Download Primary versus secondary transport of STEMI patients * an impact on

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Primary versus secondary transport of STEMI patients – an impact on transport
times and mortality.
Abdulwasya Almawiri1, Jan F. Vojacek2, Josef Bis2, Josef Stasek2 , Ziad Albahri 2 Medical Service , Hradec Kralove, Czech Republic,
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Emergency
Department of Cardiovascular Medicine I,
Charles University Prague, School of Medicine and University Hospital Hradec Kralove, Czech
Republic
Corresponding author: Ziad Albahri, Charles University Prague, Faculty of Medicine in Hradec
Kralove, Department of Pediatrics and Cardiovascular Medicine, Hradec Kralove, Czech Republic,
e-mail address: [email protected], [email protected]: tel 420 776266650
Keywords: STEMI – Primary PCI – Transport – Mortality
Brief summary:
Our study is first to show that direct transport from field to catheterization laboratory not only
significantly shortens the transport times but also translates into significant decrease of not only
one month but also one year mortality. Still significant proportion of patients are transported to
regional hospitals or to the Coronary Care Unit of the Cardiac Center and only then to the
catheterization laboratory.
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Abstract:
Aim: The door-balloon time (DBT) is linked to morbidity and mortality of patients with ST segment
elevation myocardial infarction (STEMI). Despite preferable direct transport to catheterization
laboratory (primary transport – PT), still significant proportion of STEMI patients is transported
via non-PCI regional hospitals or Coronary Care Units (secondary transport – ST) prior to primary
percutaneous coronary intervention (PPCI). This study assessed to what extent PT vs ST affects the
DBT and mortality.
Methods: Our region with 600,000 inhabitants uses 24 hours / 365 days system of immediate
transport of patients with STEMI lasting less than 12 hours to referral catheterization laboratories in
the tertiary University Hospital Cardiac Center for more than 15 years. We prospectively recorded
DBT of consecutive patients with STEMI, treated by PCI in the years 2012-2013. Consequent
follow-up was obtained in all patients.
Results: Six hundred seventy-seven patients, age 37-96 years, mean 64 ± 16 years, 475 (70%) of
them males and 202 (30%) females, were enrolled for the final analysis. From this number, 354
(52.3%) patients had PT and 323 (47.7%) ST. Median of DBT was 34±15.9 minutes for PT patients
(n=354) and 100±28.8 minutes for patients with ST (n=323) (p<0.005). One-month mortality was
4% vs 9.5% (p=0.002) in the PT vs ST group, respectively. One-year mortality in the PT and ST
groups was 7.3 vs 20.5% (p<0.005), respectively.
Conclusion: The admission of patients with STEMI to regional hospitals or Coronary Care Units
instead of direct transport to catheterization laboratory significantly prolongs the DBT and increases
mortality.
‫‪3‬‬
‫‪Abstract:‬‬
‫الهدف من الدراسة )‪:(Aim‬‬
‫تقييم تآثير التاخير في الوقت )‪(The door-balloon time - DBT‬‬
‫في نقل المرضى اللذين يعانون من الذبحه الصدريه الحادة )‪(STEMI‬‬
‫الى قسم القثطرة و العناية القلبية الجرا ء عملية قثطرة مباشرة )‪(direct- PCI‬‬
‫و تدوين الوفاة معدل خالل شهر و خالل سنة بعد عملية القثطرة بين المرضى اللذين‬
‫نقلوا من مسشفيات صغيرة او عيادات خارجيه و المرضى الذين نقلوا من البيت‬
‫مبا شرة الى قسم القثطرة و العناية القلبية‪.‬‬
‫الطريقة ‪Methods:‬‬
‫يستقبل مركز القلب في المشفى الجامعي في هرادتس كرالوف الذي يعمل ‪ ٤٢‬ساعه ‪ /‬اليوم طوال‬
‫العام المرضى اللذين يعانون من الذبحه الصدريه الحادة من المحافظه الذي نعيش فيها وماحولها من مدن صغيرة‬
‫)عدد سكانها ‪ 600000‬نسمة (‪.‬‬
‫قسمنا المرضى‬
‫بالذبحة الصدرية )‪(STEMI) ( Acute Myocardial Infarction with ST elevation‬‬
‫الى مجموعتين ‪ :‬المجموعه اآلولى تتضمن نقل مباشر الى قسم القثطرة و العناية القلبية بواسطه سيارات االسعاف‬
‫‪. Primary Transport‬‬
‫المجموعه ا لثانيه‪ :‬نقل غير مباشر للمرضى من المسشفيات االخرى الى قسم القثطرة و العناية القلبية ‪.Secondary Transport‬‬
‫الدراسة تمت بين سنة ‪ .2013 – 2012‬سجلنا الوقت من بداية االلم الصدر ي )‪(Symptom-Onset-to Balloon Time‬‬
‫عند مرضى الذبحة الصدرية )‪-Acute Myocardial Infarction with ST elevation (STEMI‬‬
‫حتى فتح الشريان المغلق‬
‫بالبالون او الشبكة )‪(by balloon or Stent‬‬
‫وسجلنا الوقت من دخول المشفى الى توسيع الشريان‬
‫خالل ‪ ٢٤‬ساعة من بدء االعراض‪,‬‬
‫المغلق )‪.(Door Balloon Time-DBT‬‬
‫سجلنا الفرق في ارتفاع الوفاة معدل ‪ Mortality‬والمراضة ‪ Morbidity‬عند المجوعتين‪.‬‬
‫النتائج ‪Results:‬‬
‫ستمئة وسبعة وسبعون مريضا‪ ,‬ا لعمر من ‪ 96-37‬سنة ‪,‬متوسط ا لعمر ‪ 64 ±16‬سنة ‪ (70%) 475 ,‬من‬
‫الرجال‬
‫و ‪ (30%) 202‬من النساء شملوا في هذه الدراسة‪.‬‬
‫من هذا الرقم ‪ (52.3%) 354 :‬نقلو مباشرة الى مركز القلب )‪ (Primary Transport‬و ‪(47.7%) 323‬‬
‫نقل غير مباشر من المسشفيات االخرى )‪. (Secondary Transport‬‬
‫متوسط الوقت )‪ (DBT‬للنقل المباشر كان ‪ 15.9±34‬دقيقة )‪ .P Valeu= (p<0.005‬وللنقل غير ا لمباشر ‪. 28.8±100‬‬
‫معدل الوفيات خالل شهر )‪ (one-month mortality‬كانت ‪ 4%‬للنقل المباشر و ‪ 9.5%‬للنقل غير ا لمباشر )‪.(P=0.002‬‬
‫معدل الوفيات خالل سنة‬
‫)‪ (one-year mortality‬كان ‪ 7.3 %‬للنقل المباشر و ‪ 20.5%‬للنقل غير المباشر )‪.(P<0.005‬‬
‫الخاتمة‪(Conclusion) :‬‬
‫النقل الغير مباشر لمرضى الذبحة الصدرية الحادة الى قسم القثطرة و العناية القلبية يرفع لديهم معدل الوفيات الشهري و السنوي ‪.‬‬
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Introduction
The importance of time aspects in the treatment of patients with ST segment elevation myocardial
infarction (STEMI) is stressed both in the American College of Cardiology and the European Society
of Cardiology guidelines [1, 2]. A primary transport (PT) of a patient with STEMI directly into the
Cardiac Centers with feasibility of an immediate primary percutaneous coronary intervention (PPCI)
and not to the nearest hospital is recommended [1, 2]. In the real situation, many delays in both prehospital and hospital phases of initial care for patients with STEMI may take place. The pre-hospital
phase comprises "symptom onset – phone" time, which is affected mainly by public education, and
"phone – admission to a Cardiac Center" time, which is mainly influenced by the organization network
and the quality of given pre-hospital emergency medical care system. Hospital phase from admission
to opening of the infarction-related artery, reflected in the door-to-balloon time (DBT), is mainly
influenced by activities and organization of a Cardiac Center. Because of the proved link between the
DBT and mortality of STEMI patients, an effort to minimize all in-hospital delays is of a great
importance [3-7].
The aims of our study were to assess to what extent the primary admission of a STEMI patient to
non-PCI centers or PCI Center Coronary Care Unit (CCU) (secondary transport – ST) prior to PCI,
instead of direct transport to the catheterization laboratory (PT), influences the DBT and affects
mortality of patients with STEMI.
Patients and methods
Our region with 600,000 inhabitants uses for more than 15 years a 24 hours / 365 days system of
immediate transport of all patients with STEMI lasting less than 12 hours to referral catheterization
laboratories in the tertiary University Hospital Cardiac Center with an option to send ECG and consult
with board certified cardiologist.
We have prospectively analyzed DBT and mortality of patients with STEMI admitted from January
1, 2012 through December 31, 2013 to the Cardiac Centre of the University Hospital in Hradec
Kralove, Czech Republic, both primarily transported from the point of first medical contact (FMC) and
secondarily from non-PCI centers. In addition to DBT, we have also recorded the mode of patient's
initial transfer (i.e. direct transport to the catheterization laboratory, to non-PCI center first, or to PCI
center CCU with a subsequent transfer to the catheterization laboratory) and the reasons for various
delays in individual patients.
The study was approved by the Ethical Committee of the University Hospital and the Faculty of
Medicine Hradec Kralove, Charles University in Prague, Czech Republic.
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Basic clinical data of all patients, including the mode and time intervals of initial transport as well as
time of all intra-hospital procedures were routinely documented. The mortality data were obtained
from the Institute of Health Information and Statistics of the Ministry of the Health, Czech Republic
and from Czech National Registry of Cardiovascular Interventions, which updates regularly
information about the death of any subject in the Registry.
Normality of data was verified by the Kolmogorov-Smirnov test. Due to the non-normal distribution
of the DBT, we used the median as a position descriptor and the interquartile range as a variability
descriptor. Difference in medians was assessed by the Mann-Whitney test. DBT distributions were
compared by Kolmogorov-Smirnov test. Statistical significance level was defined as p<0.05.
Results:
Basic clinical data
Six hundred seventy-seven patients, age 37-96 years, mean 64 ± 16 years, 475 (70%) of them males
and 202 (30%) females, were enrolled for the final analysis.
From this number, 354 (52.3%) patients were primarily transported directly to the catheterization
laboratory (PT) and 323 (47.7%) patients were transported to regional hospitals or to the Coronary
Care Unit of the Cardiac Center and only then to the catheterization laboratory (ST).
Distribution of risk factors in both groups is shown in Table 1.
Door-to-balloon time (DBT)
DBT for PT was 34+15.9 minutes (interquartile range 20-115 minutes) and DBT for ST was
100+28.8 minutes ( interquartile range 35-160 minutes) (p<0005).
Mortality
Consequent follow-up was obtained in all patients.
One-month mortality was 4.0% and 9.5% (p=0.002) in patients from PT and ST groups, respectively
(Figure 1).
One-year mortality in PT and ST groups were 7.3% and 20.5% (p<0005), respectively (Figure 2).
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Patients not included in the study.
The total of 869 patients (age 20-96 years, mean 64 ± 12.3 years, 618 i.e.71.1% were men and 251,
i.e. 28.9% women) with the working diagnosis of STEMI were admitted to the Cardiac Center of the
University Hospital in Hradec Kralove, Czech Republic from January 1, 2012 through December 31,
2013, both primarily transported from field and secondarily from non PCI centers.
Localization of STEMI is shown in the Table 2.
From this basic cohort a total of 192 patients were not enrolled for the final analysis, the reasons are
shown in Table 3.
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Fig 1. Comparison of one-month mortality in the patients from PT and ST groups.
transport, ST=secondary transport
PT=primary
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Fig 2. Comparison of one-year mortality in the patients from PT and ST groups.
transport, ST=secondary transport
PT=primary
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Table 1: Basic clinical data of patients in the study. DM=diabetes mellitus, AMI=Acute
Myocardial Infarction, CABG=Coronary Artery Bypass Graft, PCI=Percutaneous Coronary
Intervention, PT=primary transport, ST=secondary transport
ST n = 323
PT n = 354
Risk factors
n
%
n
%
DM
57
16.1
62
19.2
Hypertension
166
46.9
156
48.3
Dyslipidemia
68
19.2
79
24.5
Previous AMI
28
7.9
35
18.8
9
2.5
13
4.0
27
7.6
30
9.3
Previous Ischemic brain stroke
9
2.5
16
4.9
Chronic Lower Limb Ischemia
9
2.5
16
4.9
132
37.3
90
27.9
49
13.8
95
29.4
Previous CABG
Previous PCI
Active smoker
Stop smoker
Table 2. Localization of the STEMI in the original group of 869 patients referred to the
tertiary center. LBBB=left bundle branch block
Localization STEMI
n
%
diaphragmatic wall
434
49.9
anterior wall
362
41.7
lateral wall
41
4.7
LBBB
32
3.7
Total
869
100
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Table 3. Reasons for not including patients to the long-term follow-up from the original group
of 869 patients referred to the tertiary center with the diagnosis of STEMI. PCI=Percutaneous
Coronary Intervention
Clinical condition
n
%
acute bypass surgery
18
2.1
diffuse coronary artery disease, PCI not performed
66
7.6
coronary angiography without significant stenosis
25
2.9
3
0.3
54
6.2
death during PCI
5
0.6
unsuccessful PCI
14
1.6
pericarditis
4
0.5
no STEMI in final diagnosis
hypertrophic cardiomyopathy
2
0.2
no STEMI in final diagnosis
dissection of the thoracic aorta
1
0.1
192
22.1
coronary artery spontaneous dissection
late reperfusion
TOTAL
>12 hours
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Discussion:
Reperfusion therapy by primary coronary angioplasty is accepted standard of treatment for patients with
STEMI lasting less than 12 hours and under some circumstances also for patients with symptoms lasting
more than 12 hours. Prerequisite for successful implementation of this strategy of treatment is – besides
experienced operators in facilities performing primary PCIs on 24 hours / 365 days basis – well
elaborated system of transfer of patients from field directly to catheterization laboratory. There is growing
evidence that delay in myocardial reperfusion projects into increase of mortality [7]. These authors also
showed that rather symptom onset-to-balloon time, but not DBT, is a main predictor of mortality,
particularly in non-low-risk patients and in the absence of pre-procedural anterograde flow. Furthermore,
a symptom onset-to-balloon time more than 4 hours was identified as independent predictor of one-year
mortality [7].
According to ESC guidelines, there are four key points important for correct assessment of time
intervals in patients with an acute phase of STEMI [1]. These are:
(1) symptom onset
(2) FMC
(3) diagnosis of STEMI
(4) reperfusion.
If reperfusion therapy is PCI, the FMC-reperfusion interval should be less than 90 minutes and in large
anterior myocardial infarctions and early presenters even less than 60 minutes [1]. In the PCI centers the
DBT should be less than 60 minutes, the DBT being defined as the time between the patient’s
presentation to the hospital and the passage of the wire to open the coronary artery. From the patient’s
perspective the most important interval is total ischemic time from the onset of symptoms to the
„provision of the reperfusion therapy“[1].
These guidelines also require bypassing non-PCI hospitals in the pre-hospital triage and the Emergency
Department (ED) avoidance on arriving to PCI hospital [1]. Nevertheless, so far there are no direct hard
mortality data to support this recommendation. Moreover, several studies, registries and analyses showed
that compliance with these guidelines is still problematic and room for improvement remains.
Patients with STEMI can access a PCI facility by several routes:
(1) pre-hospital STEMI diagnosis is made by Emergency Medical Services (EMS) and the patients
are transported to a PCI facility by EMS either directly to catheterization laboratory or
(2) via Coronary Care Unit or ED of the PCI hospital;
(3) the patients present to a hospital ED followed by referral to an on-site PCI facility; or
(4) the patients are transferred from the non-PCI hospitals to a PCI facility in another hospital [8].
Our study compares DBT and short-term as well as one-year mortality of direct transport of patients
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from the field to catheterization laboratory with other routes to primary PCI and shows that direct pattern
not only significantly shortens DBT but also results in significant decrease of one-month and one-year
mortality. We confirmed in our study low mortality in patients with STEMI and with the short DBT.
Our analysis documented that the transfer of patients with STEMI to non-PCI centers or the PCIhospital CCU – as compared to the primary transport to the catheterization laboratory – results in a
very significant time prolongation prior to opening the infarct-related artery, in median by more than 1
hour. The delay of opening the infarct-related artery significantly affected 1-month as well as 1-year
mortality. One of the possible delays in hospital phase results from coronary care (or intensive care) unit
stay prior to the PCI. The reason for admission of patients with STEMI to the PCI-hospital CCU was
typically delay of the catheterization laboratory team activation by the pre-hospital emergency medical
service or the inability to quickly release one of the catheterization laboratories at the time of STEMI
patient arrival. The reason for transporting patients with STEMI to non-PCI hospitals is most frequently
lack of experience to correctly evaluate ECG by attending physicians or paramedics.
Direct transport of patients with STEMI and it’s influence on DBT was analyzed in several studies.
Self-transportation without EMS and inter-hospital transportation are significant factors causing
prolongation of the transport time. Fujii T with his coworkers [9] reported that approximately 35% of
STEMI patients did not use EMS and 21% of patients were transported to non-PCI facilities even though
they called EMS. Awareness in the community as well as among medical professionals to reduce total
ischemic time of STEMI is necessary; this involves educating the general public and EMS crews [9].
Dorsch MF et al in another study found that directly admitted patients had significantly reduced DBT
(58 vs 105 minutes, p< 0.001) and call-to-balloon time (105 vs 143 minutes, p <0 .001). The 90-minute
target for DBT was achieved in 94% of direct admissions compared to only 29% of patients referred
from the emergency room [10]. Their data correspond to our study with DBT 34+15.9 minutes for
patients directly transferred to catheterization laboratory as compared to 100+28.8 minutes for secondary
transport.
Hagiwara MA et al [11] searched databases in English, Swedish, Danish and Norwegian language
for a protocol-based pre-hospital pathways and main outcome measurements. For each hour of delay
from FMC until reperfusion in ST-elevation myocardial infarction (STEMI) there was a 10% increase
in risk of death and heart failure. The aim of this review was to describe the impact of the direct
admission of patients with STEMI to a catheterization laboratory as compared to transport via ED with
regard to delays and outcome. Median delay in DBT was significantly shorter for the direct admission
group in all 5 studies reported. Difference in median delay varied between 16 minutes and 47 minutes.
In all 7 included studies the time from symptom onset or FMC-to-balloon time was significantly
shorter in the direct admission group. The difference in median delay varied between 15 minutes and 1
hour and 35 minutes. Only two studies described hospital mortality. When combined the risk of death
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was reduced by 37%.
Time interval from symptom onset to balloon inflation, DBT and mortality in patients treated by
primary PCI was analyzed already in 2000 [5]. The median DBT was 1hour 56 minutes and the
mortality significantly increased by 41% to 62% for patients with DBT longer than 2 hours [5].
Although the data suggested important association, they already do not correspond to the current
standards. Since that time, there has been a progressive decline in DBT among reperfusion-eligible
STEMI patients [12]. Among others, appropriate activation of interventional cardiology emergency
services reduced median DBT by 33.5 minutes [13]. These improvements have contributed to a
progressive decline in mortality.
Study of Krumholz HM and coworkers analyzed changes in DBT from 2005 through 2010 and
showed that DBT declined from a median of 96 minutes in the year ending December 31, 2005, to a
median of 64 minutes in the 3 quarters ending September 30, 2010. There were corresponding
increases in the percentage of patients who had times <90 minutes (44.2% to 91.4%) and <75 minutes
(27.3% to 70.4%) [14].
A new clinical performance measure parameter DIDO (door-in-door-out) was defined as the
duration of time from arrival to discharge at the first or STEMI referral hospital [15]. Time of 30
minutes or less was observed in only a small proportion of patients transferred for primary PCI but was
associated with shorter reperfusion delays and lower in-hospital mortality [15].
Hudson MP and coworkers [16] showed that both symptom onset-to-balloon time and hospital DBT are
strongly associated with 90-day mortality following STEMI, longer DBT was significantly associated
with worse 90-day mortality (3.2%, 4.0%, 4.6%, and 5.3% for delays <60 minutes, 60 to 90 minutes, 90
to 120 minutes, and ≥120 minutes, respectively, p<0.0001).
The RESCA+31 multicentre, prospective, multidisciplinary French registry included 512 consecutive
patients with STEMI managed by emergency physicians in the pre-hospital system or ED [17]. FMC was
pre-hospital emergency care for 80% of patients, 97% received reperfusion treatment and 98% were
admitted to a cardiology intensive care unit with a catheterization laboratory. The hospital mortality rate
was 5%. Guidelines were complied with in 41% of patients for reperfusion strategies, in 47% for
adjunctive treatments and in 23% for both. In 52% of cases, emergency physicians underestimated the
delay between FMC and admission to a intensive care unit.
Fosbol EL et al [18] assessed the adherence of emergency medical services to statewide strategy in
North Carolina to bypass non-PCI centers. From 1288 patients 826 (64%) were transported directly to a
PCI facility, thereby bypassing a closer non-PCI hospital, whereas 462 (36%) were first taken to a nonPCI hospital and later transferred to a PCI hospital. Their data are similar to our experience: 52.3% of our
patients were primarily transported directly to the catheterization laboratory and 47.7% to regional
hospitals or to the Coronary Care Unit of the Cardiac Center and only then to the catheterization
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laboratory. In a multivariable analysis Fosbol EL et al [18] found that increase in differential driving
time and cardiac arrest were associated with a lesser likelihood of being taken directly to a PCI center,
whereas a history of PCI was associated with a higher likelihood of being taken directly to a PCI center.
Patients sent directly to a PCI center were more likely to have times between FMC and PCI within
guideline recommendations.
Leleu H et al [8] used the results of the pilot testing of a national quality indicator program on STEMI
in 64 hospitals in France, providing data on patient characteristics, referral route and symptom-onset-toneedle time. They compared delays for three different routes in a population of 1217 patients. Median
symptom-onset-to-needle time was186 minutes for the EMS-PCI route, 237 minutes for the ED-PCI route
and 305 minutes for the ED-transfer-PCI route. A total of 70.8% of patients were transported by EMS as
recommended. STEMI patients receive prompter care after pre-hospital diagnosis and direct transport to a
PCI facility by EMS than by visiting a hospital ED.
Le May MR and his coworkers [19] in a similar analysis assessed 1,389 consecutive patients with
STEMI referred for primary PCI: 822 (59.2%) were referred directly from the field to a PCI center, and
567 (40.8%) were transported to a non–PCI-capable hospital first. Death at 180 days in their study
occurred in 5.0% of patients transferred directly from the field, and in 11.5% of patients transported from
the field to a non–PCI-capable hospital (p <0.0001). Our study further elaborated on these findings and
documented that also the stop at the PCI-center CCU influences the short-term as well as one-year
mortality.
Limitations of our study
Our study alike all other studies on this topic is not a randomized clinical trial, so the risk of selection
bias is obvious. However, randomized study on the mode of STEMI patients transport is not feasible.
DBT may be questioned as the main parameter to evaluate the outcome of patients with acute STEMI.
We did not perform multivariate analysis to evaluate whether other factors like age, gender, a history of
prior myocardial infarction, smoking, diabetes, hypertension, heart failure, renal dysfunction and possibly
also other factors may have a negative role apart from the mode of transport, as this was not originally
planned as one of the primary goal of our study.
Conclusions:
Our study is first to show that direct transport from field to catheterization laboratory not only
significantly shortens the transport times but also translates into significant decrease of not only one
month but also one year mortality. Still significant proportion of patients are transported to regional
hospitals or to the Coronary Care Unit of the Cardiac Center and only then to the catheterization
laboratory. Secondary transport of STEMI patients from field via non-PCI centers or via PCI-centers
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CCU to catheterization laboratory not only prolongs the DBT but also increases short-term as well as oneyear mortality. Every effort should be made to implement the network with direct transfers of STEMI
patients to a catheterization laboratory for primary PCI, bypassing the non-PCI hospitals and EDs.
Supported by the PRVOUK Project P 37/03 Charles University Prague, Czech Republic
Conflict of interest statement
The authors state that there are no conflicts of interest regarding the publication of this article.
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Authors contribution:
Abdulwasya Almawiri, Jan F. Vojacek, Josef Bis, Josef Stasek
data acquisition
Abdulwasya Almawiri, Jan F. Vojacek, Ziad Albahri
manuscript preparation