266 Performance assessment of French guidelines for the management of STEMI patients out of cardiac critical care unit on clinical practices: insights from the e-MUST registry

Abstract

ObjectiveIn 2006 evidence based guidelines for STEMI reperfusion strategies out of cardiac critical care unit were published in France. The objective of this program is to assess the performance of these guidelines to improve reperfusion strategies for STEMI within 2 h from onset of symptoms, thrombolysis versus primary PCI, using the e-MUST registry data in the greater Paris area.MethodsThe e-MUST registry is a regional prospective prehospital database supported by the hospital governmental agency (ARHIF). It began tracking practice patterns for STEMI prehospital reperfusion strategies in 2000 in the greater Paris area. All STEMI with clinical and ECG features suggestive of less than 24 h duration, managed by prehospital medical team, are collected.The evidence based guidelines for STEMI patients managed out of cardiac critical care unit, including prehospital setting, were established in 2006 to stratify reperfusion strategies according to the presumed delay to cath lab. If the presumed door to cathlab delay is over 45 min and onset of symptom delay less than 12 h thrombolysis is recommended before transferring to a PCI capability hospital.Reperfusion strategies for STEMI within 2 h of onset of symptoms, either thrombolysis or primary PCI were compared in the registry through the years 2002, before guidelines, 2006, and 2008, after guidelines publication.Two groups of patients were studied according to the elected reperfusion strategy, Two subgroups of patients elected for primary PCI were distinguished according to the 45 min door to cathlab delay cut off. The onset of symptom to treatment mean delays, either lytic infusion or balloon inflation, were documented for each group and subgroup of patients.Résults Greater Paris area200220062008pSTEMI<24 h180616181689STEMI<2 h1029 (57%)1015 (63%)1042 (62%)=0.002STEMI<2 h reperfusion decision940 (91%)959 (94%)989 (95%)=0.011/Thrombolysis373 (44%)318 (36%)196 (21%)<0.001Pain (onset of symptoms) to thrombolysis mean delay (min)858080=0.0182/PCI with less than 45 min door to cathlab delay114 (12%)173 (19%)243 (26%)<0.001Pain (onset of symptom) to balloon mean delay (min)135128131=0.543/PCI with over 45 min door to cathlab delay358 (42%)403 (45%)481 (53%)<0.001Pain (onset of symptom) to balloon mean delay (min)160161160=0.410 DiscussionThe ratio of patients managed within 2 h of onset of symptoms has increased from 57% in 2002 to 62% in 2008. The rate of prehospital reperfusion decision has also increased from 91% in 2002 to 95% in 2008.Mean delays from onset of symptom to treatment were not significantly different from 2002 through 2008, either for thrombolysis, or for the primary PCI elected strategy within or over the 45 min door to cathlab delay cut off.Prehospital thrombolytic therapy was significantly less frequently elected, from 44% in 2002 to 21% in 2008.The ratio of primary PCI with over 45 min door to cathlab delay has significantly increased from 42% in 2002 to 53% in 2008.ConclusionThe e-MUST registry helps to assess the performance of guidelines on clinical p...