Reperfusion Strategies in ST Elevation Myocardial Infarction Network - Sao Paulo Registry.

Reperfusion Strategies in ST Elevation Myocardial Infarction Network - Sao Paulo Registry.

Preparation and implementation of the ST segment elevation myocardial network in Sao Paulo:

Initially, in 2009 a 24-hour central office for electrocardiogram (ECG) reading was installed at Hospital São Paulo - Paulista School of Medicine to receive EKG's sent from 126 SAMU ambulances, covering the entire São Paulo city area. The ECGs were transmitted to the central office via mobile phone, fixed phone or Internet, and immediately interpreted by a team of cardiologists, by using guidelines for STEMI ECG diagnosis. The EKG reports were sent back to the mobile phone of the transmitting ambulance. With this system in place and working adequately, the Municipal Health Secretariat of São Paulo made the fibrinolytic agent tenecteplase (TNK) available initially in four municipal emergency rooms (ER) of large peripheral hospitals, with a previous history of receiving a large number of patients with AMI (Ermelino Matarazzo ER, Campo Limpo ER, Tatuapé ER, and Saboya ER). The medical and nursing teams of these hospitals were trained and updated on the clinical diagnosis of acute coronary syndromes, ECG recognition of STEMI, and indications of thrombolytic agents and primary PTCA in STEMI. A direct and immediate contact, via an exclusive mobile phone line, was established between the advanced ambulances or the ERs and the Coronary Unit of Hospital São Paulo. Thus, a patient diagnosed with STEMI, who was at an ER or in an ambulance and could be in a catheterization laboratory in less than 90 minutes or with contra-indication to thrombolysis was referred for primary PTCA. If the advanced ambulance was very far away or if the estimated travel time for a patient at one of the ERs was longer than 90 minutes, he/she would receive TNK; after thrombolysis, the patient would be immediately transferred to Sao Paulo Hospital, and would undergo either rescue PTCA, if necessary, or cardiac catheterization within 6 to 24 hours, if clinically stable. The dose of TNK ranged from 30 mg to 50 mg, meeting the known criteria for indication and contraindication of fibrinolytic drugs. In addition to TNK, the patients received as adjuvant therapy and according to the Brazilian and international guidelines the recommended doses of morphine, low molecular weight heparin (properly corrected to weight and renal function), IV nitrates and oral medications, such as, aspirin, clopidogrel, statins and beta-blockers.

An expansion of the primary network was made in 2011 to allow 3 more ER's to be included in the network (Pirituba, Joao XXIII, Servidor Municipal) and one more in 2013 (Vila Maria), summing up at the moment 8 fixed ER units plus SAMU ambulances.

After catheterization, patients are maintained in the tertiary hospital if they are in advanced Killip class or have left main or severe LV dysfunction and were referred back to the primary center 24 hours after cath or PCI if stable, with good LV function and 1 or 2 vessel disease.