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      Implementation of a Regional Network for ST‐Segment–Elevation Myocardial Infarction (STEMI) Care and 30‐Day Mortality in a Low‐ to Middle‐Income City in Brazil: Findings From Salvador's STEMI Registry (RESISST)

      research-article
      , MD, MSc, PhD 1 , 2 , 3 , , MD, PhD 4 , , MD 5 , , MD 5 , , MD, PhD 6 , , MD 5 , , MD 5 , , MD 5 , , MD 5 , , MD 5 , , MD 5 , , MD 5 , , MD 3 , , MD 3 , , MD 6 , , MD, MHS 6 , , MD, MHS, PhD 6 ,
      Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease
      John Wiley and Sons Inc.
      Brazil, mortality, regional care, registry, ST‐segment–elevation myocardial infarction, Myocardial Infarction, Mortality/Survival, Risk Factors

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          Abstract

          Background

          Few data exist on regional systems of care for the treatment of ST‐segment–elevation myocardial infarction ( STEMI) in developing countries. Our objective was to describe temporal trends in 30‐day mortality and identify predictors of mortality among STEMI patients enrolled in a prospective registry in Brazil.

          Methods and Results

          From January 2011 to June 2013, 520 patients who received initial STEMI care at 23 nonspecialized public health units or hospitals, some of whom were transferred to a public cardiology referral center, were identified through a regional STEMI network supported by telemedicine and the local prehospital emergency medical service. We stratified patients into five 6‐month periods based on presentation date. Mean age (± SD) of patients was 62.0 (±12.2) years, and 55.6% were men. The mean Global Registry of Acute Coronary Events ( GRACE) score was 145 (±34). Overall mortality at 30 days was 15.0%. Use of dual antiplatelet therapy and statins increased significantly from baseline (January 2011) to period 5 (June 2013): 61.8% to 93.6% ( P<0.001) and 60.4% to 79.7% ( P<0.001), respectively. Rates of primary reperfusion also increased (29.1%–53.8%; P<0.001), and more patients were transferred to the referral center (44.7%–76.3%; P=0.001). Thirty‐day mortality rates decreased from 19.8% to 5.1% ( P<0.001). In multivariable analysis, factors independently associated with 30‐day mortality were higher GRACE score, history of previous stroke, lack of transfer to the referral center, and lack of use of optimized medical therapy.

          Conclusions

          Implementation of a regional STEMI system was associated with lower mortality and higher use of evidence‐based therapies.

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          Most cited references18

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          2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation

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            Reperfusion therapy for ST elevation acute myocardial infarction in Europe: description of the current situation in 30 countries

            Aims Patient access to reperfusion therapy and the use of primary percutaneous coronary intervention (p-PCI) or thrombolysis (TL) varies considerably between European countries. The aim of this study was to obtain a realistic contemporary picture of how patients with ST elevation myocardial infarction (STEMI) are treated in different European countries. Methods and results The chairpersons of the national working groups/societies of interventional cardiology in European countries and selected experts known to be involved in the national registries joined the writing group upon invitation. Data were collected about the country and any existing national STEMI or PCI registries, about STEMI epidemiology, and treatment in each given country and about PCI and p-PCI centres and procedures in each country. Results from the national and/or regional registries in 30 countries were included in this analysis. The annual incidence of hospital admission for any acute myocardial infarction (AMI) varied between 90–312/100 thousand/year, the incidence of STEMI alone ranging from 44 to 142. Primary PCI was the dominant reperfusion strategy in 16 countries and TL in 8 countries. The use of a p-PCI strategy varied between 5 and 92% (of all STEMI patients) and the use of TL between 0 and 55%. Any reperfusion treatment (p-PCI or TL) was used in 37–93% of STEMI patients. Significantly less reperfusion therapy was used in those countries where TL was the dominant strategy. The number of p-PCI procedures per million per year varied among countries between 20 and 970. The mean population served by a single p-PCI centre varied between 0.3 and 7.4 million inhabitants. In those countries offering p-PCI services to the majority of their STEMI patients, this population varied between 0.3 and 1.1 million per centre. In-hospital mortality of all consecutive STEMI patients varied between 4.2 and 13.5%, for patients treated by TL between 3.5 and 14% and for patients treated by p-PCI between 2.7 and 8%. The time reported from symptom onset to the first medical contact (FMC) varied between 60 and 210 min, FMC-needle time for TL between 30 and 110 min, and FMC-balloon time for p-PCI between 60 and 177 min. Conclusion Most North, West, and Central European countries used p-PCI for the majority of their STEMI patients. The lack of organized p-PCI networks was associated with fewer patients overall receiving some form of reperfusion therapy.
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              Treatments, trends, and outcomes of acute myocardial infarction and percutaneous coronary intervention.

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                Author and article information

                Contributors
                renato.lopes@dm.duke.edu
                Journal
                J Am Heart Assoc
                J Am Heart Assoc
                10.1002/(ISSN)2047-9980
                JAH3
                ahaoa
                Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease
                John Wiley and Sons Inc. (Hoboken )
                2047-9980
                06 July 2018
                17 July 2018
                : 7
                : 14 ( doiID: 10.1002/jah3.2018.7.issue-14 )
                : e008624
                Affiliations
                [ 1 ] Universidade Federal do Estado de São Paulo São Paulo Brazil
                [ 2 ] Universidade do Estado da Bahia Salvador Bahia Brazil
                [ 3 ] Universidade Salvador – rede Laureate Salvador Bahia Brazil
                [ 4 ] Escola Bahiana de Medicina e Saúde Pública Salvador Bahia Brazil
                [ 5 ] Serviço de Atendimento Móvel de Urgência – SAMU 192 Salvador Brazil
                [ 6 ] Duke Clinical Research Institute Duke University School of Medicine Durham NC
                Author notes
                [*] [* ] Correspondence to: Renato D. Lopes, MD, MHS, PhD, Duke Clinical Research Institute, Box 3850, 2400 Pratt Street, Durham, NC 27705. E‐mail: renato.lopes@ 123456dm.duke.edu
                Article
                JAH33331
                10.1161/JAHA.118.008624
                6064829
                29980522
                0ccec131-6163-47c7-aca2-fd3759b02fcb
                © 2018 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.

                This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.

                History
                : 05 February 2018
                : 31 May 2018
                Page count
                Figures: 4, Tables: 5, Pages: 11, Words: 7471
                Funding
                Funded by: Telemedicine Center
                Categories
                Original Research
                Original Research
                Interventional Cardiology
                Custom metadata
                2.0
                jah33331
                17 July 2018
                Converter:WILEY_ML3GV2_TO_NLMPMC version:version=5.4.3 mode:remove_FC converted:20.07.2018

                Cardiovascular Medicine
                brazil,mortality,regional care,registry,st‐segment–elevation myocardial infarction,myocardial infarction,mortality/survival,risk factors

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