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Original
article
Analysis
of
the
management
of
ST-segment
elevation
myocardial
infarction
in
Spain.
Results
from
the
ACI-SEC
Infarction
Code
Registry
Oriol
Rodrı
´guez-Leor,
a,b,c,
*Ana
Bele
´n
Cid-A
´lvarez,
d
Armando
Pe
´rez
de
Prado,
e
Xavier
Rossello
´,
b,f,g
Soledad
Ojeda,
h
Ana
Serrador,
b,i
Ramo
´n
Lo
´pez-Palop,
j
Javier
Martı
´n-Moreiras,
b,k
Jose
´Ramo
´n
Rumoroso,
l
A
´ngel
Cequier,
m
Borja
Iba
´n
˜ez,
b,f,n
Ignacio
Cruz-Gonza
´lez,
b,k
Rafael
Romaguera,
m
Sergio
Raposeiras,
o
and
Rau
´l
Moreno
b,p
;
,
on
behalf
of
the
investigators
of
the
Infarction
Code
Working
Group
of
the
Interventional
Cardiology
Association
of
the
Spanish
Society
of
Cardiology
^
a
Institut
del
Cor,
Hospital
Universitari
Germans
Trias
i
Pujol,
Badalona,
Barcelona,
Spain
b
Centro
de
Investigacio
´n
Biome
´dica
en
Red
de
Enfermedades
Cardiovasculares
(CIBERCV),
Spain
c
Institut
de
Recerca
en
Cie
`ncies
de
la
Salut
Germans
Trias
i
Pujol,
Badalona,
Barcelona,
Spain
d
Servicio
de
Cardiologı
´a,
Hospital
Clı
´nico
de
Santiago
de
Compostela,
Santiago
de
Compostela,
A
Corun
˜a,
Spain
e
Servicio
de
Cardiologı
´a,
Hospital
de
Leo
´n,
Leo
´n,
Spain
f
Centro
Nacional
de
Investigaciones
Cardiovasculares
Carlos
III
(CNIC),
Madrid,
Spain
g
Servicio
de
Cardiologı
´a,
Institut
d’Investigacio
´Sanita
`ria
Illes
Balears
(IdISBa),
Hospital
Universitari
Son
Espases,
Palma
de
Mallorca,
Balearic
Islands,
Spain
h
Servicio
de
Cardiologı
´a,
Hospital
Universitario
Reina
Sofı
´a,
Instituto
Maimo
´nides
de
Investigacio
´n
Biome
´dica
de
Co
´rdoba
(IMIBIC),
Universidad
de
Co
´rdoba,
Co
´rdoba,
Spain
i
Servicio
de
Cardiologı
´a,
Hospital
Clı
´nico
de
Valladolid,
Valladolid,
Spain
j
Servicio
de
Cardiologı
´a,
Hospital
Clı
´nico
Universitario
Virgen
de
la
Arrixaca,
El
Palmar,
Murcia,
Spain
k
Servicio
de
Cardiologı
´a,
Hospital
Universitario
de
Salamanca,
Instituto
de
Investigacio
´n
Biome
´dica
de
Salamanca
(IBSAL),
Salamanca,
Spain
l
Servicio
de
Cardiologı
´a,
Hospital
de
Galdakao-Usansolo,
Galdakao,
Vizcaya,
Spain
m
Servicio
de
Cardiologı
´a,
Hospital
de
Bellvitge-IDIBELL,
Universitat
de
Barcelona,
L’Hospitalet
de
Llobregat,
Barcelona,
Spain
n
Servicio
de
Cardiologı
´a,
IIS-Hospital
Universitario
Fundacio
´n
Jime
´nez
Dı
´az,
Madrid,
Spain
o
Servicio
de
Cardiologı
´a,
Hospital
Universitario
A
´lvaro
Cunqueiro,
Instituto
de
Investigacio
´n
Sanitaria
Galicia
Sur,
Vigo,
Pontevedra,
Spain
p
Servicio
de
Cardiologı
´a,
Hospital
de
La
Paz,
Madrid,
Spain
Rev
Esp
Cardiol.
2022;75(8):669–680
Article
history:
Received
6
July
2021
Accepted
25
October
2021
Available
online
20
January
2022
Keywords:
STEMI
Primary
angioplasty
STEMI-network
A
B
S
T
R
A
C
T
Introduction
and
objectives:
ST-segment
elevation
myocardial
infarction
(STEMI)
networks
should
guarantee
STEMI
care
with
good
clinical
results
and
within
the
recommended
time
parameters.
There
is
no
contemporary
information
on
the
performance
of
these
networks
in
Spain.
The
objective
of
this
study
was
to
analyze
the
clinical
characteristics
of
patients,
times
to
reperfusion,
characteristics
of
the
intervention
performed,
and
30-day
mortality.
Methods:
Prospective,
observational,
multicenter
registry
of
consecutive
patients
treated
in
17
STEMI
networks
in
Spain
(83
centers
with
the
Infarction
Code),
between
April
1
and
June
30,
2019.
Results:
A
total
of
5401
patients
were
attended
(mean
age,
64
13
years;
76.9%
male),
of
which
4366
(80.8%)
had
confirmed
STEMI.
Of
these,
87.5%
were
treated
with
primary
angioplasty,
4.4%
with
fibrinolysis,
and
8.1%
did
not
receive
reperfusion.
In
patients
treated
with
primary
angioplasty,
the
time
between
symptom
onset
and
reperfusion
was
193
[135-315]
minutes
and
the
time
between
first
medical
contact
and
reperfusion
was
107
[80-146]
minutes.
Overall
30-day
mortality
due
to
STEMI
was
7.9%,
while
mortality
in
patients
treated
with
primary
angioplasty
was
6.8%.
Conclusions:
Most
patients
with
STEMI
were
treated
with
primary
angioplasty.
In
more
than
half
of
the
patients,
the
time
from
first
medical
contact
to
reperfusion
was
<
120
minutes.
Mortality
at
30
days
was
relatively
low.
C
2021
Sociedad
Espan
˜ola
de
Cardiologı
´a.
Published
by
Elsevier
Espan
˜a,
S.L.U.
All
rights
reserved.
*Corresponding
author:
Unidad
de
Cardiologı
´a
Intervencionista,
Hospital
Germans
Trias
i
Pujol,
Ctra.
de
Canyet
s/n,
08916
Badalona,
Barcelona,
Spain.
E-mail
address:
oriolrodriguez@gmail.com
(O.
Rodrı
´guez-Leor).
^
See
the
supplementary
data
for
details
on
the
institutions
and
organizations
that
participated
in
the
Infarction
Code
Working
Group
of
the
Interventional
Cardiology
Association
of
the
Spanish
Society
of
Cardiology.
https://doi.org/10.1016/j.rec.2021.12.005
1885-5857/
C
2021
Sociedad
Espan
˜ola
de
Cardiologı
´a.
Published
by
Elsevier
Espan
˜a,
S.L.U.
All
rights
reserved.
Document downloaded from https://www.revespcardiol.org/?ref=1372545279, day 09/04/2023. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.Document downloaded from https://www.revespcardiol.org/?ref=1372545279, day 09/04/2023. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.
INTRODUCTION
The
superiority
of
percutaneous
coronary
intervention
(pPCI)
over
pharmacological
reperfusion
therapy
in
ST-segment
elevation
myocardial
infarction
(STEMI)
was
clearly
established
in
the
early
2000s.
1
pPCI
is
superior
to
fibrinolysis
when
performed
in
a
timely
manner
(within
120
minutes
of
the
initial
diagnosis)
by
an
experienced
team
at
a
specialized
hospital.
To
provide
the
best
reperfusion
strategy
to
as
many
patients
as
possible
within
recommended
timeframes,
scientific
societies
recommend
the
creation
of
community-wide
and
regional
STEMI
networks
to
expedite
the
delivery
of
optimal
care.
2
In
Spain,
these
systems
are
known
as
Infarction
Code
networks.
Spain’s
first
regional
networks
were
launched
in
Murcia
3
and
Navarre
4
in
2000.
In
2005,
Galicia
launched
PROGALIAM,
the
country’s
first
multiprovincial
program
for
STEMI
care.
5
Similar
programs
were
put
in
place
over
the
following
years,
and
full
national
coverage
was
achieved
in
2017,
with
the
incorporation
of
Extremadura,
the
Canary
Islands,
and
Andalusia.
6
From
2004
to
2005,
slightly
more
than
one-third
of
STEMI
patients
who
received
reperfusion
therapy
in
Spain
were
treated
with
pPCI,
7
and
this
figure
increased
to
just
over
54%
in
2012.
8
The
Interventional
Cardiology
Association
of
the
Spanish
Society
of
Cardiology
(ACI-
SEC)
publishes
annual
activity
reports,
9
but
apart
from
these
and
publications
by
regional
networks,
3,4,10,11
little
is
known
about
the
current
state
of
STEMI
care
within
Spain’s
Infarction
Code
networks.
To
characterize
the
current
situation,
20
years
after
the
creation
of
Spain’s
regional
STEMI
networks,
the
ACI-SEC
Infarction
Code
Working
Group
created
a
registry
of
consecutive
patients
with
Infarction
Code
activations
over
a
period
of
3
months.
The
aim
of
this
study
was
to
describe
the
characteristics
of
the
patients
in
the
registry,
the
care
received,
and
30-day
outcomes.
METHODS
Study
design
We
performed
an
observational
study
of
the
prospective,
national
ACI-SEC
Infarction
Code
Registry,
which
contains
data
on
patients
treated
at
83
hospitals
within
Spain’s
17
regional
STEMI
care
networks.
We
analyzed
the
clinical
characteristics
of
the
patients
included,
times
to
reperfusion,
treatment
characteristics,
and
30-day
mortality
rates.
The
patients
in
the
registry
were
treated
consecutively
over
a
3-month
period
(April
1
to
June
30,
2019).
Inclusion
criteria
Patients
for
whom
an
Infarction
Code
was
activated
in
any
of
the
regional
STEMI
care
networks
and
who
met
the
following
criteria
were
included
in
the
study:
a)
diagnosis
of
acute
coronary
syndrome
with
ST-segment
elevation,
that
is,
symptoms
compati-
ble
with
acute
coronary
syndrome
with
ST-segment
elevation
on
ECG,
a
new
left
bundle
branch
block,
or
suspected
posterior
infarction
within
24
hours
of
symptom
onset;
b)
recovery
from
cardiorespiratory
arrest
of
suspected
coronary
origin,
or
c)
cardiogenic
shock
of
suspected
coronary
origin.
Ana
´lisis
de
la
atencio
´n
al
infarto
con
elevacio
´n
del
segmento
ST
en
Espan
˜a.
Resultados
del
Registro
de
Co
´digo
Infarto
de
la
ACI-SEC
Palabras
clave:
IAMCEST
Angioplastia
primaria
Red
de
atencio
´n
al
infarto
R
E
S
U
M
E
N
Introduccio
´n
y
objetivos:
Las
redes
de
Co
´digo
Infarto
deben
garantizar
una
atencio
´n
al
infarto
agudo
de
miocardio
con
elevacio
´n
del
segmento
ST
con
buenos
resultados
clı
´nicos
y
dentro
de
los
para
´metros
de
tiempo
recomendados.
No
hay
informacio
´n
contempora
´nea
sobre
el
funcionamiento
de
estas
redes
en
Espan
˜a.
El
objetivo
es
analizar
las
caracterı
´sticas
clı
´nicas
de
los
pacientes
atendidos,
el
tiempo
hasta
la
reperfusio
´n,
las
caracterı
´sticas
de
la
intervencio
´n
realizada
y
la
mortalidad
a
30
dı
´as.
Me
´todos:
Registro
prospectivo,
observacional
y
multice
´ntrico
de
pacientes
los
consecutivos
atendidos
en
17
redes
de
Co
´digo
Infarto
en
Espan
˜a
(83
centros
con
Co
´digo
Infarto)
entre
el
1
de
abril
y
el
30
de
junio
de
2019.
Resultados:
Se
atendio
´a
5.401
pacientes
(media
de
edad,
64
13
an
˜os;
el
76,9%
varones),
de
los
que
4.366
(80,8%)
sufrieron
un
infarto
con
elevacio
´n
del
ST.
De
estos,
se
trato
´al
87,5%
con
angioplastia
primaria,
al
4,4%
con
fibrinolisis
y
al
8,1%
sin
reperfusio
´n.
En
los
casos
tratados
con
angioplastia
primaria,
el
tiempo
entre
el
inicio
de
los
sı
´ntomas
y
la
reperfusio
´n
fue
193
[135-315]
min
y
el
tiempo
entre
el
primer
contacto
me
´dico
y
la
reperfusio
´n,
107
[80-146]
min.
La
mortalidad
total
a
30
dı
´as
por
infarto
agudo
de
miocardio
con
elevacio
´n
del
ST
fue
del
7,9%,
mientras
que
entre
los
pacientes
tratados
con
angioplastia
primaria
fue
del
6,8%.
Conclusiones:
Se
trato
´con
angioplastia
primaria
a
la
inmensa
mayorı
´a
de
los
pacientes
con
infarto
agudo
de
miocardio
con
elevacio
´n
del
ST,
y
en
ma
´s
de
la
mitad
de
los
casos
el
tiempo
desde
el
primer
contacto
me
´dico
hasta
la
reperfusio
´n
fue
<
120
min.
La
mortalidad
a
30
dı
´as
fue
relativamente
baja.
C
2021
Sociedad
Espan
˜ola
de
Cardiologı
´a.
Publicado
por
Elsevier
Espan
˜a,
S.L.U.
Todos
los
derechos
reservados.
Abbreviations
ACI-SEC:
Interventional
Cardiology
Association
of
the
Spanish
Society
of
Cardiology
pPCI:
primary
percutaneous
coronary
intervention
STEMI:
ST-segment
myocardial
infarction
O.
Rodrı
´guez-Leor
et
al.
/
Rev
Esp
Cardiol.
2022;75(8):669–680
670
Document downloaded from https://www.revespcardiol.org/?ref=1372545279, day 09/04/2023. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.Document downloaded from https://www.revespcardiol.org/?ref=1372545279, day 09/04/2023. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.
Variable
definition
and
collection
The
study
variables
were
entered
into
a
centralized
online
database
and
are
shown
in
the
supplementary
data.
All
the
variables
are
defined
in
the
study
protocol.
Each
hospital
assigned
a
person
to
evaluate
and
add
the
data
to
the
registry.
The
ACI-SEC
Infarction
Code
Working
Group
also
appointed
a
coordinator
for
each
regional
network
to
act
as
a
liaison
and
clarify
doubts.
The
statistical
analyses
were
performed
by
the
authors
of
this
article.
The
timelines
from
symptom
onset
to
reperfusion
were
defined
according
to
the
European
guidelines
on
STEMI
management.
2
For
each
case,
the
hospitals
were
asked
to
provide
a
subjective
opinion
on
whether
there
had
been
an
undue
delay
between
the
first
medical
contact
and
reperfusion
(yes/no)
and
if
so,
to
offer
a
reason.
Code
activations
were
considered
inappropriate
when,
following
evaluation
on
arrival
at
the
pPCI
center,
the
patient
did
not
meet
any
of
the
clinical
or
electrocardiographic
(ECG)
criteria
for
STEMI.
12
Appropriate
activations
were
classified
as
clinical
false
positives
when
the
definitive
diagnosis
was
a
condition
other
than
STEMI
and
as
angiographic
false
positives
when
no
culprit
lesion
was
detected.
12
The
study
protocol
was
approved
by
the
Infarction
Code
Working
Group
and
the
lead
ethics
committee.
The
committee
considered
it
unnecessary
to
obtain
informed
consent
as
the
anonymity
of
the
data
was
guaranteed.
Statistical
analysis
Continuous
variables
are
expressed
as
mean
standard
deviation
and
categorical
variables
as
frequencies
and
percentages.
Between-group
baseline
variables
were
compared
using
the
t
test
or
chi-square
test
as
appropriate.
Times
to
reperfusion
are
expressed
as
median
[interquartile
range]
and
were
compared
using
the
Mann-
Whitney
U
test.
Statistical
significance
was
set
at
P
<
.05.
All
statistical
analyses
were
performed
in
STATA
version
15IC
(Stata
Corp.,
USA).
RESULTS
Infarction
code
patients
In
the
3-month
study
period,
5401
patients
were
treated
within
Spain’s
17
regional
STEMI
care
networks.
The
flow
of
patients
according
to
their
final
diagnosis
is
shown
in
figure
1,
together
with
a
breakdown
of
the
reperfusion
strategy
used
in
those
diagnosed
with
STEMI
(4366
patients,
80.8%).
Overall,
3792
patients
(87.5%)
underwent
pPCI,
189
(4.4%)
underwent
fibrinolysis,
and
353
(8.1%)
received
no
reperfusion
therapy.
The
flow
of
patients
according
to
treatment
decision
taken
during
the
first
medical
contact,
treatment
administered
(pPCI,
fibrinolysis,
or
no
reperfusion),
and
final
diagnosis
is
shown
in
figure
2.
The
breakdown
of
code
activations
according
to
appropriate-
ness,
final
diagnoses,
and
ECG
findings
is
shown
in
figure
3.
ECG
findings
and
final
diagnoses
were
available
for
4820
activations
and
of
these,
4571
(94.8%)
were
classified
as
appropriate.
There
were
3901
true
positives
for
STEMI
(80.9%),
580
clinical
false
positives,
and
90
angiographic
false
positives.
Code
activation
was
classified
as
inappropriate
in
249
cases;
there
were
183
true
negatives
and
just
66
false
negatives
(1.4%
of
total).
Differential
characteristics
of
patients
diagnosed
with
stemi
vs
another
condition
The
clinical
characteristics
of
patients
with
a
final
diagnosis
of
STEMI
vs
another
condition
are
summarized
in
table
1.
STEMI
was
significantly
more
common
in
men,
smokers,
and
patients
without
hypertension
or
a
history
of
ischemic
heart
disease,
PCI,
or
heart
surgery.
Patients
diagnosed
with
a
condition
other
than
STEMI
were
significantly
more
likely
to
have
ventricular
tachycardia
and
asystole
and
to
need
mechanical
ventilation
during
their
first
medical
contact;
mortality
rates
were
also
higher
at
this
stage.
Figure
1.
Flowchart
showing
patients
with
Spanish
Infarction
Code
activations
from
April
to
June
2019
for
whom
a
definitive
diagnosis
was
recorded.
Also
shown
is
the
reperfusion
strategy
used
in
patients
diagnosed
with
STEMI.
NSTE-ACS,
non–ST-segment
elevation
acute
coronary
syndrome;
pPCI,
primary
percutaneous
coronary
intervention;
STEMI,
ST-segment
elevation
myocardial
infarction.
O.
Rodrı
´guez-Leor
et
al.
/
Rev
Esp
Cardiol.
2022;75(8):669–680
671
Document downloaded from https://www.revespcardiol.org/?ref=1372545279, day 09/04/2023. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.Document downloaded from https://www.revespcardiol.org/?ref=1372545279, day 09/04/2023. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.
Figure
2.
Flow
chart
showing
patients
with
Spanish
Infarction
Code
activations
from
April
to
June
according
to
treatment
decision
during
FMC,
reperfusion
strategy
applied,
and
final
clinical
diagnosis.
FMC,
first
medical
contact;
NSTE-ACS,
non–ST-segment
elevation
acute
coronary
syndrome;
pPCI,
primary
percutaneous
coronary
intervention;
STEMI,
ST-segment
elevation
myocardial
infarction.
Figure
3.
Flowchart
showing
patients
according
to
appropriateness
of
code
activation
together
with
final
clinical
diagnosis
and
electrocardiographic
findings
in
each
case.
True
and
false
positives
were
calculated
as
a
percentage
of
all
the
codes
analyzed.
AMI,
acute
myocardial
infarcion;
LBBB,
left
bundle
branch
block;
RBBB,
right
bundle
branch
block.
O.
Rodrı
´guez-Leor
et
al.
/
Rev
Esp
Cardiol.
2022;75(8):669–680
672
Document downloaded from https://www.revespcardiol.org/?ref=1372545279, day 09/04/2023. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.Document downloaded from https://www.revespcardiol.org/?ref=1372545279, day 09/04/2023. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.
Reperfusion
strategies
among
stemi
patients
The
clinical
characteristics
of
patients
diagnosed
with
STEMI
are
summarized
according
to
reperfusion
strategy
in
table
2,
which
also
shows
the
characteristics
of
the
first
medical
contact
and
the
clinical
timelines
(from
symptom
onset
to
reperfusion).
Compared
with
patients
who
underwent
pPCI,
those
treated
with
fibrinolysis
(n
=
189)
were
younger,
more
likely
to
be
men,
and
less
likely
to
be
treated
at
a
specialized
pPCI
hospital.
They
were
also
more
likely
to
have
ventricular
fibrillation
and
to
die
during
the
first
medical
contact.
They
had
a
shorter
time
from
symptom
onset
to
first
medical
contract.
Median
time
from
first
medical
contact
to
initiation
of
fibrinolysis
was
36.5
[IQR,
20-68]
minutes.
Overall,
106
patients
(56.1%)
treated
with
fibrinolysis
underwent
rescue
PCI,
while
74
(39.2%)
underwent
deferred
revascularization
of
the
culprit
lesion.
Coronary
angiography
without
revascularization
was
performed
in
7
patients
(3.7%);
2
patients
(1.1%)
did
not
undergo
angiography
as
they
died
during
the
first
medical
contact.
Reasons
for
performing
fibrinolysis
rather
than
pPCI
were
an
estimated
time
to
pPCI
of
>
120
minutes
in
64%
of
patients
and
unavailability
of
pPCI
in
19%.
Other
reasons
were
given
for
17.3%
of
patients.
Compared
with
patients
treated
with
pPCI,
those
who
did
not
receive
reperfusion
therapy
were
older
and
more
likely
to
be
women,
have
pre-existing
heart
failure,
and
present
with
asystole
or
cardiogenic
shock
or
die
during
the
first
medical
contact.
Table
1
Clinical
characteristics
of
patients
treated
within
Spain’s
regional
Infarction
Code
networks
according
to
final
diagnosis
(STEMI
vs
other
condition)
STEMI
(n
=
4366)
Not
STEMI
(n
=
888)
P
Total
(n
=
5254)
Age,
y
64
13
63
14
.92
64
13
Men
3403/4365
(78.0)
642/888
(72.3)
<
.0001
4045/5253
(76.9)
Personal
medical
history
Hypertension
2210/4335
(51.1)
459/835
(55.6)
.014
2669/5160
(51.7)
Diabetes
mellitus
1091/4314
(25.3)
220/824
(26.7)
.40
1311/5138
(25.5)
Dyslipidemia
1961/4326
(45.3)
371/822
(45.1)
.92
2332/5148
(45.3)
Active
smoking
1895/4268
(44.4)
229/819
(28.0)
<
.0001
2124/5087
(41.8)
Previous
ischemic
heart
disease
452/4318
(10.5)
122/818
(14.9)
<
.0001
574/5136
(11.2)
Previous
PCI
445/4234
(10.5)
114/802
(14.2)
.002
559/5036
(11.1)
Previous
heart
surgery
51/4232
(1.2)
27/804
(3.4)
<
.0001
78/5036
(1.6)
Previous
stroke
176/4222
(4.2)
39/794
(4.9)
.34
215/5016
(4.3)
Killip
class
on
admission
I
3462/4248
(81.5)
565/689
(82.0)
.015
4027/4937
(81.6)
II
337/4248
(7.9)
35/689
(5.1)
372/4937
(7.5)
III
129/4248
(3.0)
30/689
(4.4)
159/4937
(3.2)
IV
320/4248
(7.5)
59/689
(8.6)
379/4937
(7.7)
First
medical
contact
Out-of-hospital
emergency
services
1519/4303
(35.3)
263/808
(32.6)
<
.0001
1782/5111
(34.9)
Primary
care
center
1038/4303
(24.1)
150/808
(18.6)
1188/5111
(23.2)
Non-pPCI
hospital
965/4303
(22.4)
242/808
(30.0)
1207/5111
(23.6)
pPCI
hospital
781/4303
(18.2)
153/808
(18.9)
934/5111
(18.3)
Treatment
decision
at
time
of
first
medical
contact
pPCI
3721/4233
(87.9)
666/797
(83.6)
<
.0001
4387/5030
(87.2)
Fibrinolysis
173/4233
(4.1)
8/797
(1.0)
181/5030
(3.6)
Transfer
to
non-pPCI
hospital
for
decision
77/4233
(1.8)
15/797
(1.9)
92/5030
(1.8)
Transfer
to
pPCI
hospital
for
decision
262/4233
(6.2)
108/797
(13.6)
370/5030
(7.4)
Complications
during
first
contact
Ventricular
fibrillation
287/4366
(6.6)
64/888
(7.2)
.49
351/5252
(6.7)
Ventricular
tachycardia
53/4366
(1.2)
26/888
(2.9)
<
.0001
79/5254
(1.5)
Atrioventricular
block
149/4366
(3.4)
7/888
(0.8)
<
.0001
156/5254
(3.0)
Asystole
62/4366
(1.4)
24/888
(2.7)
.006
86/5254
(1.7)
Cardiogenic
shock
187/4366
(4.3)
42/888
(4.7)
.55
229/5254
(4.4)
Mechanical
ventilation
181/4366
(4.2)
77/888
(8.7)
<
.0001
258/5254
(4.9)
Death
9/4366
(0.2)
6/888
(0.7)
.017
15/5254
(0.3)
Clinical
timelines
Time
from
symptom
onset
to
first
medical
contact,
min
67
[30-165]
60
[24.5-180]
<
.001
65
[30-170]
Time
from
first
medical
contact
to
ECG,
min
7
[4-15]
8
[5-15]
.006
7
[4-15]
Time
from
diagnosis
to
code
activation,
min
5
[0-15]
0
[0-15]
<
.001
5
[0-15]
Time
from
first
medical
contact
to
code
activation,
min
15
[6-35]
24
[10-60]
<
.001
15
[7-39.5]
ECG,
electrocardiogram;
PCI,
percutaneous
coronary
intervention;
pPCI,
primary
percutaneous
coronary
intervention;
STEMI,
ST-segment
elevation
myocardial
infarction.
Not
included:
147
patients
whose
final
diagnosis
was
not
reported.
Values
are
expressed
as
No.
(%)
or
median
[interquartile
range].
O.
Rodrı
´guez-Leor
et
al.
/
Rev
Esp
Cardiol.
2022;75(8):669–680
673
Document downloaded from https://www.revespcardiol.org/?ref=1372545279, day 09/04/2023. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.Document downloaded from https://www.revespcardiol.org/?ref=1372545279, day 09/04/2023. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.
Table
2
Clinical
and
first
medical
contact
characteristics
and
times
from
symptom
onset
to
reperfusion
in
patients
with
STEMI
according
to
reperfusion
strategy
pPCI
(n
=
3792)
Fibrinolysis
(n
=
189)
No
reperfusion
(n
=
353)
pPCI
vs
fibrinolysis,
P
pPCI
vs
no
reperfusion,
P
Age,
y
63.5
12.9
61.5
11.7
66.5
14.0
.032
<
.001
Men
2971/3792
(78.4)
159/188
(84.6)
193/343
(56.3)
.042
<
.001
Personal
medical
history
Hypertension
1910/3773
(50.6)
94/187
(50.3)
193/343
(56.3)
.92
.045
Diabetes
mellitus
948/3754
(25.3)
40/187
(21.4)
94/341
(27.6)
.23
.35
Dyslipidemia
1699/3764
(45.1)
93/188
(49.5)
154/343
(44.9)
.24
.93
Active
smoking
1677/3716
(45.1)
97/188
(51.6)
107/333
(32.1)
.08
<
.001
Previous
ischemic
heart
disease
380/3761
(10.1)
19/187
(10.2)
47/338
(13.9)
.98
.028
Previous
PCI
386/3681
(10.5)
14/185
(7.6)
40/336
(11.9)
.20
.42
Previous
heart
surgery
39/3681
(1.1)
0/184
(0)
10/335
(3.0)
.16
.002
Previous
stroke
150/3673
(4.1)
7/181
(3.4)
18/336
(5.4)
.89
.27
Killip
class
on
admission
I
3064/3724
(82.3)
136/182
(74.7)
238/311
(76.5)
.08
<
.001
II
297/3724
(8.0)
20/182
(11.0)
19/311
(6.1)
III
108/3724
(2.9)
8/182
(4.4)
10/311
(3.2)
IV
255/3724
(6.9)
18/182
(9.9)
44/311
(14.2)
First
medical
contact
Out-of-hospital
emergency
services
1338/3754
(35.6)
50/187
(26.7)
119/330
(36.1)
<
.001
.89
Primary
care
center
912/3754
(24.3)
49/187
(26.2)
75/330
(22.7)
Non-pPCI
hospital
799/3754
(21.3)
77/187
(41.2)
75/330
(22.7)
pPCI
hospital
705/3754
(18.8)
11/187
(5.9)
61/330
(18.5)
Treatment
decision
at
time
of
first
medical
contact
pPCI
3416/3707
(92.2)
1/188
(0.5)
279/307
(90.9)
<
.001
.67
Fibrinolysis
0/3707
(0)
173/188
(92.0)
0/307
(0)
Transfer
to
non-pPCI
hospital
for
decision
61/3707
(1.7)
10/188
(5.3)
5/307
(1.6)
Transfer
to
pPCI
hospital
for
decision
230/3707
(6.2)
4/188
(2.1)
23/307
(7.5)
Complications
during
first
contact
Ventricular
fibrillation
242/3792
(6.4)
24/189
(12.8)
21/353
(6.0)
.001
.75
Ventricular
tachycardia
42/3792
(1.1)
5/189
(2.7)
6/353
(1.7)
.056
.32
Atrioventricular
block
132/3792
(3.5)
7/189
(3.7)
10/353
(2.8)
.87
.52
Asystole
46/3792
(1.2)
4/189
(2.1)
12/353
(3.4)
.28
.001
Cardiogenic
shock
144/3792
(3.8)
12/189
(6.3)
29/353
(8.2)
.08
<
.001
Mechanical
ventilation
147/3792
(3.9)
15/189
(7.9)
19/353
(5.4)
.006
.17
Death
1/3792
(0.0)
2/187
(1.1)
6/353
(1.7)
<
.001
<
.001
Clinical
timelines
Time
from
symptom
onset
to
first
medical
contact,
min
66
[30-165]
60
[30-120]
75
[30-210]
.016
.17
Time
from
first
medical
contact
to
ECG,
min
7
[4-15]
6
[3.5-15]
8
[4-13]
.13
.72
Time
from
diagnosis
to
code
activation,
min
5
[0-15]
9
[0-30]
5
[0-18]
.001
.47
Time
from
first
medical
contact
to
code
activation,
min
15
[6-35]
10
[5-25]
15
[8-41]
<
.001
.29
Time
from
symptom
onset
to
reperfusion,
min
193
[135-315]
120
[75-195]
-
<
.001
-
Time
from
first
medical
contact
to
reperfusion,
min
107
[80-146]
36.5
[20-68]
-
<
.001
-
ECG,
electrocardiogram;
PCI,
percutaneous
coronary
intervention;
pPCI,
primary
percutaneous
coronary
intervention;
STEMI,
ST-segment
elevation
myocardial
infarction.
Not
included:
32
patients
without
specification
of
reperfusion
strategy.
Values
are
expressed
as
No.
(%)
or
median
[interquartile
range].
O.
Rodrı
´guez-Leor
et
al.
/
Rev
Esp
Cardiol.
2022;75(8):669–680
674
Document downloaded from https://www.revespcardiol.org/?ref=1372545279, day 09/04/2023. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.Document downloaded from https://www.revespcardiol.org/?ref=1372545279, day 09/04/2023. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.
Angiographic
and
procedure-related
characteristics
of
patients
treated
with
ppci
Angiographic
and
procedure-related
characteristics
for
STEMI
patients
treated
with
pPCI
are
shown
in
table
3.
Radial
access
was
used
in
>
90%
of
cases;
63%
of
patients
had
single-vessel
disease,
while
28%
required
mechanical
thrombectomy.
The
mean
number
of
stents
implanted
was
1.30
0.72
per
patient;
bare-metal
stents
were
used
in
just
7%
of
cases.
Plain
angioplasty
or
thrombectomy
was
used
in
4.4%
of
revascularized
patients
who
did
not
receive
a
stent.
PCI
was
used
to
treat
a
nonculprit
artery
during
pPCI
in
6.8%
of
patients.
Although
7.5%
of
patients
presented
with
cardiogenic
shock,
a
hemodynamic
support
device
(mainly
an
intra-aortic
balloon
pump)
was
used
in
just
2.4%
of
cases.
Most
patients
were
treated
with
aspirin
(97.6%)
and
P2Y
12
receptor
inhibitors
(95.1%).
Ticagrelor
was
the
most
widely
used
inhibitor
(52.5%).
Timelines
from
symptom
onset
to
reperfusion
in
stemi
patients
The
timelines
from
symptom
onset
to
reperfusion
in
STEMI
patients
treated
with
pPCI
are
shown
in
figure
4.
The
median
times
calculated
were
66
[IQR,
30-165]
minutes
for
symptom
onset
to
first
medical
contact,
107
[IQR,
80-146]
minutes
for
first
medical
contact
to
reperfusion,
and
193
[IQR,
135-315]
minutes
for
symptom
onset
to
reperfusion.
A
time
of
<
120
minutes
from
first
contact
to
reperfusion
was
observed
in
71.4%
of
patients
treated
by
emergency
medical
services,
48.6%
of
patients
treated
at
a
non-pPCI
hospital,
and
74.3%
of
patients
treated
at
a
pPCI
hospital.
Time
from
symptom
onset
to
first
medical
contact
in
patients
treated
with
fibrinolysis
was
60
[IQR,
30-120]
minutes.
The
other
times
were
36.5
[IQR,
20-68]
minutes
for
first
medical
contact
to
initiation
of
fibrinolysis
and
120
[IQR,
75-195]
minutes
for
symptom
onset
to
initiation
of
fibrinolysis.
Median
time
from
fibrinolytic
administration
to
revascularization
in
the
106
patients
who
required
rescue
PCI
was
165
[130-255]
minutes.
Coronary
angiography
was
performed
within
24
hours
in
86.4%
of
the
81
patients
who
underwent
this
procedure
after
effective
fibrinolysis.
An
undue
delay
from
first
medical
contact
to
reperfusion
(>
120
minutes)
was
reported
for
44.7%
of
patients.
The
main
reason
given
(in
18.5%
of
cases)
was
a
delay
in
the
initial
diagnosis
(figure
5).
Time
from
first
medical
contact
to
ECG
was
>
10
min-
minutes
in
30.8%
of
patients.
Clinical
outcomes
Complications
during
first
medical
contact,
cardiac
catheteri-
zation,
and
subsequent
hospitalization
are
shown
in
table
4.
In-hospital
and
30-day
mortality
rates
are
shown
in
figure
4.
Mortality
was
lower
in
patients
diagnosed
with
STEMI
than
in
those
diagnosed
with
another
condition
(5.5%
vs
7.3%
for
in-
hospital
mortality
[P
=
.032]
and
7.9%
vs
10.7%
for
30-day
mortality
[P
=
.009]).
Respective
rates
according
to
the
reperfu-
sion
strategy
employed
in
the
STEMI
group
were
4.8%
and
6.8%
for
pPCI
and
6.4%
and
9.6%
for
fibrinolysis.
Mortality
was
significantly
higher
in
patients
who
not
receiving
reperfusion:
12.4%
for
in-
hospital
mortality
and
18.2%
for
30-day
mortality
(figure
6).
DISCUSSION
We
have
characterized
the
current
situation
of
STEMI
care
within
Spain’s
regional
Infarction
Code
networks.
The
most
noteworthy
findings
are
that
a)
>
80%
of
patients
received
a
final
diagnosis
of
STEMI,
and,
of
these,
>
87%
were
treated
with
pPCI
(<
5%
underwent
fibrinolysis
and
just
over
8%
did
not
receive
reperfusion
therapy);
b)
median
time
to
reperfusion
in
the
pPCI
group
was
193
minutes
from
symptom
onset
and
107
minutes
from
first
medical
contact;
c)
the
main
reason
given
for
undue
delays
between
first
medical
contact
and
reperfusion
was
a
delay
in
the
initial
diagnosis;
and
d)
30-day
mortality
rates
were
7.9%
for
patients
with
STEMI
and
6.8%
for
those
treated
with
pPCI.
The
Spanish
public
health
care
system
has
17
regional
STEMI
care
networks
comprising
83
hospitals
that
provide
interrupted
pPCI
services
365
days
a
year.
According
to
the
ACI-SEC
activity
report
for
2019,
22
529
PCIs
were
performed
in
patients
with
myocardial
infarction;
of
these,
91.8%
were
primary
procedures,
Table
3
Primary
percutaneous
coronary
intervention
characteristics
in
STEMI
patients
Radial
access
3302/3659
(90.2)
Baseline
TIMI
flow
0
2697/3687
(73.2)
1
295/3687
(8.0)
2
330/3687
(8.9)
3
365/3687
(9.9)
Final
TIMI
flow
0
37/3722
(1.0)
1
22/3722
(0.9)
2
129/3722
(3.5)
3
3523/3722
(94.7)
Antiplatelet
treatment
Aspirin
2947/3020
(97.6)
Clopidogrel
1000/3019
(33.1)
Ticagrelor
1586/3019
(52.5)
Prasugrel
286/3019
(9.5)
Culprit
vessel
Left
truncus
arteriosus
57/3693
(1.5)
Anterior
descending
artery
1615/3693
(43.7)
Circumflex
artery
586/3693
(15.9)
Right
coronary
artery
1421/3693
(38.5)
Graft
14/3693
(0.4)
Diseased
vessels,
No
1
2358/3728
(63.3)
2
909/3728
(24.4)
3
461/3728
(12.4)
Hemodynamic
support
devices
None
3701/3792
(97.6)
Intra-aortic
balloon
pump
56/3792
(1.5)
Impella
9/3792
(0.2)
ECMO
4/3792
(0.1)
Other
22/3792
(0.6)
Type
of
intervention
Mechanical
thrombectomy
1084/3792
(28.6)
Balloon
dilation
1647/3792
(43.4)
Metal
stent
implantation
262/3792
(6.9)
Drug-eluting
stent
implantation
3365/3792
(88.7)
Stents
implanted
per
patient,
No.
1.30
0.72
Intervention
on
nonculprit
vessel
241/3.536
(6.8)
ECMO,
extracorporeal
membrane
oxygenation;
STEMI,
ST-segment
elevation
myocardial
infarction;
TIMI,
thrombolysis
in
myocardial
infarction.
O.
Rodrı
´guez-Leor
et
al.
/
Rev
Esp
Cardiol.
2022;75(8):669–680
675
Document downloaded from https://www.revespcardiol.org/?ref=1372545279, day 09/04/2023. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.Document downloaded from https://www.revespcardiol.org/?ref=1372545279, day 09/04/2023. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.
2.5%
were
rescue
procedures
after
failed
fibrinolysis,
and
5.7%
were
deferred
or
scheduled
procedures.
9
These
figures
are
consistent
with
the
rates
observed
in
the
current
registry.
Spain’s
regional
Infarction
Code
networks
have
provided
nationwide
coverage
since
2017,
6
resulting
in
improved
treatment
for
patients
with
STEMI.
According
to
data
from
the
MASCARA
study,
7
just
37%
of
STEMI
patients
who
received
reperfusion
therapy
from
2004
to
2005
were
treated
with
pPCI,
compared
with
54%
in
2012
13
and
95.3%
in
the
current
registry.
Reperfusion
rates
have
also
increased
significantly.
Just
8%
of
patients
in
our
series,
for
example,
did
not
receive
reperfusion
therapy
compared
with
36%
of
patients
in
2012.
13
These
improvements
have
been
accompanied
by
a
sizeable
decrease
in
in-hospital
mortality
rates
(from
9.2%
in
2012
13
to
5.5%
in
our
registry).
The
inappropriate
code
activation
rate
observed
in
our
study
is
similar
to
rates
reported
elsewhere,
which
can
range
from
5%
to
31%,
depending
on
the
definition.
14
In
Spain,
data
from
the
Catalan
Infarction
Code
network
for
2010
to
2011
showed
an
inappropriate
activation
rate
of
12.2%,
an
angiographic
false
positive
rate
of
14.6%,
and
a
clinical
false
positive
rate
of
11.6%.
15
These
rates
are
similar
to
those
observed
in
the
current
study.
Conditions
finally
diagnosed
as
something
other
than
STEMI
were
the
cause
of
greater
diagnostic
uncertainty
during
the
first
medical
contact,
with
patients
more
likely
to
be
transferred
to
a
pPCI
hospital
for
diagnostic
confirmation
and
treatment
decision.
More
than
50%
of
patients
with
an
inappropriate
code
activation
did
not
have
ST-
segment
elevation
on
ECG.
Defining
an
ideal
inappropriate
activation
rate
is
difficult,
as
an
excessively
high
rate
would
result
in
considerable
overuse
of
resources,
while
an
excessively
low
rate
would
mean
that
not
all
STEMI
patients
would
receive
the
treatment
they
needed.
Training
for
the
health
care
professionals
involved
in
the
diagnosis
of
STEMI
is
crucial,
16
particularly
considering
that
the
main
reason
given
for
excessive
time
to
reperfusion
in
our
series
was
a
delay
in
the
initial
diagnosis.
Median
time
from
first
medical
contact
to
reperfusion
by
pPCI
was
107
minutes;
this
is
in
line
with
the
European
guideline
recommendation
for
the
management
of
acute
STEMI
2
and
shorter
than
times
reported
for
other
countries
in
Europe.
17
Nonetheless,
the
hospitals
analyzed
reported
an
undue
delay
in
45%
of
cases,
although
these
delays
did
not
necessarily
mean
reperfusion
was
not
performed
within
the
recommended
120
minutes
from
first
medical
contact.
The
above
results
would
appear
to
indicate
the
achievement
of
considerable
improvements.
Further
improve-
ments
could
be
achieved
by
local
monitoring
of
times
to
reperfusion
to
detect
excessive
delays
and
areas
for
improve-
ment.
18,19
Expeditious
reperfusion
care
is
critical,
as
reductions
in
delays
have
been
linked
to
lower
adverse
cardiovascular
outcome
rates.
20
Figure
4.
Timelines
from
symptom
onset
to
reperfusion
in
patients
with
ST-segment
elevation
myocardial
infarction
treated
with
primary
percutaneous
coronary
intervention.
IQR,
interquartile
range.
O.
Rodrı
´guez-Leor
et
al.
/
Rev
Esp
Cardiol.
2022;75(8):669–680
676
Document downloaded from https://www.revespcardiol.org/?ref=1372545279, day 09/04/2023. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.Document downloaded from https://www.revespcardiol.org/?ref=1372545279, day 09/04/2023. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.
Radial
access
for
PCI
has
been
associated
with
lower
morbidity
and
mortality
in
STEMI
21,22
and
clearly
emerged
as
the
route
of
choice
in
Spain,
being
used
in
>
90%
of
pPCIs.
Mechanical
thrombectomy
was
used
in
>
28%
of
patients.
Based
on
the
results
of
the
TOTAL
trial,
23
European
guidelines
advise
against
routine
thrombectomy,
while
recognizing
its
potential
benefits
in
patients
with
a
high
thrombus
burden.
2
We
unfortunately
did
not
have
access
to
data
on
lesion
characteristics
to
determine
the
presence
of
abundant
thrombus
material
in
the
cases
treated
by
throm-
bectomy
in
our
series,
but
the
rate
observed
would
appear
to
be
in
keeping
with
the
guideline
recommendation.
Use
of
stents
was
also
in
line
with
guideline
recommendations,
as
drug-eluting
stents
were
used
in
almost
89%
of
cases
and
bare-metal
stents
in
just
7%.
The
data
from
the
ACI-SEC
Infarction
Code
registry
should
shed
light
on
current
deficiencies
in
clinical
practice
and
help
evaluate
the
quality
of
STEMI
care
in
Spain.
Although
the
creation
of
the
Spanish
Infarction
Code
networks
was
an
arduous
journey
during
which
economic
and
structural
shortcomings
were
often
compensated
by
the
dedication
and
commitment
of
those
at
the
frontline
of
care,
24
the
improved
clinical
outcomes
have
made
the
efforts
worthwhile.
Apart
from
ensuring
the
continued
functioning
of
these
complex
programs,
it
is
now
crucial
to
provide
the
different
network
components
with
the
necessary
funding
to
ensure
their
long-term
sustainability.
6
Figure
5.
Reasons
for
undue
delays
between
first
medical
contact
and
reperfusion.
Observation
of
an
undue
delay
between
the
first
medical
contact
and
reperfusion
did
not
necessarily
mean
that
reperfusion
was
not
performed
within
the
recommended
120
minutes.
In
fact,
reperfusion
was
performed
within
120
minutes
of
the
first
medical
contact
in
53.2%
of
cases,
but
21.5%
of
these
were
considered
to
involve
an
undue
delay.
PCI,
primary
cutaneous
intervention.
O.
Rodrı
´guez-Leor
et
al.
/
Rev
Esp
Cardiol.
2022;75(8):669–680
677
Document downloaded from https://www.revespcardiol.org/?ref=1372545279, day 09/04/2023. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.Document downloaded from https://www.revespcardiol.org/?ref=1372545279, day 09/04/2023. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.
Limitations
This
study
has
a
number
of
limitations
inherent
to
any
multicenter
observational
study.
Inaccuracies
and
misclassifica-
tion,
for
example,
can
occur
when
data
are
collected
and
evaluated
by
individual
centers,
without
centralized
monitoring.
Interven-
tional
cardiology
data,
however,
are
quite
well
standardized
around
the
world
and
the
online
data
entry
form
was
designed
to
be
intuitive
and
universally
applicable.
It
should
also
be
noted
that
STEMI
patients
treated
outside
the
Infarction
Code
networks
are
not
included
in
the
registry,
although
the
selection
bias
introduced
is
probably
minimal
due
to
their
small
number.
Patients
with
subacute
myocardial
infarction
who
did
not
meet
the
criteria
for
emergent
reperfusion
were
also
not
included.
Although
the
data
from
the
registry
are
from
2019,
there
have
been
no
major
organizational
changes
that
would
have
affected
the
functioning
of
the
networks
in
the
last
2
years,
or
any
significant
changes
to
the
European
STEMI
guidelines
(published
in
2017).
In
addition,
a
study
conducted
during
the
first
wave
of
the
coronavirus
2019
pandemic
did
not
detect
any
changes
to
reperfusion
strategies
or
time
from
first
medical
contact
to
reperfusion,
although
it
did
find
an
increase
in
STEMI-associated
mortality,
partly
attributable
to
longer
ischemia
times.
25
CONCLUSIONS
This
analysis
of
the
ACI-SEC
Infarction
Code
registry
shows
the
current
state
of
STEMI
care
within
Spain’s
regional
networks.
Overall,
>
80%
of
patients
received
a
definitive
diagnosis
of
STEMI,
and
the
vast
majority
received
reperfusion
therapy,
in
most
cases
by
pPCI.
Time
from
first
medical
contact
to
reperfusion
was
<
120
minutes
in
>
50%
of
cases.
In-hospital
and
30-day
mortality
rates
have
improved
significantly
since
the
national
implementa-
tion
of
Spain’s
Infarction
Code
networks.
The
participating
hospitals,
however,
reported
undue
delays
in
almost
50%
of
patients,
with
most
cases
being
attributed
to
a
delay
in
the
initial
diagnosis.
The
different
agents
involved
in
these
networks
should
take
the
necessary
steps
to
expedite
reperfusion
care.
Table
4
Complications
during
first
medical
contact,
cardiac
catheterization,
and
subsequent
hospitalization
STEMI
(n
=
4366)
Not
STEMI
(n
=
888)
P
Total
(n
=
5254)
Complications
during
first
contact
Ventricular
fibrillation
287/4366
(6.6)
64/888
(7.2)
.49
351/5252
(6.7)
Ventricular
tachycardia
53/4366
(1.2)
26/888
(2.9)
<
.0001
79/5254
(1.5)
Atrioventricular
block
149/4366
(3.4)
7/888
(0.8)
<
.0001
156/5254
(3.0)
Asystole
62/4366
(1.4)
24/888
(2.7)
.006
86/5254
(1.7)
Cardiogenic
shock
187/4366
(4.3)
42/888
(4.7)
.55
229/5254
(4.4)
Mechanical
ventilation
181/4366
(4.2)
77/888
(8.7)
<
.0001
258/5254
(4.9)
Death
9/4366
(0.2)
6/888
(0.7)
.017
15/5254
(0.3)
Complications
during
cardiac
catheterization
Ventricular
fibrillation
87/4366
(2.0)
5/888
(0.6)
.003
92/5254
(1.8)
Ventricular
tachycardia
45/4366
(1.0)
6/888
(0.7)
.33
51/5254
(1.0)
Atrioventricular
block
94/4366
(2.2)
3/888
(0.3)
<
.0001
97/5254
(1.9)
Asystole
26/4366
(0.6)
6/888
(0.7)
.78
32/5254
(0.6)
Acute
pulmonary
edema
50/4366
(1.2)
5/888
(0.6)
.12
55/5254
(1.1)
Cardiogenic
shock
158/4366
(3.6)
22/888
(2.5)
.088
180/5251
(3.4)
Mechanical
ventilation
67/4366
(1.5)
13/888
(1.5)
.88
80/5254
(1.5)
Death
41/4366
(0.9)
7/888
(0.8)
.67
48/5254
(0.9)
Complications
during
hospitalization
Ventricular
fibrillation
86/4366
(2.0)
12/888
(1.4)
.21
98/5254
(1.9)
Ventricular
tachycardia
75/4366
(1.6)
11/888
(1.2)
.31
86/5254
(1.6)
Atrioventricular
block
77/4366
(1.6)
7/888
(0.8)
.035
84/5254
(1.6)
Asystole
38/4366
(0.9)
12/888
(1.4)
.18
50/5254
(1.0)
Acute
pulmonary
edema
98/4366
(2.2)
27/888
(3.0)
.16
125/5254
(2.4)
Cardiogenic
shock
247/4366
(5.7)
45/888
(5.1)
.48
292/5254
(5.6)
Mechanical
ventilation
123/4366
(2.8)
31/888
(3.5)
.29
154/5254
(2.9)
Stent
thrombosis
46/4366
(1.1)
0/888
(0)
.002
46/5254
(0.9)
Reinfarction
31/4366
(0.7)
0/888
(0)
.012
31/5254
(0.6)
Mechanical
complication
26/4263
(0.6)
2/862
(0.2)
.2
28/5125
(0.6)
Hemorrhage
39/4366
(0.9)
2/888
(0.2)
.039
41/5254
(0.8)
STEMI,
ST-segment
elevation
myocardial
infarction.
O.
Rodrı
´guez-Leor
et
al.
/
Rev
Esp
Cardiol.
2022;75(8):669–680
678
Document downloaded from https://www.revespcardiol.org/?ref=1372545279, day 09/04/2023. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.Document downloaded from https://www.revespcardiol.org/?ref=1372545279, day 09/04/2023. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.
Figure
6.
In-hospital
and
30-day
mortality
rates
according
to
definitive
diagnosis
(STEMI
or
other)
and
reperfusion
strategy
in
patients
diagnosed
with
STEMI.
pPCI,
primary
percutaneous
coronary
intervention;
STEMI,
ST-segment
elevation
myocardial
infarction.
O.
Rodrı
´guez-Leor
et
al.
/
Rev
Esp
Cardiol.
2022;75(8):669–680
679
Document downloaded from https://www.revespcardiol.org/?ref=1372545279, day 09/04/2023. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.Document downloaded from https://www.revespcardiol.org/?ref=1372545279, day 09/04/2023. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.
WHAT
IS
KNOWN
ABOUT
THE
TOPIC?
–
pPCI
is
the
treatment
of
choice
in
STEMI
when
performed
by
an
experienced
team
within
recom-
mended
timeframes,
and
where
possible,
within
coor-
dinated
care
systems.
–
Spain’s
first
regional
Infarction
Code
networks
were
implemented
in
2000
and
the
journey
to
achieve
nationwide
coverage
was
completed
in
2017.
–
Little
has
been
published
on
clinical
STEMI
outcomes
since
the
nationwide
implementation
of
the
networks.
WHAT
DOES
THIS
STUDY
ADD?
–
Most
STEMI
patients
analyzed
received
reperfusion
therapy,
mostly
by
pPCI;
time
from
first
medical
contact
to
reperfusion
was
<
120
minutes
in
>
50%
of
cases.
–
Mortality
rates
have
improved
significantly
since
the
widespread
implementation
of
the
Infarction
Code
networks.
–
Undue
delays,
mostly
attributable
to
a
delay
in
the
initial
diagnosis,
were
detected
in
almost
50%
of
patients.
FUNDING
No
funding
was
received.
AUTHORS’
CONTRIBUTIONS
Writing
of
manuscript:
O.
Rodrı
´guez-Leor,
A.B.
Cid-A
´lvarez,
and
A.
Pe
´rez
de
Prado.
Revision
of
manuscript:
all
authors.
Statistical
analysis:
O.
Rodrı
´guez-Leor
and
X.
Rossello
´.
Revision
of
database:
O.
Rodrı
´guez-Leor,
A.B.
Cid-A
´lvarez,
and
A.
Pe
´rez
de
Prado.
Coordination
of
regional
Infarction
Code
networks:
all
authors.
CONFLICTS
OF
INTEREST
A.
Pe
´rez
de
Prado
has
received
personal
funding
from
iVascular,
Boston
Scientific,
Terumo,
Bbraun,
and
Abbott
Vascular;
A
´.
Cequier
has
received
personal
funding
from
Ferrer
International,
Terumo,
Astra
Zeneca,
and
Biotronik.
The
other
authors
report
no
conflicts
of
interest
in
relation
to
the
content
of
this
article.
APPENDIX.
SUPPLEMENTARY
DATA
Supplementary
data
associated
with
this
article
can
be
found
in
the
online
version
available
at
https://doi.org/10.1016/j.rec.2021.
12.005
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Document downloaded from https://www.revespcardiol.org/?ref=1372545279, day 09/04/2023. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.Document downloaded from https://www.revespcardiol.org/?ref=1372545279, day 09/04/2023. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.
