Role of primary care physicians in treating patients

544856
ACC0010.1177/2048872614544856European Heart Journal: Acute Cardiovascular CareYayehd et al.
research-article2014
EUROPEAN
SOCIETY OF
CARDIOLOGY ®
Original scientific paper
Role of primary care physicians in
treating patients with ST-segment
elevation myocardial infarction
located in remote areas (from the
REseau Nord-Alpin des Urgences
[RENAU], Network)
European Heart Journal: Acute Cardiovascular Care
1–10
© The European Society of Cardiology 2014
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DOI: 10.1177/2048872614544856
acc.sagepub.com
Komlavi Yayehd1,2, Cécile Ricard1, François-Xavier Ageron1,
Léna Buscaglia1, Dominique Savary1, Bernard Audema3, Diane
Lacroix1, Manuela Barthes3, Patrick Joubert3, Gaël Gheno1, and
Loic Belle1, for the RENAU-RESURCOR study investigators
Abstract
Background: European guidelines for ST-segment elevation myocardial infarction (STEMI) encourage healthcare
networks to increase rates of, and decrease delays to, reperfusion. We examined the impact of training primary care
physicians (PCPs) to use equipment for pre-hospital management of STEMI patients in remote areas.
Methods and results: A network for cardiac emergencies was set up in the French Northern Alps in 2002 and a registry
of STEMI patients has been kept since. In 2005, 24 local volunteer PCPs were trained and equipped with electrocardiograms,
fibrinolysis kits, and automated external defibrillators to deal with cardiac emergencies in remote areas (>30-minute
ambulance travelling time). In this study, when the central call dispatcher received a telephone call from a patient in a
remote area reporting chest pain with a high probability of STEMI, the dispatcher sent a mobile intensive care unit (MICU)
with an emergency physician on board and asked the local PCP, if available, to manage the patient while awaiting arrival of
the MICU. Patients in whom the diagnosis of STEMI was confirmed were taken by MICU to an interventional cardiology
hospital. We report on patients who received care from a PCP before arrival of the MICU. Between 2005 and 2010, 4,015
patients were enrolled in the registry; 180 patients were located in a remote area, of whom 140 were in an area covered
by a participating PCP. Of the 62 patients attended by a PCP before MICU arrival, 27 received thrombolysis and eight
patients with ventricular tachycardia/fibrillation were shocked with an automated external defibrillator by the PCP. Mean
times from telephone call to thrombolysis were shorter when the patient was attended by a PCP (45.0 ± 25.5 vs 62.4 ±
23.4 min without intervention; p = 0.003). STEMI diagnosis without contraindication to thrombolysis was confirmed in 26
of 27 patients treated as such by PCPs and 1 patient was diagnosed with a Tako-Tsubo syndrome.
Conclusion: PCP care of STEMI patients located in isolated areas appears efficient, with high rates of resuscitation and
thrombolysis and a shorter delay to reperfusion.
Keywords
ST-segment elevation myocardial infarction, primary care physician, thrombolysis
Received: 11 May 2014; Accepted: 4 July 2014
1Hospital
of Annecy, France
Teaching Hospital of Campus, Lomé, Togo
3Médecins de Montagne, Chambéry, France
2University
Corresponding author:
Loic Belle, Department of Cardiology, CHR Annecy, 1 avenue de
l’hôpital 74370 Metz-Tessy, France.
Email: [email protected]
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European Heart Journal: Acute Cardiovascular Care
Introduction
Timely diagnosis and early reperfusion therapy is recommended in patients with acute ST-segment elevation myocardial infarction (STEMI) to minimize the risk of adverse
outcomes.1,2 Although primary percutaneous coronary
intervention (PCI) is the preferred reperfusion strategy,
fibrinolysis offers an alternative, particularly in settings
where primary PCI cannot be performed within the recommended timeframe.1,2 In France, the emergency medical
system (EMS) comprises a medical emergency dispatching centre in each administrative department (500,000 to 1
million inhabitants) with a nationwide telephone number
(15) and mobile intensive care units (MICUs) affiliated
with each hospital and staffed by emergency physicians. In
the emergency situation, the population is encouraged to
dial 15 and the dispatching centre sends a MICU, when
required. The establishment of the EMS has led to reductions in the delay to reperfusion for STEMI.3 For patients
located in remote areas (especially tourists in mountain
resorts),
however,
early
MICU
management
remains challenging. The purpose of this study is to report
our findings from a study involving STEMI patients
located in remote areas in Haute-Savoie and managed
through a regional emergency cardiac network.
Methods
We analysed the data from patients with acute STEMI
enrolled in an ongoing regional prospective registry in the
Northern Alps in France. The rationale for and methods
used have been detailed previously.4–7
The Northern Alps encompasses three French administrative departments (or counties; Isère, Savoie, and HauteSavoie) covering 15,000 km2, with an estimated population
of 1,860,000 but with wide seasonal variations due to tourism. The Haute-Savoie department covers high mountainous areas and has approximately 700,000 inhabitants. Five
hospitals are located in this department (St-Julien-enGenevois, Annemasse, Sallanches, Thonon, Annecy), all
of which have a MICU, and 1 (Annecy) has catheterization
laboratory facilities. Patients in Haute-Savoie also have
access to the catheterization laboratory facilities in two
neighbouring hospitals, located in Geneva and Grenoble
(Figure 1).
Figure 1. Map (and detail) showing locations of hospitals and primary care physician offices and available facilities.
MICU = mobile intensive care unit.
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Yayehd et al.
The RESeau des URgences CORonaires (RESURCOR)
network is a coordinated regional system of care for patients
with cardiac emergencies, as a part of the REseau NordAlpin des Urgences (RENAU) network started in October
2002 in the Northern Alps for the management of emergencies in the Northern French Alps. RESURCOR involves all
15 acute care hospitals (including 3 PCI centres) in this
region, along with three EMS call centres and 12 centres
with MICUs affiliated with the hospitals.
The aim of the RESURCOR network is to provide
prompt diagnosis and reduce delays to initiating recommended treatments in medical emergencies, particularly in
acute STEMI. Twenty-four PCPs in 12 medical offices
have been involved in RESURCOR since 2005. These
PCPs are trained and equipped by the EMS to deal with
cardiac emergencies through the provision of electrocardiogram (ECG) machines and automated external defibrillators (AEDs) (Figure 1). Nineteen of the PCPs were also
trained and equipped to administer pre-hospital fibrinolysis. All physicians (including the PCPs) involved in the
RESURCOR network were invited to meetings where the
overall policy of the network and the recommendations for
timely reperfusion therapy were presented and discussed.
As part of the RESURCOR network, a triage algorithm
and set of treatment protocols for coronary reperfusion
were established according to published guidelines1,2 and
available resources, and were approved by representatives
of the EMS call centres, MICUs, emergency departments,
coronary care units, and coronary interventional staff. The
triage algorithm and treatment protocols were disseminated
through pocket cards and booklets and are available at a
dedicated website (www.renau.org). The recommendations
are reviewed and updated annually according to the most
recent published evidence.
The triage algorithm recommends that physicians at
EMS call centres dispatch a MICU when they receive a call
from a patient with symptoms suggestive of acute myocardial infarction starting within the previous 12 hours.7
MICUs are staffed by emergency or critical care physicians
who can administer pre-hospital fibrinolysis and/or activate
the closest catheterization laboratory on route for primary
PCI, depending on anticipated delays in initiating reperfusion. The network recommends direct admission to a PCI
centre irrespective of the administration and type of reperfusion therapy. When the central call dispatcher receives a
telephone call from a patient located in a remote area who
reports chest pain with a high probability of STEMI, the
dispatcher asks the local PCP, if available, to attend the
patient while awaiting arrival of the MICU. If the diagnosis
of STEMI is confirmed, helicopter transportation to the
PCI hospital can be requested subject to availability,
weather conditions, and visibility.4
In the RESURCOR registry, data were collected prospectively on the clinical baseline characteristics, time to
reperfusion therapy, and coronary angiography findings in
patients with STEMI. Fibrinolysis was considered to have
been given by a PCP if a record to this effect was included
in the patient’s medical record and if the injection of drug
had been done before arrival of the MICU. Additional data
were recorded retrospectively from hospital clinical files in
patients treated by a PCP. The data collection methods,
verification procedures, accuracy, and primary outcomes
have been reported in detail elsewhere.5,6,8,9
In this analysis, data from patients located in remote
areas (> 30-minute delay between telephone call to the
EMS and arrival of the ambulance; ‘remote group’) were
compared with data from patients located close to a hospital ( 30-minute delay; ‘local group’). Second, in remote
areas, data from patients who received a PCP intervention
were compared with data from patients who did not receive
a PCP intervention.
Categorical variables are expressed as counts and percentages and comparisons made with the chi-squared test.
Continuous variables are described with means and standard deviations and comparisons made with Student’s t test.
Time variables were log-transformed. For all tests, statistical significance were set at p < 0.05. The data were analysed using IBM SPSS Statistics 21 (IBM Corp, NY).
Results
Between 1 January 2005 and 31 December 2010, 4,015
consecutive patients were enrolled in the RESURCOR registry. The patient flow chart is shown in Figure 2. In 1,357
of these patients, STEMI had occurred in the department of
Haute-Savoie; 431 of these patients were admitted direct to
the emergency department and 926 were treated in a MICU.
Of the 926 patients, 180 were in a remote area (140 in an
area with a participating PCP) and 730 were in a local area;
data were missing for 16 patients. Sixty-two patients were
treated by a participating PCP, 52 of whom were equipped
to administer fibrinolytic therapy.
The baseline characteristics, management, and delays to
treatment for patients located in remote and local areas are
given in Table 1. Patients in the remote group were younger
than those in local group and a greater proportion experienced a cardiac arrest as the initial presentation. More
patients in the remote group were treated with pre-hospital
fibrinolysis and transported to hospital by helicopter, and
the delays from telephone call to MICU arrival, to receipt
of pre-hospital reperfusion, and to hospital admission were
longer. Other clinical characteristics were similar between
the two groups. None of the patients in the two groups were
treated with hospital fibrinolysis.
The characteristics and management of patients in the
remote group are given in Table 2, according to whether
they received an intervention from a PCP while awaiting
arrival of the MICU. Of the 74 patients who did not receive
a PCP intervention, 31 were in an area not covered by a
PCP, and 43 patients were in an area covered by a PCP but
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European Heart Journal: Acute Cardiovascular Care
4015 patients enrolled in the
RESURCOR registry from 2005 to 2010
2658 patients located outside
Haute-Savoie
1357 patients located in Haute-Savoie
431 patients with no
intervention by MICU
926 patients with intervention by MICU
730 patients located locally + 16
with missing data
180 patients located in a remote
area
31 patients located in a remote area not
covered by a PCP + 9 with missing data
140 patients located in a remote area
covered by PCP
74 patients located in a remote area with no
PCP + 44 with missing data
43 patients with no PCP intervention + 35
with missing data
62 patients with
PCP intervention
9 patients with PCP with no fibrinolysis
facilities + 1 with missing data
52 patients with PCP with fibrinolysis
facilities intervention
Figure 2. Flow chart of study population.
MICU = mobile intensive care unit; PCP = primary care physician; RESURCOR = RESeau des URgences CORonaires.
who was unavailable to attend the patient. Baseline clinical
characteristics were well matched between the two groups,
with the exception of cardiogenic shock, which was more
frequent in the group attended by a PCP.
In the PCP-intervention group, 27 of 62 patients (43.5%)
were treated with fibrinolysis before arrival of the MICU
and 17 were treated with fibrinolysis by the MICU onboard physician. After admission to hospital, 17 patients
underwent primary PCI and 1 patient did not receive any
reperfusion therapy within 12 hours of symptom onset. The
time from telephone call to the EMS to receipt of fibrinolysis was reduced by an average of 17 minutes in the group
attended by a PCP (45.05 ± 25.5 vs 62.3 ± 25.9 minutes,
p = 0.003) (Table 2).
The in-hospital characteristics, management, and outcomes of patients in the remote group who received a
PCP intervention before MICU arrival are shown in
Table 3. All 62 patients were admitted direct by the
MICUs to hospitals with catheterization laboratory facilities and underwent coronary angiography, 35 on admission (17 primary PCI and 18 angiograms after suspected
failed fibrinolysis) and 27 during the hospital stay. The
final diagnosis was STEMI in 59 of 62 cases; other diagnoses were Tako-Tsubo syndrome, myopericarditis, and
left bundle branch block with non-STEMI as a final
diagnosis. All patients experienced a rise in troponin
concentration, with a local threshold value for detecting
myocardial infarction >0.3 ng/L. Cardiologists confirmed the indication for fibrinolysis in all 27 patients
(26 with a final diagnosis of STEMI and one with TakoTsubo syndrome) who received PCP-administered prehospital fibrinolysis.
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Yayehd et al.
Table 1. Baseline characteristics, management, and delays to treatment in STEMI patients located in remote and local areas.
Factor
Remote area
(n=180)
Local area
(n=730)
P value
Age, mean ± SD, years
Men, n (%)
Medical history, n (%)
Unstable angina <1 week before STEMI*
Angina pectoris
Percutaneous coronary intervention
Coronary artery bypass
Initial presentation, n (%)
Cardiogenic shock
Anterior location of STEMI
Non-anterior location of STEMI
Left bundle branch block
Large infarction†
Cardiac arrest as initial presentation
Management, n (%)
Helicopter transportation
Fibrinolysis (pre- or in-hospital)
Prehospital fibrinolysis
Fibrinolysis given by the primary care physician‡
Direct transfer to PCI hospital
Primary PCI
Glycoprotein IIb/IIIa inhibitor§
Emergent coronary angiography after fibrinolysis
Emergency PCI after fibrinolysis
Delay, mean ± SD, minutes
Symptom onset to call to EMS
Call to MICU arrival
Call to fibrinolysis (pre- or in-hospital)
Call to fibrinolysis (prehospital fibrinolysis)
Call to hospital admission (for patients on
fibrinolysis)¶
Call to hospital admission for sheath insertion
(primary PCI)**
61.0 ± 12.6
147 (82)
63.1 ± 13.4
567 (78)
0.05
0.24
48 (27)
22 (12)
15 (8)
2 (1,1)
228 (31)
109 (15)
72 (10)
20 (2,7)
0.23
0.36
0.54
0.28
6 (3)
67 (37)
105 (62)
6 (3)
88 (49)
15 (8)
24 (3)
300 (41)
391 (57)
18 (2)
344 (47)
34 (5)
0.96
0.37
0.21
0.44
0.62
0.05
69 (39)
117 (65)
114 (63)
27 (15)
165 (92)
60 (34)
65 (37)
74 (63)
44 (38)
58 (8,1)
398 (55)
379 (52)
0 (0)
650 (89)
300 (41)
271 (38)
253 (64)
175 (44)
<0.001
0.009
0.006
–
0.30
0.06
0.89
0.95
0.22
106.5 ± 124.0
32.0 ± 17.9
55.5 ± 26.7
54.2 ± 24.5
136.6 ± 52.9
99.0 ± 123.5
13.6 ± 19.5
50.4 ± 24.9
47.8 ± 20.2
112.4 ± 39.6
0.07
<0.001
0.06
0.01
<0.001
143.5 ± 61.9
120.1 ± 77.8
<0.001
EMS = emergency medical system; MICU = mobile intensive care unit; PCI = percutaneous coronary intervention, SD = standard deviation; STEMI =
ST-elevation myocardial infarction.
*Data missing for 26 patients.
†ST elevation in 5 leads for anterior myocardial infarction or mirror in 3 precordial leads for inferior myocardial infarction.
‡Data missing for 17 patients.
§Data missing for 8 patients.
¶Delay calculated for 103/117 patients in remote areas and for 369/398 patients in local areas.
**Delay calculated for 57/60 patients in remote areas and for 287/300 patients in local areas.
Out of 180 (38%) patients in the remote group, 69 were
transported to hospital by helicopter (Table 4). We observed
no differences in delays to MICU arrival, receipt of fibrinolytic therapy, or hospital admission for those transported to
hospital by helicopter versus by road. Among the 60
patients who underwent primary PCI, the time from telephone call to admission for primary PCI was significantly
shorter in the patients transported by helicopter (p = 0.04).
Forty-nine of the 926 patients had a cardiac arrest before
first medical or paramedical (fire brigade) contact, of which
13 out of 49 were located in a remote area covered by a PCP.
The first medical contact was with a PCP in eight of these
patients, six of whom received an electric shock from an AED
by the PCP; 5 of these patients were discharged alive from
hospital (Figure 3). Five patients had a cardiac arrest after the
first medical/paramedical contact, two after arrival of the PCP
(but before arrival of the MICU); both of these patients
received an electric shock administered by the PCP, one of
whom was discharged alive from hospital.
Discussion
In this prospective registry performed in the French
Northern Alps, one-fifth of the patients with STEMI
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European Heart Journal: Acute Cardiovascular Care
Table 2. Baseline characteristics, management, and delays to treatment in patients in the remote areas, according to PCP
intervention before MICU arrival.
Factor
Year of enrolment
2005
2006
2007
2008
2009
2010
Age, mean ± SD, years
Men, n (%)
Unstable angina <1 week before STEMI*
History of angina pectoris
History of percutaneous coronary intervention
History of coronary artery bypass
Initial presentation, n (%)
Cardiogenic shock
Anterior location of STEMI
Non-anterior location of STEMI
Left bundle branch block
Large infarction†
Cardiac arrest
Management, n (%)
Helicopter transportation,
Fibrinolysis (pre- or in-hospital)
Prehospital fibrinolysis
Fibrinolysis given by the primary care physician
Direct transfer to PCI hospital
Primary PCI
Glycoprotein IIb/IIIa inhibitor
Emergent coronary angiography after fibrinolysis
Emergency PCI after fibrinolysis
Delay, mean ± SD, minutes
Symptom onset to call to EMS
Call to MICU arrival
Call to fibrinolysis (pre- or in-hospital)
Call to fibrinolysis (pre-hospital fibrinolysis)
Call to hospital admission (for patients on
fibrinolysis)‡
Call to hospital admission for sheath insertion§
Intervention from
PCP (n=62)
No intervention
from PCP (n=74)
P
value
11 (18)
6 (10)
5 (8)
13 (21)
13 (21)
13 (21)
58.7 ± 12.9
49 (79)
16 (26)
7 (12)
6 (10)
1 (1)
11 (15)
11 (15)
17 (23)
6 (8)
15 (20)
14 (19)
61.7 ± 11.9
60 (81)
19 (26)
11 (15)
6 (8)
1 (1)
0.16
0.76
0.99
0.56
0.72
1.00
5 (8)
22 (36)
37 (60)
2 (3)
32 (53)
8 (13)
0
30 (42)
40 (55)
2 (3)
34 (46)
5 (7)
0.02
0.59
0.50
0.99
0.45
0.53
30 (50)
44 (71)
44 (71)
27 (44)
55 (89)
17 (28)
46 (78)
27 (61)
18 (41)
27 (37)
45 (61)
43 (58)
0 (0)
69 (93)
28 (39)
54 (74)
25 (56)
13 (29)
0.13
0.17
0.12
106.6 ± 114.2
29.5 ± 18.9
45.0 ± 25.5
45.0 ± 25.5
136.3 ± 63.9
90.8 ± 131.2
33.1 ± 17.4
62.3 ± 25.9
62.4 ± 23.4
137.5 ± 41.9
0.08
0.11
0.003
0.003
0.71
145.1 ± 84.9
145 ± 52.3
0.58
0.35
0.22
0.59
0.58
0.23
EMS = emergency medical system; MICU = mobile intensive care unit; PCI = percutaneous coronary intervention; SD = standard deviation; STEMI =
ST-elevation myocardial infarction.
*Data missing for 6 patients.
†ST elevation in 5 leads for anterior myocardial infarction or mirror in 3 precordial leads for inferior myocardial infarction.
‡Delay calculated for 38/44 patients in PCP group and 39/45 in no-PCP group.
§Delay calculated for all 17 patients in PCP group and for 25/28 in no-PCP group.
managed by a MICU were located in isolated areas. Most
(78%) of these patients were in areas covered by a PCP
trained and equipped to provide pre-hospital treatment for
STEMI; however, only 44% of the patients were actually
treated by a PCP while awaiting arrival of the MICU. The
diagnoses made by PCPs appear reliable and safe, with
95% of the initial STEMI diagnoses being confirmed
subsequently, along with all 27 indications for fibrinolytic
therapy. Intervention by a PCP also significantly reduced
the delay from telephone call to receipt of fibrinolysis, by
an average of 17 minutes. For patients located in remote
areas, who experienced long delays between the initial telephone call to the emergency services and the arrival of the
MICU, the time to initiation of fibrinolysis was shorter in
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Yayehd et al.
Table 3. In-hospital information: STEMI patients managed by PCPs in remote areas.*
Factor
MICU location, n (%)
Annecy
Annemasse
Sallanches
Thonon
Missing data
Hospital admission, n (%)
Annecy
Genève
Grenoble
Infarct-related artery at coronary angiography, n (%)
Thrombosis (TIMI 0–1 flow)
Stenosis
Spontaneous dissection
Normal
Infarct-related artery, n (%)
Left main
Left anterior descending
Right coronary
Circumflex
None
Final diagnosis, n (%)
STEMI
Myopericarditis
NSTEMI (left bundle branch block)
Tako-Tsubo syndrome
Maximum troponin concentration, mean ± SD, ng/L
Revascularization, n (%)
None
Coronary artery bypass graft
PCI
In-hospital death, n (%)
All patients
treated by
PCPs (n=62)
Patients treated by PCPs
able to give prehospital
fibrinolysis (n=52)
28 (45)
2 (3)
21 (34)
10 (16)
1 (2)
26 (50)
2 (4)
13 (25)
10 (19)
1 (2)
51 (82)
9 (15)
2 (3)
43 (83)
8 (15)
1 (2)
29 (47)
30 (48)
1 (2)
2 (3)
24 (46)
25 (48)
1 (2)
2 (4)
3 (5)
23 (37)
26 (42)
8 (13)
2 (3)
2 (4)
21 (40)
22 (42)
5 (10)
2 (4)
59 (95)
1 (2)
1 (2)
1 (2)
97.5 ± 97.7
49 (94)
1 (2)
1 (2)
1 (2)
84.6 ± 85.7
8 (13)
3 (5)
51 (82)
2 (4)
8 (15)
2 (4)
42 (81)
3 (5)
EMS = emergency medical system; MICU = mobile intensive care unit; NSTEMI = non-ST elevation myocardial infarction; PCI = percutaneous
coronary intervention; PCP = primary care physician; SD = standard deviation; STEMI = ST-elevation myocardial infarction.
Table 4. Delays to treatment in STEMI patients in remote areas according to mode of transportation to hospital.
Time, mean ± SD*
Transportation by
helicopter (n=69)
Transportation
by road (n=107)
P value
Symptom onset to call to EMS
Call to MICU arrival
Call to fibrinolysis
Call to admission to hospital†
Call to admission for primary PCI‡
106.2 ± 122.8
31.9 ± 18.8
58.2 ± 30.0
144.4 ± 68.2
126.5 ± 40.6
103.8 ± 120.3
32.0 ± 17.2
54.4 ± 25.4
132.9 ± 43.2
158.9 ± 75.3
0.79
0.87
0.97
0.42
0.04
EMS = emergency medical service; MICU = mobile intensive care unit; PCI = percutaneous coronary intervention; SD = standard deviation.
*Data missing for 4 patients.
†Delay calculated for 111/117 patients with fibrinolysis.
‡Delay calculated for 56/60 patients with primary PCI.
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European Heart Journal: Acute Cardiovascular Care
926 pa!ents enrolled in the RESURCOR
registry in the Haute-Savoie with interven!on
of MICU
49 pa!ents with cardiac arrest as ini!al clinical
presenta!on
15 pa!ents located in a remote area
13 pa!ents located in a remote area covered by
a PCP
5 pa!ents with no PCP
interven!on
8 pa!ents with PCP
interven!on
6 electric shocks
delivered by PCP
2 electric shocks delivered by
firefighters/paramedics before PCP arrival
5 pa!ents alive
2 pa!ents alive
Figure 3. Patients with cardiac arrest as the initial presentation.
PCP = primary care physician; RESURCOR = RESeau des URgences CORonaires.
those treated by a PCP compared with those not treated by
a PCP. The benefit of early intervention by a PCP in acute
STEMI was also demonstrated by the early treatment of
cardiac arrest, with electric shocks delivered by PCPs in 8
patients. However, one area for improvement is the rate of
fibrinolytic therapy and the delay to perform that therapy:
27 patients received fibrinolysis but only two of the other
35 patients treated by PCP with STEMI had contraindications to this therapy, and were therefore candidates for prehospital fibrinolysis. A gain of a mean of 17 minutes for
starting fibrinolysis could seem short10 and may be reduced
further in the future.
Delays in transportation to hospital (and the performance of PCI) were longer for patients in remote than in
local areas. Treatment by a PCP (versus no treatment by a
PCP) did not lead to a reduction in the transportation time
for patients in remote areas. Thus, while treatment by a
PCP did not decrease transportation delay (caused by the
remote location), it did reduce the time to initiation of
fibrinolysis.
Transportation by helicopter did not decrease delay to
MICU arrival because this mode of transport was generally
chosen after confirmation of the diagnosis, by either the
PCP or the MICU team (arriving by road). The delay to hospital admission was numerically but not statistically significantly lower in patients transported to hospital by helicopter,
most likely because of a lack of power (n=176 patients).
However, helicopter transfer did reduce significantly the
delay from telephone call to primary PCI (Table 4).
Reducing the delay to starting fibrinolytic therapy in eligible patients with STEMI remains challenging. An analysis of studies in which 6,434 patients were randomized to
pre-hospital or in-hospital thrombolysis showed a large
reduction (17%; odds ratio 0.83; 95% CI 0.70–0.98) in allcause hospital mortality with pre-hospital treatment.11 For
this purpose, the French pre-hospital EMS was established,
with an emergency physician on board the MICU.12,13
Studies of pre-hospital care with fibrinolytic therapy
administered by paramedics have been reported elsewhere,
including: Senegal,14 the United States,15 Canada,15–17
Spain,18 Sweden,19 New Zealand,20 India,21 and the United
Kingdom.22,23 A case has even been reported of fibrinolysis
performed by a nurse on board a cruise ship.24 In France,
pre-hospital organizations do not address the management
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Yayehd et al.
of patients located in remote or inaccessible areas. Such
situations require the involvement of medical or paramedic
systems, as has been reported in two other settings. The
first, from Scotland, involved the Grampian Region Early
Anisteplase Trial (GREAT), performed in 146 patients with
STEMI with 30 or more minutes of travelling time to hospital, and treated with fibrinolysis by general practitioners.
The authors reported a shorter call-to-needle time for
fibrinolysis performed by general practitioners versus inhospital fibrinolysis, which translated to improved survival
at 1 year (83% vs 73%; p < 0.05).25 The second report – the
Donegal Area Rapid Treatment Study (DARTS) – from
Ireland, also showed that pre-hospital thrombolysis reduced
call-to-needle times for patients living remotely from the
hospital.26 The 2004 New Zealand guidelines included a
strong recommendation to allow general practitioners to
start fibrinolysis treatment,26 but no reports on this approach
appear to have been published.
The pre-hospital system in France, with an emergency
physician on board the MICU, is already well established
and has reduced delays to starting fibrinolytic therapy in
STEMI.27 Our experience, where PCPs are trained and
equipped to provide pre-hospital thrombolysis before the
arrival of the MICU, shows that the delay to initiating reperfusion therapy in this population can be reduced further,
especially for patients located in remote regions.
The practice of early fibrinolysis could be encouraged
by the results of the recent Strategic Reperfusion Early
After Myocardial Infarction (STREAM) study, which
reported a non-inferior rate of the composite outcome of
death, cardiogenic shock, congestive heart failure, or reinfarction at 30 days in patients treated by prompt fibrinolysis
and direct transfer to PCI centres for emergency rescue or
early coronary angiography when compared with patients
treated with primary PCI alone.28 Immediate transfer to a
PCI centre following fibrinolysis performed in a non-PCI
centre is encouraged by the results from the NORwegian
randomized study on DIstrict treatment of ST-Elevation
Myocardial Infarction (NORDISTEMI), which reported a
significant reduction in the composite 12-month end point
of death, reinfarction, or stroke in patients immediately and
systematically transferred for PCI compared with patients
transferred for PCI only when fibrinolysis failed.29
The practice of fibrinolysis may also be encouraged by
the high rate of patients with a delay of more than 120 minutes to reach the catheterization laboratory who are then
candidates for fibrinolysis.1 Indeed, in the French Registry
on Acute ST-elevation and non-ST-elevation Myocardial
Infarction 2010 (FAST-MI 2010), the median time from
first medical contact to performance of primary PCI was
110 minutes.30 Moreover, from our registry of 6,169
patients with STEMI enrolled between 2002 and 2011, 556
of 2,244 (25%) patients treated with primary PCI without a
contraindication to fibrinolysis had a delay from first medical contact to artery puncture greater than 120 minutes
(data not published). The results from several registries of
local and national STEMI networks confirm that major
delays persist in a significant proportion of patients (7%–
25%) despite the presence of well-established STEMI networks, and are associated with an increase in early and late
mortality.31
Limitations
This retrospective observational study is limited by the constraints of such an analysis. Important data were not collected, such as cardiovascular risk factors and hemodynamic
status. However, only limited data were collected in an effort
to improve the completeness of data capture. The original
aim of the ongoing RESURCOR registry was to provide
physicians with feedback on clinical practice with the aim of
improving quality of care, and was not specifically designed
to answer research questions. Our sample population is relatively small, and our data on time to fibrinolysis and would
need to be confirmed in a larger study.
Conclusion
In our experience, the treatment of patients with STEMI by
primary care physicians – general practitioners trained and
equipped to face the emergency situation – in remote areas
allows reliable early and rapid administration of fibrinolysis and, when required, resuscitation.
Acknowledgements
We thank the primary care physicians involved in this study: Dr
Yann Hurry (Argentière), Dr Bernard Audema, Dr Jean-Mark
Bertrand, Dr Marc-Hervé Binet, Dr Diane Lacroix (Avoriaz), Dr
Manuella Barthes, Dr Patrick Joubert (Flaine), Dr Nicolas Berthier
(Grand-Bornand), Dr Jean-Paul Marcou (La Chapelle
D’abondance), Dr Jean-Baptiste Delay, Dr Jean-Noël Giraud, Dr
Antoine Pecheur, Dr Florent Retailleau (La Clusaz), Dr JeanPierre Schmitt (Les Contamines), Dr Jacques Riegel (Lullin), Dr
Patrick Benier, Dr Jean-Marc Maniglier, Dr Dominique Lamy,
(Megève), Dr Thierry Audiard, Dr Jean-Paul Dupoux-Cabiac
(Praz sur Arly), Dr Philippe Bour, Dr Olivier Bretton, Dr Régis
Vansteeger (Samoens), Dr Michel Delporte (Saint Jean D’aulps).
Sophie Rushton-Smith, PhD, provided editorial assistance and
was funded by the authors.
Conflict of interests
The authors declare that there is no conflict of interest.
Funding
This research received no specific grant from any funding agency
in the public, commercial, or not-for-profit sectors.
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