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)

Abstract

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

The effects of mobile health on emergency care in low- and middle-income countries: A systematic review and narrative synthesis

“…Telecardiology support for HCWs, in particular, was a recurrent theme encountered in this sector of mHealth. Six observational studies evaluating tele-cardiology support in acute coronary syndrome for prehospital providers or other HCWs such as emergency or primary care providers demonstrated significantly improved rates of administration of aspirin (91% vs 58%), improved rates of primary reperfusion, faster door-to-balloon (D2B) time for STEMI (D2B time <90 minutes: 82.5 vs 26.0%), a reduction of in-hospital mortality rates (12.3% vs 7.1%), and a reduction in thirty-day mortality rates (19.8 vs 5.1%) [ 32 , 33 , 36 , 39 , 40 , 42 ]. The lone RCT in this subgroup randomized ambulances staffed with EMS providers to real-time telehealth support vs standard care for the rate of correct primary diagnosis in the prehospital arena.…”

“…Four observational cohorts found their respective interventions to decrease mortality rates [ 36 , 40 , 45 , 50 ]. Two before-and-after observational trials evaluating regional telecardiology programs in Brazil found these system wide interventions significantly increased rates of primary reperfusion in STEMI (29.1 vs 53.8%) and ICU admission (32.4 vs 66.1%) while decreasing both thirty-day mortality rates (19.8 seconds, 5.1%) and in-hospital mortality rates (12.3 vs 7.1%) [ 36 , 40 ]. A yearlong ICU-based study evaluated weekly tele-education conferences focused on ICU structure, processes, and outcomes in Bosnia and Herzegovina.…”

Kreislaufstillstand unter besonderen Umständen

“…Angemessene Ressourcen sicherstellen. Regionale STEMI-Netzwerke haben dazu beigetragen, die Zeitintervalle bis zur Reperfusion zu verkürzen und die Reanimationserfolge zu verbessern [ 258 – 263 ]. Initiativen zur Bildung solcher Netzwerke sollen gefördert und diesen sollen ausreichende personelle und materielle Ressourcen einschließlich einer angemessenen Schulung des Personals (Kenntnisse der EKG-Interpretation und ALS-Kompetenz) ermöglicht werden [ 264 ].…”

Comparison of Real-Life Systems of Care for ST-Segment Elevation Myocardial Infarction

“…To improve the care of STEMI patients in the whole region in Brazil, implementation of a regional STEMI network supported by telemedicine and utilizing local pre-hospital EMS might be the best solution. This system of care was associated with lower mortality and higher use of evidence-based therapies, as suggested by a recent analysis from Brazil [ 48 ].…”