[Evolution since 2002 of the management of patients with ST elevated acute coronary syndrome (STEMI) in Île-de-France. E-MUST survey]. / Augmentation du taux de décision de reperfusion myocardique des patients ayant un syndrome coronaire aigu avec sus-décalage du segment ST. Analyse du registre e-MUST (2002 à 2010) des SAMU/SMUR d'Île-de-France.

INTRODUCTION: ST-segment-elevation acute myocardial infarction (STEMI) is a therapeutic emergency. Early reperfusion is the key to successful reperfusion. Guidelines recommend organizing regional networks. In France, this starts with a call to a medical dispatch center, the SAMU-centre 15. The aim of this study was to evaluate regional STEMI management using data collected from 2002 to 2010. METHODS: Observational, prospective, multicenter survey. STEMI patient with chest pain lasting for less than 24hours managed by 40 mobile emergency and resuscitation service (SMUR) and 8 emergency medical system (SAMU) from the Greater Paris Area (Île-de-France) were analyzed. Demographic data, cardiovascular risk factors, infarction location, decision of reperfusion and delays were collected. The rate of coronary reperfusion was chosen as the primary endpoint. RESULTS: Eleven thousand five hundred and eighty-eight patients enrolled from 2002 to 2010 were analyzed. Median age was 59.9 (51.0 to 72.9) years; 9080 (78.5%) were men. The number of patients included decreased from 1376 in 2002 to 1119 in 2010. Reperfusion was achieved by fibrinolysis in 2644 (23%) cases and primary angioplasty in 7999 (69%) cases. The rate of decision of coronary reperfusion significantly increased from 86.7% in 2002 to 94.8% in 2010 (P<0.0001). Interaction between the increasing decision of reperfusion and all factors studied (demographics, cardiovascular risk factors, infarct location and delays) was significant only for family history of coronary artery disease (P=0.03). In-hospital mortality was 2.8% (321 cases). CONCLUSION: The number of patients with STEMI managed by the SAMU declined slightly over the past decade. The rate of decision of reperfusion progressively increased up to 95%. Entrance into the network by the SAMU-centre 15 is a guarantee of a wide and early access to the coronary reperfusion.

Outcomes of primary percutaneous coronary interventions in nonagenarians with acute myocardial infarction.

BACKGROUND: Few data are available on primary percutaneous coronary intervention (pPCI) in nonagenarians. In a large prospective registry on pPCI for STEMI we compared the demographics, procedural and in-hospital outcomes between nonagenarians (age ≥ 90 years) and patients aged < 90 years. METHODS AND RESULTS: We included 26,157 consecutive patients with pPCI in the Greater Paris Area region between 2003 and 2011. Of these, 418 (1.6%) were ≥ 90 years old. Nonagenarians (versus patients < 90 years) were more likely to be female (62.3% versus 22.5%, p < 0.0001), nonsmokers (81.6% versus 36.7%, p < 0.0001), in cardiogenic shock (Killip IV) upon admission (10.5% versus 4.8%, p < 0.001), and had significant co-morbidities. Over two-thirds of patients underwent procedures via the radial artery (61% versus 72.1%, p = 0.007). Both groups had high and similar angiographic success rates (98.1% versus 98.7%, p = 0.33). Drug-eluting stents were used less often in nonagenarians (4.4% versus 16.7%, p < 0.0001). Hospital mortality was significantly much higher in patients over 90 years old (24.9% versus 5.1%, p < 0.001) in univariate analysis. After adjustment for sex, cardiogenic shock, diabetes, triple vessel disease, drug-eluting stent use and glycoprotein IIb/IIIa inhibitors use, mortality remains higher in nonagenarian patients (OR: 4.31; 95% CI: 3.26-5.71, p < 0.0001). CONCLUSIONS: In a real-world setting, we found important demographic differences in nonagenarian compared to younger patients. Despite achieving a high rate of reperfusion with pPCI using mainly radial access, similar to that achieved in younger patients, hospital mortality was higher in nonagenarians.

Is the volume-outcome relation still an issue in the era of PCI with systematic stenting? Results of the greater Paris area PCI registry.

AIMS: In acute myocardial infarction (AMI), primary percutaneous transluminal angioplasty (PTCA) is the preferred option when it can be performed rapidly. Because of the limited access to high PTCA volume centres in some areas, it has been suggested that PTCA could be performed in low-volume centres on AMI patients. Little data exist on the validity of this strategy in modern era PTCA. METHODS AND RESULTS: The Greater Paris area comprises 11 million inhabitants and accounts for 18% of the French population. In 2001, the hospital agency of the Greater Paris area set up a registry of all PTCAs performed in this region. Data from 2001 and 2002 was analysed. Hospitals performing <400 PTCAs per year were classified as low-volume. A case-control analysis (propensity score) compared in-hospital mortality in low- and high-volume centres. A total of 37 848 angioplasty procedures were performed in 44 centres during the study period; 24.7% were performed in low-volume centres. A non-statistically significant trend towards reduced in-hospital mortality was noted in high-volume centres as opposed to low-volume centres: 2.01 vs. 2.42%, P = 0.057. In-hospital mortality rates were significantly different in the sub-group of emergency procedures: 6.75% in high- vs. 8.54% in low-volume centres, P = 0.028. No difference was noted between low- and high-volume centres in non-emergency procedures (0.62 vs. 0.62%, P = 0.99). CONCLUSION: In the era of modern stenting, a clear inverse relationship exists between hospital PTCA volume and in-hospital mortality after emergency procedures. Tolerance of low-volume thresholds for angioplasty centres with the purpose of providing primary PTCA in AMI should not be recommended, even in underserved areas.