Impact of the Type of First Medical Contact within a Guideline-Conform ST-Elevation Myocardial Infarction Network: A Prospective Observational Registry Study.

AIMS: The impact of type of first medical contact (FMC) in the setting of a guideline conform metropolitan ST-elevation myocardial infarction (STEMI) network providing obligatory primary percutaneous coronary intervention (PCI) is unclear. METHODS AND RESULTS: 3,312 patients were prospectively included between 2006 and 2012 into a registry accompanying the "Cologne Infarction Model" STEMI network, with 68.4% primarily presenting to emergency medical service (EMS), 17.6% to non-PCI-capable hospitals, and 14.0% to PCI-capable hospitals. Median contact-to-balloon time differed significantly by FMC with 89 minutes (IQR 72-115) for EMS, 107 minutes (IQR 85-148) for non-PCI- and 65 minutes (IQR 48-91) for PCI-capable hospitals (p < 0.001). TIMI-flow grade III and in-hospital mortality were 75.7% and 10.4% in EMS, 70.3% and 8.6% in non-PCI capable hospital and 84.4% and 5.6% in PCI-capable hospital presenters, respectively (p both < 0.01). The association of FMC with in-hospital mortality was not significant after adjustment for baseline characteristics, but risk of TIMI-flow grade < III remained significantly increased in patients presenting to non-PCI capable hospitals. CONCLUSION: Despite differences in treatment delay by type of FMC in-hospital mortality did not differ significantly. The increased risk of TIMI-flow grade < III in patients presenting to non PCI-capable hospitals needs further study.

Long-term medication adherence in patients with ST-elevation myocardial infarction and primary percutaneous coronary intervention.

AIMS: Besides early percutaneous coronary intervention (PCI) long-term medical treatment is crucial for outcomes after ST-elevation myocardial infarction (STEMI). The present study aimed to identify predictors of adherence to evidence-based medication in this high risk population. METHODS AND RESULTS: A total of 1025 consecutive patients with adjudicated STEMI treated by primary PCI in a single centre as part of the Cologne Infarction Model (KIM) were prospectively analysed. Gender-specific multivariate predictors of long-term medication adherence were identified. Follow-up with available information on drug use was completed for 610 of 738 (82.7%) patients confirmed to be alive after a median period of 36 months. Adherence was persistently high for evidence-based medication with 90.8% for acetylsalicylic acid (ASA), 88.2% for statins, 87.5% for beta-blockers and 79.2% for ACE-inhibitors or angiotensin-receptor blockers (ARBs). Patients with a history of heart failure had a higher medication adherence to beta-blockers, ACE-inhibitors/ARBs and diuretics, whereas long-term prescription rates for calcium channel blockers (CCBs) were lower in patients with reduced versus preserved ejection fraction. Patients with a history of hypertension presented higher medication adherence to CCBs, ACE-inhibitors/ARBs and diuretics but not to beta-blockers. On multivariate analysis, age, body mass index (BMI), hypertension, chronic kidney disease and lack of PCI were independently associated with prescription of diuretics at follow-up. In women, adherence was lower to beta-blockers and higher to CCBs compared to men. CONCLUSION: In the high risk population of STEMI patients long-term adherence to evidence-based medication is high. The lower adherence to beta-blockers and higher prescription rate for CCBs in women needs particular attention.

Implementation of guidelines for the treatment of acute ST-elevation myocardial infarction: the Cologne Infarction Model Registry.

BACKGROUND: The aim of the Köln (Cologne) Infarction Model is to examine the feasibility of obligatory treatment of ST-segment-elevation myocardial infarction (STEMI) by first-line percutaneous coronary intervention. METHODS AND RESULTS: The study was performed in Cologne with >1 million citizens, 5 coronary intervention centers, and 11 primary care hospitals. Twelve-lead ECG was available for all emergency medical service (EMS) teams. Partners guaranteed direct transfer of STEMI patients to a catheterization laboratory. A total of 519 patients treated within KIM in 2006 were included in the study. Of these, 24% presented at a primary care hospital, 11% presented directly at a coronary intervention center, 5% were transferred by EMS to primary care hospitals, and 60% were directly transferred by EMS to a catheterization laboratory. In 91% of cases, the catheterization laboratory was notified of the patient's arrival in advance. False-positive ECG diagnosis of STEMI by EMS accounted for 6%. Median treatment times were as follows: from the start of symptoms to first medical contact, 120 minutes; phone to balloon, 70 minutes; and door to balloon, 49 minutes. Of all patients, 93% underwent angiography; 409 patients were treated by coronary intervention, and 24 underwent emergency coronary artery bypass graft. Thrombolysis in Myocardial Infarction grade 3 flow was obtained in 89%. In the hospitals, deaths and new myocardial infarctions were observed in 12.1% and in 1.9% of all patients, respectively. CONCLUSIONS: The Cologne Infarction Model provides evidence for the feasibility of obligatory treatment of STEMI by primary coronary intervention in a metropolitan setting. Acceptance of treatment pathways allowed nearly all STEMI patients to undergo coronary angiography. ECG competence of EMS was excellent. Treatment times were within postulated limits. Results, including mortality, were within a high quality range.