Implementation of Guidelines Improves the Standard of Care

TLDR

The study aimed to assess whether implementing recent STEMI guidelines reduces in‑hospital mortality in a metropolitan setting. A network linking the Viennese Ambulance System with five high‑volume cardiology centers was established to deliver rapid reperfusion—either PPCI or thrombolysis—within 2–3 hours of symptom onset. Implementation of the guideline‑based network increased reperfusion from 66 % to 86.6 %, reduced non‑reperfusion from 34 % to 13.4 %, shifted use from thrombolysis (50.5 % to 26.7 %) to PPCI (16 % to ~60 %), and lowered in‑hospital mortality from 16 % to 9.5 %, with PPCI proving more effective beyond 3 h after symptom onset.

Abstract

Background— The purpose of this study was to determine whether implementation of recent guidelines improves in-hospital mortality from acute ST-elevation myocardial infarction (STEMI) in a metropolitan area. Methods and Results— We organized a network that consisted of the Viennese Ambulance Systems, which is responsible for diagnosis and triage of patients with acute STEMI, and 5 high-volume interventional cardiology departments to expand the performance of primary percutaneous catheter intervention (PPCI) and to use the fastest available reperfusion strategy in STEMI of short duration (2 to 3 hours from onset of symptoms), either PPCI or thrombolytic therapy (TT; prehospital or in-hospital), respectively. Implementation of guidelines resulted in increased numbers of patients receiving 1 of the 2 reperfusion strategies (from 66% to 86.6%). Accordingly, the proportion of patients not receiving reperfusion therapy dropped from 34% to 13.4%, respectively. PPCI usage increased from 16% to almost 60%, whereas the use of TT decreased from 50.5% to 26.7% in the participating centers. As a consequence, in-hospital mortality decreased from 16% before establishment of the network to 9.5%, including patients not receiving reperfusion therapy. Whereas PPCI and TT demonstrated comparable in-hospital mortality rates when initiated within 2 to 3 hours from onset of symptoms, PPCI was more effective in acute STEMI of >3 but <12 hours’ duration. Conclusions— Implementation of recent guidelines for the treatment of acute STEMI by the organization of a cooperating network within a large metropolitan area was associated with a significant improvement in clinical outcomes.