Leitlinienkonforme interventionelle Therapie des akuten ST-Hebungsinfarktes in ländlichen Regionen durch Netzwerkbildung

Hintergrund und Fragestellung: Die Therapie des akuten Myokardinfarktes verlangt eine rasche und komplette myokardiale Reperfusion. Die primäre perkutane Koronarintervention (PCI) ist der Thrombolyse hinsichtlich Mortalität, Re-Infarkten und Schlaganfallrisiko zwar überlegen, jedoch in Deutschland nicht flächendeckend verfügbar.

Patienten und Methode: Zwischen 08/2001 und 12/2002 wurden 322 Patienten mit ST-Hebungsinfarkt (STEMI) innerhalb eines regionalen Infarkt-Netzwerks (ein PCI-Zentrum und 7 Kliniken der Primärversorgung) nach standardisierten Therapieleitlinien interventionell behandelt. 160 Patienten wurden aus einem Primärzentrum verlegt (Transfer-Gruppe, 63,4 Jahre, 71,8 % Männer), 162 direkt im PCI-Zentrum aufgenommen (Zentrums-Gruppe, 61,7 Jahre, 73,8 % Männer). Zwischen Symptombeginn und Arztkontakt vergingen in der Transfer-Gruppe 205 min, in der Zentrums-Gruppe 195 min; 7,8 % der Zentrums- und 7,2 % Transfer-Patienten befanden sich im kardiogenen Schock. Eine komplette Nachbeobachtungsphase über 6 Monate lag für 95 % der Patienten vor.

Ergebnisse: Die mittlere Transportzeit zur PCI betrug für die Transfer-Gruppe 54 min. Bei 95,1 % der Patienten der Transfer- und 94,4 % der Zentrums-Gruppe erfolgte eine PCI am Infarktgefäß. Zusätzlich erhielten 96 % der Patienten einen Glykoprotein-IIb/IIIa-Rezeptorblocker. Bei präinterventioneller Gabe des GP-IIb/IIIa-Antagonisten zeigten 22,3 % der Patienten bereits vor PCI einen wieder normalisierten (TIMI-3) Blutfluss im Infarktgefäß gegenüber 14,9 % bei alleiniger Vortherapie mit Heparin/Acetylsalicylsäure. Nach PCI wiesen 87,5 % der Zentrums- und 86,3 % der Transfer-Gruppe einen TIMI-3-Fluss im Infarktgefäß auf. Beide Gruppen zeigten im Verlauf keinen Unterschied hinsichtlich Myokardnekrose (Transfer vs. Zentrum: CK 2482 vs. 2481 U/l, CKMB 302 vs. 264 U/l), Letalität (30 Tage; 5,3 vs. 5,2 %, 6 Monate: 7,3 vs. 7,1 %), NYHA-Stadium (1,41 vs. 1,43) und linksventrikulärer Ejektionsfraktion nach 6 Monaten (0,41 vs. 0,43).

Folgerungen: Der Aufbau eines regionalen Infarkt-Netzwerkes mit logistischer Verknüpfung von Krankenhäusern der Primärversorgung mit einem erfahrenen interventionellen Zentrum sichert eine leitliniengerechte, optimierte Therapie von Patienten mit STEMI in einer ländlichen Region.

Background and objectives: Therapy of acute myocardial infarction demands rapid and complete myocardial reperfusion. Primary percutaneous coronary intervention (PCI) performed is superior to thrombolytic therapy in reducing mortality, non-fatal reinfarction and stroke, but is not available in rural Germany.

Patients and methods: From 8/2001 to 12/2002 322 patients with STEMI were treated by PCI with standardized therapeutic guidelines within a regional infarction-network comprising one interventional centre and 7 community hospitals without PCI facilities. 160 patients were relocated (transferred) from a community hospital without PCI facilities (transfer group, 63.4 yrs., 71.8 % men); 162 patients were admitted directly to the interventional centre (centre group, 61.7 yrs., 73.8 % men). The interval from onset of symptoms to first medical contact was 205 minutes in the transfer group, and 195 minutes in the centre group. 7.8 % of the centre group and 7.2 % of the transfer group patients were in cardiogenic shock. 95 % of patients have completed a 6-month’s follow-up.

Results: In the transfer group median transportation time to PCI was 54 minutes. PCI of the infarct-related artery (IRA) was performed in 95.1 % of transferred patients after transfer and in 94.1 % of patients with direct admission. In addition 96 % of all patients received a GP IIb/IIIa receptor inhibitor. In case of preinterventional application of the GP IIb/IIIa receptor inhibitor 22.3 % of patients revealed normal (TIMI-3) flow of the IRA before PCI, compared to 14.9 % TIMI-3 flow with 5000 IE Heparin/500 mg aspirin alone (p < 0.05). After PCI normalized flow in the IRA was documented in 87.5 % after direct admission and 86.3 % after transfer. No differences between groups were shown with respect to infarct size (transfer vs. centre: CK 2482 vs. 2481 U/I; CKMB 302 vs. 264 U/I), mortality (30 days: 5.3 vs. 5.2 %, 6 months: 7.3 vs. 7.1 %); NYHA (1.41 vs. 1.43) and left ventricular ejection fraction (0.41 vs. 0.43).

Conclusions: The organization of a regional infarction-network with logistic alliance of community hospitals with one experienced interventional centre ensures timely PCI for patients with STEMI according to present guidelines even in rural areas.

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