"The treatment of the acute coronary syndrome in the County Hospital Dubrovnik before and after implementation of primary percutaneous coronary intervention strategy"

Akutni koronarni sindrom (AKS) kliniĉko je stanje kojemu je u podlozi naglo nastala kritiĉna ishemija miokarda. AKS podrazumijeva dva entiteta: nestabilnu anginu pektoris (NAP) i infarkt miokarda. Uz simptome i EKG nalaz njihovo meĊusobno razlikovanje temelji se na laboratorijskoj potvrdi (infarkt) ili iskljuĉivanju miokardne nekroze (NAP) nalazom tropinina T ili I i/ili MB-frakcije kreatin kinaze. Uz nekrozu miokarda, bolesnici se dijele na temelju EKG-nalaza na one s infarktom miokarda s ST-elevacijom (STEMI) i infarktom miokarda bez ST-elevacije (NSTEMI). Terapija izbora za STEMI je primarna perkutana koronarna intervencija (pPCI) ili fibrinoliza. U NSTEMI PCI se radi odmah kod nestabilnih bolesnika a kod ostalih kasnije. Cilj ovoga rada bio je prikazati rad tima za invazivnu kardiologiju u OB „Dubrovnik“ u dvogodišnjem razdoblju prije uvoĊenja trajne pripravnosti (2011 - 2012 ) u odnosu na razdoblje nakon uvoĊenja trajne pripravnosti (2013- 2014), na uzorku od 1104 bolesnika koji su invazivno obraĊeni u ta dva razdoblja. Nakon uvoĊenja trajne pripravnosti porastao je ukupan broj svih invazivno obraĊenih bolesnika, od 375 na 729, za 94,4%. MeĊu invazivno obraĊenima znaĉajano je porastao udio hitno primljenih bolesnika, od 41,5% na 65,0%. U drugom razdoblju porastao je i broj ukupno primljenih bolesnika s AKS, od 359 na 442, za 23% kao i udio invazivnih obrada bolesnika s AKS, od 59,3% u prvom razdoblju na gotovo sve bolesnike, 97,3% u drugom razdoblju. Porast udjela invazivnih obrada zabiljeţen je kod bolesnika s NAP, od 95,4% u prvom na 99,4% bolesnika u drugom razdoblju. Kod bolesnika s NSTEMI taj porast je bio od 56,9% na 96% a kod bolesnika s STEMI od 30,6% na 95,5%. U redovitom dnevnom radu samo uvoĊenje pripravnosti pridonijelo je povećanju udjela bolesnika s NSTEMI, od 10,9% na 19,7%. S teţim bolesnicima u drugom razdoblju povećao se i mortalitet, s 0,26 na 1,51% no ta razlika nije bila statistiĉki znaĉajna. Unatoĉ većem udjelu hitno primljenih bolesnika trajanje hospitalizacije se smanjilo, sa 7,14 ± 5,31 na 7,02 ± 5,40 dana, doduše bez statistiĉke znaĉajnosti. PCI uĉinjena je kod 40,8% invazivno obraĊenih bolesnika u oba perioda. Udio uĉinjenih zahvata bio je sliĉan na LAD (41,2% vs. 44,0%; p=0,677), na ACx (23,5% vs. 18,1%; p=0,245), na OM grani (10,% vs 12,1%; p=0,676) kao i na RCA (39,2% vs. 30,9%; p=0,140) a broj zahvata se razlikuje na deblu LKA kojih je u razdoblju nakon uvoĊenja pripravnosti bilo 3 a u prethodnom razdoblju ih nije bilo. Nalazi se i razlika u udjelu zahvata na dijagonalnoj grani (2,0% vs. 3,7%) i na posterodescendentnoj grani (0,6% vs 3,7%). Znaĉajno je poraslo korištenje radijalnog pristupa nakon uvoĊenja pripravnosti, od 0,5% (samo 2 pretrage) na 55,4% (403 pretrage; p>0,01). Prosjeĉan broj balonskih dilatacija po bolesniku u razdoblju 2013.-2014. godine se smanjio (0,51 vs. 0,73; p>0,001) a broj implantiranih stentova po bolesniku ostao je sliĉan, kako metalnih stentova (BMS) tako i stentova koji otpuštaju lijek (DES). Broj implantacija balona koji otpuštaju lijek (DEB) znaĉajno je porastao nakon uvoĊenja trajne pripravnosti (p=0,05). U odnosu na prethodno razdoblje uvoĊenje trajne pripravnosti (2013.-2014. godine) u OB „Dubrovnik“ prestala je potreba za dolaskom gostujućih operatera, znaĉajno je porastao ukupan broj invazivno obraĊenih bolesnika, broj bolesnika primljenih s AKS kao i njihovih invazivnih obrada, navlastito onih s STEMI i NSTEMI. Na osnovu više pokazatelja, osim znaĉajnog poboljšanja skrbi za bolesnike naše ţupanije, porasla je i kvaliteta rada u invazivnom kardiološkom laboratoriju.Acute Coronary Syndrome (ACS) is a clinical condition caused by acute onset of critical myocardial ischemia. ACS consists of two entities: unstable angina pectoris (UAP) and myocardial infarction. Together with symptoms and the ECG finding, the distinction between them is based on a laboratory confirmation (infarct) or exclusion of myocardial necrosis (NAP). Patients with laboratory confirmation of MI are according to ECG finding divided to two groups: those with myocardial infarction with ST elevation (STEMI) and those with myocardial infarction without ST elevation (NSTEMI). Therapies of choice for STEMI patients are the primary percutaneous coronary intervention (pPCI) and fibrinolysis, while NSTEMI patients are treated primarily with PCI method only in the case of clinical instability. Other NSTEMI patients are treated by PCI method in postponed time (usually within 24-72 hours). The aim of this study was to present the work of the team for invasive cardiology in the GH "Dubrovnik" in the two-year period, before the introduction of permanent 24/7 on call duty (2011-2012) (first group) in relation to the period with available 24/7 on call duty for invasive cardiology (2013-2014) (second group). The sample included 1104 invasively treated patients in these two periods. After starting with 24/7 on call duty in this Laboratory the total number of invasively treated patients increased from 375 to 729, for 94.4%. Among them, the proportion of patients urgently reffered to PCI increased from 41.5% to 65.0%. In the second group, the number of patients with ACS reffered to PCI increased from 359 to 442, by 23%, and the proportion of invasively treated patients with ACS, from 59.3% in the first group rose to almost all patients, 97.3% in the second group. An increase in proportion of invasively treated patients was observed in patients with UAP, from 95.4% in the first to 99.4% of patients in the second group. In patients with NSTEMI, the increase was 56.9% at 96% and in STEMI patients from 30.6% to 95.5%. In regular daily work, the introduction of 24/7 on call duty contributed to an increase in proportion of patients with NSTEMI, from 10.9% to 19.7%. Mortality rate was also increased in the second analyzed due to highr proportion of the more serious patients, from 0.26 to 1.51%, but this difference was not statistically significant. Despite higher proportion of urgently reffered patients, the duration of hospitalization decreased from 7.14 ± 5.31 to 7.02 ± 5.40 days, statistically insignificant indeed. PCI was performed in 40.8% invasively treated patients in both groups. Lesions on LAD (41.2% versus 44.0%, p = 0.677), ACx (23.5% versus 18.1%, p = 0.245), OM granule (10, % vs 12.1%, p = 0.676) as well as RCA (39.2% versus 30.9%, p = 0.140) were treated with similar frequency, but the number of interventions on LMCA differs, which were 3 in the second group compared to 0 in the first group. There is also a difference in the proportion of interventions on the diagonal branch (2.0% vs. 3.7%) and on the posterior descending artery (0.6% vs. 3.7%). There was also significant increase in the use of transradial approach in the second group, from 0.5% (only 2 tests) to 55.4% (403 tests; p> 0.01). Average number of balloon dilatations per patient in 2013-2014 period declined (0.51 vs. 0.73, p> 0.001), and the number of implanted stents per patient remained similar, both for the metal stents (BMS) and the drug-releasing stents (DES) implantation. The number of drug eluting balloon implants (DEBs) increased significantly in the second analyzed group (p = 0.05). In relation to the previous period, the introduction of 24/7 on call duty for invasive cardiology in the GH "Dubrovnik" (2013- 2014) ceased the need for the arrival of guest operators, significantly increased the overall number of invasively treated patients, the number of patients received with ACS and their invasive treatment, those with STEMI and NSTEMI. Based on a numerous indicators, beside significant improvement in patient care in our county, the quality of work in the invasive cardiology laboratory has increased