According to current guidelines for the management of patients with myocardial infarction-segment elevation ST (STEMI), the optimal timing for primary percutaneous coronary intervention (PCI) are 90 minutes from first contact with medical personnel, or admission to the hospital. Still not entirely clear whether the delay is related coronary intervention (so-called time "the door - a cylinder» (door-to-balloon (D2B)) within these 90 minutes, with high mortality or the risk of adverse outcome is increased only during percutaneous coronary intervention after 60 minutes from receipt of the patient. To assess the relationship between time D2B and hospital mortality, American scientists to analyze data from the National Cardiovascular Registry, sponsored by the American College of Cardiology (American College of Cardiology National Cardiovascular Data Registry).
Methods and progress in the study.
In 2005-2006 included in the register of STEMI patients received in the first 12 hours of the disease (n = 64 676). After excluding patients who received thrombolytic therapy before PCI, transferred from other hospitals in the age of 18 and over 99 years, with missing data on D2B and D2B <15 minutes, and> six hours, the final cohort of the study was 43,801 patients. D2B time was defined as the time from admission to first balloon inflation. Statistical analysis was performed in four categories D2B: <60, 60-89, 90-119 and ≥ 120minutes, as well as taking into account for the D2B as a continuous variable. Relationship between D2B and hospital mortality was assessed by logistic regression with adjustment for the following factors: gender, race, age, clinical symptoms at admission(shock, renal failure, time of symptoms prior to hospitalization), medical history (diabetes, left ventricular ejection fraction, chronic pathology lungs), especially PCI (balloon contrast pulsation enlarged application, thrombin inhibitors, the operational the weekend) and coronary anatomy (lesion of left coronary artery, proximal left anterior descending artery, coronary score changes in the classification of the American Society of cardiac angiography and intervention ( reference).
Median D2B time was 83 minutes (interquartile range - 62-109 minutes). 57.9% of patients received PCI within 90 minutes of receipt. The overall mortality in a cohort study was 4.6% (1999/43801). D2B time was 14 minutes longer in patients who died (96 versus 82 minutes in the survivors, p <0,001).In the four-time intervals D2B mortality was: <60 minutes- 3.2% (323/9971), 60-89 minutes- 3.7% (568/15388), 90-119 minutes- 4, 6% (44, 6% 10208), ≥ 120 minutes- 7.7% (635/8234), P trend <0.001. In multivariate analysis between the time of D2B, and mortality encountered direct nonlinear relationship. At the time, 30 minutes D2B mortality was 3.0% at 60minutes- 3.5% at 90minutes- 4.3% at 120 minutes - 5.6% at 150 minutes - 7.0% at 180 minutes - 8, 4% at 210 minutes - 9.7% at 240 minutes - 10, 3% (p <0,001). Thus, reducing D2B time from90 minutes to60minuteswas associated with decreased mortality by 0.8%, while reducing D2B time from60 minutes to30minutes- at 0.5%.
After excluding 4166patients with cardiogenic shock between D2B big time with an increased risk of death persisted: when D2B <60 minutes - 1.7% (156/9111), with 60-89 minutes - 1.8% (247/14 024)at 90-119 minutes- 2.2% (203/9226) and ≥ 120 minutes of -3.6% (262/7274),P trend <0.001.
This American National Cardiovascular Registry showed that any delay time D2B STEMI patients coming to primary PCI, is accompanied by greater hospital mortality, even within the recommended90 minutes. The results indicate the need to minimize the timing of the primary PCI, even in those hospitals in which coronary intervention is recommended in the current period.
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