title: The acute myocardial infarction with ST segment elevation Udine registry (Come-to-Udine): predictors of 3 years mortality.
abstract: BACKGROUND
  Percutaneous coronary intervention (PCI) is considered the best treatment for acute myocardial infarction with ST segment elevation (STEMI), but it is difficult to deliver.
  
  
  OBJECTIVE
  To report on long-term mortality predictors in a registry based on a 'hub and spoke' model, according to the initial strategy: thrombolysis followed or not by PCI, invasive strategy followed or not by primary PCI and no reperfusion.
  
  
  RESULTS
  From May 2001 to June 2003, 514 patients (mean age 67 +/- 12) with STEMI onset less than 12 h (<24 h if pain ongoing) were enrolled, 34% transferred from spoke centers. Patients were stratified according to thrombolysis in myocardial infarction risk score (TRS) and to local high-risk criteria (LHRC, one of the following: contraindication to thrombolysis, cardiogenic shock, anterior or right ventricular location, ST segment elevation in > or =6 leads, Killip class >1 and previous STEMI). Mean TRS score was 4.0 and 53% of patients met LHRC. Thrombolysis was undertaken in 49% of patients, invasive strategy in 29% and no reperfusion in 22%. The latter had higher TRS (4.9) but only 40% met LHRC. Reperfusion time was significantly longer in patients who underwent PCI as compared with those who underwent thrombolysis (223 vs. 120 min, P < 0.0001). Patients in the thrombolysis group had better risk profiles and underwent emergency or elective revascularization within 30 days in 66% of cases. Overall, long-term mortality rate (36 months) was 23.3%. Both TRS and LHRC identified patients with higher mortality (43 and 32%, respectively). Multivariate analysis showed age, left ventricular ejection fraction and Killip class more than 1 to be significant predictors of mortality (P < 0.0001/P < 0.0001/P = 0.0103), whereas reperfusion strategy and time to treatment were not.
  
  
  CONCLUSIONS
  An initial strategy of thrombolysis followed by emergency or elective PCI as appropriate is still an option in a setting in which limited resources are available. Decision-making based on risk scores and time from symptom onset lead to proper patient selection and even to foregoing reperfusion without affecting mortality.
authors.affiliation: SOC di Cardiologia, Azienda Ospedaliero-Universitaria S. Maria della Misericordia, Udine, Italy.
authors.forename: Guglielmo
authors.initials: G
authors.lastname: Bernardi
authors.forename: Antonio
authors.initials: A
authors.lastname: Di Chiara
authors.forename: Ilaria
authors.initials: I
authors.lastname: Armellini
mesh_terms: D000368:Aged; D015906:Angioplasty, Balloon, Coronary / Q000401:mortality*; D003131:Combined Modality Therapy; D005260:Female; D015276:Health Care Rationing / Q000458:organization & administration; D006297:Health Services Accessibility / Q000458:organization & administration*; D006764:Hospitals, Community / Q000458:organization & administration*; D006801:Humans; D007558:Italy / Q000453:epidemiology; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000401:mortality* / Q000628:therapy*; D018579:Patient Selection; D010360:Patient Transfer / Q000458:organization & administration*; D016016:Proportional Hazards Models; D012042:Registries; D018570:Risk Assessment; D012307:Risk Factors; D015912:Thrombolytic Therapy / Q000401:mortality*; D013997:Time Factors; D016896:Treatment Outcome