Analysis of the aplication the reperfusion therapy in according to estimated level of risk patients with ST elevation myocardial infarction in Serbia

Iako je primena reperfuzione terapije (RT) u Srbiji počela pre 30 godina, do 2006 godine se u infarktu miokarda sa ST elevacijom (STEMI) primenjivala samo fibrinolitička terapija (FT) od kada se uvodi i primarna perkutana koronarna intervencija (p-PCI). Od 2002 godine, kada je zabeležena primena RT u 25% bolesnika sa STEMI, beleži se smanjenje intrahospitalnog mortaliteta ali je još uvek procenat bolesnika koji ne dobiju RT visok. Dobro je poznato da prognoza STEMI bolesnika zavisi od vremena koje prodje od početka simptoma do primene RT, ali i od niza komorbiditeta, faktora rizika, prethodne koronarne bolesti, godina starosti, pola, veličine i lokalizacije infarkta. Do sada nema dovoljno podataka o mortalitetu i tipu primenjene reperfuzione terapije kod bolesnika sa STEMI u Srbiji, zemlji u tranziciji. Poznato je da je odluka o primeni reperfuzione terapije i tip terapije uslovljena blizinom sale za kateterizaciju i mogućnosti da se što pre primeni p-PCI u toku 24h/7 dana u nedelji, ali i od ostalih navedenih faktora koji se odnose na bolesnika. Cilj rada je da se analiziraju mogućnosti i karakteristike koje bi imale uticaj na procenu rizika akutnog oboljenja, koji bi bio u skladu sa primenom odredjene vrste terapije. Ciljevi ovog istraživanja su da se u Srbiji, kod bolesnika sa STEMI: 1. utvrdi povezanost procenjenog stepena rizika i vremena proteklog od početka simptoma na odluku o primeni i tipu RT i 2. efekat primenjene RT na hospitalni tok i ishod u zavisnosti od napred navedenih faktora. Materijal i metode: Istraživanje je studija preseka sprovedena od 01.01.2007.-31.12.2009. godine, bazirana na podacima iz Hospitalnog registra za akutni koronarni sindrom u Srbiji (HORAKS). Kriterijum za uključivanje u studiju su konsekutivni bolesnici kod kojih su ispunjeni uslovi za postavljanje dijagnoze STEMI prema Evropskim preporukama. Tokom 3 posmatrane godine, na terirotiji Srbije je lečeno 22424 bolesnika sa STEMI. Bolesnici su prema načinu lečenja podeljeni u tri terapijske grupe: grupa lečena p-PCI (p-PCI grupa), grupa lečena FT (FT grupa) i grupa koja nije lečena RT (ne-RT grupa). Rezultati: U analizu je uključeno 15354 konsekutivnih pacijenata, srednjih godina starosti 63.58±11.97 godina, med 64 (55-73), odnos muškaraca/žena je bio 65/35%. U p-PCI grupi je bilo N=3370 bolesnika (21.9%), u FT grupi N=5132 bolesnika (33.4%), a u ne-RT grupi N=6852 (44.6%). Reperfuziona terapija se kod bolesnika sa visokim rizikom manje primenjuje, p-PCI i FT konsekutivno: stariji ≥65 godina 16.2% i 27.6%; srčana insuficijencija (SI) 14% i 31.1%; dijabetes 17.6% i 29.4%; cerebrovaskularna bolest (CVI) 17.9% i 23.9%; prethodni infarkt miokarda 16.2% i 27.1%; anemija 11.8% i 26.4%; bubrežna slabost 12.4% i 28.4%; predhodna perferna vaskularna bolest 12.% i 25.7%...Although, the treatment using reperfusion therapy (RT) in patients with ST elevation myocardial infarction (STEMI) started 30 years ago in Serbia, the use of fibrinolysis therapy (FT) has been only possible until 2006 years. The implementation primary percutaneous coronary intervention (p-PCI) was started to be applied during 2006 year. Since 2002, when it was recorded that RT was applied in 25%, the application is growing, especially in recent years. It is associated with reduction of in-hospital mortality. However, the percentage of patients with STEMI who do not receive RT is still high. It is well known that prognosis of ST-segment elevation myocardial infarction (STEMI) patients (pts) is time-dependent, but it depends on comorbidities, risk factors, previous coronary diseases, age, gender, the size and localization of the myocardial infarction. Until now, there are not enough data about mortality and the type of applied RT in STEMI patients in Serbia as a transition country. It is known that decision about application and type of RT is conditioned by distance to the catheterization laboratory and possibility of the emergency application p-PCI within 24 hours/7 days in a week, but it also depends on other factors which are related to the patients. The aim of the present work is to analyze abilities and characteristics, which could have an influence on risk evaluation acute disease and in accordance to that application and type of therapy. Moreover, during the study, it was great importance to: 1. determine which factors have the influence on fewer application of RT in STEMI patients, in Serbia, a country in transition, and to establish if application of RT and type of RT depend on the risk level of patients and the time of symptoms onset and 2. analyze the effects of RT on in-hospital outcome depending on the previously mentioned factors. Materials and Methods: The research is across sectional study, with used data from the Hospital registry for acute coronary syndrome in Serbia (HORAKS) from 01.01.2007-31.01.2009 year. Criteria for inclusion in the study are consecutive patients in whom the diagnosis of STEMI was in accordance to European guidelines. During the three analyzed years, 22424 patients were treated with STEMI in Serbia. Patients are divided according to the method of treatment in three groups: 1. patients treated with p-PCI (p-PCI group), 2. patients treated with FT (FT group) and 3. patients not treated with RT (non-RT group). Results: The analysis includes 15354 patients, average age of 63.58±11.97 years, med 64 (55-73), male/female ratio was 65/35%. The p-PCI group includes N=3370 patients (21.9%), the FT group of N=5132 patients (33.4%), and the non-RT group of N=6852 (44.6%) patients. In patients with high risk, RT is less applied, p-PCI and FT consecutively: elderly ≥65 yr. 16.2% and 27.6%; heart failure (HF) 14% and 31.1%; diabetes 17.6% and 29.4%; stroke 17.9% and 23.9%; previous myocardial infarction 16.2% and 27.1%; anemia 11.8% and 26.4%; renal failure 12.4% and 28.4%; previous vascular disease 12.% and 25.7%..