Development of regionalized STEMI care networks in Brazil

LETTER TO THE EDITOR

Development of regionalized STEMI care networks in Brazil

Davi Jorge Fontoura Solla^I,II; Nivaldo Menezes Filgueiras-Filho^I; Ivan de Mattos Paiva-Filho^I

^IServiço de Atendimento Móvel de Urgência (SAMU)

^IIFaculdade de Medicina da Universidade Federal da Bahia (FMB/UFBA), Salvador, BA - Brazil

^{Mailing Address}

Keywords: Myocardial Infarction; Urban Health Services; Emergency Medical Services; Ambulances; Brazil.

Dear Editor,

We read with great interest the article by Caluza et al. "ST-Elevation myocardial infarction network: systematization in 205 cases reduced clinical events in the public health care system". The creation of regionalized STEMI care networks, integrating different levels of complexity, reduces time interval until treatment, including door-to-needle and door-to-balloon time and increases the proportion of primary reperfusion, currently constituting a class I recommendation, level of evidence: B^1,2. In fact, the implementation of STEMI care networks and systems has been a trend for more than a decade³, and, in 2011, through the "Line of care of acute myocardial infarction in the emergency care network", the implementation of STEMI care networks in metropolitan regions became a recommendation of the Ministry of Health of Brazil⁴.

The aforementioned study drew our attention because we develop a similar initiative through the metropolitan Mobile Emergency Care Service (Samu) in the city of Salvador, state of Bahia, Brazil. In July 2009, we created an integrated regionalized network involving the entire public emergency system of Salvador (city and state; emergency departments and general hospitals) and the two public cardiology referral centers with catheterization laboratory availability⁵.

When drawing a parallel with our local experience, we congratulate the authors of this network in Sao Paulo for the results regarding the transfer of 100% of patients to a referral center and the proportion of primary reperfusions, chemical or mechanical, of over 90%. In our cohort, due to a series of obstacles that are not the subject of this letter, just below 60% of the patients could benefit from transference to referral centers and we observed an overall proportion of primary reperfusion of 45% (excluding the 20% that sought medical care beyond the therapeutic window of 12 hours).

In time, no admission beyond the 12-hour window was reported in the São Paulo network. Were there any cases with this profile? How were they managed? Furthermore, are there records regarding the time intervals from symptom onset (pain-admission, admission-electrocardiogram, door-to-needle and/or door-to-balloon)?

We emphasize how praiseworthy the initiative of a STEMI care network implemented by Caluza et al. is, as well as the clinical results achieved. To our knowledge, there are not many such networks in Brazil and Latin America, in contradiction to the evidence and successful experiences in European countries and North America.

References

Manuscript received December 21, 2012, revised manuscript February 22, 2013 accepted February 22, 2013.

Reply

We appreciate the comments by Solla¹ about the article we published in the Brazilian Archives of Cardiology² (ABC) and agree that unfortunately in our country, the "networks" for treatment of myocardial infarction with ST elevation are still in their infancy, unlike well-established systems in Europe^3,4 and in United States, as published by Cannon et al⁵. In this sense, it is interesting that our results, currently with 620 cases, are close to established networks as shown in Table 1 below, to which we added our experience according to what was published in JACC⁶.

We have followed the results of Solla, Filgueiras and Carvalho in Salvador, through presentations at national congresses and now with the publication of their article in Circulation Outcomes⁷; we offer our congratulations and acknowledge their results. We agree that the line of care for AMI adopted by the Ministry of Health and supported by the Brazilian Society of Cardiology is a step in the right direction.

Regarding the questions specifically formulated by the authors:

1) We did not include in this sample, and we apologize if we were not clear enough in the article, patients with more than 12-hour evolution; currently, these cases fortunately comprise a small proportion of patients in the network, (less than 10% of total in Hospital São Paulo). This is due to the fact that care systematization and Telecardio virtually eliminated time loss caused by transferring patients from one place to another, until you have reached a diagnosis and treatment is initiated. The cases that did not undergo reperfusion had specific reasons: neoplasms undergoing treatment, pericarditis diagnosis, trauma postoperative period, recent coronary angiography, finding of occluded small vessels. The very few cases included with more than 12 hours of symptom onset were due to persistent and significant pain;

2) Some time intervals in our experience: median of time from onset to needle of 3.5 hours; onset to balloon, 93 minutes (primary PCI) and onset to catheterization in invasive drug cases, of little more than 9 hours. These data reflect the fast use of Tenecteplase (TNK) and not too prolonged transfer, preventing deterioration of patients at the points of origin, with consequent contribution to the low mortality achieved;

3) Electrocardiogram (ECG) interpretation made by the Telecardio system of Hospital São Paulo, for Samu and AMA participants had a time of diagnostic information of less than 2 minutes. For ECGs performed in the participating ERs, this time interval was greater, with a median of 17 minutes in cases with complete information available.

Our systematization requires that the patient being submitted to primary PCI have a diagnosis-to-balloon time of less than 90 minutes, except in cases of absolute contraindication to thrombolysis. Under these conditions, the outcome, currently comprising 620 cases, considering the limitations of a registry, showed no significant difference in mortality after the use of TNK followed by coronary angiography/intervention if necessary (80% of sample) versus primary angioplasty, with a hospital mortality rate of 6.5%.

Sincerely,

Ana Christina Vellozo Caluza

Antonio Carlos Carvalho

On behalf of the other authors

References

Correspondência:

Davi Jorge Fontoura Solla

Rua Marechal Floriano, 41, Apto. 101, Canela

CEP 40110-010, Salvador, BA - Brasil

E-mail: [e-mail], [e-mail]

Artigo recebido em 21/12/12; revisado em 21/12/12; aceito em 22/02/13.

Carta-resposta

Agradecemos os comentários de Solla¹ a respeito do artigo que publicamos nos ABC² e concordamos que infelizmente em nosso meio as "redes" para tratamento de infarto com supradesnivelamento ainda estão em seu início, diferentemente de sistemas bem estabelecidos na Europa^3,4 e nos Estados Unidos, como publicado por Cannon e cols.⁵. Nesse sentido, é interessante que nossos resultados, hoje com 620 casos, se aproximam de redes já estabelecidas conforme tabela 1 adiante em que adicionamos nossa experiência ao exemplo publicado no JACC⁶.

Temos acompanhado os resultados do grupo de Solla, Filgueiras e Carvalho em Salvador, mediante apresentações em Congressos nacionais e agora com a publicação no Circulation Outcomes⁷; parabéns e nosso reconhecimento pelos resultados obtidos. Concordamos que a Linha de Cuidado do IAM adotada pelo Ministério da Saúde e apoiada pela Sociedade Brasileira de Cardiologia é um passo na direção correta.

Quanto às perguntas especificamente formuladas:

1) Não colocamos nessa amostra, e nos desculpamos se não fomos claros o suficiente no artigo, pacientes com mais de 12 horas de evolução; esses casos hoje constituem na rede, felizmente, uma proporção pequena de pacientes (menor que 10% do total no Hospital São Paulo). Até porque, a sistematização do atendimento e o Telecardio praticamente eliminaram a perda de tempo do paciente decorrente de ir de um local para outro até ter o diagnóstico e o tratamento iniciado. Os casos que não realizaram reperfusão tinham razões específicas: neoplasias em tratamento, reconhecimento de que se tratava de pericardite, pós-operatório de trauma, cinecoronariografia recente, achado de artérias ocluídas pequenas. Os pouquíssimos casos incluídos com mais de 12 horas de início do quadro o foram por causa de dor persistente e importante;

2) Alguns intervalos de tempo de nossa experiência: mediana do tempo de início do quadro para agulha de 3,5 horas, início do quadro para balão de 93 minutos (ATC primária) e início do quadro para cateterismo nos casos de fármaco invasiva de pouco mais de 9 horas. Esses dados refletem o uso rápido de Tenecteplase (TNK) e transferência não muito prolongada, impedindo deterioração dos pacientes nos pontos de origem, com consequente contribuição na baixa mortalidade obtida;

3) A interpretação do eletrocardiograma (ECG) feita pelo sistema Telecardio do Hospital São Paulo, para o Samu e AMA participantes, teve um tempo de informação do diagnóstico menor que 2 minutos. Nos ECG feitos nos PS participantes o tempo foi maior, mediana 17 minutos nos casos com informação completa disponível.

A nossa sistematização exige que o paciente a ser submetido a ATC primária tenha o tempo diagnóstico-balão inferior a 90 minutos, exceto em casos com contraindicação absoluta ao trombolítico. Nessas condições o resultado obtido, agora em 620 casos, com as limitações de um registro, não mostrou diferença significante de mortalidade após o uso de TNK seguido de cineangiografia/intervenção se necessário (80% da amostra) versus angioplastia primária, com mortalidade hospitalar de 6,5%.

Atenciosamente,

Ana Christina Vellozo Caluza

Antonio Carlos Carvalho,

pelos demais autores

Referências

• 1. Steg PG, James SK, Atar D, Badano LP, Blömstrom-Lundqvist C, Borger MA, et al. Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology (ESC). ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J. 2012;33(20):2569-619.
• 2. O'Gara PT, Kushner FG, Ascheim DD, Casey DE, Chung MK, De Lemos JA, et al; American College of Emergency Physicians; Society for Cardiovascular Angiography and Interventions. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2012;61(4):e78-140.
• 3. Rokos IC, Larson DM, Henry TD, Koenig WJ, Eckstein M, French WJ, et al. Rationale for establishing regional ST-elevation myocardial infarction receiving center (SRC) networks. Am Heart J. 2006;152(4):661-7.
• ⁴
  Ministério da Saúde. Portaria nº 2.994: Linha do cuidado do infarto agudo do miocárdio na rede de atenção às urgências. Brasília; 2011.
• 5. Solla DJ, Paiva Filho I de M, Delisle JE, Braga AA, Moura JB, Moraes XD Jr, et al. Integrated regional networks for ST-segment-elevation myocardial infarction care in developing countries: the experience of Salvador, Bahia, Brazil. Circ Cardiovasc Qual Outcomes. 2013;6(1):9-17.
• 1. Solla DJ, Figueiras NM, Paiva-Filho IM. Desenvolvimento de redes regionalizadas de atenção a IAM com supra ST no Brasil. Arq Bras Cardiol. 2013 (in press).
• 2. Caluza AC, Barbosa AH, Gonçalves I, Oliveira CA, Matos LN, Zeefried C, et al. Rede de infarto com supradesnivelamento de ST: sistematização em 205 casos diminui eventos clínicos na rede pública. Arq Bras Cardiol. 2012;99(5):1040-8.
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• 4. Widimsky P, Wijns W, Fajadet J, de Belder M, Knot J, Aaberge L, et al. Reperfusion therapy for ST elevation acute myocardial infarction in Europe: description of the current situation in 30 countries. Eur Heart J. 2010;31(8):943-57.
• 5. Cannon CP, Bahit MC, Haugland JM, Henry TD, Schweiger MJ, McKendall GR, et al. Underutilization of evidence-based medications in acute ST elevation myocardial infarction: results of the Thrombolysis in Myocardial Infarction (TIMI) 9 Registry. Crit Pathw Cardiol. 2002;1(1):44-52.
• 6. Huynh T, Birkhead J, Huber K, O'Loughlin J, Stenestrand U, Weston C, et al. The pre-hospital fibrinolysis experience in Europe and North America and implications for wider dissemination. JACC Cardiovasc Interv. 2011;4(8):877-83.
• 7. Solla DJ, Paiva Filho I de M, Delisle JE, Braga AA, Moura JB, Moraes XD Jr, et al. Integrated regional networks for ST-segment-elevation myocardial infarction care in developing countries: the experience of Salvador, Bahia, Brazil. Circ Cardiovasc Qual Outcomes. 2013;6(1):9-17.

Publication Dates

• Publication in this collection
  28 May 2013
• Date of issue
  May 2013