Dissertations / Theses on the topic 'Angioplastia primaria'

El documento digital no refiere asesor
Objetivo: Determinar el impacto de implantar el Programa de Asistencia Permanente en los tiempos de actuación y el perfil de los pacientes tratados con angioplastia primaria atendidos en el HNERM de julio 2011 al junio 2014. Metodología: Estudio observacional, descriptivo, retrospectivo de corte transversal. El tamaño de la muestra está conformado por 176 pacientes con IMA ST elevado tratados con angioplastia primaria que cumplieron los criterios de inclusión y ninguno de exclusión. Para describir variables cualitativas se emplearon frecuencias absolutas y relativas, para variables cuantitativas se emplearon medidas de tendencia central y dispersión. Resultados: Entre las características epidemiológicas de los pacientes incluidos se observó una edad promedio de 65.7 años, siendo en gran parte de casos: menores de 60 años (36.4%), pacientes de sexo masculino (82.4%), casados (63.1%) y de ocupación empleados (47.2%). La principales comorbilidades fueron la HTA (61.1%) y dislipidemia (58.3%). El tiempo entre la llegada del paciente al hospital y la angioplastia primaria (tiempo puerta-balón) en la mayoría de casos fue > 90 minutos; asimismo, las medianas de los tiempos simples fueron: tiempo 1 (inicio de los síntomas-llegada al hospital), 194 minutos; tiempo 2 (llegada al hospital-evaluación por el médico de emergencia), 40.5 minutos; tiempo 3 (evaluación por el médico de emergencia-atención por el especialista), 40 minutos; tiempo 4 (atención por el especialista-apertura de la arteria), 36 minutos. La mayoría de pacientes tuvieron un tiempo de isquemia menor a 12 horas y una severidad del IAM ST elevado fueron catalogados como Killip I (89.4%) y Killip II (5.6%). El impacto de la atención oportuna del programa de asistencia permanente en la evolución de la función cardiaca en pacientes con IMA ST elevado demostró un mayor grado de afectación cardiaca severa y leve cuando el tiempo de demora en la atención por el especialista fue mayor a 30 minutos, no observándose relación alguna entre este tiempo y la evolución de la función cardiaca (p=0.271). Si bien hubieron mayores casos de afectación cardiaca severa, moderada y leve en pacientes con un tiempo de isquemia total menor a 12 horas, la evolución a corto plazo de la función cardiaca no se vio afectada por el tiempo de isquemia total (p=0.615). El éxito de la angioplastia (TIMI III) se dio en el 94.3% de pacientes y solo el turno de atención del paciente se asoció a esta condición (p=0.023). Conclusiones: El impacto en tiempo de actuación demostró que si bien el tiempo recomendable puerta-balón para la angioplastia se cumplió en una minoría de casos, el tiempo de isquemia no afectó la severidad del IAM ST elevado. El tiempo de demora en la atención por el especialista mayor a 30 minutos aumentó la frecuencia de casos de afección funcional cardiaca severa y leve. El tiempo de isquemia menor a 12 horas permitió observar mayores casos de función cardiaca óptima. La única condición asociada al éxito de la angioplastia primaria fue el turno de atención.
Trabajo académico

Tot i la seva curta vida –la primera angioplàstia coronària la va dur a terme Andreas Grüntzig l’any 1977-, l’intervencionisme coronari percutani ha representat una revolució en el tractament de la patologia coronària. L’objectiu d’aquesta tesi és analitzar diferents condicionants de l’angioplàstia coronària en pacients amb infart de miocardi amb elevació del segment ST (IAMEST) i/o xoc cardiogènic, que estan relacionats amb el pronòstic: 1) Condicionants temporals (I). Anàlisi del retard fins a la reperfusió en funció del lloc on es realitza el primer contacte amb el sistema assistencial . • Anàlisis de los tiempos de atención en pacientes con infarto agudo de miocardio tratados con angioplastia primaria según su procedencia y según el horario de realización del procedimiento. Rev Esp Cardiol 2011;64(6):476-483. 2) Condicionants temporals (II). Anàlisi dels canvis en el retard fins a la reperfusió després de la integració d’una xarxa local dins d’una xarxa regional d’atenció a l’infart, el Codi Infart a Catalunya. • Integration of a local into a regional primary angioplasty action plan (the Catalan Codi Infart network) reduces time to reperfusion. Int J Cardiol 2013;168(4):4354-4357. 3) Condicionants funcionals i anatòmics. Anàlisi del paper de l’accés transradial en pacients amb xoc cardiogènic. • Transradial percutaneous coronary intervention in cardiogenic shock: a single-center experience. Am Heart J 2013;165(3):280-285. 4) Condicionants anatòmics. Anàlisi del paper de l’accés transradial en pacients amb edat ≥75 anys amb IAMEST en els que es realitza angioplàstia primaria. • Results of primary percutaneous intervention in patients ≥75 years treated by the transradial approach. Am J Cardiol 2014;113(3):452-456. Per la realització d’aquest treball s’ha confeccionat un registre prospectiu observacional de pacients consecutius tractats amb angioplàstia en el context de l’IAMEST i/o de xoc cardiogènic atesos en un centre terciari entre 2007 i 2013. En la primera etapa del registre (2007-2010) es va objectivar que l’anàlisi dels diferents intervals de temps entre l’inici dels símptomes i la reperfusió permet identificar punts febles del sistema on es produeixen demores no justificades; i que el lloc on es realitzava el primer contacte mèdic (hospital amb disponibilitat d’angioplàstia primària, hospital sense disponibilitat d’angioplàstia primaria o atenció extrahospitalària pel SEM) tenia una influència en el retard. La realització de la intervenció en horari laboral o en horari de guàrdia no influïa en el retard, en contra del que havien suggerit altres publicacions. Amb la posada en marxa del Codi Infart, l’any 2010, es va millorar l’organització de la xarxa amb un increment del nombre de pacients que van rebre tractament de reperfusió i un increment en l’angioplàstia primària com a tractament d’elecció, amb una disminució del retard fins a la reperfusió quan es comparava amb el període previ. L’anàlisi dels pacients amb xoc cardiogènic va mostrar que l’accés radial és factible en dues terceres parts dels pacients i que l’absència de pols radial era la principal causa de triar la via femoral com a alternativa. Una troballa interessant va ser la relació entre l’accés radial i la disminució de la mortalitat en l’anàlisi multivariant. En els pacients amb edat ≥75 anys als quals es va practicar angioplàstia primària l’accés radial va ésser possible en quasi bé tots els casos (>95%). Tot i la complexitat dels pacients, el seguiment va demostrar una incidència de mortalitat i esdeveniments cardíacs majors significativament inferior a la que s’havia reportat prèviament en aquest subgrup de pacients quan el procediment es realitzava per accés transfemoral.
Despite its short life-the first coronary angioplasty was carried out by Andreas Grüntzig in 1977-percutaneous coronary interventions have represented a revolution in the treatment of coronary disease. The objective of this thesis is to analyze different factors of coronary angioplasty in patients with myocardial infarction with ST segment elevation (STEMI) and / or cardiogenic shock, which are related to the prognosis: 1) Time Factors (I). Analysis of delay to reperfusion depending on where the first medical contact was made. • Anàlisis de los tiempos de atención en pacientes con infarto agudo de miocardio tratados con angioplastia primaria según su procedencia y según el horario de realización del procedimiento. Rev Esp Cardiol 2011;64(6):476-483. 2) Time Factors (II). Analysis of changes in the delay to reperfusion after integrating a local network within a regional network, the Codi Infart Network in Catalonia. • Integration of a local into a regional primary angioplasty action plan (the Catalan Codi Infart network) reduces time to reperfusion. Int J Cardiol 2013;168(4):4354-4357. 3) Anatomical and Functional Factors. Analysis of the role of transradial access in patients with cardiogenic shock. • Transradial percutaneous coronary intervention in cardiogenic shock: a single-center experience. Am Heart J 2013;165(3):280-285. 4) Anatomical Factors. Analysis of the role of transradial access in patients aged ≥75 years with STEMI treated with primary angioplasty. • Results of primary percutaneous intervention in patients ≥75 years treated by the transradial approach. Am J Cardiol 2014;113(3):452-456. We made a prospective observational registry of consecutive patients treated with angioplasty in the context of STEMI and / or cardiogenic shock between 2007 and 2013. In the first phase of the registry (2007-2010) the analysis of different time intervals between symptom onset and reperfusion permited to identify weaknesses in the system and unjustified delays. The place where the first contact medical was made (hospital with or without 7/24 PCI or outpatient care by SEM) had an influence on the delay. The performance of the operation at work or on call time did not affect the delay, contrary to what had suggested other publications. With the launch of the Codi Infart in 2010, the improvement in the organization of the network was related to an increase in the number of patients who received reperfusion therapy and an increase in primary angioplasty as the treatment of choice with a reduction of the delay to reperfusion when compared with the previous period. The analysis of patients with cardiogenic shock showed that radial access was feasible in 2/3 of patients and that the absence of radial pulse was the main femoral approach. We find a relationship between radial access and decreased mortality in the multivariate analysis. In patients aged ≥75 years who underwent primary angioplasty radial access was possible in almost all cases (> 95%). Despite the complexity of patient monitoring showed an incidence of mortality and major cardiac events was significantly lower than that previously reported in this subgroup of patients when the procedure is performed by transfemoral access.

Introduction: Achieving optimal times of reperfusion in STEMI patients transferred for primary percutaneos coronary intervention (PCI) remains a challenge, particularly in geographically disperse regions. Our goal was to create a prediction model of STEMI diagnosis - wire crossing time and perform an internal validation. Methods: Prospective cohort study of patients admitted to the critical care unit (2007-2018) diagnosed with STEMI who required to be transferred to PCI center. An analysis was carried out to identify the predictive variables leading to a delay in STEMI diagnosis -wire crossing times. Afterwards, a prediction model was created and an internal validation of this model was performed. Results: A total of 1.049 patients were included during the study period. The delaying predictive factors were: severe Killip on admission (Killip ≥3) (OR 1,100 IC 95% (1,048-1,155) p=0,0001), coronary artery bypass grafting (OR 1,241 IC 95% (1,119-1,377) p <0,001), out-of-hospital cardiac arrests (OR 1,150 IC 95% (1,078-1,228) p <0,001), lateral ischemia (OR 1,065 IC 95% (1,030-1,102) p=0,0002), first medical contact in a non-PCI center (OR 1,225 IC 95% (1,174-1,279) p<0,001), primary healthcare center (OR 1,183 IC 95% (1,131-1,238) p<0,001), home care (OR 1,077 IC 95% (1,026-1,131) p=0,003) and distance (Km) from PCI center; < 40 Km (OR 1,034 IC 95% (1,026-1,043) p<0,001) and >40 Km (OR 1.079 IC 95% (1,066-1,092) . Internal validation showed a square R of 0.355 and a correlation of 0.6. The area under the curve to predict time >120 minutes was 0.785. Conclusions: STEMI diagnosis-wire crossing time predictor variables were identified and included in a prediction model. Internal validation was success. This tool could be useful in clinical practice when taking relevant decisions in STEMI patients
Introducció: És difícil aconseguir temps òptims d´angioplàstia primària (AP) en un percentatge de pacients amb IAMEST procedents del medi extra-hospitalari o d'hospitals sense programa d'AP. Disposar d'una eina de predicció del temps d'AP desde el diagnòstic podria ser útil. El nostre objectiu va ser crear un model de predicció del temps d'ECG diagnòstic-pas de guia i realitzar una validació d'aquest model. Mètode Estudi de cohorts prospectiu de pacients ingressats a la unitat de cures crítiques cardiològiques (2007-2018) amb IAMEST, tractats amb AP i que van requerir ser traslladats a un centre amb disponibilitat d'hemodinàmica. Es va realitzar un anàlisi per identificar les variables predictores de demora de l'ECG diagnòstic- pas de guia, es va crear un model de predicció d'aquest temps i una validació interna del model. Resultats Es van incloure un total de 1.049 pacients en l'estudi. Les variables incloses en el model de predicció van ser la insuficiència cardíaca greu a l'ingrés (Killip ≥3) (OR 1,100 IC 95% (1,048-1,155) p = 0,0001), la cirurgia cardíaca prèvia de bypass (OR 1,241 IC 95% (1,119-1,377) p <0,001), la mort sobtada extrahospitalària (OR 1,150 IC 95% (1,078-1,228) p <0,001), la localització lateral de l'IAM (OR 1,065 IC 95% (1,030-1,102) p = 0, 0002), el primer contacte amb hospital sense disponibilitat d'hemodinàmica (OR 1,225 IC 95% (1,174-1,279) p <0,001), centre d'atenció primària (OR 1,183 IC 95% (1,131-1,238) p <0,001), domicili ( OR 1,077 IC 95% (1,026-1,131) p = 0,003) i finalment la distància al centre amb hemodinàmica; <40 Km (OR 1,034 IC 95% (1,026-1,043) p <0,001) i> 40 km (OR 1.079 IC 95% (1,066-1,092) p <0,001). La validació interna va mostrar un R quadrat de 0,355 i una correlació de 0,6. L'àrea sota la corba per a temps superiors a 120 minuts va ser de 0,785. Conclusions Identificades les variables predictores del temps ECG diagnòstic-pas de guia es va crear un model de predicció, amb una validació interna satisfactòria, que pot ser útil en la presa de decisions clíniques en el IAMEST

La bifurcation coronaire est un site privilégié d’athérosclérose. Jusqu’alors aucune des techniques de stenting provisionnel percutanées avec juxtaposition de ballons n’a démontré de bénéfice clinique. Ces échecs peuvent être expliqués par le non-respect de la géométrie fractale des bifurcations qui pourtant doit toujours guider la revascularisation (correction de la malapposition et optimisation de l’ostium de la branche collatérale). Fort de ce constat, nous avons imaginé une nouvelle technique séquentielle et simple, en 3 temps, le rePOT, associant Proximal Optimizing Technique (POT) initial, ouverture de la branche collatérale et POT final. Son évaluations s’est voulue progressive en 4 étapes : 1) concept, 2) preuve expérimentale de concept, 3) confirmation des bénéfices mécaniques in vivo, et 4) validation clinique. Dans ce travail nous avons donc d’abord expérimentalement démontré la supériorité du résultat mécanique final du rePOT par rapport aux techniques non séquentielles de provisional stenting (manuscrit # 1). Ainsi, le rePOT effondre la malapposition globale du stent, conserve la circularité proximale physiologique et optimise l’obstruction ostiale résiduelle de la branche accessoire. Ces excellents résultats sont confirmés indépendamment du design ou de la composition des stents (manuscrits # 2, 4). Nous avons par ailleurs démontré l’importance de chacune des 3 étapes du rePOT: POT initial (manuscrit # 1), ouverture de SB et POT final (manuscrit # 3). Enfin, fort de ces démonstrations expérimentales, nous avons confirmé in vivo avec mesures OCT itératives à la fois les excellents résultats expérimentaux et la bonne évolution clinique à moyen terme (manuscrit # 5). Ce travail démontre donc étape par étape, de l’expérimentale à la clinique, l’ensemble des bénéfices de cette nouvelle technique séquentielle de stenting provisionnel "rePOT", devenue une référence en Europe dans la revascularisation percutanée des bifurcations coronaires
Coronary bifurcations are a preferential location for atherosclerosis development. Until now, no technic with balloons juxtaposition demonstrated a clinical benefit in percutaneous coronary bifurcation revascularization by provisional stenting (with 1 stent). Successive failures could be explained by the absence of respect of the bifurcations fractal geometry, which need to be systematically followed during all revascularization (correction of the malapposition and optimization of the side branch ostium). Thus, we imagined a new technique, simple and sequential, in 3 steps, named rePOT. It is combining initial Proximal Optimizing Technique (POT), side-branch opening and final POT. We proposed a demonstration in 4 steps : 1) concept, 2) experimental proofs of concept, 3) confirmation of the clinical benefits in vivo, and 4) clinical validation. In this work, we experimentally demonstrated the superiority of the final mechanical results of the rePOT compared to all non-sequential provisional stenting (manuscript # 1). Thus, rePOT decreased stent global malapposition, maintained the initial proximal circularity and optimized the final ostial side branch obstruction. These excellent results were confirmed independently of stent design or material (manuscripts # 2, 4). Moreover, we demonstrated the specific benefits of each steps of the rePOT : initial POT (manuscript # 1), SB opening, and final POT (manuscript # 3). Finally, we confirmed in vivo, with serial OCT analysis, these excellent mechanical results and the good clinical outcome at mid-term. (manuscript # 5). Thank to this step by step demonstration, from experimental to clinic, we confirmed all benefits of this new provisional stenting sequential technique "rePOT". Thereby, before the last step of the demonstration, rePOT became a reference in Europe for the percutaneous revascularization of coronary bifurcations

Thrombolysis remains the predominant reperfusion strategy for ST segment elevation myocardial infarction (STEMI) in the United Kingdom. Although primary angioplasty may offer superior outcomes, the logistics of delivering this therapy in the UK have not been investigated. This thesis describes the development of a pilot primary angioplasty service in North East London. Outcomes are compared with the thrombolytic strategy, and platelet activation is explored as a possible biological mechanism determining reperfusion. The impact of the thrombolytic strategy on revascularisation following STEMI in North East London was first investigated. Thrombolytic delivery was effective, but necessitated frequent early revascularisation, leading to prolonged hospital stay. A primary angioplasty service was developed at the cardiac centre, and expanded to serve six network hospitals. Within the limitations of a daytime pilot, the service improved clinical outcomes, and was associated with a substantial reduction in hospital stay. Two admission strategies were compared - direct access to the cardiac centre following pre-hospital diagnosis by ambulance crews, and transfer of patients presenting to network emergency (A&E) departments after upstream administration of abciximab and clopidogrel. Direct access significantly reduced reperfusion times. Upstream anti-platelet therapy improved angiographic reperfusion prior to primary angioplasty, possibly compensating for inter hospital transfer delays. A subgroup of STEMI patients underwent platelet activation studies. Lower baseline platelet monocyte aggregate (PMA) levels predicted improved angiographic reperfusion following primary angioplasty, supporting the concept that PMAs may reflect plaque rupture severity, and may promote microvascular 2 dysfunction. Early anti-platelet therapy reduced PMAs following intervention, which may explain the benefit of early abciximab observed in clinical trials. In summary this thesis has demonstrated that primary angioplasty can be del ivered safely and eff ectively in North East London. The eff icacy of reperf usion may be determined by mechanisms involving platelet activation. Delivery of a 24 hour seven day service should now be addressed.

Early restoration of infarct-related artery (IRA) blood flow and myocardial perfusion in patients with acute STEMI is associated with preservation of left ventricular function, myocardial salvage and reduction in mortality (GUSTO, 1993, FTT -Group, 1994, Berger et al., 1999, Cannon et al., 2000, De Luca et al., 2004, Shavelle et al., 2005, Brodie et al., 2006). Wider implementation of PPCI in the UK is limited by different geography and demography of the patients presenting with STEMI. There are difficulties in initiating a PPCI service and delivering therapy within recommended timelines. This has been due mainly to lack of facilities and trained staff, uncertainties about the cost-effectiveness of the strategy and difficulties in changing established practice. The widespread introduction of PPCI would have major implication for the reorganisation of health care provision. The primary aim of this thesis is the evaluation of a reorganisation of service from one based on thrombolysis (including a rescue angioplasty service) to a PPCI service at The lames Cook University Hospital for patients with acute myocardial infarction. The long-term outcomes of rescue PCI (rPCI), its use in high-risk groups, and an analysis of the predictors of failed rPCI procedures, form the basis of the first part of this thesis. Additional analysis reflects the change from one pathway of service delivery to another with the development of a PPCI service.

Objectifs. L'infarctus aigu du myocarde (IDM) touche chaque année plus de 120 000 personnes en France. Nous nous sommes intéressés à la prise en charge du SCA avec sus-décalage du segment ST (ST+). Deux stratégies de revascularisation coronaires s'offrent à nous : la thrombolyse intraveineuse et l'angioplastie primaire. Notre travail a évalué l'impact du choix de ces stratégies dans la phase aiguë de l'infarctus du myocarde, à travers la mise en place d'un réseau associant la médecine d'urgence et la cardiologie interventionnelle autour d'un référentiel partagé. Méthode. Nous avons mis en place un réseau cardiologie - urgence (RESCUe), qui a fédéré au sein d'une association 37 structures d'urgence (SU), 19 structures mobiles d'urgence et de réanimation (SMUR) et 10 centres de cardiologie interventionnelle (CCI) dans un bassin géographique de 3 millions d'habitants. Notre méthode de travail s'articulait autour de trois axes : édition de référentiels partagés, formation et évaluation. Résultats. Dès la mise en place de RESCUe, nous avons lancé un essai multicentrique, contrôlé et randomisé, l'étude AGIR². En douze mois 320 SCA ST+ ont été inclus. Dès la prise en charge en SMUR tous les patients ont reçu 250 mg d'aspirine, 600 mg de clopidogrel, un bolus intraveineux de 60 IU/kg d'héparine avant d'être transférés en CCI pour une angioplastie primaire. Si le bénéfice d'une administration de tirofiban en SMUR n'était pas supérieur à son administration en CCI, AGIR² a conforté les bases d'une collaboration en réseau entre médecine d'urgence et cardiologie interventionnelle autour d'un référentiel thérapeutique partagé. Depuis, l'angioplastie primaire est progressivement devenue la stratégie de reperfusion de référence du SCA ST+ sur notre bassin. Pour évaluer son impact nous avons mis en place un registre observationnel couvrant l'ensemble des SU, SMUR et CCI du réseau. Entre 2009 et 2013 nous avons pris en charge 2418 patients en SMUR avec un diagnostic d'infarctus aigu du myocarde. Parmi eux, 2119 (87.6%) ont bénéficié d'une angioplastie primaire et 299 (12.4%) d'une thrombolyse intraveineuse. Nous avons observé une augmentation du recours à l'angioplastie primaire de 78.4% en 2009 à 95.9% en 2013 (P<0.001). Le délai médian ECG - arrivée en CCI était de 48 min, ECG - angioplastie 94 min et arrivée – angioplastie 43 min. Les délais symptôme – ECG et ECG – thrombolyse sont restés stables de 2009 à 2013, mais les délais symptôme – angioplastie et ECG – arrivée en CCI – angioplastie ont diminué (P<0.001). Au total 2146 (89.2%) patients avaient un délai ECG – arrivée en CCI ≤90 min, un délai confortant le choix d'une angioplastie primaire chez 97.7% d'entre eux en 2013, conformément aux recommandations. De 2009 à 2013, la mortalité hospitalière (4-6%) et celle à 30 jours (6-8%) est restée stable. Nous avons complété notre travail par une analyse de la conformité des mesures de prévention secondaire aux recommandations. A un an post-IDM, l'association bétabloquants – aspirine – statines – inhibiteurs de l'enzyme de conversion et la correction des facteurs de risque était liée à une meilleure survie. Parmi les 5161 patients pris en charge dans nos SU et en SMUR et sortis vivant de CCI, 2991 (58%) ont bénéficié de cette stratégie optimale avec un HR de 0.12 (95% CI 0.07–0.22; P<0.001). Les patients les plus graves étaient ceux les moins bien traités, à cause des contre-indications aux traitements (insuffisance rénale, risque hémorragique). Conclusion. Dans notre bassin géographique, la mise en place d'un réseau cardiologie urgence a abouti à l'augmentation du recours à l'angioplastie primaire, conformément aux recommandations. Il n'y a pas eu d'effet sur la mortalité précoce. Un bénéfice sur la mortalité à un an est observé chez les patients qui ont bénéficié de mesures de prévention secondaire optimales
Objective. Acute myocardial infarction (AMI) annually affects more than 120 000 people in France. We studied the management of ST elevation MI (STEMI). Two reperfusion strategies are available: intravenous thrombolysis (TL) and primary percutaneous coronary intervention (PPCI). Our study aimed to evaluate the impact of these strategies in the acute phase of myocardial infarction through the establishment of an emergency network based on a shared protocol with interventional cardiology. Methods. We established a regional emergency cardiovascular network (RESCUe Network) that covers a population of 3 million inhabitants across five administrative counties, including urban and rural territories. All nineteen MICUs, thirty seven emergency departments and 10 catheterization laboratories participate in the network. We edited regularly updated guidelines, set up a doctors’ training program and implemented an evaluation registry. Results. We setup the AGIR-2 study, a multicenter, controlled, randomized study, to explore prehospital high-dose tirofiban in patients undergoing PPCI. Three hundred and twenty patients with STEMI were included over a period of 12 months. All of them received 250 mg of aspirin, 600 mg of clopidogrel and 60 IU/kg bolus of high molecular weight heparin before admission to the catheterization laboratory. If prehospital initiation of high-dose bolus of tirofiban did not improve outcome, AGIR-2 study reinforced the collaborative network between emergency medicine and interventional cardiology. Since then, PPCI has gradually become the reference reperfusion strategy for STEMI in our network. Using data from our registry, we studied STEMI patients treated in mobile intensive care units (MICUs) between 2009 and 2013. Among 2418 patients, 2119 (87.6%) underwent PPCI and 299 (12.4%) prehospital TL (94.0% of whom went on to undergo PPCI). Use of PPCI increased from 78.4% in 2009 to 95.9% in 2013 (Ptrend<0.001). Median delays included: first medical contact (FMC)–PCI centre 48 min, FMC–balloon inflation 94 min, and PCI centre– balloon inflation 43 min. Times from symptom onset to FMC and FMC to TL remained stable during 2009 to 2013, but times from symptom onset to first balloon inflation and FMC to PCI centre to first balloon inflation decreased (P<0.001). In total, 2146 (89.2%) had an FMC–PCI centre delay ≤90 min with PPCI use up to 97.7% in 2013 in accordance with guidelines. Inhospital (4–6%) and 30-day (6–8%) mortalities remained stable from 2009 to 2013. Finally, we sought to assess the effect of strict adherence to current international guidelines on 1-year all-cause mortality in a prospective cohort of patients with STEMI. After multivariable adjustment, the association between the optimal therapy (OT) group (Betablockers, Antiplatelet agents, Statins, angiotensin-converting enzyme [ACE] Inhibitors, and Correction of all risk factors) and survival remained significant, with a hazard ratio of 0.12 (95% CI 0.07–0.22; P<0.001). Of the 5161 patients discharged alive, 2991 (58%) were prescribed OT. Patients characteristics in the under treatment (UT) group were worse than those in the OT group because of contraindications to optimal treatment (renal failure, bleeding risk). Conclusion. The establishment of an emergency network in our area resulted in an increased use of PPCI in accordance with ESC guidelines with no effect on early mortality. Reduction of one year mortality was observed in patients who received optimal secondary prevention treatment

La prise en charge de l'infarctus du myocarde est un enjeu de santé publique. Le pronostic de cette pathologie a été régulièrement amélioré, notamment grâce aux progrès des techniques de revascularisation coronaire (trombolyse et angioplastie). Après un rappel des principales études ayant conduit aux recommandations actuelles sur la prise en charge de l'infarctus à la phase aiguë, nous avons analysé la cohorte des patients admis pour SCA ST+ au CHU de Brest de juillet 2006 à octobre 2008 et déterminé le circuit et les délais de prise en charge. La comparaison de cette étude brestoise aux registres bretons et nationaux révèle des avancées majeures sur les dix dernières années, avec toutefois des améliorations à apporter notamment sur l'utilisation de la thrombolise préhospitalière, l'entrée dans le circuit thérapeutique par le "15" et la régulation des appels reçus par les médecins généralistes.

L’étude de la trajectoire de soins du malade offr un angle particulièrement adapté pour l’analyse et l’évaluation de la continuité des soins dans le réseau de la santé. Le concept de trajectoire de soins a émergé en France au début des années quatre-vingt. Il permet d’identifier les discontinuités de soins, d’observer la déviation par rapport aux guides de pratique ou trajectoires idéales et permet en outre d’analyser les effets liés aux écarts observés. Il se différencie des autres concepts et mesures de la continuité des soins principalement parce qu’il offr un point de vue "patient" en plus de permettre l’analyse d’une ou de plusieurs dimensions: temporelle, géographique, interdisciplinaire, relationnelle, informationnelle. Cette méthode permet au chercheur de fixer les bornes de la trajectoire, selon les besoins de l’étude. Dans le cas de la trajectoire de soins hospitaliers de l'infarctus aigu du myocarde avec élévation du segment ST (IAMEST), en observant principalement la dimension temporelle, peut-on identifier des trajectoires de soins déviantes par rapport aux trajectoires idéales (du début des symptômes à l’angioplastie primaire [plus petit ou égal à] 120 minutes), identifier les facteurs qui les influencent et en mesurer les impacts? La présente étude en est une de cohorte rétrospective faite à l'aide d'analyses secondaires de données médico-administratives, avec un échantillon des cas d’IAMEST du CHUS Fleurimont cumulé sur trois ans (2005 - 2007). Elle permet de mieux comprendre la méthodologie et le concept de trajectoire de soins et s’adresse principalement aux issues et processus de soins de même qu’aux écarts observés entre les recommandations publiées dans des guides de pratique et la réalité de la pratique. Elle vise à identifier les variables spatio-temporelles en lien avec les écarts observés. Les principaux résultats nous montrent que 87.8% des patients ont une trajectoire réelle de plus de 120 minutes. Les femmes sont plus âgées ont moins d’IAMEST que les hommes ; 69 % des patients ont un temps de présentation de moins de 2 heures, les femmes ont un délai de présentation presque identique aux hommes mais elles ont un délai de traitement plus long que ceux-ci avec respectivement une médiane de 123 et 110 minutes. Finalement, on constate que les trajectoires déviantes, les personnes âgées et le sexe féminin font augmenter la durée de séjour. L’étude des trajectoires de soins démontre une efficace avec les données médico-administratives québécoises.[symboles non conformes]

L'imagerie par tomographie en cohérence optique (OCT) est prometteuse comme support de la prise de décision au cours des procédures d'interventions coronariennes percutanées (PCI), pou évaluer les lésions athéromateuses, juger de la bonne implantation du stent, et dépister les lésions vasculaires dues au stent. L'OCT représente donc bien une aide potentielle pour le cardiologue interventionnel tout au long de la procédure de stenting, avec un impact certain sur la stratégie interventionnelle initialement programmée. De plus, l'OCT se révèle comme un nouvel outil pour prédire la dissection des bords de stent chez les patient avec ACS sans élévation du segment ST, rendant possible une stratification des patients quant à ce risque. Des essais cliniques randomisés sont maintenant nécessaires pour savoir si l'assistance par l'OCT pendant la procédure améliore le pronostic à long terme des patients après PCI
Optical Coherence Tomography (OCT) imaging is promising in decision making during Percutaneus Coronary Interventions {PCI) procedures, including evaluating controversial plaque lesions, assessing stent implantation, and surveying stent-related vascular injury. Thus, OCT has potential to guide interventional cardiologists throughout the stent implantation procedure, impacting on planned interventional strategy. In addition, OCT is the most novel image technology to predict stent edge dissection for patients with non-ST-segment elevation ACS, enabling risk stratification of patients who are at a higher risk of this complication. Large-scale randomized trials are now warranted to assess whether OCT results and guidance during de procedure improve long-term clinical outcomes of PCis

L’activité plaquettaire joue un rôle clé dans la physiopathologie de l’infarctus du myocarde avec sus-décalage du segment ST (IDM ST+). La réactivité plaquettaire est augmentée lors d’un IDM ST+, traité par angioplastie primaire ou par fibrinolyse avec succès. La relation entre la réactivité plaquettaire résiduelle après un pré-traitement, la charge athérothrombotique et la qualité de la reperfusion myocardique reste peu décrite dans le cadre des IDM ST+. La tomographie par cohérence optique et celle plus récente par domaine de fréquence offrent une imagerie de haute résolution permettant l’identification et la quantification précise de la charge athérothrombotique intracoronaire (CAT). La CAT résiduelle intra-stent peut aider à mieux comprendre la relation entre la réactivité plaquettaire et la reperfusion. Dans un premier temps, nous avons évalué la précision des tests VerifyNow et PFA en comparaison à l’agrégométrie optique pour la détection de l’hyperréactivité plaquettaire dans le contexte particulier des IDM ST+ traités par fibrinolyse avec succès. Nous avons aussi décrit les caractéristiques de la CAT avant et après angioplastie selon la présence d’une rupture de plaque ou d’une érosion coronaire chez des patients traités par fibrinolyse avec succès. Ensuite, nous avons étudié la relation entre la réactivité plaquettaire résiduelle (en réponse au ticagrelor et à l’aspirine) mesurée par VerifyNow et la reperfusion myocardique chez des patients traités par angioplastie primaire. En parallèle, nous avons décrit la relation entre la reperfusion myocardique et la CAT résiduelle intra-stent dans la même cohorte
Platelet activity plays a key role in the pathophysiology of ST-segment elevation myocardial infarction (STEMI). Platelet reactivity is enhanced after STEMI treated with primary percutaneous coronary intervention (PCI) or successful thrombolysis. The relationship between residual platelet reactivity after pre-treatment, the atherothrombotic burden and the quality of reperfusion remains poorly described in STEMI. Optical coherence tomography (OCT) and optical frequency domain imaging (OFDI) provide high resolution imaging allowing identification and accurate quantification of intracoronary atherothrombotic burden (ATB). Residual in-stent ATB may help to better understand the relation between platelet reactivity and reperfusion. First, we assessed the accuracy of the point-of-care tests VerifyNow and PFA in comparison to light transmittance aggregometry to detect high on-treatment platelet reactivity (HPR) in the particular setting of STEMI successfully treated with fibrinolysis. We also described the characteristics of ATB before and after PCI according to the underlying presence of rupture or erosion in patients successfully treated with fibrinolysis. Then, we assessed the relationship between residual platelet reactivity (in response to ticagrelor and aspirin) using VerifyNow and myocardial reperfusion in primary PCI patients. In parallel, we studied the relationship between myocardial reperfusion and residual in-stent ATB in the same cohort

ABSTRACT: Introduction: Despite achieving normal epicardial coronary artery flow after primary percutaneous coronary intervention (P-PCI), a significant proportion of patients with acute ST elevation myocardial infarction has a poorer outcome because of microvascular coronary damage and/or dysfunction. Endothelial dysfunction may play a role in this microvascular coronary damage after STEMI, and its evaluation by peripheral arterial tonometry may be useful to predict the extent of microvascular coronary damage and the extent of myocardial infarction. Objectives: To evaluate the relation of early peripheral endothelial dysfunction, as measured by the reactive hyperemia index (RHI, obtained by peripheral arterial tonometry) and the index of microcirculatory resistance (IMR) immediately after P-PCI and to access the relation between RHI and IMR values and: 1) the extent of myocardial infarct evaluated by contrast enhanced cardiac magnetic resonance (ceCMR) and troponin release; 2) the extent of microvascular obstruction (MVO), evaluated by ceCMR and by other available indirect indicators; 3) late (3 months) left ventricular remodelling, measured by echocardiography. Methods: Observational, prospective cohort study. Patients with a first STEMI successfully treated with P-PCI, hemodynamically stable and without contra-indications for adenosine administration were included. After successful P-PCI, IMR was determined, using a pressure-wire. RHI was evaluated acutely and after 24 hours, using EndoPAT; endothelial dysfunction was defined as RHI<1.67, and RHI was also analysed by tertiles. Corrected TIMI frame count (cTFC) and TIMI myocardial perfusion grade (TMBG) were evaluated at the end of the procedure. Blood tests for cardiac biomarkers were collected on admission and on scheduled intervals during the first 48 hours. ECGs were recorded before and immediately after P-PCI and at 90 and 180 minutes, for ST resolution evaluation. Left ventricular global and regional function were evaluated by echocardiography at baseline and at 3 months. ceCMR was performed on the 7-8th day post-MI. Results: 60 patients were included (48 males, mean age 59.6±12.7 years). In the first acute RHI values were higher than expected (mean 2.15±0.58) suggesting important technical pitfalls; no relation was found between this acute RHI and any of the infarct extent or microvascular obstruction indicators. Mean RHI values measured at 24 hours were 1.87±0.60. Patients with an RHI<1.67 on this second evaluation tended to have higher IMR (median 40.5 IQR 54.4 vs. median 22.0 IQR 26.0, p=0.09), worse ST resolution, worse angiographic (cTFC and TMPG) results and had more MVO in the ceCMR (54.1% vs. 11.1%, p=0.03). They also had significantly larger infarcts as evaluated by peal TnI (p=0.024) and AUC TnI (p=0.012) and a tendency to have larger infarcts in the ceCMR. Left ventricular ejection fraction (LVEF) was lower and wall motion score index (WMSI) was higher in the first Echocardiogram in these patients. IMR median values were 24 (IQR 33). IMR strongly correlated with MVO on the ceCMR (r=0.91, p<0.0001; ROC curve 0.723, CI95% 0.500-0.896, p=0.018). Patients with IMR>24 had significantly worse ST resolution and angiographic indicators of microvascular dysfunction. IMR also correlated with infarct mass (r=0.70, p<0.001) and salvage mass (r=0.35, p=0.014) in the ceCMR. Patients with IMR>24 had significantly higher peak (p=0.013) and AUC (p=0.003) TnI. LVEF improved significantly only in patients with IMR<24 (p=0.01). IMR independent predictors were age, glucose and HbA1c. Conclusions: RHI measured in the acute phase of STEMI after P-PCI seems to be unfeasible. RHI measured 24h after the P-PCI is feasible and predicts infarct size and MVO, confirming endothelial dysfunction as an important mechanism in microvascular dysfunction in STEM patients. IMR is strongly correlated with MVO and predicts both infarct size and LV remodelling.
RESUMO: Introdução: Apesar da normalização do fluxo coronário epicárdico após intervenção coronária percutânea primária (ICP-P), uma proporção significativa dos doentes com enfarte agudo do miocárdio com elevação do segmento ST (EAMcST) têm piores resultados clínicos devido ao desenvolvimento de lesão ou disfunção microvascular coronária. A disfunção endotelial provavelmente desempenha um papel nesta lesão microvascular coronária e a sua avaliação por tonometria arterial periférica poderá ser útil para prever a extensão da lesão microvascular e a extensão do enfarte. Objectivos: Avaliar a relação da disfunção endotelial periférica precoce, avaliada pelo índice de hiperémia reactiva (IHR, obtido por tonometria arterial periférica) com o índice de resistência da microcirculação (IRM), medido imediatamente após a ICP-P e estimar a relação entre o IHR e o IRM e, 1) a extensão do enfarte, avaliada por ressonância magnética cardíaca com contraste (RMCc) e pela curva de libertação de Troponina I; 2) a extensão da obstrução microvascular (OMV), avaliada por RMCc e por outros indicadores indirectos; 3) a remodelagem ventricular esquerda tardia (aos 3 meses), avaliada por ecocardiografia. Métodos. Estudo observacional, prospectivo, de coorte. Foram incluídos doentes com um primeiro EAMcST, tratados com sucesso por ICP-P, hemodinamicamente estáveis e sem contra-indicações para administração de adenosina. Depois da ICP-P, o IRM foi medido usando um fio de pressão. O IHR foi avaliado na fase aguda e novamente 24 horas depois da ICP-P. A disfunção endotelial foi definida como um IHR<1,67 e o IHR foi também analisado por tercis. Os indicadores angiográficos de reperfusão (contagem corrigida de frames e grau de perfusão miocárdica TIMI) foram avaliados no final da ICP-P. Foram colhidas análises na admissão e em horários definidos nas primeiras 48 horas para avaliação da Troponina I. Antes, imediatamente após e 90 e 180 minutos depois da ICP-P foram registados electrocardiogramas, para avaliação da resolução das alterações do segmento ST. A função ventricular esquerda global e segmentar foi avaliada por ecocardiografia após a ICP-P e aos 3 meses. A RCMc foi efectuada ao 7-8º dia após o EAMcST. Resultados: Foram incluídos 60 doentes (48 homens, idade media 59,6±12,7 anos). Na primeira avaliação, os valores de IHR foram muito superiores ao esperado (média 2,15±0,58), provavelmente por erros técnicos incontornáveis, não se relacionando com nenhum dos indicadores de extensão do enfarte ou de OMV. Na segunda avaliação, às 24h, os valores médios de IRH foram 1,87±0,60. Os doentes com IRH <1,67 tiveram tendencialmente valores mais elevados de IRM (mediana 40,5 IIQ 54,4 vs. mediana 22,0 IIQ 26,0, p=0,09), pior resolução do segmento ST, piores resultados nos indicadores angiográficos de OMV e maior probabilidade de ter OMV na RMNc (54,1% vs. 11,1%, p=0,03). Também tiveram enfartes de maior dimensão na avaliação pela TnI I máxima (p=0,004) e pela área sob a curva de TnI (p= 0,012). A fracção de ejecção do ventrículo esquerdo (FEVE) foi menor e o score de motilidade segmentar (SMS) maior nestes doentes. A mediana do IRM foi 24 (IIQ 33). O IRM correlacionou-se fortemente com a OMV avaliada na RMNc (r=0.91, p<0.001; curva ROC 0,723, IC95% 0,500-0,896, p=0,018). Nos doentes com IRM >24, a resolução do ST foi significativamente menor e os indicadores angiográficos de reperfusão foram significativamente piores. O IRM também se correlacionou com a massa de enfarte (r=0,70, p<0,001) e a massa de miocárdio salvo (r=0,35, p=0,014) na RMCc. Os doentes com IRM>24 tiveram valores significativamente mais elevados de TnI máxima (p=0,013) e ASC de TnI (p=0,003). A FEVE melhorou de forma significativa apenas nos doentes com IMR<24 (p=0,01). Os preditores independentes do IRH foram a idade, a glicemia na admissão e a HbA1c na admissão. Conclusões: Não parece ser possível avaliar de forma fidedigna o IHR na fase aguda do EAMcST após ICP-P. O IHR medido 24h após a ICP-P é mensurável de forma adequada e prevê a dimensão do enfarte e da OMV, confirmando a disfunção endotelial como um mecanismo importante na disfunção microvascular em doentes com EAMcST. O IRM correlaciona-se fortemente com a OMV e permite prever a dimensão do enfarte e o risco de remodelagem ventricular esquerda.

Introdução: É fundamental a rápida reperfusão da artéria responsável pelo enfarte agudo do miocárdio com supradesnivelamento ST (EAMST). As actuais guidelines recomendam que o intervalo entre a chegada do doente ao hospital e o momento em que a artéria é aberta, por angioplastia primária (tempo “porta-balão”), seja inferior a 90 minutos. Objectivo: Foi objectivo deste estudo avaliar a proporção de doentes com EAMST que não recebeu a angioplastia primária dentro dos tempos recomendados e, usar a metodologia da Health Failure Mode and Effect Analysis (HFMEA) e Stream Analysis para detectar as falhas, determinar a sua etiologia e repercussões, numa lógica de causalidade, e propor as alterações que conduzam à sua correcção. Resultados: Entre Junho de 2005 e Dezembro de 2008 foram incluídos 415 doentes, com idade 62+12 anos, tratados por angioplastia directa no contexto de EAMST. O tempo “porta-balão” médio foi de 116+97minutos e 44% dos doentes receberam o tratamento para além dos 90 minutos recomendados. Os sistemas de triagem não conseguiram identificar como emergente ou urgente 22% dos doentes com EAMST. A equipa de HFMEA apontou como causas mais pontuadas a falta de fiabilidade do protocolo de Manchester, a demora na realização do electrocardiograma e a ausência de uma sala de angiografia específica para a cardiologia. Conclusão: Um importante número de doentes com EAMST foi tratado, por angioplastia directa, para além do tempo recomendado pelas guidelines. A HFMEA e a Stream Analysis são importantes instrumentos de diagnóstico das disfunções identificadas e na proposta de alterações que conduzam à sua melhoria.
Introduction: Rapid reperfusion of the responsible artery is fundamental in patients with acute ST-segment elevation myocardial infarction (STEMI). Present guidelines recommend that the interval between the patient’s hospital admission and the opening of the artery by primary angioplasty (“door-to-balloon” time) be less than 90 minutes. Objective: The objective of this study was to evaluate the proportion of patients with acute STEMI that did not undergone primary angioplasty within recommended times and to use the Health Failure Mode and Effect Analysis (HFMEA) and the Stream Analysis in order to identify the failures, to determine its aetiology and repercussions in a cause-effect logic, and to propose changes that lead to the correction of the situation. Results: Between June 2005 and December 2008, 415 patients, aged 62+12 years, were submitted to direct angioplasty in the context of acute STEMI. “Door-toballoon” time was 116+97 minutes; 44% of the patients received treatment after the recommended 90 minutes. The admission screening systems were unable to identify 22% of patients with acute STEMI as emergency admissions or urgency admissions. The HFMEA team identified as the most scored causes of failures the effectiveness of the Manchester Triage System in classifying the STEMI patients, the excessive time to perform electrocardiogram and the lack of an angiography suite for cardiology department. Conclusion: A significant number of patients with acute STEMI are treated by direct angioplasty after the time recommended by the guidelines. The HFMEA and the Stream Analysis are important diagnostic tools for the identified dysfunctions and the change proposal that may lead to improvement.

Tese de doutoramento, Medicina (Cardiologia), Universidade de Lisboa, Faculdade de Medicina, 2017
Introduction Geoffrey Hartzler was the pioneer of primary angioplasty (P-PCI) when he treated the first patient with acute ST-segment elevation myocardial infarction (STEMI) in 1981. It would be about a decade before Cindy Grines and Bill O’Neill demonstrated that P-PCI was superior to fibrinolysis and would take nearly two decades until the guidelines considered P-PCI as a class I indication for the treatment of STEMI. Since the beginning of fibrinolysis studies it is widely known that the time from the onset symptoms to reperfusion was decisive for the success of the therapy. Also in P-PCI, the total ischemia time span has an impact on the results. Since this technique is much more demanding both from the logistic point of view and the availability of trained teams, the time factor plays a fundamental role in the results. Despite the scientific evidence of the benefits of reperfusion in STEMI, a significant proportion of patients worldwide still remain out of revascularization. Even in the Western more developed countries, many patients do not have access to P-PCI. In Europe there is an important heterogeneity in the practice of P-PCI, with high performance levels in the north and suboptimal levels in the south. The “Stent for Life Initiative” (SFL) was created in this context to reduce the differences among the various countries through measures to increase patient access to P-PCI. Identical initiatives were developed in the United States of America. Although in Portugal there is an interventional cardiology network that covers almost the whole country, and a good network of roads which allow a reasonable access (less than two hours) to P-PCI, in the middle of the last decade, it was one of the European countries with one of the lowest P-PCI rates. It was also observed that in Portugal only a small percentage of STEMI patients asked for help through 112. Most of them travelled to secondary hospitals, without primary angioplasty, therefore requiring secondary transportation, with a meaningful impact on treatment delay. Given the strong prognostic implications of total ischemia time (between the onset of symptoms and the time of reperfusion therapy), it is important not only to monitor all these timings, but also to identify where the main barriers to a good system performance are and to plan actions in order to improve quality indicators of the P-PCI in Portugal. The rapid technical progress in the areas of medical devices and pharmacology, along with the strong growth in the number of procedures, increased the need for recording data from the real world. The implementation in 2002 of the registries of the Portuguese Society of Cardiology (PSC), allowed a wide scrutiny of interventional cardiology practice and the management of acute coronary syndromes. The continuous recording of interventions, and the benchmark between national and international centres, are fundamental tools for the knowledge of the current situation of interventional cardiology and for the decision making. No less important is the scientific potential which the Portuguese Society of Cardiology registries program really represent. Objectives The main objectives were: 1. To evaluate the trends of P-PCI overtime in Portugal together with evaluation of performance indicators. 2. To identify quality indicators of P-PCI in Portugal, particularly the conundrum of delay in P-PCI access, in both the patient and the system delay components. Methods 1. A retrospective study based on the data of questionnaires distributed to Portuguese interventional cardiology centres (1992-2003) was performed in order to assess the earlier trends of PCI in Portugal. 2. The period of 2002/2003 was a landmark in the Portuguese interventional cardiology due to the beginning of the National Registries of the Portuguese Society of Cardiology. Retrospective evaluations of prospectively collected data from the National Registry of Interventional Cardiology (ClinicaTrials.gov identifier NCT01867801) and from the National Registry of Acute Coronary Syndromes (ClinicaTrials.gov identifier NCT01642329) from 2002 to 2013 were performed in order to assess the evolution of PCI in Portugal and particularly P-PCI. These data were complemented with official data from the General Directorate of Health for the years under review. 3. In-hospital mortality as a surrogate of quality indicators among centres. The presence (or absence) of cardiac surgery was also compared. 4. In order to assess the patient and system delay components, a prospective crosssectional study (Momentos) was carried out during one month per year (2011-2014), in all interventional cardiology centres in Mainland Portugal and integrated in the “Via Verde Coronaria”. Data of 994 patients suspected of having STEMI with less than 12 hours of evolution and proposed to P-PCI, who were admitted to 18 Portuguese centres of interventional cardiology were collected for a one-month period, every year from 2011 to 2014. Patient delay was defined as the time from symptom onset to first medical contact (FMC). It was considered a continuous variable and was expressed in minutes. System delay was defined as the time from first contact with the health care system to the initiation of reperfusion therapy. This variable was analysed as continuous or categorical variable (cut-off value 90 minutes). “Door-to-Balloon time” (D2B) was defined as the time from entrance at the P-PCI centre to the moment of reperfusion and was evaluated as well as continuous or categorical variable (cut-off value of 60 min). Following the “Momento Zero” study (2011) a public awareness campaign for the symptoms of heart attack and to how to call for help in order to improve the patient delay (“Act Now – Save a Life”, from the SFL initiative). Educational programs were implemented for professionals aimed at improving the performance on Acute Coronary Syndromes management and treatment. Univariate analysis and logistic regression models of multivariate analysis were used to determine the predictors of “patient delay” and “system delay” overtime. Exponential beta coefficients (exp (beta)), and 95% confidence intervals (CIs) were reported for continuous variables. Odds Ratio (OR) and 95% confidence intervals (CIs) were reported for categorical variables. The analysis was conducted at a 5% level of significance. Results 1. From 1992 to 2001 the evaluation questionnaires distributed in Portuguese interventional cardiology centres showed an increase of 1,193% in coronary interventions in comparison to 1992, with a total of 8,465 procedures and a rate of coronary interventions of 848 per million population in 2003. During this period, this PCI rate per million population in Portugal was lower than the mean European rate (848 vs. 1194). 2. According to the prospective and multicenter evaluation of the RNCI and the official data of the Directorate-General for Health, in 2013, 3,524 P-PCIs were performed, representing an increase of 315% compared to 2002. In 2002, P-PCI represented 16% of the total number of PCI, and in the years 2012-2013 they represented 25%. Between 2002 and 2013 the number of procedures per million inhabitants increased from 106 to 338 and rescue angioplasty decreased from 71%, in 2002, to 16%, in 2006, and to 2%, in 2013. During the study period, the use of drug eluting stents increased from 10% to 70%. After 2008, there was an increased use of aspiration thrombectomy, reaching 47% in 2013. The use of glycoproteins IIb / IIIa inhibitors decreased from 73% in 2002 to 24% in 2013. The radial access increased from 8% in 2008 to 55% in 2013. 3. Between 2002 and 2006, hospital mortality from coronary angioplasty in hospitals without cardiac surgery compared to hospitals with surgery 0.3% in both cases among patients with chronic angina; 1.5% and 1.0% (ns) respectively in patients with acute coronary syndromes; 4.0% and 5.0% (ns) in patients with acute ST-segment elevation myocardial infarction and no cardiogenic shock; 50.9% and 53.4% (ns) in patients with cardiogenic shock. 4. In the study “Momentos”, conducted monthly between 2011 and 2014, there were no significant differences in patient delay (114 min in 2011 and 119 min in 2015). The multivariable analysis identified five predictors of patient delay: age ≥ 75 (Exp(beta) 1.28; CI95% 1.10-1.50; p=0.001), onset symptoms during the night (Exp(beta) 1.26; CI95% 1.10-1.45; p=0.001), and primary healthcare unit before first medical contact (Exp(beta) 1.75; CI95% 1.41-2.16; p<0.001) were indicators of longer time and call 112-EMS (Exp(beta) 0.84; CI95% 0.71-1.00; p=0.045) and transportation by National Institute of Medical Emergency (INEM) to the P-PCI facility (Exp(beta) 0.71; CI95% 0.59-0.84; p<0.001) were indicators of a shorter patient delay. There were also no significant changes in the “system delay” (115 min in 2011 and 127 min in 2014) and D2B (54 min in 2011 and 64 min in 2014) during the study period. Only 27% of patients had a system delay ≥ 90 min. The system delay of less than 90 min was achieved in only 13% of patients undergoing secondary transportation versus 33% of cases where no transfer was required. The multivariate analysis identified four predictors of “system delay”: age ≥ 75 years (OR 2.57, CI 95% 1.50-4.59, p = 0.001), attendance a unit without P-PCI (OR 4.08; CI 95% to 2.75-6.10, p <0.001), call 112 (OR 0.47, CI95% 0.32-0.68, p <0.001) and “Centro” region (OR 3.43, CI 95% 1.60-8.31, p = 0.003). Conclusions The registries of Portuguese Society of Cardiology (PSC) allow a better knowledge of the activity of Portuguese cardiology in general and primary angioplasty in particular. The data collected allowed us to characterize the Portuguese intervention practice in Portugal and to plan a strategy to improve the performance. It was possible to verify that the practice of elective and primary coronary angioplasty performed in hospitals without on-site surgery is a safe practice, with results similar to those obtained in hospitals with surgery. The implementation of centres in peripheral regions, without cardiac surgery, allowed the P-PCI to be a reality in practically the entire national territory. Although at the beginning of this millennium both the Portuguese distribution of P-PCI centres and the road network were satisfactory, Portugal was one of the European countries with lower P-PCI implementation, which led PSC to join the SFL initiative. Despite the weak initial implementation, between 2002 and 2013 the rate of coronary angioplasty per million people increased by a factor of 3. Rescue angioplasty was overcome by primary angioplasty in 2006. New trends in the treatment of acute myocardial infarction with ST-segment elevation were observed, with the use of drug eluting stents and radial access, with rates similar to the European average. Despite a public awareness campaign for the symptoms of myocardial infarction and the need for calling the emergency number 112 in such circumstances (“Act Now – Save a Life” SFL initiative), in the four years the patient’s delay was not significantly reduced. Given the difficulty in achieving significant progress in reducing time to first medical contact through classic campaigns, it is important to analyse which factors are strongly associated with longer delays and to try to build campaigns and actions that are more focused on these more difficult populations. In our study, it was observed that the elderly and the onset of symptoms during the night period was associated with an increase in “patient delay”. Inversely, asking for help through 112 and being transported by National Institute for Medical Emergencies (INEM) was associated with a shorter time. The “Door-to-Balloon” time (D2B) represents only a small part of the total ischemic time. In Portugal the D2B is within the values recommended by the guidelines but unfortunately most patients did not have access to an earlier reperfusion, mainly as a result of the need for secondary transportation (about half of them entered hospitals without interventional cardiology). There were also no significant changes in the “system delay” during the study period. A higher percentage of patients achieved a system delay of less than 90 min when no secondary transportation was required. Four predictors of system delay were identified: age greater than 75 years, attending hospitals without P-PCI, no call to 112, and living in the “Centro region”. Ideally, patients should be treated with P-PCI but it will be mandatory to evaluate and monitor system delays in order for patients to have access to the best therapy that in each case requires and to see if P-PCI is used in a timely manner (where it may clearly be superior to fibrinolysis). The data collected throughout the SFL initiative was associated with the implementation of a number of specific educational programs for patients and professionals aimed at improving system-wide performance.