title: Reperfusion therapy in ST-segment elevation myocardial infarction in the Veteran Administration Caribbean Healthcare System; search for improvement.
abstract: BACKGROUND
  Patients that present with acute STEMI have proven morbidity and mortality benefit from early reperfusion therapy. The American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend either fibrinolytic therapy within 30 minutes or a primary percutaneous coronary intervention (PPCI) within 90 minutes of patients arrival to the Emergency Department. Despite these recommendations, some patients do not receive reperfusion therapy and less than half receive it on time.
  
  
  OBJECTIVE
  Describe and analyze our reperfusion therapy performance in patients presenting with acute ST segment elevation myocardial infarct (STEMI) in the Veteran Administration Caribbean Healthcare System (VACHS), and determine potential causes for reperfusion therapy delays and develop strategies and a tailored algorithm according to our clinical findings and available institutional resources.
  
  
  METHODS
  Retrospective analysis of patients admitted to the VACHS with a discharge diagnosis of STEMI, from 01/01/2007 until 04/10/2008.
  
  
  RESULTS
  A total of 55 patients met inclusion criteria for STEMI diagnosis. Of these, only 30 patients had active indication for reperfusion therapy. Reperfusion therapy was given in 97% of the cases, 69% with PPCI and 31% with fibrinolytic therapy (tenecteplase). In general the selection of reperfusion therapy seemed adherent to ACC/AHA STEMI guidelines. The reperfusion time goal was superior with thrombolytic therapy compared to PPCI, with 43% and 15% respectively. PPCI performed off regular tour of duty was significantly delayed compared to regular day shift, with a mean time of 221 and 113 minutes respectively (p=0.027).
  
  
  CONCLUSIONS
  Most of the patients presenting with STEMI to the VACHS undergo reperfusion therapy. PPCI was the most frequent selected reperfusion approach. The PPCI time goal was infrequently met. The most significant cause for PPCI delay was related to performance off regular tour of duty. These finding support the implementation of a tailored STEMI reperfusion algorithm favoring timely reperfusion.
authors.affiliation: Cardiology Section, Department of Medicine, Veterans Administration Caribbean Healthcare System, One Veterans Plaza, St. Casia 10, San Juan, PR 00921-3200, USA. Jose.Escabi@med.va.gov
authors.forename: José
authors.initials: J
authors.lastname: Escabí-Mendoza
mesh_terms: D000368:Aged; D000465:Algorithms; D015906:Angioplasty, Balloon, Coronary; D000075202:Contraindications; D017023:Coronary Angiography; D004562:Electrocardiography; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D006801:Humans; D008297:Male; D009203:Myocardial Infarction / Q000175:diagnosis / Q000000981:diagnostic imaging / Q000628:therapy*; D015425:Myocardial Reperfusion; D011647:Puerto Rico; D012189:Retrospective Studies; D000077785:Tenecteplase; D015912:Thrombolytic Therapy; D013997:Time Factors; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use; D016896:Treatment Outcome; D014481:United States; D014493:United States Department of Veterans Affairs
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator; D000077785:Tenecteplase