What is the clinical evidence from this study?

Study design: Observational. Population: acute ST-elevation myocardial infarction (STEMI). Intervention: Implementation of guidelines via a cooperating network vs. Before establishment of the network. Primary outcome: in-hospital mortality.

May 16, 2006

Implementation of Guidelines Improves the Standard of Care

Key Result

Implementation of guidelines via a cooperating network for acute STEMI decreased in-hospital mortality from 16% before establishment to 9.5%.

Study Design

Type

Observational

Multicenter

Yes

Structured PICO

Does the implementation of recent guidelines via a cooperating regional network reduce in-hospital mortality in patients with acute STEMI?

Population

Patients with acute STEMI in Vienna evaluated before and after the implementation of a cooperating network for reperfusion strategies.

Exposure

Implementation of recent guidelines via a cooperating network (Viennese Ambulance Systems and 5 high-volume interventional cardiology departments) to expand primary percutaneous catheter intervention (PPCI) and optimize reperfusion strategy

Comparator

Standard of care before the establishment of the network

Outcome

In-hospital mortalityhard clinical

Organizing a regional network to implement STEMI guidelines significantly increased the use of primary PCI and reduced in-hospital mortality.

Main Result

Absolute Event Rate: 9.5% vs 16%

Abstract

BACKGROUND: The purpose of this study was to determine whether implementation of recent guidelines improves in-hospital mortality from acute ST-elevation myocardial infarction (STEMI) in a metropolitan area. METHODS AND RESULTS: We organized a network that consisted of the Viennese Ambulance Systems, which is responsible for diagnosis and triage of patients with acute STEMI, and 5 high-volume interventional cardiology departments to expand the performance of primary percutaneous catheter intervention (PPCI) and to use the fastest available reperfusion strategy in STEMI of short duration (2 to 3 hours from onset of symptoms), either PPCI or thrombolytic therapy (TT; prehospital or in-hospital), respectively. Implementation of guidelines resulted in increased numbers of patients receiving 1 of the 2 reperfusion strategies (from 66% to 86.6%). Accordingly, the proportion of patients not receiving reperfusion therapy dropped from 34% to 13.4%, respectively. PPCI usage increased from 16% to almost 60%, whereas the use of TT decreased from 50.5% to 26.7% in the participating centers. As a consequence, in-hospital mortality decreased from 16% before establishment of the network to 9.5%, including patients not receiving reperfusion therapy. Whereas PPCI and TT demonstrated comparable in-hospital mortality rates when initiated within 2 to 3 hours from onset of symptoms, PPCI was more effective in acute STEMI of >3 but <12 hours' duration. CONCLUSIONS: Implementation of recent guidelines for the treatment of acute STEMI by the organization of a cooperating network within a large metropolitan area was associated with a significant improvement in clinical outcomes.