Temporal Trends of System of Care for STEMI: Insights from the Jakarta Cardiovascular Care Unit Network System

Abstract

AimGuideline implementation programs are of paramount importance in optimizing acute ST-elevation myocardial infarction (STEMI) care. Assessment of performance indicators from a local STEMI network will provide knowledge of how to improve the system of care.Methods and ResultsBetween 2008–2011, 1505 STEMI patients were enrolled. We compared the performance indicators before (n = 869) and after implementation (n = 636) of a local STEMI network. In 2011 (after introduction of STEMI networking) compared to 2008–2010, there were more inter-hospital referrals for STEMI patients (61% vs 56%, p<0.001), more primary percutaneous coronary intervention (PCI) procedures (83% vs 73%, p = 0.005), and more patients reaching door-to-needle time ≤30 minutes (84.5% vs 80.2%, p<0.001). However, numbers of patients who presented very late (>12 hours after symptom onset) were similar (53% vs 51%, NS). Moreover, the numbers of patients with door-to-balloon time ≤90 minutes were similar (49.1% vs 51.3%, NS), and in-hospital mortality rates were similar (8.3% vs 6.9%, NS) in 2011 compared to 2008–2010.ConclusionAfter a local network implementation for patients with STEMI, there were significantly more inter-hospital referral cases, primary PCI procedures, and patients with a door-to-needle time ≤30 minutes, compared to the period before implementation of this network. However, numbers of patients who presented very late, the targeted door-to-balloon time and in-hospital mortality rate were similar in both periods. To improve STEMI networking based on recent guidelines, existing pre-hospital and in-hospital protocols should be improved and managed more carefully, and should be accommodated whenever possible.

Association between Adherence to Guideline-Recommended Preventive Medications and In-Hospital Mortality among Non-Reperfused ST-Elevation Myocardial Infarction Patients Admitted to a Tertiary Care Academic Center in a Developing Country

“…Data quality was maintained and verified regularly by the primary investigator of the registry (SD). The hospital provides a 24/7 cardiovascular service, including primary percutaneous coronary intervention (pPCI) and is hosting the regional STEMI network [17][18][19]. More details on the STEMI network characteristics in Jakarta was previously described [17].…”

“…Since the hospital provide a 24/7 service, most of the STEMI cases were transferred to the national cardiovascular hospital, particularly during off-hours. A pre-hospital triage form was developed to improve the acute phase management [19].…”

“…The majority (74.9%) of the non-reperfused patients were late presenters, defined as presenting >12 h from symptoms of STEMI [25]. Diagnosis of STEMI was made based on the presence of typical chest pain and ST-segment elevation (≥0.1 mV) in two or more contiguous leads on the initial ECG [16,17,19]. Acute reperfusion therapy was defined as pPCI or fibrinolytic therapy.…”

“…Acute reperfusion therapy, preferably timely primary percutaneous coronary intervention (pPCI) conducted maximally within 120 minutes since the first medical contact or STEMI diagnosis, is the best management for ischemic STEMI patients transferred from non-capable pPCI hospitals to capable pPCI hospitals [9,11]. Despite continued attempts to implement this emergency care in patients with STEMI presenting at hospitals, up to more than 50% of these patients still did not receive acute reperfusion therapy [14,15], especially in developing countries such as India [15], Indonesia [15][16][17][18][19], Phillipines [15], and Vietnam [20]. Even in developed countries, around 20%-30% of patients with STEMI who were eligible for reperfusion still failed to receive this evidence-based intervention [21][22][23].…”

Challenges and solutions in medically managed ACS in the Asia-Pacific region: Expert recommendations from the Asia-Pacific ACS Medical Management Working Group

“…In-hospital mortality was 13% in STEMI patients who did not receive reperfusion therapy, compared with 6% receiving fibrinolysis and 5% undergoing primary PCI. Following the establishment of a local STEMI network in Jakarta, 2011 data from the JAC registry showed significant increases in inter-hospital referral rates for STEMI patients and rates of primary PCI procedures, but in-hospital mortality changed little between 2008 and 2009 (8% versus 7%), indicating that improvements in pre-hospital and in-hospital protocols to improve the overall standard of care are still needed [49].…”