Læknablaðið - 01.01.2016, Blaðsíða 17

LÆKNAblaðið 2016/102 17
R A N N S Ó K N
ENGLISH SUMMARY
Introduction: ST-segment Elevation Myocardial Infarction (STEMI) is a
life-threatening disease and good outcome depends on early restoration
of coronary blood flow. Primary percutaneous coronary intervention
(PPCI) is the treatment of choice if performed within 120 minutes of
first medical contact (FMC) but in case of anticipated long transport or
delays, pre-hospital fibrinolysis is indicated. The aim was to study tran-
sport times and adherence to clinical guidelines in patients with STEMI
transported from outside of the Reykjavik area to Landspitali University
Hospital in Iceland.
Materials and methods: Retrospective chart review was conducted
of all patients diagnosed with STEMI outside of the Reykjavik area and
transported to Landspitali University Hospital in Reykjavik in 2011-2012.
Descriptive statistical analysis and hypothesis testing was applied.
Results: Eighty-six patients had signs of STEMI on electrocardiogram
(ECG) at FMC. In southern Iceland nine patients (21%) underwent
PPCI within 120 minutes (median 157 minutes) and no patient received
fibrinolysis. In northern Iceland and The Vestman Islands, where long
transport times are expected, 96% of patients eligible for fibrinolysis
(n=31) received appropriate therapy in a median time of 57 minutes.
Significantly fewer patients received appropriate anticoagulation treat-
ment with clopidogrel and enoxaparin in southern Iceland compared to
the northern part. Mortality rate was 7% and median length of stay in
hospital was 6 days.
Conclusions: Time from FMC to PPCI is longer than 120 minutes in
the majority of cases. Pre-hospital fibrinolysis should be considered as
first line treatment in all parts of Iceland outside of the Reykjavik area.
Directly electronically transmitted ECGs and contact with cardiologist
could hasten diagnosis and decrease risk of unnecessary interhospital
transfer. A STEMI database should be established in Iceland to facilitate
quality control.
Transport and treatment of patients with STEMI in rural Iceland – Only a few patients receive PPCI within
120 minutes
Sigmundsson TS1, Arnarson D2, Rafnsson A3, Magnusson V, Gunnarsson GT2,5, Thorgeirsson G4
1Department of Anaesthesiology, Surgical Services and Intensive Care Medicine, Karolinska University Hospital, Sweden, 2Faculty of Medicine University of Iceland, 3Dept. of anaesthe-
tics and intensive care | Landspitalinn University Hospital Reykjavik, 4Dept. of Cardiology, 5Akureyri Hospital, Iceland.
Key words: STEMI, fibrinolysis, quality of care, medical transport, rural medicine.
Correspondence: Þórir Sigmundsson, thorir.sigmundsson@karolinska.se
Heimildir
1. Terkelsen CJ, Sorensen JT, Maeng M, Jensen LO, Tilsted
HH, Trautner S, et al. System delay and mortality among
patients with STEMI treated with primary percutaneous
coronary intervention. JAMA 2010; 304: 763-71.
2. Van de Werf F, Bax J, Betriu A, Blomstrom-Lundqvist
C, Crea F, Falk V, et al. Management of acute myocar-
dial 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:
2909-45.
3. Steg PG, James SK, Atar D, Badano LP, Blomstrom-
Lundqvist C, Borger MA, et al. ESC Guidelines for the
management of acute myocardial infarction in patients
presenting with ST-segment elevation. Eur Heart J 2012;
33: 2569-619.
4. Sigmundsson TS, Gunnarsson B, Benediktsson S,
Gunnarsson GT, Duason S, Thorgeirsson G. Flutningstími
og gæði meðferðar hjá sjúklingum með ST-hækkunar
hjartadrep á Norður- og Austurlandi. Læknablaðið 2010;
96: 159-65.
5. Thygesen K, Alpert JS, White HD. Universal definition of
myocardial infarction. J Am Coll Cardiol 2007; 50: 2173-95.
6. Knudsen L, Stengaard C, Hansen TM, Lassen JF, Terkelsen
CJ. Earlier reperfusion in patients with ST-elevation myo-
cardial infarction by use of helicopter. Scand J Trauma
Resusc Emerg Med 2012; 20: 70.
7. Baigent C, Collins R, Appleby P, Parish S, Sleight P, Peto
R. ISIS-2: 10 year survival among patients with suspected
acute myocardial infarction in randomised comparison of
intravenous streptokinase, oral aspirin, both, or neither.
The ISIS-2 (Second International Study of Infarct Survival)
Collaborative Group. BMJ 1998; 316: 1337-43.
8. Sabatine MS, Cannon CP, Gibson CM, Lopez-Sendon JL,
Montalescot G, Theroux P, et al. Addition of clopidogrel to
aspirin and fibrinolytic therapy for myocardial infarction
with ST-segment elevation. N Engl J Med 2005; 352: 1179-
89.
9. Chen ZM, Jiang LX, Chen YP, Xie JX, Pan HC, Peto R, et
al. Addition of clopidogrel to aspirin in 45,852 patients
with acute myocardial infarction: randomised placebo-
controlled trial. Lancet 2005; 366: 1607-21.
10. Huber K, Bates ER, Valgimigli M, Wallentin L, Kristensen
SD, Anderson JL, et al. Antiplatelet and anticoagulation
agents in acute coronary syndromes: What is the current
status and what does the future hold? Am Heart J 2014;
168: 611-21.
11. Verheugt FW, Montalescot G, Sabatine MS, Soulat L,
Lambert Y, Lapostolle F, et al. Prehospital fibrinolysis with
dual antiplatelet therapy in ST-elevation acute myocardial
infarction: a substudy of the randomized double blind
CLARITY-TIMI 28 trial. J Thromb Thrombolysis 2007; 23:
173-9.
12. Montalescot G, van 't Hof AW, Lapostolle F, Silvain J,
Lassen JF, Bolognese L, et al. Prehospital ticagrelor in
ST-segment elevation myocardial infarction. N Engl J Med
2014; 371: 1016-27.
13. Alexopoulos D, Xanthopoulou I, Goudevenos J. Effects
of P2Y12 receptor inhibition in patients with ST-segment
elevation myocardial infarction. Am J Cardiol 2014; 113:
2064-9.
14. Arnar DO. Klínískar leiðbeiningar um greiningu og með-
ferð sjúklinga með brjóstverk. 2009. landspitali.is/lisalib/
getfile.aspx?itemid=19460. - desember 2015.
15. Sabatine MS, Morrow DA, Montalescot G, Dellborg M,
Leiva-Pons JL, Keltai M, et al. Angiographic and clinical
outcomes in patients receiving low-molecular-weight
heparin versus unfractionated heparin in ST-elevation
myocardial infarction treated with fibrinolytics in the
CLARITY-TIMI 28 Trial. Circulation 2005; 112: 3846-54.
16. Grines C, Patel A, Zijlstra F, Weaver WD, Granger C,
Simes RJ. Primary coronary angioplasty compared with
intravenous thrombolytic therapy for acute myocardial
infarction: six-month follow up and analysis of individual
patient data from randomized trials. Am Heart J 2003; 145:
47-57.
17. Keeley EC, Boura JA, Grines CL. Primary angioplasty
versus intravenous thrombolytic therapy for acute myoc-
ardial infarction: a quantitative review of 23 randomised
trials. Lancet 2003; 361: 13-20.
18. Morrison LJ, Verbeek PR, McDonald AC, Sawadsky BV,
Cook DJ. Mortality and prehospital thrombolysis for acute
myocardial infarction: A meta-analysis. JAMA 2000; 283:
2686-92.
19. Bjorklund E, Stenestrand U, Lindback J, Svensson L,
Wallentin L, Lindahl B. Pre-hospital thrombolysis delive-
red by paramedics is associated with reduced time delay
and mortality in ambulance-transported real-life patients
with ST-elevation myocardial infarction. Eur Heart J 2006;
27: 1146-52.
20. Danchin N, Blanchard D, Steg PG, Sauval P, Hanania G,
Goldstein P, et al. Impact of prehospital thrombolysis for
acute myocardial infarction on 1-year outcome: results
from the French Nationwide USIC 2000 Registry.
Circulation 2004; 110: 1909-15.
21. Armstrong PW, Gershlick AH, Goldstein P, Wilcox R,
Danays T, Lambert Y, et al. Fibrinolysis or primary PCI in
ST-segment elevation myocardial infarction. N Engl J Med
2013; 368: 1379-87.
22. Bonnefoy E, Lapostolle F, Leizorovicz A, Steg G,
McFadden EP, Dubien PY, et al. Primary angioplasty ver-
sus prehospital fibrinolysis in acute myocardial infarction:
a randomised study. Lancet 2002; 360: 825-9.
23. Miedema MD, Newell MC, Duval S, Garberich RF,
Handran CB, Larson DM, et al. Causes of delay and asso-
ciated mortality in patients transferred with ST-segment-
elevation myocardial infarction. Circulation 2011; 124:
1636-44.
24. Widimsky P, Wijns W, Fajadet J, de Belder M, Knot J,
Aaberge L, et al. Reperfusion therapy for ST elevation
acute myocardial infarction in Europe: description of the
current situation in 30 countries. Eur Heart J 2010; 31: 943-
57.
25. ucr.uu.se/swedeheart/index.php/start-scaar - september
2015.
26. Steg PG, Cambou JP, Goldstein P, Durand E, Sauval P,
Kadri Z, et al. Bypassing the emergency room reduces
delays and mortality in ST elevation myocardial infarc-
tion: the USIC 2000 registry. Heart 2006; 92: 1378-83.