Minas Telecardio 2: Implantação da linha de cuidado do infarto do miocárdio na Região Ampliada Norte de Minas Gerais

Abstract

Introduction: In Brazil, there are considerable disparities in access to healthcare. In-hospital mortality in acute myocardial infarction (AMI) patients treated via the public health system is much higher than in those with private health insurance due to limited access to intensive care, reperfusion methods and other therapeutic treatments. Telecardiology may be a tool to improve cardiac care and reduce inequalities of cardiac access to specialized care. Purpose: To implement a STEMI system of care in the Northern of Minas Gerais to improve quality of care and outcomes in a rural and deprived Brazilian region with considerable social inequalities. Methods: The quality of care and outcomes of STEMI was evaluated in two cohorts before (n=214) and after (n=143) implementation of the coordinated regional management protocol. Before the implementation of the protocol, the prehospital transportation times were measured; the Ministry of Health ACS (acute coronary syndrome) protocol was adapted to regional needs and the flow proposal was presented to local meetings; the medication was standardized; a tablet-based digital electrocardiogram (ECG) was developed and tested in ambulances. Central to the protocol was a tablet-based digital ECG recording in the emergency ambulance that was transmitted for analysis by trained professionals and a flowchart developed to guide the choice of reperfusion therapy for STEMI, according to the transportation time. If the pre-hospital ECG was diagnostic, it triggered a management cascade considering anticipated journey times of (1) less than 2 hours: a direct transfer to the regional intervention center with reperfusion by primary percutaneous coronary intervention (PPCI); or (2) more than 2 hours: pre-hospital fibrinolysis. The ambulance staff, physicians and nurses of the local hospitals were extensively trained with protocols of chest pain, ACS syndrome, prehospital fibrinolysis and in how to use the digital-ECG. Results: Following implementation of the protocol, there was an increase in the frequency of patients with suspected chest pain (5.2 % to 23.9%) or AMI (28.3% to 82.0%) that performed a prehospital ECG. The adjusted medical delay (system delay minus transport time) decreased by 40%, 221 minutes, (95% confidence interval: -66%, -13%). The proportion of reperfusion therapy increased from 46.0% to 70.6% (p<0.001), and in eligible patients from 70.6% to 80.8% (p=0.045), with increases in treatment with aspirin (94.2% to 100 % [p=0.003]) and P2Y12 inhibitors (87.5% to 100% [p<0.001]). The in-hospital mortality showed a non-significant decrease from 17.2 % to 11.6% (odds ratio 0.73 [95% confidence intervals 0.34 to 1.60]). Conclusion: The implementation of a system of care for patients with STEMI using telecardiology led to marked improvements in the quality of care in a remote Brazilian region with limited resources.