STEMI 临床救治路径的优化 如何缩短 DTB 时间

心内科医师的观点

马根山

东南大学附属中大医院2011.03.26

根据现行 STEMI 患者急诊 PCI 指南和医院质控要求 Door-to-balloon (D2B) 时间 < or = 90 minutes.

DTB 的时间界定

Time-to-admission and time-to-treatment for STEMI.

Barbagelata A, et al. J Electrocardiol. 2007;40(3):257-64

临床宣教不足，患者缺乏对 STEMI 的认识，致使患者发病时不能及时就医；院前急救系统不健全， EMS 系统未充分利用；急诊科医生对 SEIMI 判断不敏感 ;

医患之间的信任度不高，医患沟通困难；

医疗资源分配不均，有介入资格的医院和个人集中在中心城

市；

设备的可行性 ?

目前的问题：

影响 D2B 时间的因素 1 、病人就诊的时间是工作日还是节假日？ 2 、病人就诊的方式是门诊还是急诊？ 3 、病人入 CCU 时有无症状？ 4 、病人是否使用了 EMS （急救医疗服

务系统）转运？

Magid DJ, et al. JAMA. 2005 Aug 17;294(7):803-12

Relationship between time of day, day of week, timeliness of reperfusion, and in-hospital mortality for patients with acute STEMI.

病人就诊的时间点影响 D2B 的时间

Guideline Adherence for Fibrinolytic Therapy and Percutaneous Coronary Intervention by Patient Arrival Period

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ents

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Door-to-Drug Time, min Door-to-Balloon Time, min

Regular hours: weekdays, 7 am-5 pm;Off-hours: weekdays 5 pm-7 am and weekends.

Door-to-Drug and Door-to Balloon Subintervals by Patient Arrival Period

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Door-to-Drug Subinterval Door-to-Balloon Subinterval

Door-to data refers to the time interval from hospital arrival to electrocardiogram (ECG) completion

非工作时间就诊的 STEMI 病人 D2B 时间延长，并且与工作时间就诊的病人比较其住院死亡率增高 (odds ratio, 1.07; 95% CI, 1.01-1.14; P = 0.02).

直接从急诊室转入导管室，可以减少 STEMI 病人 D2B 的时间？

Protocol During Cardiology Activation/RoutineTransfer Period (October 1, 2004, Through August 31, 2005)

Emergency department physicians requested immediate cardiology evaluation for all STEMI patients. After patient evaluation, the cardiologist activated the catheterization laboratory by contacting the catheterization laboratory coordinator during regular hours (7 AM to 5 PM weekdays) or the hospital operator during off-hours (weekends and 5 PM to 7 AM weekdays). During regular hours, the catheterization laboratory coordinator notified the emergency department to transfer the patient when a catheterization room became available.During off-hours, transfer to the catheterization laboratory occurred on arrival of 2 catheterization staff members.

从 2004 年 10 月 01 日至 2005 年 8 月 31 日， STEMI 病人到达医院后，急诊医生立即要求心脏科会诊，在对病人评价后通知导

管室或医院值班的介入医生，导管室再通知急诊室转运病人

Protocol During Emergency Department Activation/Immediate Transfer Period (September1, 2005, Through June 26, 2006)

On September 1, 2005, at 7 AM, we implemented a protocol mandating (1) emergency department physician activation of the catheterization laboratory and (2) immediate transfer of the patient to an immediately available catheterization laboratory by an in-house emergency heart attack response team (EHART) consisting of an emergency department nurse, a critical care unit nurse, and a chest pain unit nurse. The only exceptions to immediate transfer by the nursing staff

2005 年 9 月 01 日至 2006 年 06 月 26 日，急诊科医生直接通知导管室，在导管室有空的情况下，立即

转运病人去导管室，这可由相关的护士决定

Summary of Processes During the 2 Study Time Periods

ED indicates emergency department; cath lab, catheterization laboratory.*In the first period, the 1 call to activate the cath lab was to the cath lab coordinator during daytime and through the operator at night. In the second time period, all calls went through the operator.

Door

EKG

ED Physician Evaluation

Cardiology Evaluation

Cath Lab Activation

Cath Lab Staff Arrival

Cath Lab Setup

Transfer to Cath Lab

Cath/PCI

Serial Model

Door

EKG

ED Physician Evaluation

Cath Lab Activation

Transfer to Cath Lab

Cath Lab Setup

Cardiology Evaluation

Cath Lab Staff Arrival

Cath/PCI

Parallel ModelTim

e

Primary and Secondary End Points

Primary and Secondary End Points

Primary and Secondary End Points

急诊室医生直接联系并立即转运病人至导管室可降低 D2B 时间，减少梗死面积，缩短住院时间，减低住院费用。

影响 D2B 时间的因素 患者及家属对疾病的认知程度 医患沟通的难易程度 患者家庭的经济状况 在有介入导管室条件，但介入资格医生

没有或不在时？

physician versus patient transfer?

Zhang Q, Shen WF, et al. Chin Med J (Engl). 2008 Mar 20;121(6):485-91.

转运病人还是转运医生可以缩短 D2B的时间

Study flowchart

Patients diagnosed as STEMI with 12-hour of

symptoms at local hospitals

Randomization

Physician transfer n=165

Patient transfer n=169

n=1713: Refuse to receive primary PCI therapy4: Unconscious at the time of hospital arrival

Tertiary hospital

Primary PCI

Physicians from tertiary hospital

Baseline characteristics

Door-to-balloon time betweentwo groups

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50

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250

Physician transer Patient transfer

Door-

to-b

allo

on t

ime (

min

)

●●

●●●●

●●●

●

●

●

●●●●

(95±20) min

(147±29) min

P<0.0001

Time to treatment in two groups

Parameters Physician transfer group

(n=165) Patient transfer group

(n=169) P value

Median Mean ± SD Median Mean ± SD

Symptom onset to local hospital (minutes) 211 264±156 185 241±167 0.38

Diagnosis to randomization (minutes) 29 29±6 28 28±6 0.25

Call ambulance to local hospital (minutes) - - 21 22±7

Doctor or patient transfer time (minutes) 33 34±5 35 35±4 0.08

Arrival to tertiary hospital to Cath Lab (minutes) - - 15 15±3

Door-to-balloon (minutes)

92 95±20 141 147±29 <0.0001

Door-to-balloon <90 minutes (n (%)) 35(21.2) 13(7.7) <0.001

Procedural characteristics

TIMI: thrombolysis in myocardial infarction; DES: drug-eluting stent; GP: glycoprotein; IABP: intra-aortic balloon counterpulsation; PCI: percutaneous coronary intervention

In-hospital and 30-day clinical outcomes

MACE-free survival rate at 30-day clinical follow-up

Physician transfer group: 91.0%

Patient transfer group: 82.9%

Log rank: P=0.043

Time ( day )

Cum

ula

tive M

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ree s

urv

ival

(×1

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%)

转运医生的益处

该研究提示：及时安排有资质和经验的介入医生前往有条件进行心脏介入的单位行 STEMI 病人急诊介入治疗是可行的，安全的，并且能缩短 D2B 的时间和减少 30天的 MACE

Lachance P, et al. J Invasive Cardiol. 2008 Nov;20(11):623-6

ECG-guided immediate intervention at the time of primary PCI to reduce door-to-balloon

time in ST-elevation myocardial infarction patients.

心电图指导的急诊 PCI

组 1: 心电图指导的急诊 PCI ，未完成心肌酶和其他相关检查

组 2 ：完成全部急诊冠脉事件评价后行急诊PCI

分组：

结 果

组 1 组 2 P values

N= 87 192

catheterization laboratory DTB (mins)

21 25.5 < 0.0001

median DTB (mins) 80 90 0.01

timely reperfusion (DTB < 90 min)(%)

63 49 0.04

Impact of different clinical pathways on outcomes of patients with acute ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention: the RAPID-AMI study.

Zhang Q, Shen WF, et al.Chin Med J (Engl). 2009 Mar 20;122(6):636-42.

不同的临床径路影响 D2B 的时间

Methods:

Patients with definite STEMI, who upon arrival at the emergency room were triaged to undergo primary PCI.

Rapid group: 271 patients were brought directly to catheterization laboratory;

Non-rapid group: 275 patients were admitted to CCU or cardiac ward first, and then transferred to the catheterization laboratory.

Primary endpoint: door-to-balloon (D2B) time.

Distribution of door-to-balloon time

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30

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147

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1116

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<90 90-120 121-150 151-180 >180

Rapi d Group

Non-Rapi d Group

Door-to-balloon time ( minutes )

P<0.0001

P<0.0001

P<0.0001

P<0.0001

P<0.343

Relationship between presenting time and door-to-balloon time

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Al l pati ents Regul ar-hours Off -hours

Rapi d Group

Non-Rapi d Group

D to

B tim

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A: Cumulative death-free survival rates for the two groups. B: MACE-free survival rate between two groups

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Time ( days) Time ( days)

Rapid group 94.5%Rapid group 90.1%

Non-Rapid group 89.5%Log-rank P=0.035

Non-Rapid group 84.0%Log-rank P=0.035

Independent predictors of 30-day mortality.

Dorsch MF, et al. Am Heart J. 2008 Jun;155(6):1054-

8

Direct ambulance admission to the cardiac catheterization laboratory significantly reduces door-to-balloon times in primary percutaneous coronary intervention

从救护车直接到导管室是否减少 D2B 的时间

Door- and call-to-balloon times according to source of admission. Hospital 1 ER is 3 miles from PCI center. Hospital 2 ER is 19 miles from PCI center.

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Di rect admi ssi on PCI center ER Hospi tal 1 ER Hospi tal 2 ER

Door- to-bal l oonCal l - to-bal l oon

(n=172)

(n=188)

(n=147)

(n=70)

Min

ute

s

Call-to-balloon targetDoor-to-balloon target

Percentage of patients achieving the target for door-to-balloon time (90 minutes) and call-to-balloon time (120 minutes) according to source of admission. Hospital 1 ER is 3 miles from PCI center. Hospital 2 ER is 19 miles from PCI center.

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Di rect admi ssi on PCI center ER Hospi tal 1 ER Hospi tal 2 ER

Door- to-bal l oonCal l - to-bal l oon

(n=172)

(n=188)

(n=147)

(n=70)

% o

f pati

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ach

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arg

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疑似 STEMI 病人直接从救护车转运至导管室，可以明显降低 D2B 时间，并且可以真正实现 D2B 时间 90 分钟的目标值。

Weaver AN, et al. Catheter Cardiovasc Interv. 2010;75(5):695-9

Arterial access and door-to-balloon times for primary PCI in patients presenting with acute STEMI

急诊手术路径是否影响 D2B 时间

Baseline Characteristics of Patients

BMI = body mass index, MI = myocardial infarction, CAD = coronary artery disease, PCI = percutaneous coronary intervention, CABG = cor-onary artery bypass grafting.

Procedural and Process Times Measured from Door to Balloon

经桡动脉急诊介入治疗较经股动脉明显缩短 D2B 时间

Procedural Complications

Pancholy S, et al. Catheter Cardiovasc Interv. 2010;75(7):99

1-5

Comparison of door-to-balloon times for primary PCI using transradial versus transfemoral approach

Distribution of Procedures by Operator

Operator 1 Operator 2 Operator 3 Operator 4 Operator 5

Transradial procedures 71 38 0 0 0

Transfemoral procedures 3 6 80 62 53

Total number of procedures 74 44 80 62 53

Demographic Variables

Door-to-balloon times

70± 1772± 14

0102030405060708090

100

Transfemoral Transradi al

P>0.27

Door-to-balloon times were similar between patients undergoing primary PCI via transfemoral or transradial route.

Procedural Characteristics

Comparison of Access Site Complications between Transradial and Transfemoral Groups

Major Adverse Cardiac Events at One Year Follow-up

BMC Cardiovascular Disorders 2009, 9:32

Outlier payments defined as hospital charges>$100,000 and hospital revenue>$100,000 both decreased significantly with adoption of the ED Activation/Immediate Transfer process

11. 5%

1. 3%

7. 7%

0%0%

5%

10%

15%

Cardi ol ogy Acti vati on Routi neTransfer

ED Acti vati on I mmedi ate Transfer

Hospi tal Charges>$100, 000

Hospi tal Revenue>$100, 000

P=0.015

P=0.022D2B 时间缩短，不仅减轻住院期间病人和医保的经济负担，而且此效益一直持续术后一年

(1) Autonomous ambulance diagnosis (ECG transmission?);

(2) Emergency department physician activation of the catheterization la

b.;

(3) Immediate patient transfer to an immediately available catheterizati

on laboratory;

(4) Direct CCU admission, based on a pre-hospital ECG;

(5) Open access direct to the catheter lab.

(6) Arterial access, transradial versus transfemoral ?

(7) ECG-guided immediate intervention without complete coronary ev

aluation;

(8) Physician versus patient transfer?

(9) Admission time of day, day of week?

理想的措施