[Telecardiology in the management of acute myocardial infarction: the experience of the provincial network of Mantova]. / La telecardiologia nella gestione dell'infarto miocardico acuto: l'esperienza della rete provinciale di Mantova.

BACKGROUND: Since June 2001 we activated a program for the treatment of acute myocardial infarction, based on the early assessment of the patient's risk profile, on telematic connection among care centers and optimization of critical pathways for access to care. The aim of this work was to assess the effectiveness of telemedicine in the reduction of time to treatment. METHODS: Mantova, a province of eastern Lombardy (northern Italy) is provided with one single sanitary district with one (tertiary hospital) referring hospital equipped with a cath lab on call 24/24 hours for primary coronary angioplasty (PTCA) and cardiac surgery and 6 community hospitals: 2 with coronary care units, 2 with a cardiology section, and 2 rehabilitation hospitals. The emergency medical system transport, activated 24/24 hours, consists of 6 advanced life support (ALS) ambulances and 11 basic life support (BLS) ambulances (2 with trained nurse staff). Each ALS ambulance is equipped with a semiautomatic defibrillator LIFEPACK 12 coupled with cellular telephone GSM transmission of the 12-lead ECG. RESULTS: In the first 3-year activity of the project 340 patients with acute myocardial infarction underwent primary PTCA: 248 (73%) referred to first aid of the nearest hospital reached either by BLS ambulance or by their own means of transport and were hence transferred to the referring hospital for primary PTCA (group A), while 92 patients (27%) were aided at their own house by ALS ambulances and, after transmission of the 12-lead ECG to the referring coronary care unit, were directly transferred to the cath lab (group B). Decisional delay was 144 +/- 65 min in group A while 74 +/- 37 min in group B. Mean door-to-balloon time was 76 +/- 26 min in group A and 47 +/- 21 min in group B. High incidence of post-procedural TIMI 3 flow was achieved in both groups. In-hospital mortality was 6.8% in group A e 5.4% in group B. CONCLUSIONS: Our data show that patients referring directly to ALS ambulances had a lower decisional delay. Transmission of the patient's ECG and clinical parameters allows an early and accurate diagnosis and assessment of the individual risk profile with a consistent reduction in time to treatment and positive effects on the mortality rate.

[Network for the treatment of acute myocardial infarction in the province of Mantova: results after 2 years of work]. / Rete provinciale per la terapia deII'infarto miocardico acuto a Mantova: risultati di due anni di attività.

BACKGROUND: Since June 2001, in the province of Mantova, we have been carrying out a program for the management of acute myocardial infarction based on early assessment of the patients' risk profile, on telematic connection among care centers and on optimization of in- and out-of-hospital critical pathways for the access to care. METHODS: Our network provides connection among the following centers: advanced life support ambulances, 7 hospitals, 3 coronary care units, 1 cath lab on call 24 hours a day for primary angioplasty, 1 thoracic surgery division. This program, through its strong telematic platform, allows early assessment of myocardial infarction, and provides primary angioplasty to all high-risk patients, being fibrinolytic treatment reserved only to the low-risk patients admitted in peripheral hospitals. RESULTS: Two hundred and twenty patients with acute myocardial infarction were treated with angioplasty; 179 (81%) patients underwent primary angioplasty, 26 (12%) patients facilitated angioplasty and 15 patients (7%) rescue angioplasty; 121 patients (55%) were first admitted in the Mantova hospital, 65 patients (30%) were referred to Mantova from peripheral hospitals and 34 patients (15%) were directly transported to the cath lab by advanced life support ambulances. Procedural success was obtained in 98% of cases, with 05% intraprocedural mortality. In-hospital mortality was 55%, while mortality of cardiogenic shock patients was 36%. Recurrence of acute myocardial infarction occurred in 1% and major bleeding in 2.2% of patients. One patient with cardiogenic shock died during transport. Mean door-to-balloon time was 73 min with 39% reduction in the second period of recruitment after telematic connection. CONCLUSIONS: This program, developed in the setting of a provincial network for the management of acute myocardial infarction, provided primary angioplasty to all high-risk patients, with a high procedural success rate. Within a few months, time to treatment was minimized by the employment of telematic facilities.