[TCT2008]医生转运方案能改善ST段抬高心梗患者治疗结果（REVERSE-STEMI）

Physician-Transfer Strategy Could Improve STEMI Outcomes

 

将具有介入资质的医生转运到有设备、但缺乏相应资源的医院，进行直接经皮冠脉介入术（PCI），可比转运患者产生更好的结果。

 

中国上海瑞金医院REVERSE-STEMI研究组的张奇博士，在TCT 2008会议上发布了研究摘要。他们进行了一项前瞻性、多中心、随机试验，评价医生（而非患者）转运方案，对促进ST段抬高心肌梗死（STEMI）患者进行快速有效PCI的可行性。研究入选2005年11月至2007年11月间在上海市五所医院就诊的连续334例STEMI患者（症状发作≤12个小时）。随机分组进行直接PCI术，一组采用医生转运方案，另一组采用患者转运方案。主要终点是就诊-球囊扩张时间（D2B），住院和30天主要不良心脏事件（MACE），包括死亡、非致命性再梗和靶血管血运重建。

 

再灌注时间更短

 

医生转运组D2B时间比患者转运组更短（95±20分钟 vs.147±29分钟；P＜0.0001）。而且，医生转运组的患者有21.2%其D2B时间小于90分钟，而患者转运组能达到这个时间的只占7.7%（P＜0.0001）。研究者称，尽管D2B时间在医生转运组明显降低，但是在操作成功率或住院时间方面，两组没有明显差距。

 

不良事件减少

 

研究者发现，MACE率在医生转运组更低，住院期间（6.7% vs.11.2%；P=0.14）与1个月随访期间（8.9% vs.17.2%；P=0.03）情况均如此。他们说医生转运组30天MACE率较低很可能是由于D2B时间缩短的缘故。

 

张奇博士在电话采访中说，“在中国，有1,000多家医院有造影设备，但是根据国内的相关规定，将近一半的医院缺乏充分具备PCI手术资质的医生。大中型城市虽然具有较完备的医疗系统，并且发展了足够数量的大型PCI中心。但是，转运PCI患者的急救系统还不完善。”他强调，1年随访结果将在2008年年底公布，医生转运方案在可以实行、且无法规限制的城市中，可证明是降低D2B时间最好的方案之一。

 

“这项研究的结果显示，在中国，当地方医院具有造影设备，但是缺乏技术熟练的操作者来实行直接PCI术时，医生转运方案是可行并可能优于患者转运的。”他补充说，基本的前提条件是要建立有效的医生转运系统。 

 

（《医心评论》编辑 刘瑞琦 翻译 马秀芹 校对）

 

（来源：www.tctmd.com）

 

Physician-Transfer Strategy Could Improve STEMI Outcomes 
  

By TCT Daily Staff

 

The transfer of qualified physicians to facilities that lack them, but are otherwise equipped to provide primary percutaneous coronary intervention (PCI), resulted in better outcomes than when patients themselves were transferred to a PCI-capable facility.

 

Zhang Qi, MD, and colleagues from the REVERSE-STEMI group, from Ruijin Hospital in Shanghai, China, presented their abstract at TCT 2008. They conducted a prospective, multicenter, randomized trial to assess the feasibility of transferring physicians, rather than patients, to facilitate quick and efficient PCI following ST-segment elevation myocardial infarction (STEMI).

 

Investigators randomly assigned 334 consecutive STEMI patients − all of whom had experienced symptoms for 12 hours or less − to receive primary PCI by either a physician-transfer or patient-transfer strategy. The patients all presented at five local Shanghai hospitals between November 2005 and November 2007.

 

The main endpoints were door-to-balloon time and in-hospital and 30-day major adverse cardiac events (MACE), including death, non-fatal reinfarction, and target vessel revascularization.

 

Shorter time to reperfusion

 

The physician-transfer group had shorter door-to-balloon times than the patient-transfer group (95 ± 20 minutes vs. 147 ± 29 minutes; P < .0001). Furthermore, 21.2% of patients in the physician-transfer group had door-to-balloon times <90 minutes, compared with 7.7% of those in the patient-transfer group (P < .001).

 

Although door-to-balloon time was significantly reduced in the physician-transfer group, there was no statistically significant difference in procedural success or the length of hospital stay between the two groups, the investigators reported.

 

Fewer adverse events

 

The researchers did find a lower rate of MACE in the physician-transfer group, both during hospitalization (6.7% vs. 11.2%; P = .14) and at 1-month follow-up (8.9% vs. 17.2%; P = .03). They said the lower 30-day MACE rate is likely a result of the shorter door-to-balloon time in the physician-transfer group.

 

"In China, there are more than 1,000 hospitals equipped with angiography facilities, but nearly half of the hospitals lack operators who are qualified to perform PCI according to Chinese regulations," Qi said in a telephone interview. "In large- and medium-size cities, networks of care centered on an adequate number of high-volume PCI centers have been developed; however, the ambulance transfer system to transport patients from the hospitals at which they present is still not well established."

 

Noting that one-year follow-up results will be available by late 2008, Qi said the physician-transfer strategy could prove to be among the best tactics to reduce door-to-balloon time in countries where this approach is feasible and where regulations do not prohibit it.

 

"The results of this study indicate that in China, physician transfer to a local hospital, where angiographic facilities are available but where there is a lack of qualified operators to perform primary PCI, is feasible and may be superior to patient transfer from a non-PCI-capable hospital," Qi said, adding that the essential prerequisite is to organize effective networks for physician transfer.