常德农村地区急性ST段抬高型心肌梗死患者院前溶栓治疗后的观察分析

Trends in clinical outcomes and survival following prehospital thrombolytic therapy given by ambulance clinicians for acute ST elevation myocardial infarction in Changde rural areas

目的:探索常德农村地区急性ST段抬高型心肌梗死(ST-segment elevation myocardial infarction, STEMI)患者院前溶栓治疗后的临床结局和生存趋势。方法:观察2020-2022年常德农村地区给予院前溶栓患者的临床结局。院前医生接诊可疑心肌梗死的患者后,对其进行初步的评估与治疗,评估包括完善床旁12导心电图、肌钙蛋白T,心电图通过远程心电系统,将信息传输给院内胸痛中心(急诊科、心内科、导管室),肌钙蛋白T的结果通过院内胸痛中心微信群进行传输,患者的基本信息、体检结果以及相关临床指标通过院前电子病历系统,实施院前与胸痛中心的互通。是否行溶栓治疗由心内科专家进行决策。结果:共385例STEMI患者接受院前溶栓治疗,患者年龄中位数为61.2岁,其中77%为男性,院前再灌注治疗节省的时间为131 min。在症状出现后2 h内接受院前溶栓治疗的比例从2020年的21%上升到2022年的39%,差异有统计学意义(P=0.003)。首次医疗接触后24 h内接受冠状动脉造影或经皮冠状动脉介入治疗(percutaneous coronary intervention, PCI)的患者比例从56.4%增加到95.6%,差异有统计学意义(P<0.001)。STEMI后收缩期心力衰竭从19.3%下降到8.9%,差异有统计学意义(P=0.021),而患者1年死亡率下降了50%,达到5.6%。13例患者出现急性院外心脏骤停(out-of-hospital cardiac arrest, OHCA),所有患者均成功除颤。10例(2.6%)患者发生重大出血事件。结论:院前溶栓治疗是一种可行和安全的干预措施,可用于STEMI长距离转诊过程中,PCI实施前改善心肌再灌注的先行方案。

Objective:To will explore the clinical outcomes and survival trends after prehospital thrombolysis in patients with acute ST elevation myocardial infarction(STEMI)in the rural area of Changde.Methods:The outcomes of a prehospital thrombolytic therapy system in changde rural area during three years were observed.Electrocardiogram(ECG)through remote ECG system,the information transmission to the hospital chest pain center(emergency department,cardiology,catheterization).The results of the troponin T through the hospital chest pain center WeChat group transmission.The patients basic information,physical examination results and related clinical indicators through pre-hospital electronic medical record system,the implementation of pre-hospital and chest pain center.The decision making whether to perform thrombolysis is made by a cardiologist.Results:A total of 385 STEMI patients received prehospital thrombolytic therapy,median patient age was 61.2 years,and 77%were men.Time saved by prehospital reperfusion therapy was 131 minutes.The proportion who got prehospital thrombolytic therapy within 2 hours of symptom onset increased from 21%in 2020 to 39%in 2022,with a statistically significant difference(P=0.003).The proportion who underwent coronary angiography or percutaneous coronary intervention within 24 hours of first medical contact increased from 56.4%to 95.6%,with a statistically significant difference(P<0.001).Post-STEMI systolic heart failure decreased from 19.3%to 8.9%,with a statistically significant difference(P=0.021),while 1-year mortality fell,non-significantly,by 50%over time to reach 5.6%.Thirteen patients suffered acute out-of-hospital cardiac arrest,all were successfully defibrillated.Ten patients had major bleeding events(2.6%).Conclusion:Prehospital thrombolytic therapy is a feasible and safe intervention used in rural settings with long evacuation lines before percutaneous coronary intervention facilities.