区域协同体系对不具备急诊冠脉介入能力医院急性心肌梗死患者救治的影响
Impact of regional collaborative network on the rescue of patients with ST-elevation acute myocardial infarction in hospitals not capable of percutaneous coronary intervention

甘小勤.区域协同体系对不具备急诊冠脉介入能力医院急性心肌梗死患者救治的影响[J].内科急危重症杂志,2019,25(6):446-449

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DOI：10.11768/nkjwzzzz20190603

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作者	单位	E-mail
甘小勤	华中科技大学同济医学院附属同济医院	thisiszhou@163.com

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中文摘要:

目的:总结以具备急诊冠状动脉介入治疗(PCI)能力医院(PCI医院)胸痛中心为核心的区域协同救治体系对未具备PCI能力医院(非PCI医院)救治急性ST段抬高型心肌梗死（STEMI）患者疗效的影响、目前现状及问题，以探索改进措施。方法: 调取华中科技大学同济医学院附属同济医院胸痛中心数据库中2016年8月1日~2017年7月31日与2018年8月1日~2019年7月31日2个时间段的数据，分析比较区域协同救治体系建立前后，首诊于非PCI医院STEMI患者的诊治流程及治疗效果。结果: 区域协同救治体系建立后，患者首次医疗接触(FMC)至首份心电图时间从(17.7±40.7)min缩短至(7.9±8.5)min (P<0.01)，10min内完成心电图达标率从52.1%提高至72.1%(P<0.01)；FMC至负荷剂量双抗血小板聚集药时间明显缩短\[(36.7±29.3)min vs (30.0±18.7)min，P<0.05\]；FMC至抗凝给药时间虽有缩短趋势但差异无统计学意义\[(92.8±79.7)min vs (71.0±55.6)min，P=0.20\]；FMC至溶栓时间有降低趋势但差异无统计学意义\[(117.4±126.0)min vs (79.5±61.2)min，P=0.20\]；采取溶栓早期介入策略者比例由9.0%升至17.3%(P<0.05)；患者当地医院入门至转出时间未见统计学差异\[(269.9±530.5)min vs (298.3±337.5)min，P=0.60\]；转诊患者绕行华中科技大学同济医学院附属同济医院急诊的比例从55.7%提高至75.8%(P<0.01)；转诊患者急诊PCI术前造影罪犯血管TIMI血流从0.29±0.82提高至0.93±1.23(P<0.01)，然而FMC至球囊扩张时间较前延长\[(363.2±209.1)min vs (422.9±302.7)min，P<0.05\]，转诊患者住院期间心力衰竭发生率(5.7% vs 4.0%，P=0.38)、死亡率(2.3% vs 0.9%，P=0.25)虽有下降，但均未见统计学差异。结论: 基于胸痛区域协同救治体系，对首诊于非PCI医院STEMI患者的早期规范化救治有明显改进，带来疗效的改善，但转诊延迟仍然普遍。

英文摘要:

Objective: To investigate the impact of the regional collaborative network on the rescue of patient with ST-elevation acute myocardial infarction (STEMI) initially diagnosed in hospitals not capable of percutaneous coronary intervention (non-PCI hospital), and explore the countermeasure. Methods: The data from the collaborative network database of chest pain center were analyzed, and the early rescue timeline after first medical contact (FMC) of STEMI patients in the non-PCI hospitals was compared before (from August 1st, 2016 to July 31st, 2017) and after (from August 1st, 2018 to July 31st, 2019) establishment of the collaborative networks. Results: A total of 502 STEMI patients were included in the study. As compared with the baselines of earlier time after the establishment of the regional collaborative network for acute chest pain, the mean FMC to the first electrocardiogram time was significantly shortened from (17.7±40.7) min to (7.9±8.5) min （P<0.01）. The ECG compliance rate of less than 10 min was increased from 52.1% to 72.1% (P<0.01). The time of FMC to loading dose of dual-antiplatelet administration was significantly shortened \[(36.7±29.3) min vs (30.0±18.7) min, P<0.05\]. The FMC to anticoagulation time had a shortened trend, but the difference was not statistically significant \[(92.8±79.7) min vs (71.0±55.6)min, P=0.20\]. There was a decrease in the FMC to thrombolysis time, but the difference also was not statistically significant \[(117.4±126.0) min vs (79.5±61.2)min,P=0.20\].The proportion 〖LM〗of patients taking thrombolytic + early intervention strategy increased from 9.0% to 17.3% (P<0.05). There was no statistically significant difference in the time of door-in-door-out in non-PCI hospitals \[(269.9±530.5) min vs (298.3±337.5) min, P=0.60\]. The proportion of referral patients bypassing our hospital emergence room increased from 55.7% to 75.8% (P<0.01). Among these referral STEMI patients, angiography showed that the culprit artery TIMI flow was improved from 0.29±0.82 to 0.93±1.23 (P<0.01). The time of FMC to balloon dilation was significantly longer than before \[(363.2±209.1) min vs (422.9±302.7) min,P<0.05\]. The incidence of heart failure (5.7% vs 4.0%, P=0.38) and death (2.3% vs 0.9%, P=0.25) during hospitalization decreased. However, no statistically significant difference was observed. Conclusion: Based on the regional collaborative network for acute chest pain, the rescue of patients with STEMI initially diagnosed in non-PCI hospitals has been improved through early standardized treatment, while thrombolytic + early intervention strategies are less, and the delay in referral is still widespread.