 49 (2.1) 21 (4.6) 7 (1.6) 1 (0.3) 11 (2.1) 9 (1.8) <0.001 Anterior wall MI 1099 (45.5) 199 (43.1) 221 (47.0) 182 (45.0) 246 (45.4) 251 (46.5) 0.78 Inferior wall MI 1231 (50.9) 234 (50.6) 243 (51.7) 215 (53.2) 281 (51.8) 258 (47.8) 0.51 . All (n=2418) . 2009 (n=462) . 2010 (n=470) . 2011 (n=404) . 2012 (n=542) . 2013 (n=540) . Ptrend . Age (years), median (IQR) 62 (52–75) 64 (54–77) 62 (52–74) 63 (51–74) 62 (51–74) 62 (52–74) 0.006 Male, n (%) 1899 (78.5) 351 (76.0) 358 (76.2) 324 (80.2) 435 (80.3) 431 (79.8) 0.36 BMI (kg/m2), median (IQR) 26 (24–29) 26 (24–29) 26 (24–29) 26 (24–28) 26 (24–29) 26 (24–29) 0.34 Risk factors, n (%)  Hypertension 1070 (44.7) 223 (48.3) 198 (42.2) 180 (45.5) 235 (44.4) 234 (43.7) 0.43  Hypercholesterolaemia 937 (39.1) 185 (40.0) 172 (36.6) 162 (40.6) 207 (38.7) 211 (39.6) 0.76  Diabetes mellitus (type I or II) 347 (14.4) 72 (15.6) 66 (14.0) 51 (12.6) 79 (14.6) 79 (14.6) 0.80  Current smoking 978 (40.4) 167 (36.1) 183 (38.9) 167 (41.3) 242 (44.6) 219 (40.6) 0.09  Obesity (BMI ⩾30 kg/m2) 443 (19.8) 83 (19.3) 85 (19.1) 69 (18.2) 90 (18.1) 116 (23.8) 0.16 Cardiovascular history, n (%)  Myocardial infarction 276 (11.4) ND 37 (7.9) 60 (14.9) 78 (14.4) 101 (18.7) <0.001  Stroke 29 (1.3) 1 (0.2) 1 (0.3) 11 (2.8) 10 (1.9) 6 (1.1) 0.003 Pre-STEMI medications, n (%)  Aspirin 313 (17.7) ND 47 (14.6) 67 (16.6) 92 (17.0) 107 (19.8) 0.27  Statin 379 (21.4) ND 52 (18.1) 83 (20.5) 111 (20.5) 133 (24.6) 0.13  β-blocker 288 (16.2) ND 46 (16.0) 66 (16.3) 88 (16.2) 88 (16.3) 0.99  ACEI 219 (12.4) ND 30 (10.5) 49 (12.1) 70 (12.9) 70 (13.0) 0.72 Clinical status  Heart rate (bpm), median (IQR) 75 (64–90) 75 (64–90) 75 (64–90) 76 (60–90) 77 (65–90) 77 (65–91) 0.60  SBP <100 mmHg, n (%) 145 (6.1) 27 (5.9) 29 (6.2) 20 (5.0) 39 (7.3) 30 (5.6) 0.66  Killip status, n (%)   1 2081 (90.7) 404 (88.2) 402 (91.2) 343 (91.5) 471 (91.3) 461 (91.3) 0.39   2 125 (5.4) 28 (6.1) 26 (5.9) 21 (5.6) 25 (4.8) 25 (5.0) 0.88   3 40 (1.7) 5 (1.1) 6 (1.4) 10 (2.7) 9 (1.7) 10 (2.0) 0.47   4 49 (2.1) 21 (4.6) 7 (1.6) 1 (0.3) 11 (2.1) 9 (1.8) <0.001 Anterior wall MI 1099 (45.5) 199 (43.1) 221 (47.0) 182 (45.0) 246 (45.4) 251 (46.5) 0.78 Inferior wall MI 1231 (50.9) 234 (50.6) 243 (51.7) 215 (53.2) 281 (51.8) 258 (47.8) 0.51 Data are among patients with non-missing data. ACEI: angiotensin-converting enzyme inhibitor; bpm: beats per minute; BMI: body mass index; IQR: interquartile range; MI: myocardial infarction; ND: no data; SBP: systolic blood pressure; STEMI: ST-segment elevation myocardial infarction. Open in new tab History of myocardial infarction (MI) increased significantly during the course of the study (from 7.9% in 2010 to 18.7% in 2013; Ptrend<0.001), as did history of stroke (from 0.2% in 2009 to 1.1% in 2013; Ptrend=0.003). Incidences of hypertension (44.7%), hypercholesterolaemia (39.1%), diabetes (14.4%), current smoking (40.4%) and obesity (19.8%), however, remained stable. Pre-STEMI treatment data were not available for 2009, but during 2010–2013, 17.6% of patients took aspirin, 21.4% took statins, 16.2% took beta-blockers and 12.4% took angiotensin-converting enzyme inhibitors; these percentages remained stable from 2010 to 2013 (Table 1). STEMI specifications A total of 2418 patients had STEMI. Anterior wall MI occurred in 45.5% of patients (Table 1). Only 9.3% of patients had heart failure, 6.1% had systolic blood pressure <100 mmHg and 2.1% had cardiogenic shock. There was no evolution over the 5-year period in the proportion of severe patients. Pre-hospital antithrombotic use The majority (93.8%) of patients received aspirin in the pre-hospital setting, with little variation over time (Table 2). The use of clopidogrel and glycoprotein IIb/IIIa inhibitors reduced significantly over time, while the use of prasugrel and ticagrelor increased. Pre-hospital antithrombotic use among patients with confirmed STEMI in the RESCUe registry Table 2. Pre-hospital antithrombotic use among patients with confirmed STEMI in the RESCUe registry . All (n=2418) . 2009 (n=462) . 2010 (n=470) . 2011 (n=404) . 2012 (n=542) . 2013 (n=540) . Ptrend . Aspirin 2269 (93.8) 431 (93.3) 435 (92.6) 388 (96.0) 506 (93.4) 509 (94.3) 0.25 Clopidogrel 1282 (53.0) 382 (82.7) 367 (78.1) 257 (63.6) 186 (34.3) 90 (16.7) <0.01 Prasugrel 368 (20.8) 0 52 (18.1) 99 (24.5) 173 (31.9) 44 (8.1) <0.01 Ticagrelor 410 (37.9) 0 0 0 91 (16.8) 319 (59.1) <0.01 LMWH 1369 (77.2) 0 234 (81.5) 331 (81.9) 389 (71.8) 415 (76.9) <0.01 Unfractionated heparin 217 (12.2) 0 37 (12.9) 45 (11.1) 81 (14.9) 54 (10.0) 0.079 Bivalirudin 7 (0.6) 0 0 0 6 (1.1) 1 (0.2) 0.13 Glycoprotein IIb/IIIa inhibitors 288 (12.1) 216 (49.3) 71 (15.8) 0 1 (0.2) 0 <0.01 . All (n=2418) . 2009 (n=462) . 2010 (n=470) . 2011 (n=404) . 2012 (n=542) . 2013 (n=540) . Ptrend . Aspirin 2269 (93.8) 431 (93.3) 435 (92.6) 388 (96.0) 506 (93.4) 509 (94.3) 0.25 Clopidogrel 1282 (53.0) 382 (82.7) 367 (78.1) 257 (63.6) 186 (34.3) 90 (16.7) <0.01 Prasugrel 368 (20.8) 0 52 (18.1) 99 (24.5) 173 (31.9) 44 (8.1) <0.01 Ticagrelor 410 (37.9) 0 0 0 91 (16.8) 319 (59.1) <0.01 LMWH 1369 (77.2) 0 234 (81.5) 331 (81.9) 389 (71.8) 415 (76.9) <0.01 Unfractionated heparin 217 (12.2) 0 37 (12.9) 45 (11.1) 81 (14.9) 54 (10.0) 0.079 Bivalirudin 7 (0.6) 0 0 0 6 (1.1) 1 (0.2) 0.13 Glycoprotein IIb/IIIa inhibitors 288 (12.1) 216 (49.3) 71 (15.8) 0 1 (0.2) 0 <0.01 Data are among patients with non-missing data. LMWH: low-molecular weight heparin; STEMI: ST-segment elevation myocardial infarction. Open in new tab Table 2. Pre-hospital antithrombotic use among patients with confirmed STEMI in the RESCUe registry . All (n=2418) . 2009 (n=462) . 2010 (n=470) . 2011 (n=404) . 2012 (n=542) . 2013 (n=540) . Ptrend . Aspirin 2269 (93.8) 431 (93.3) 435 (92.6) 388 (96.0) 506 (93.4) 509 (94.3) 0.25 Clopidogrel 1282 (53.0) 382 (82.7) 367 (78.1) 257 (63.6) 186 (34.3) 90 (16.7) <0.01 Prasugrel 368 (20.8) 0 52 (18.1) 99 (24.5) 173 (31.9) 44 (8.1) <0.01 Ticagrelor 410 (37.9) 0 0 0 91 (16.8) 319 (59.1) <0.01 LMWH 1369 (77.2) 0 234 (81.5) 331 (81.9) 389 (71.8) 415 (76.9) <0.01 Unfractionated heparin 217 (12.2) 0 37 (12.9) 45 (11.1) 81 (14.9) 54 (10.0) 0.079 Bivalirudin 7 (0.6) 0 0 0 6 (1.1) 1 (0.2) 0.13 Glycoprotein IIb/IIIa inhibitors 288 (12.1) 216 (49.3) 71 (15.8) 0 1 (0.2) 0 <0.01 . All (n=2418) . 2009 (n=462) . 2010 (n=470) . 2011 (n=404) . 2012 (n=542) . 2013 (n=540) . Ptrend . Aspirin 2269 (93.8) 431 (93.3) 435 (92.6) 388 (96.0) 506 (93.4) 509 (94.3) 0.25 Clopidogrel 1282 (53.0) 382 (82.7) 367 (78.1) 257 (63.6) 186 (34.3) 90 (16.7) <0.01 Prasugrel 368 (20.8) 0 52 (18.1) 99 (24.5) 173 (31.9) 44 (8.1) <0.01 Ticagrelor 410 (37.9) 0 0 0 91 (16.8) 319 (59.1) <0.01 LMWH 1369 (77.2) 0 234 (81.5) 331 (81.9) 389 (71.8) 415 (76.9) <0.01 Unfractionated heparin 217 (12.2) 0 37 (12.9) 45 (11.1) 81 (14.9) 54 (10.0) 0.079 Bivalirudin 7 (0.6) 0 0 0 6 (1.1) 1 (0.2) 0.13 Glycoprotein IIb/IIIa inhibitors 288 (12.1) 216 (49.3) 71 (15.8) 0 1 (0.2) 0 <0.01 Data are among patients with non-missing data. LMWH: low-molecular weight heparin; STEMI: ST-segment elevation myocardial infarction. Open in new tab Delays Figure 2 shows the median (IQR) times between symptom onset and call to the medical dispatch centre (SAMU) and FMC (electrocardiogram recording by MICU physician) for all patients (whether treated with PPCI or thrombolysis (with or without subsequent PCI)). It also shows the median (IQR) times between FMC, thrombolysis, PCI centre admission and first balloon inflation in each group, along with total ischaemic times. Delays among all patients with non-missing data. Data are median (IQR) delays in minutes. *Delays to PCI centre admission and FBI in the thrombolysis group are among those who subsequently underwent PCI Figure 2. Open in new tabDownload slide IQR: interquartile range; FMC: first medical contact (electrocardiogram); FBI: first balloon inflation; PCI: percutaneous coronary intervention; SAMU: service d’aide médicale urgente (medical dispatch centre). Among all patients (PPCI or thrombolysis (with or without subsequent PCI)), times from symptom onset to FMC and FMC to thrombolysis remained stable during 2009–2013, but times from symptom onset to first balloon inflation and FMC to PCI centre to first balloon inflation decreased significantly (Table 3). Early hospital management of patients with confirmed STEMI in the RESCUe registry Table 3. Early hospital management of patients with confirmed STEMI in the RESCUe registry . 2009 (n=462) . 2010 (n=470) . 2011 (n=404) . 2012 (n=542) . 2013 (n=540) . Ptrend . Symptom onset to call to SAMU 55 (29–129) 60 (29–140) 40 (19–129) 45 (15–110) 47 (15–112) <0.001 Symptom onset to FMC 75 (47–150) 85 (52–180) 79 (47–165) 75 (49–144) 81 (52–147) 0.16 Symptom onset to FBI 213 (154–325) 218 (165–405) 193 (138–309) 186 (138–300) 191 (146–296) <0.001 FMC to thrombolysis 20 (15–30) 21 (16–27) 15 (9–28) 19 (12–28) 16 (12–26) <0.001 FMC to PCI centre 52 (40–70) 52 (41–75) 52 (39–71) 48 (35–68) 48 (36–66) <0.001 FMC to FBI 106 (87–140) 109 (84–151) 96 (75–125) 91 (73–131) 91 (74–121) <0.001 PCI centre to FBI 52 (39–76) 51 (36–72) 40 (28–58) 42 (30–58) 40 (28–57) . 2009 (n=462) . 2010 (n=470) . 2011 (n=404) . 2012 (n=542) . 2013 (n=540) . Ptrend . Symptom onset to call to SAMU 55 (29–129) 60 (29–140) 40 (19–129) 45 (15–110) 47 (15–112) <0.001 Symptom onset to FMC 75 (47–150) 85 (52–180) 79 (47–165) 75 (49–144) 81 (52–147) 0.16 Symptom onset to FBI 213 (154–325) 218 (165–405) 193 (138–309) 186 (138–300) 191 (146–296) <0.001 FMC to thrombolysis 20 (15–30) 21 (16–27) 15 (9–28) 19 (12–28) 16 (12–26) <0.001 FMC to PCI centre 52 (40–70) 52 (41–75) 52 (39–71) 48 (35–68) 48 (36–66) <0.001 FMC to FBI 106 (87–140) 109 (84–151) 96 (75–125) 91 (73–131) 91 (74–121) <0.001 PCI centre to FBI 52 (39–76) 51 (36–72) 40 (28–58) 42 (30–58) 40 (28–57) Data are median (IQR) delays in minutes among all patients (whether treated with PPCI or thrombolysis (with or without PCI)) with non-missing data. Cath-lab: catheterisation laboratory; FBI: first balloon inflation; FMC: first medical contact; IQR: interquartile range; NS: not significant; PPC: percutaneous coronary intervention; PPCI: primary percutaneous coronary intervention; STEMI: ST-segment elevation myocardial infarction. Open in new tab Table 3. Early hospital management of patients with confirmed STEMI in the RESCUe registry . 2009 (n=462) . 2010 (n=470) . 2011 (n=404) . 2012 (n=542) . 2013 (n=540) . Ptrend . Symptom onset to call to SAMU 55 (29–129) 60 (29–140) 40 (19–129) 45 (15–110) 47 (15–112) <0.001 Symptom onset to FMC 75 (47–150) 85 (52–180) 79 (47–165) 75 (49–144) 81 (52–147) 0.16 Symptom onset to FBI 213 (154–325) 218 (165–405) 193 (138–309) 186 (138–300) 191 (146–296) <0.001 FMC to thrombolysis 20 (15–30) 21 (16–27) 15 (9–28) 19 (12–28) 16 (12–26) <0.001 FMC to PCI centre 52 (40–70) 52 (41–75) 52 (39–71) 48 (35–68) 48 (36–66) <0.001 FMC to FBI 106 (87–140) 109 (84–151) 96 (75–125) 91 (73–131) 91 (74–121) <0.001 PCI centre to FBI 52 (39–76) 51 (36–72) 40 (28–58) 42 (30–58) 40 (28–57) . 2009 (n=462) . 2010 (n=470) . 2011 (n=404) . 2012 (n=542) . 2013 (n=540) . Ptrend . Symptom onset to call to SAMU 55 (29–129) 60 (29–140) 40 (19–129) 45 (15–110) 47 (15–112) <0.001 Symptom onset to FMC 75 (47–150) 85 (52–180) 79 (47–165) 75 (49–144) 81 (52–147) 0.16 Symptom onset to FBI 213 (154–325) 218 (165–405) 193 (138–309) 186 (138–300) 191 (146–296) <0.001 FMC to thrombolysis 20 (15–30) 21 (16–27) 15 (9–28) 19 (12–28) 16 (12–26) <0.001 FMC to PCI centre 52 (40–70) 52 (41–75) 52 (39–71) 48 (35–68) 48 (36–66) <0.001 FMC to FBI 106 (87–140) 109 (84–151) 96 (75–125) 91 (73–131) 91 (74–121) <0.001 PCI centre to FBI 52 (39–76) 51 (36–72) 40 (28–58) 42 (30–58) 40 (28–57) Data are median (IQR) delays in minutes among all patients (whether treated with PPCI or thrombolysis (with or without PCI)) with non-missing data. Cath-lab: catheterisation laboratory; FBI: first balloon inflation; FMC: first medical contact; IQR: interquartile range; NS: not significant; PPC: percutaneous coronary intervention; PPCI: primary percutaneous coronary intervention; STEMI: ST-segment elevation myocardial infarction. Open in new tab Among only those patients who underwent PPCI, median (IQR) times from FMC to first balloon inflation also decreased significantly over time (100 (85–124) minutes in 2009; 100 (80–126) minutes in 2010; 94 (74–119) minutes in 2011; 89 (73–125) minutes in 2011; 89 (73–114) minutes in 2013; Ptrend<0.001). Reperfusion strategy A total of 2410 patients (99.7%) were transferred directly to a PCI-capable centre. Coronary angiography was performed in 98.8% of patients; increasing from 96.3% in 2009 to 99.4% in 2013 (Ptrend<0.001). There was increasing use of radial access in patients undergoing coronary angiography, from 74.4% in 2009 to 90.1% in 2013. Most patients (87.6%) underwent PPCI, and only 12.4% received pre-hospital thrombolysis. The use of intravenous glycoprotein IIb/IIIa inhibitors in catheterisation laboratories decreased among all patients from 47.5% in 2010 to 32.4% in 2013 (Ptrend<0.001), and in the PPCI group from 55.9% in 2010 to 33.3% in 2013 (Ptrend<0.001) (Table 4). There were no significant differences in therapeutic strategy between men and women. The use of PPCI increased from 78.4% in 2009 to 95.9% in 2013 (Ptrend<0.001) whereas the rate of pre-hospital thrombolysis decreased from 21.6% in 2009 to 4.1% in 2013 (Ptrend<0.001). This finding was observed similarly for men and women. Procedural characteristics among PPCI patients (with or wthout angioplasty) Table 4. Procedural characteristics among PPCI patients (with or wthout angioplasty) . All (n=2017) . 2009 (n=357) . 2010 (n=355) . 2011 (n=361) . 2012 (n=519) . 2013 (n=515) . Ptrend . Arterial access  Radial 1728 (84.1) 235 (73.0) 265 (77.9) 306 (85.2) 458 (88.2) 464 (90.3) <0.001  Femoral 326 (15.9) 87 (27.0) 75 (22.1) 53 (14.8) 61 (11.8) 50 (9.7) <0.001 Angioplasty 1943 (92.3) 323 (90.7) 329 (92.7) 331 (91.7) 481 (92.7) 479 (93.0) 0.75  Stenting 1583 (82.3) 296 (84.6) 286 (86.9) 281 (86.7) 362 (78.2) 358 (78.3) <0.001   DES 411 (35.0) NA 35 (19.4) 55 (19.9) 131 (36.1) 190 (53.7) <0.001   BMS 754 (64.3) NA 140 (77.8) 219 (79.3) 231 (63.6) 164 (46.3) <0.001   Both 8 (0.7) NA 5 (2.8) 2 (0.7) 1 (0.3) 0 (0) 0.0018 Glycoprotein IIa/IIIb inhibitor 591 (40.6) NA 118 (55.9) 139 (42.9) 182 (39.3) 152 (33.3) <0.001 Initial TIMI flow grade 0 1308 (63.0%) 238 (67.2%) 222 (62.9%) 221 (62.3%) 309 (60.6%) 318 (63.1%) 0.39 1 106 (5.1%) 18 (5.1%) 13 (3.7%) 19 (5.4%) 30 (5.9%) 26 (5.2%) 0.71 2 196 (9.4%) 39 (11.0%) 40 (11.3%) 25 (7.0%) 46 (9.0%) 46 (9.1%) 0.28 3 466 (22.4%) 59 (16.7%) 78 (22.1%) 90 (25.4%) 125 (24.5%) 114 (22.6%) 0.04 Final TIMI flow grade 0 83 (4.3%) 22 (6.2%) 17 (5.0%) 24 (7.1%) 7 (1.5%) 13 (2.9%) 0.0003 1 18 (0.9%) 3 (0.8%) 4 (1.2%) 2 (0.6%) 3 (0.7%) 6 (1.3%) 0.77 2 71 (3.6%) 13 (3.7%) 14 (4.1%) 13 (3.8%) 19 (4.1%) 12 (2.6%) 0.76 3 1777 (91.2%) 315 (89.2%) 307 (89.8%) 301 (88.5%) 429 (93.7%) 425 (93.2%) 0.023 . All (n=2017) . 2009 (n=357) . 2010 (n=355) . 2011 (n=361) . 2012 (n=519) . 2013 (n=515) . Ptrend . Arterial access  Radial 1728 (84.1) 235 (73.0) 265 (77.9) 306 (85.2) 458 (88.2) 464 (90.3) <0.001  Femoral 326 (15.9) 87 (27.0) 75 (22.1) 53 (14.8) 61 (11.8) 50 (9.7) <0.001 Angioplasty 1943 (92.3) 323 (90.7) 329 (92.7) 331 (91.7) 481 (92.7) 479 (93.0) 0.75  Stenting 1583 (82.3) 296 (84.6) 286 (86.9) 281 (86.7) 362 (78.2) 358 (78.3) <0.001   DES 411 (35.0) NA 35 (19.4) 55 (19.9) 131 (36.1) 190 (53.7) <0.001   BMS 754 (64.3) NA 140 (77.8) 219 (79.3) 231 (63.6) 164 (46.3) <0.001   Both 8 (0.7) NA 5 (2.8) 2 (0.7) 1 (0.3) 0 (0) 0.0018 Glycoprotein IIa/IIIb inhibitor 591 (40.6) NA 118 (55.9) 139 (42.9) 182 (39.3) 152 (33.3) <0.001 Initial TIMI flow grade 0 1308 (63.0%) 238 (67.2%) 222 (62.9%) 221 (62.3%) 309 (60.6%) 318 (63.1%) 0.39 1 106 (5.1%) 18 (5.1%) 13 (3.7%) 19 (5.4%) 30 (5.9%) 26 (5.2%) 0.71 2 196 (9.4%) 39 (11.0%) 40 (11.3%) 25 (7.0%) 46 (9.0%) 46 (9.1%) 0.28 3 466 (22.4%) 59 (16.7%) 78 (22.1%) 90 (25.4%) 125 (24.5%) 114 (22.6%) 0.04 Final TIMI flow grade 0 83 (4.3%) 22 (6.2%) 17 (5.0%) 24 (7.1%) 7 (1.5%) 13 (2.9%) 0.0003 1 18 (0.9%) 3 (0.8%) 4 (1.2%) 2 (0.6%) 3 (0.7%) 6 (1.3%) 0.77 2 71 (3.6%) 13 (3.7%) 14 (4.1%) 13 (3.8%) 19 (4.1%) 12 (2.6%) 0.76 3 1777 (91.2%) 315 (89.2%) 307 (89.8%) 301 (88.5%) 429 (93.7%) 425 (93.2%) 0.023 Data are among patients with non-missing data. TIMI: thrombolysis in myocardial infarction.; DES: drug-eluting stent; BMS: bare-metal stent; PPCI: primary percutaneous coronary intervention. Open in new tab Table 4. Procedural characteristics among PPCI patients (with or wthout angioplasty) . All (n=2017) . 2009 (n=357) . 2010 (n=355) . 2011 (n=361) . 2012 (n=519) . 2013 (n=515) . Ptrend . Arterial access  Radial 1728 (84.1) 235 (73.0) 265 (77.9) 306 (85.2) 458 (88.2) 464 (90.3) <0.001  Femoral 326 (15.9) 87 (27.0) 75 (22.1) 53 (14.8) 61 (11.8) 50 (9.7) <0.001 Angioplasty 1943 (92.3) 323 (90.7) 329 (92.7) 331 (91.7) 481 (92.7) 479 (93.0) 0.75  Stenting 1583 (82.3) 296 (84.6) 286 (86.9) 281 (86.7) 362 (78.2) 358 (78.3) <0.001   DES 411 (35.0) NA 35 (19.4) 55 (19.9) 131 (36.1) 190 (53.7) <0.001   BMS 754 (64.3) NA 140 (77.8) 219 (79.3) 231 (63.6) 164 (46.3) <0.001   Both 8 (0.7) NA 5 (2.8) 2 (0.7) 1 (0.3) 0 (0) 0.0018 Glycoprotein IIa/IIIb inhibitor 591 (40.6) NA 118 (55.9) 139 (42.9) 182 (39.3) 152 (33.3) <0.001 Initial TIMI flow grade 0 1308 (63.0%) 238 (67.2%) 222 (62.9%) 221 (62.3%) 309 (60.6%) 318 (63.1%) 0.39 1 106 (5.1%) 18 (5.1%) 13 (3.7%) 19 (5.4%) 30 (5.9%) 26 (5.2%) 0.71 2 196 (9.4%) 39 (11.0%) 40 (11.3%) 25 (7.0%) 46 (9.0%) 46 (9.1%) 0.28 3 466 (22.4%) 59 (16.7%) 78 (22.1%) 90 (25.4%) 125 (24.5%) 114 (22.6%) 0.04 Final TIMI flow grade 0 83 (4.3%) 22 (6.2%) 17 (5.0%) 24 (7.1%) 7 (1.5%) 13 (2.9%) 0.0003 1 18 (0.9%) 3 (0.8%) 4 (1.2%) 2 (0.6%) 3 (0.7%) 6 (1.3%) 0.77 2 71 (3.6%) 13 (3.7%) 14 (4.1%) 13 (3.8%) 19 (4.1%) 12 (2.6%) 0.76 3 1777 (91.2%) 315 (89.2%) 307 (89.8%) 301 (88.5%) 429 (93.7%) 425 (93.2%) 0.023 . All (n=2017) . 2009 (n=357) . 2010 (n=355) . 2011 (n=361) . 2012 (n=519) . 2013 (n=515) . Ptrend . Arterial access  Radial 1728 (84.1) 235 (73.0) 265 (77.9) 306 (85.2) 458 (88.2) 464 (90.3) <0.001  Femoral 326 (15.9) 87 (27.0) 75 (22.1) 53 (14.8) 61 (11.8) 50 (9.7) <0.001 Angioplasty 1943 (92.3) 323 (90.7) 329 (92.7) 331 (91.7) 481 (92.7) 479 (93.0) 0.75  Stenting 1583 (82.3) 296 (84.6) 286 (86.9) 281 (86.7) 362 (78.2) 358 (78.3) <0.001   DES 411 (35.0) NA 35 (19.4) 55 (19.9) 131 (36.1) 190 (53.7) <0.001   BMS 754 (64.3) NA 140 (77.8) 219 (79.3) 231 (63.6) 164 (46.3) <0.001   Both 8 (0.7) NA 5 (2.8) 2 (0.7) 1 (0.3) 0 (0) 0.0018 Glycoprotein IIa/IIIb inhibitor 591 (40.6) NA 118 (55.9) 139 (42.9) 182 (39.3) 152 (33.3) <0.001 Initial TIMI flow grade 0 1308 (63.0%) 238 (67.2%) 222 (62.9%) 221 (62.3%) 309 (60.6%) 318 (63.1%) 0.39 1 106 (5.1%) 18 (5.1%) 13 (3.7%) 19 (5.4%) 30 (5.9%) 26 (5.2%) 0.71 2 196 (9.4%) 39 (11.0%) 40 (11.3%) 25 (7.0%) 46 (9.0%) 46 (9.1%) 0.28 3 466 (22.4%) 59 (16.7%) 78 (22.1%) 90 (25.4%) 125 (24.5%) 114 (22.6%) 0.04 Final TIMI flow grade 0 83 (4.3%) 22 (6.2%) 17 (5.0%) 24 (7.1%) 7 (1.5%) 13 (2.9%) 0.0003 1 18 (0.9%) 3 (0.8%) 4 (1.2%) 2 (0.6%) 3 (0.7%) 6 (1.3%) 0.77 2 71 (3.6%) 13 (3.7%) 14 (4.1%) 13 (3.8%) 19 (4.1%) 12 (2.6%) 0.76 3 1777 (91.2%) 315 (89.2%) 307 (89.8%) 301 (88.5%) 429 (93.7%) 425 (93.2%) 0.023 Data are among patients with non-missing data. TIMI: thrombolysis in myocardial infarction.; DES: drug-eluting stent; BMS: bare-metal stent; PPCI: primary percutaneous coronary intervention. Open in new tab The initial and final TIMI flow grades for patients undergoing PPCI are detailed in Table 4. Initial TIMI flow grade 3 increased from 16.7% in 2009 to 22.6% in 2013 (Ptrend=0.04). Final TIMI flow grade 3 increased from 89.2% in 2009 to 93.2% in 2013. Corresponding data for the thrombolysis group are 40.7–61.9% for initial TIMI flow grade 3 (Ptrend=0.07) and from 94.4% to 100% for final TIMI flow grade 3 (Ptrend<0.05). Among the 2406/2418 patients with known timings for reperfusion, the numbers of ‘early’ and ‘late’ transferred PPCI and thrombolysis patients are shown in Figure 3. Reperfusion therapy strategies between 2009 and 2013 in the RESCUe network. The timing of treatment was not known for 10 PPCI patients (two in 2010; three in 2012; five in 2013) and two thrombolysis patients (one in 2010; one in 2012) Figure 3. Open in new tabDownload slide PPCI: primary percutaneous coronary intervention; TL: thrombolysis. Among those with known timings, there were 2146 (89.2%) ‘early transferred patients’, 1940 PPCI and 206 thrombolysis (Figure 1). They accounted for 90.5% of patients in 2009, 86.5% in 2010 87.6% in 2011, 90.7% in 2012 and 90.1% in 2013 (Ptrend=0.13). Between 2009 and 2013, ‘early transferred patients’ became significantly less likely to receive pre-hospital thrombolysis (17.0% in 2009, 20.0% in 2010, 7.9% in 2011, 3.1% in 2012, 2.3% in 2013; Ptrend<0.001). Correspondingly, the rate of PPCI in this group increased significantly (83.0% in 2009, 80.0% in 2010, 92.1% in 2011, 96.9% in 2012, 97.7% in 2013; Ptrend<0.001). Among 260 ‘late transferred patients’, the rates of thrombolysis were much higher than in ‘early transferred patients’, but still decreased over time (65.9% in 2009, 47.6% in 2010, 28.0% in 2011, 14.0% in 2012, 20.8% in 2013; Ptrend<0.001), while PPCI use increased (34.1% in 2009, 52.4% in 2010, 72.0% in 2011, 86.0% in 2012, 79.2% in 2013; Ptrend<0.001). Mortality In-hospital (4–6%) and 30-day (6–8%) mortalities remained reasonably stable from 2009 to 2013 (Figure 4). Among those with known mortality status at 30 days (139 patients could not be contacted at 30 days), overall 30-day mortalities were 8.1% (16/197) in the early transferred thrombolysis group and 5.6% (5/90) in the late transferred thrombolysis group; 6.5% (119/1825) in the early transferred PPCI group and 10.1% (16/158) in the late transferred PPCI group. In-hospital and 30-day mortality between 2009 and 2013 in the RESCUe network. Percentages for 30-day mortality are of patients with non-missing data; data were missing for 21, 33, 19, 33 and 33 patients in 2009–2013, respectively Figure 4. Open in new tabDownload slide Mortality rates were higher among PPCI patients who had femoral versus radial access (in-hospital mortality: 51/326 (15.6%) versus 48/1728 (2.8%); 30-day mortality: 58/252 (23%) versus 71/1613 (4.4%)). Mortality among radial access patients did not change significantly during the study, but among femoral access patients mortality increased significantly (in-hospital mortality 11.0% in 2009 to 22.6% in 2013; Ptrend=0.047; 30-day mortality 12.2% to 29.8%; Ptrend=0.01). Not surprisingly, in-hospital and 30-day mortality was higher among patients in cardiogenic shock (Killip 4) (18/49 (36.7%) and 21/48 (43.8%)). Discussion Patients with STEMI are candidates for reperfusion therapy with either thrombolysis or PPCI. Coronary reperfusion has been reported to improve outcomes in patients presenting within the 12 hours after the onset of symptoms. If PPCI is not possible within 2 hours of FMC, thrombolysis should be started as soon as possible. The RESCUe registry is the largest contemporary permanent survey of STEMI in France. It enrolled 4212 patients during 2009–2013, the majority of whom (63.1%) were treated in MICUs before being transferred to PCI centres. Among this population, we analysed the choice of reperfusion strategy based on European Society of Cardiology guidelines1–3 in patients for whom there was evidence of STEMI.4 The rate of false STEMI diagnosis (9.1%) in the RESCUe registry is in line with existing data (9–13%).5–8 In the current analysis of RESCUe registry data, almost all patients received reperfusion therapy. The use of pre-hospital thrombolysis decreased precipitously, from 21.6% in 2009 to 4.1% in 2013 (Ptrend<0.001) while the use of PPCI increased from 78.4% to 95.9% (Ptrend<0.001). The use of PPCI also increased in ‘early transferred patients’, from 83.0% in 2009 to 97.7% in 2013, highlighting a consistency of practice with guidelines. However, the decline in the use of thrombolysis in ‘late transferred patients’ (from 65.9% in 2009 to 20.8% in 2013) underscores discordance between practice and guidelines. In 1999, an analysis of the USIK registry concluded that PPCI was not superior to thrombolysis in terms of survival.9 However, an observational registry in 2006 showed the superiority of PPCI, regardless of time delay.10 In 2010, an analysis of 16 randomised controlled trials concluded that the mortality benefit of PPCI appears to be time dependant, with a longer transfer delay lowering the survival advantage of PPCI.11 Our results are in line with these findings, as 30-day mortality was higher among late versus early transferred PPCI patients (10.1% versus 6.5%). However, it should be noted that there were only 158 patients in our late transferred PPCI group with known 30-day mortality status, so these results should be interpreted with caution. In the RESCUe registry, in-hospital mortality among PPCI patients was lower among those with FMC to PCI centre admission ⩽90 versus > 90 minutes (90/1940 (4.6%) versus 12/169 (7.1%)). This is in line with a French study that reported in-hospital mortalities of 3.0–8.7% for short (⩽80 minutes) to long (⩾156 minutes) times from FMC to sheath insertion among 703 STEMI patients.12 They also reported that, among patients with a long delay (>2 hours) from symptom onset to FMC, the mortality difference was lost (7.0% for short to 7.8% for long FMC to sheath insertion times).12 However, in the RESCUe registry, among PPCI patients with prolonged onset of symptoms to FMC delay (>120 minutes), shorter FMC to PCI centre time (⩽90 minutes) was still associated with lower mortality than longer transfer time (17/609 (2.8%) versus 6/72 (8.3%)). In the RESCUe registry, mortality did not decrease over time despite increased use of PPCI, reduced delays and increased use of radial access. It is not clear why mortality did not improve, but it should be noted that although the use of PPCI increased, most thrombolysis patients went on to undergo PCI, so the overall rate of PCI was high (approximately 90%) throughout the study. Also, a history of MI increased significantly from 2010 to 2013 (7.9% to 18.7%; P<0.001), which could have had a detrimental effect on mortality. This and other unknown factors could have cancelled out the expected beneficial effects. Various factors need to be considered when choosing between PPCI and thrombolysis. The Danish Multicenter Randomized Study on Fibrinolytic Therapy Versus Acute Coronary Angioplasty in Acute Myocardial Infarction (DANAMI-2) showed a superiority of PPCI in high-risk patients, defined by a TIMI score of ⩾5.13 However, it should be noted that thrombolysis was administered in hospital and the time of treatment in the PPCI group was defined as the time of first injection of contrast in the coronary artery rather than first balloon inflation. In an analysis of the American National Registry of Myocardial Infarction, Pinto et al. agreed with the American College of Cardiology/American Heart Association STEMI guidelines14 that the choice of PPCI or thrombolysis should be based on both delays and patient characteristics.15 Taking the above considerations into account, the RESCUe network protocol states that if PPCI is chosen, every effort must be made to keep the transfer time by MICU ⩽90 minutes. In our analysis, only 8.0% of PPCI patients did not meet this target (i.e. their transfer delay was >90 minutes). Considering this delay as a quality indicator for the ongoing evaluation of practice, such a deviation seems acceptable, especially as patients with contraindications to thrombolysis were not excluded from this analysis as this information was not collected. Also, our median transfer time (50 minutes) was similar to that observed in Vienna after the development of a local network in a metropolitan area (52 minutes), which led to an increase in PPCI (16–60%) and a reduction in thrombolysis (51–27%).16 The median (IQR) times from FMC to thrombolysis or first balloon inflation were 20 (14–29) and 98 (78–135) minutes, respectively. The FMC to thrombolysis delay did not change significantly from 2009 to 2013, but the significant decrease in FMC to first balloon inflation may have contributed to the decrease in thrombolysis and the promotion of PPCI in a larger number of patients. The current findings are encouraging, considering that the implementation of PPCI in many other European countries remains suboptimal.17 Our PPCI rate in 2011 (89.6%), however, was close to that reported in the UK in the same year (94%).18 Coronary angiography was performed in the vast majority of our patients (98.8%). In 87.3% of cases in the PPCI group, patients underwent angioplasty within 1 hour of their arrival at the PCI centre. As expected, the rate of angioplasty within 1 hour was lower in the thrombolysis group (56.9%), as not all thrombolysis patients had electrocardiogram or clinical evidence of failed reperfusion after thrombolysis. For comparison, only 36% of patients who underwent thrombolysis in the STrategic Reperfusion Early After Myocardial Infarction (STREAM) study benefited from immediate or rescue angiography;19 while in the Vienna registry, 50% of patients underwent immediate coronary angiography.16 Our results are largely in line with those of the USIK, Unité de Soins Intensifs Coronaires (USIC), and French Registry of Acute ST-Elevation or non-ST-elevation Myocardial Infarction (FAST-MI).20 These registries recruited patients with STEMI or non-ST-segment elevation myocardial infarction during a specified 1-month period during 1995 (USIK), 2000 (USIC) and 2005 and 2010 (both FAST-MI). Among patients with confirmed STEMI, the initial pathway was MICU in 0%, 23%, 41% and 49% of patients in each survey, respectively.20 In our study, 63% of patients during 2009–2013 were initially treated in a MICU, somewhat higher than the 49% in 2010. In USIK/USIC/FAST-MI, 51% down to 25% of patients in each registry had no reperfusion therapy. This is much higher than in the RESCUe registry, where all STEMI patients received reperfusion therapy. This highlights the success of the RESCUe network in making sure that STEMI patients receive appropriate treatment. In USIK/USIC/FAST-MI, of those who underwent fibrinolysis or PPCI, the rate of PPCI increased from 24% (1995) to 81% (2010).20 The latter is similar to our rate of 78–96% PPCI. Finally, 30-day mortality in USIK/USIC/FAST-MI fell from 13.7% in 1995 to 4.4% in 2010;20 the latter being similar to our rate of 6–8%. In our analysis, some strengths and limitations deserve to be highlighted. The particularity of our registry is to have included patients treated by out-of-hospital emergency physicians. However, our patients are those managed in real life. Nearly all patients with acute MI are transferred directly to catheterisation laboratories. This is a consequence of the establishment of the RESCUe network. The RESCUe guidelines also highlight the importance of keeping the FMC to balloon time as short as possible. Thus, the potential time delay for transportation remains a determining factor in the choice of thrombolysis at the expense of PPCI. Optimising the management of patients with MI by setting up a network organisation has resulted in easier access to PCI-capable centres. The observed differences in outcome between patients who underwent radial versus femoral access may be due in part to confounders. On the other hand, we did not stratify our population according to mortality risk,21 while every patient has a different mortality risk profile.11 However, we observed very low rates of shock and heart failure in both groups. In conclusion, the use of PPCI increased from 2009 to 2013 in the French RESCUe network, which is in line with guidelines, but there was no associated evolution in early mortality. Acknowledgement The authors would like to thank the emergency physicians and cardiologists who participated in this registry. They also thank the RESCUe network for the practical implementation of this registry and statistical analysis. Conflict of interest EB-C reported grants and personal fees from Astra Zeneca and grants from Daiichi Sankyo, outside the submitted work. All other authors report no conflicts of interest. Funding This work was supported by the Rhône-Alpes Agency for Health. Editorial support for this paper was provided by Dr Jenny Lloyd (Medlink Healthcare Communications Ltd) and was funded by the authors. References 1 Van de Werf F , Bax J, Betriu Aet al. ; ESC Committee for Practice Guidelines (CPG) . Management of acute myocardial infarction in patients presenting with persistent ST-segment elevation: the Task Force on the Management of ST-Segment Elevation Acute Myocardial Infarction of the European Society of Cardiology . Eur Heart J 2008 ; 29 : 2909 – 2945 . 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TI - Five-year evolution of reperfusion strategies and early mortality in patients with ST-segment elevation myocardial infarction in France
JF - European Heart Journal. Acute Cardiovascular Care
DO - 10.1177/2048872615623065
DA - 2017-10-01
UR - https://www.deepdyve.com/lp/oxford-university-press/five-year-evolution-of-reperfusion-strategies-and-early-mortality-in-DLA9uD4R11
SP - 573
EP - 582
VL - 6
IS - 7
DP - DeepDyve
ER -