Efficacy and safety of out-of-hospital intravenous metoprolol administration in anterior ST-segment elevation acute myocardial infarction: insights from the METOCARD-CNIC trial.

STUDY OBJECTIVE: We seek to examine the efficacy and safety of prereperfusion emergency medical services (EMS)-administered intravenous metoprolol in anterior ST-segment elevation myocardial infarction patients undergoing eventual primary angioplasty. METHODS: This is a prespecified subgroup analysis of the Effect of Metoprolol in Cardioprotection During an Acute Myocardial Infarction trial population, who all eventually received oral metoprolol within 12 to 24 hours. We studied patients receiving intravenous metoprolol by EMS and compared them with others treated by EMS but not receiving intravenous metoprolol. Outcomes included infarct size and left ventricular ejection fraction on cardiac magnetic resonance imaging at 1 week, and safety by measuring the incidence of the predefined combined endpoint (composite of death, malignant ventricular arrhythmias, advanced atrioventricular block, cardiogenic shock, or reinfarction) within the first 24 hours. RESULTS: From the total population of the trial (N=270), 147 patients (54%) were recruited during out-of-hospital assistance and transferred to the primary angioplasty center (74 intravenous metoprolol and 73 controls). Infarct size was smaller in patients receiving intravenous metoprolol compared with controls (23.4 [SD 15.0] versus 34.0 [SD 23.7] g; adjusted difference -11.4; 95% confidence interval [CI] -18.6 to -4.3). Left ventricular ejection fraction was higher in the intravenous metoprolol group (48.1% [SD 8.4%] versus 43.1% [SD 10.2%]; adjusted difference 5.0; 95% CI 1.6 to 8.4). Metoprolol administration did not increase the incidence of the prespecified safety combined endpoint: 6.8% versus 17.8% in controls (risk difference -11.1; 95% CI -21.5 to -0.6). CONCLUSION: Out-of-hospital administration of intravenous metoprolol by EMS within 4.5 hours of symptom onset in our subjects reduced infarct size and improved left ventricular ejection fraction with no excess of adverse events during the first 24 hours.

Modelo de intervención coronaria percutánea primaria en la Comunidad de Galicia / The primary percutaneous coronary intervention program in Galicia

A pesar de haberse demostrado que la reperfusión precoz mediante intervención coronaria percutánea es la terapia más eficiente en pacientes con infarto agudo de miocardio, menos del 20% de estos pacientes son tratados así. La generalización del uso de esta terapéutica está muy relacionada con el desarrollo de modelos asistenciales con centros referentes y centros de referencia como nodos de la red. Sobre esta base conceptual, se desarrolló un modelo asistencial en red en la Comunidad Autónoma de Galicia. El programa gallego de atención del infarto agudo de miocardio con elevación del segmento ST (PROGALIAM), para una población de unos 2.750.000 habitantes. En él se establecieron dos grandes objetivos: disminuir la mortalidad y la morbilidad mejorando la expectativa de calidad de vida del paciente con infarto y promover la equidad en el acceso a las prestaciones del sistema sanitario, para disminuir la variabilidad en el uso de recursos y tecnologías diagnósticas y terapéuticas en este contexto clínico. De forma que por carretera, según las isocronas de transporte del 061, el 92% de la población podía acceder a la realización de una intervención coronaria percutánea primaria en menos de 90 min y el 99%, en menos de 120 min. Desde el año 2006 que se implantó el protocolo hasta diciembre de 2009, se ha tratado en los tres hospitales, nodos de la red (Coruña, Santiago y Vigo) PROGALIAM, a un total de 4.917 pacientes con infarto agudo de miocardio. La mediana del tiempo de transporte desde los hospitales sin unidades de hemodinámica a los centros con hemodinámica ha sido de 80 min. Cuando el 061 efectuó un traslado primario (domicilio-hospital con hemodinámica) directo, el tiempo dolor-sala de hemodinámica se acortó en un 39% en comparación con el traslado secundario (pacientes que acudieron a sus hospitales de zona y traslado por el 061 a hospitales con unidades de hemodinámica). La mortalidad media hospitalaria observada ha sido del 5% tras intervención coronaria percutánea primaria y del 12% tras intervención coronaria percutánea de rescate. En conclusión, el establecimiento de un programa de reperfusión coronaria con intervención coronaria percutánea en pacientes con infarto agudo de miocardio en la Comunidad Autónoma de Galicia (PROGALIAM) ha homogeneizado el tratamiento y ha proporcionado la mejor terapéutica posible a estos pacientes, con alta eficiencia en la reducción de la mortalidad (AU)

Although theoretically early reperfusion using percutaneous coronary intervention is the most effective treatment for patients with acute myocardial infarction, less than 20% actually receive it. The region of Galicia in Spain has developed a treatment program and network: the Galician treatment program for STsegment elevation acute myocardial infarction (PROGALIAM), which covers a population of some 2750000 inhabitants. The program has two principal objectives: to reduce mortality and morbidity while improving the quality of life of myocardial infarction patients; and to promote equality of access to health-care services in order to reduce the variability in uptake of diagnostic and therapeutic resources and techniques in patients with the condition. From the establishment of the program in 2006 to December 2009, the three referral hospitals in the PROGALIAM network (in Coruña, Santiago and Vigo) have treated a total of 4917 patients with acute myocardial infarction. The median transport time from a hospital without a catheterization laboratory to a center with such a facility was 80 minutes. When an emergency 061 call resulted in immediate transport to a referral hospital (i.e. from home to catheterization laboratory), the time from symptom onset to catheterization was 39% less than the time following a subsequent referral (i.e. for patients who were admitted to their local hospital and then transferred by the emergency services to a hospital with a catheterization laboratory). Average in-hospital mortality ranged from 5% following primary percutaneous coronary intervention to 12% following rescue percutaneous coronary intervention. In conclusion, the establishment of a program of coronary reperfusion by percutaneous coronary intervention in patients with acute myocardial infarction in the Galicia region (PROGALIAM) both ensured and equalized access to the best possible treatment for these patients, and was highly effective in reducing mortality (AU)