改善急性心肌損傷病患之預後及縮短直接介入性心導管治療之院內策略評估

Assess the Intra-hospital Strategies for Improving Outcome and Reducing the Door-to-Balloon Time in Acute Myocardial Injury

林瑞萍(Jui-Ping Lin)

指導教授 ： 邱文達

共同指導教授 ： 蔡行瀚(Shin-Han Tsai)

臺北醫學大學/公共衛生暨營養學院/傷害防治學研究所/碩士(2008年)

https://doi.org/10.6831/TMU.2008.00041

摘要

背景：心血管疾病多年來均為全球十大死因之首。在美國，每二十秒就有一人被診斷為急性心肌梗塞，其死亡率高達三成以上。緊急直接介入性心導管治療術可以有效地降低急性心肌梗塞的死亡率，且病患從急診室至完成氣球擴張所花費的時間愈短，就會有較佳的預後。本研究是藉由提升醫院管理機制，執行相關介入措施，縮短病人從急診室至完成氣球擴張的時間，探討其改善預後之成效分析。
方法：本研究係收集北區某社區型醫院自2004年01月01日至2007年12月31日，由急診室收入院並接受直接介入性心導管診療術之急性心肌梗塞病人之臨床資料，比較介入措施執行前(2004年01月01日到2006年06月30日)與介入措施執行後(2006年07月01日到2007年12月31日)，病患從急診室至完成氣球擴張所花費的時間以及預後相關指標。相關之介入措施包括跨部門之協調、聯合研討會議、工作人員的在職教育與訓練、調整心臟專科醫師值班方式以及建立AMI-PPCI標準作業流程。
結果：收案總件數共計225人。平均發病年齡為63.4 ± 13.5歲；其中男性178人(79.1%)；研究結果指出，介入措施執行前(114人)與介入措施執行後(111人)兩階段病人的基本人口學特質並無統計學上顯著的差異；經由介入措施的實施後，病人從急診室至建立靜脈輸液的時間縮短13分鐘(p＜.05)、會診心臟專科醫師的間隔時間縮短72分鐘(p＜.05)、轉送心導管室的間隔時間縮短31分鐘(p＜.05)，完成氣球擴張的間隔時間平均縮短46分鐘(p＜.05)。上述介入措施明顯地降低了病人的疾病嚴重度(Killip)，接受再次心導管治療的比率由39.5%降低為 6.3%(p<0.05)，顯著提升預後品質，但死亡率在前後兩階段(6.1%與 8.1%)，則沒有顯著之差異。
討論：本研究係國內首篇藉由醫院管理介入措施，包括跨部門之協調、聯合研討會議、工作人員的在職教育與訓練、調整心臟專科醫師值班方式(24小時院內待命)以及建立AMI-PPCI標準作業流程等，以縮短急性心肌梗塞病人自急診室至完成氣球擴張所花費的時間以及提升預後品質成效之臨床分析。

關鍵字

急性心肌損傷 ； 緊急直接介入性心導管治療術 ； 病人抵達急診室至接受氣球擴張之間隔時間

並列摘要

Background: Cardiovascular disease is the leading cause of death in the world. Acute myocardial infarction (AMI) occurred every 20 seconds in U.S. and approximately one-third AMI cases died. Primary percutaneous coronary intervention (PPCI) decreased mortality of AMI significantly and the door-to-balloon time is shorter, the prognosis is better. In this study, we tested whether intra-hospital administration efforts could short door-to balloon time and improve patient’s outcome or not.
Method: We collected AMI subjects who received PPCI in our hospital from 2004 Jan. 01 to 2007 Dec.31. We compare door-to balloon time and clinical outcome before- (from 2004. Jan.01 to 2006 Jun.30) and after- (2006 Jul. 01 to 2007 Dec.31) intra-hospital administration interventions. These interventions included inter-department coordination, regular combined meeting; staff education, cardiology specialist stay in hospital even during off-time and set up AMI-PPCI standard procedure.
Results: Totally 225 consecutive AMI subjects recruited and age was 63.4 ± 13.5 years, male accounted for 79.1%. There were no significant difference in patient’s characteristics between before-intervention group (114 cases) and after-intervention group (111 cases). Our data demonstrated administration interventions shorted door-to-I.V. set time significantly by 13 minutes (from 39 ± 10.1 to 16.7 ± 6.6 min, p<0.05), door-to-cardiology visit time was shorted by 72 minutes (from 185.9 ± 26.9 to 113.9 ± 15.9 min, p<0.05), door-to-cath lab time was shorted by 31 minutes (from 276 ± 24.6 to 245.3 ± 27.5 min, p<0.05), and door-to-balloon time was shorted by 46 minutes (from 308 ± 25.3 to 261.8 ± 27.8 min, p<0.05) in the after-intervention group. These interventions improved patients’ outcome in decrease of severity of illness (Killip Classification) and reduction of need of repeat revascularization (re-PCI 39.5% to 6.3%, p<0.05) significantly, but no significant differences was found in mortality rate (6.1% vs. 8.1%) between two groups.
Conclusion: This is the first study in Taiwan to show that intra-hospital administration effort including education, inter-department coordination, regular combined meeting and cardiology specialist standby in hospital in off-time can short the door-to-balloon time and provide better clinical outcome in patients who received PPCI for acute myocardial injury.

並列關鍵字

Acute Myocardial Injury ； Primary Percutaneous Coronary Intervention ； Door-to-Balloom time

參考文獻

3. Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction - executive summary: a report of the American College of Cardiology/American Heart Association task force on practice guidelines (writing committee to revise the 1999 guidelines for the management of patients with acute myocardial infarction). JACC. Vol 44, No. 3, 2004: August 4,2004:671-719.

4. Hasdai D, Topo l EJ, Kilaru R, et al. Frequency, patient characteristics, and outcomes of mild-to-moderate heart failure complicating ST-segment elevation acute myocardial infarction: lessons from 4 international fibrinolytic therapy trials. Am Heart J. 2003;145:73-79

7. Bureau of Health Promotion, Taiwan, 2008

8. Elizabeth H. Bradley, Ph.D., Jeph Herrin, Ph.D., Yongfei Wang, M.S., et al. Strategies for Reducing the Door-to-Balloon Time in Acute Myocardial Infarction. NEJM 2006;355:2308-20.

9. ACC/AHA 2005 Guideline Update for PCI