[TCT2007]STEMI治疗新方案降低就诊－介入治疗时间

New Program Help Reduce Door-to-Balloon Time

　　在过去的12年中，入院90分钟内接受球囊扩张血管成形术的STEMI患者数量增加近1倍，从34%增加到现在的近65%。

　　为了进一步促进这一良好局面，美国心脏病协会（AHA）实施了一项“使命：生命线”计划，该计划在全国推广目的是使STEMI患者的就诊－介入治疗时间降得更低以确保STEMI患者能够在入院90分钟内接受球囊血管成形术。

　　美国加州大学洛杉矶校区海港医学中心的French医生介绍说，产生这一良好趋势的另一因素是STEMI患者抵达医院的时间明显减少。在美国，症状发生－就诊时间从2001年的1.75小时降到2006年的1.4小时。

　　STEMI患者入院后接受治疗方案的变化也是就诊－介入治疗时间减少的原因之一。研究发现，在过去的5年中，接受静脉溶栓治疗的患者下降到15%，而接受急诊PCI的患者增加到现在的65%。而非转诊患者，就诊－导管室时间由1994年的近80分钟下降到2006年的约50分钟。

　　French医生指出，STEMI患者运送时间延迟也是影响就诊－介入治疗时间的因素之一。不过，研究显示患者的运送时间也从1994年的6.4小时降到1996年的2.5小时。

　　如果只考虑由首次心电图定诊为STEMI的情况，不论转诊患者还是未转诊患者，从症状发作到介入治疗的时间都持续降低。1994年，这一时间是6.9小时，2006年降到4.3小时。与之相应，未转诊患者，这一时间由1994年的4小时减少为2006年的3.2小时。

　　French指出，减少治疗过程的延误时间也是很重要的，因为延误治疗可以增加患者住院期间的死亡率。接受急诊PCI的未转院患者，住院期间死亡率由1990年的9.7%降到2004年的4.2%，而转院患者则由5.3%降到4.2%。

　　French同时指出，STEMI患者入院前接受ECG检查有助于降低就诊－介入治疗时间。这可以使患者缩短PCI术前检查时间，从而及时接受PCI术。

　　Indianapolis 方案

　　St. Francis 心脏病中心的Khot医生介绍了在2005年他所在医院实行的旨在缩短就诊－介入治疗时间的方案。当STEMI患者入院时，首先确保急诊科医生通知导管室。此外，确保患者由院内护理人员迅速运送到值班导管室。为了进一步减少时间，心脏科医生应当在急诊科、运送患者至导管室途中或导管室内对患者进行评估。

　　实施此方案大幅缩短了就诊－介入治疗时间。方案实施之前，约有28%的患者入院90分钟内接受了介入治疗。实施之后，这一比例增加到71%。

　　Khot医生说，现在他们医院STEMI患者的平均就诊－介入治疗时间约为43分钟。但在晚上和周末，这一时间大约为70分钟。对于转院患者，这一时间约为75分钟。

　　这一方案的实施也明显降低了每位患者的住院总花费。

　　Boston方案

　　麻省总医院血管和介入科主任Rosenfield 医生介绍了最近在波士顿实施的旨在缩短就诊－介入治疗时间的Boston方案。Boston方案强调对于所有STEMI患者都要转院到有能力实施PCI手术的医院，这减少了患者因运送到不能进行PCI手术的医院，而不得不转院到能够行PCI手术医院的可能。

　　Rosenfield 医生说，波士顿市实施这项方案后效果显著。2004年，就诊－介入治疗时间在90分钟内的患者占64%，2006年达73%。2006年就诊－介入治疗时间平均为67.5分钟，2004年为83.5分钟，2005年为73分钟。

　　Rosenfield 医生指出“上述成绩的取得是波士顿全市医疗工作者集体努力的结果，特别是波士顿市急救医疗系统的医护人员以及导管室和急诊科各级领导做出了突出贡献。”Braden医生是治疗复杂冠心病和急诊介入治疗领域的先驱，他于2007年8月13日逝世，年仅50岁。Braden医生是每年TCT会议的参与者，也是CRF发起的教育计划的发起人之一。他是一位优秀的临床医生，也是一位杰出的介入心脏病学专家。我们缅怀他无比的智慧，天才的灵感，回味与他的友谊和他令人愉悦的幽默感。

　　(阜外心血管病医院　丁立刚 高立建　编译)

New Programs Help Reduce Door-to-Balloon Time

An increasing number of patients now receive balloon angioplasty in less than 90 minutes.

In the past 12 years, the number of nontransfer patients receiving balloon angioplasty treatment within 90 minutes of entering the hos¬pital has nearly doubled, from 34% of patients to approximately 65%.

To further help this trend, the American Heart Association implemented “Mission: Lifeline,” an initiative meant to lower door-to-balloon time even more. Hospitals nationwide now are implementing programs to make sure STEMI patients receive balloon angioplasty in less than 90 minutes.

Another factor contributing to this improvement is faster transport times, according to William J. French, MD, from the Harbor-UCLA Medical Center. Nationally, symptom onset-to-door times decreased from approximately 1.75 hours in 2001 to 1.4 hours in 2006.

Another contributing factor is the care patients receive once they arrive at the hospital. Studies show IV lytic therapy has decreased to 15% and primary PCI has increased in the past 5 years to 65%. For nontransfer patients, the door-to-catheterization lab time decreased from nearly 80 minutes in 1994 to approximately 50 minutes in 2006.

French pointed to lagging transfer times and delays as one problem impacting door-to-balloon time for STEMI patients. However, studies show transfer times also are decreasing from 6.4 hours in 1994 to approximately 2.5 hours in 1996.

The number of hours between symptom onset and balloon treatment continues to decrease for both transfer and nontransfer patients when considering STEMI on first ECG only. In 1994, the time between symptom onset and balloon treatment was approximately 6.9 hours compared with 4.3 hours in 2006. Comparatively, for nontransfer patients, this time decreased from approximately 4 hours in 1994 to 3.2 hours in 2006.

French noted that it is important to lessen delay in treatment because time delays lead to increased mortali¬ty during hospitalization. The percent of primary PCI patient deaths during hospitalization decreased from 9.7% in 1990 to 4.2% in 2004 in nontrans¬fer patients and from 5.3% to 4.2% in transfer patients.

Studies also show that patients who have prehospital ECGs decrease their door-to-balloon times. The goal, according to French, is to achieve timely access to PCI for STEMI patients.

Indianapolis program

Umesh Khot, MD, from the St. Francis Heart Center in Indianapolis, Ind., discussed initiatives designed to reduce door-to-balloon time that were implemented in his hospital in 2005. The hospital’s staff resolved to ensure that emergency department physicians activated the catheterization lab when patients with STEMI were admitted.

Furthermore, a policy was implemented to guarantee that patients would be immediately transferred to an available cath lab by in-house nursing staff. To further reduce time, a cardiologist would evaluate the patient in the emergency department, en route to the cath lab, or in the cath lab.

The program was associated with a significant reduction in door-to-balloon times. Prior to its implementation, 28% of patients achieved door-to-balloon time in 90 minutes or less. Following implementation, this percentage increased to 71%.

Khot said the average door-to-bal¬loon time for STEMI patients admitted to his hospital during regular hours is now about 43 minutes. During nights and weekends, the average door-to-balloon time is about 70 minutes. The average door-to-balloon time for transfer patients is about 75 minutes.

The program also has had a significant benefit on total hospital cost per patient (Figure).

 
Boston initiative

Kenneth Rosenfield, MD, section head of vascular medicine and intervention in the Division of Cardiology at Massachusetts General Hospital, discussed recent initiatives in Boston intended to reduce door-to-balloon times. The Boston program dictates that all STEMI patients are transported only to PCI-capable hospitals. This reduces the likelihood that these patients will have to be transferred between hospitals.

Rosenfield said the citywide effort has already achieved results. In 2006, 73% of patients with STEMI experienced door-to-balloon times of 90 minutes or less. This increased from 64% in 2004. In 2006, the average door-to-balloon time was 67.5 minutes. This was a reduction from 83.5 minutes in 2004 and 73 minutes in 2005.

“Significant reductions were achieved in door-to-balloon time as a result of a citywide effort spearheaded by Boston EMS working together with laboratory leaders and emergency department leaders,” he said.Gregory A. Braden, MDGregory A. Braden, MD, a pioneer in the treatment of patients with complex coronary artery disease and emerging interventional devices, died on August 13, 2007, at the age of 50.Dr. Braden was a yearly faculty member at the annual TCT Symposium in addition to numerous other courses sponsored by the Cardiovascular Research Foundation. He was a superb clinician as well as a dedicated academic interventional cardiologist. We will greatly miss Greg’s talents and insights, inspiration, camaraderie, and heartwarming humor. the Cardiovascular Research FoundationIn Memoriam.