Evidence from networks & registries

Overall STEMI management via STEMI networks and registries can significantly improve the treatment and care individual STEMI patients receive. Data from the Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital (ANH) in Minneapolis, Minnesota, USA have shown that implementing a STEMI network11 that utilises a pharmaco-invasive strategy where necessary can reduce time-to-treatment and improve patient outcomes.

STEMI Network

  • In stages, investigators at ANH developed a guideline-based, standardised treatment system for STEMI patients based on their geographical location relative to ANH, a PCI-capable centre.
  • The Minneapolis Heart Institute (MHI) “developed a regional programme for transfer of patients with STEMI for PCI from 30 community hospitals in Minnesota using a standardised protocol and an integrated transfer system.”11

The participating community hospitals were zoned as follows:

Participating community hospitals Table showing categorisation of hospitals into two zones and preferred protocol

 

  • No significant differences in overall mortality at 1 year among Zones 1 and 2 and the PCI-capable centre, ANH.
  • No differences in in-hospital, 30-day or 1-year mortality between Zones 1 and 2, despite longer ischaemic times for these patients compared to the PCI-capable centre.
  • Zone 2 patients had similar outcomes to those treated in the PCI-capable centre.

A pharmaco-invasive approach, involving rapid transfer to a PCI-capable facility in combination with standardised protocols (with an integrated transfer system) has similar patient outcomes as presentation directly at a PCI-capable facility.

STEMI Registries - AMICO

The Minneapolis Heart Institute at Abbott Northwestern Hospital collaborated with investigators at four other regional centres (Dartmouth Hitchcock Medical Centre, Leipzig Heart Centre, Hartford Hospital and the University of Texas at Houston/Memorial Hermann Hospital) to form the Alliance for Myocardial Infarction Care Optimisation (AMICO) registry.12

  • The effect of pre-hospital, half-dose fibrinolytic therapy followed by urgent PCI (FAST-PCI) versus PPCI without fibrinolytic acceleration with respect to mortality, re-infarction and stroke rates in STEMI patients.

The data based on 2,869 patients showed:

  • Significantly fewer deaths and recurrent myocardial infarction for patients treated with the FAST-PCI strategy versus PPCI
  • No difference in stroke rates.

“It is feasible, safe, and effective to use a pre-hospital (before transfer), reduced-dose fibrinolytic agent coupled with effective antithrombotic treatment, followed by PCI for STEMI.”12

STEMI Registries – Level 1 MI

Patients treated within one of the 31 feeder hospitals in the Minneapolis Heart Institute (MHI) at Abbott Northwestern Hospital and at the MHI are entered into the “Level 1 MI” database which is a prospective registry.13

As mentioned previously, STEMI patients presenting to hospitals further than 100 km away from the MHI, are treated with a pharmaco-invasive strategy using half-dose fibrinolysis. STEMI patients presenting to a hospital within 100 km of the MHI are rapidly transferred to the MHI for coronary angiography and PPCI, unless weather prevents a timely transfer, in which case, the patient is treated with pharmaco-invasive strategy.

From April 2003 to December 2009, 2,634 consecutive STEMI patients were enrolled in the database.

The 1-year Kaplan-Meier survival curves comparing PPCI with the pharmaco-invasive strategy are nearly identical, suggesting “pharmaco-invasive therapy utilising half-dose fibrinolysis, clopidogrel, and [unfractionated heparin], combined with emergent transfer for immediate PCI, may be a safe and effective reperfusion strategy for STEMI patients with expected delays due to long distances to a PCI centre.”13

 

References: 
  1. Henry TD, et al. A Regional System to Provide Timely Access to Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction. Circulation 2007;116(7):721-728.
  2. Denktas AE, et al. Reduced-Dose Fibrinolytic Acceleration of ST-Segment Elevation Myocardial Infarction Treatment Coupled with Urgent Percutaneous Coronary Intervention Compared to Primary Percutaneous Coronary Intervention Alone: Results of the AMICO (Alliance for Myocardial Infarction Care Optimization) Registry. J Am Coll Cardiol Intv 2008;1:504-510.
  3. Larson DM, et al. Safety and Efficacy of a Pharmaco-Invasive Reperfusion Strategy in Rural ST-Elevation Myocardial Infarction Patients with Expected Delays Due to Long-Distance Transfers. Eur Heart J 2012;33:1232-1240.
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