Results of an infarction care telemedicine program

Background: In Brazil, myocardial infarction affects approximately 300 thousand individuals per year, with mortality rate of 30%, and 80% of deaths occur in the first 24 hours. The telemedicine systems, such as Latin America Telemedicine Infarct Network, aim to optimize the stages from triage to treatment. Communication among the emergency care units and tertiary care services is known to be difficult, and the system aims to interconnect triage, physician and transport, facilitating transfer of patients to the cath lab. Therefore, implementing a telemedicine system for myocardial infarction and assessment of cardiovascular outcomes is justified. The objective of this study was to analyze the implementation of a telemedicine program, the characteristics of the population and the time intervals for treatment and transfer, in addition to in-hospital mortality. Methods: A cohort study with 110 individuals diagnosed as ST-segment elevation myocardial infarction in five emergency care units in the city of Aparecida de Goiânia, from November 2015 to August 2018. Results: In the period described, 110 patients were treated, mean age of 58±11 years, 72.2% were male, 53.6% hypertensive, 23.6% diabetic, 27.3% active smokers and 6.4% had a history of previous infarction. Of the patients admitted, 90.9% were submitted to primary percutaneous coronary intervention, and 8.2% of total number of patients died within the first 30 days. Conclusion: Implementing a telemedicine system resulted in reduced mortality as compared to the public health system. Despite better care, we observed longer transfer time, which justifies the need to implement fibrinolytic therapy in secondary care units.


INTRODUCTION
The ST-segment elevation myocardial infarction (STEMI) is a clinical syndrome characterized by chest pain associated with ST-segment elevation on the electrocardiogram (ECG) and elevated myocardial necrosis markers. 1 According to the fourth update of the universal definition, it is characterized by the elevation of myocardial necrosis biomarkers (troponins) associated with electrocardiographic and/or typical clinical manifestation. 2 Infarction stands out due to its elevated mortality, especially in the acute phase, in which up to 65% of deaths occur in the first hour, and up to 80% in the first 24 hours, and most deaths occur outside the hospital environment. 3,4 North American evidence shows that patients take about 1 hour and 30 minutes to 2 hours to seek medical assistance, while less than 20% get to the service within this period in Brazil. 1,3 With broader knowledge about the pathophysiology and treatments of the disease, the precise diagnosis and reduced time to conduct and read the ECG led to a significant reduction in mortality, as well as the administration of timely treatment, resulting in well-established current goals. 3 We have the objective of performing coronary cineangiography and primary percutaneous coronary intervention (PCI) in up to 90 minutes after patient admission to the emergency department, whereas in transfers from a hospital to a qualified center, the goal is in up to 120 minutes. Another feasible option would be the performance of thrombolysis within 30 minutes of admission in those medical facilities where PCI is not available, or if the patient's transfer is estimated at longer than 120 minutes. 1,3,5,6 Despite progression of diagnostic methods, access of patients to tertiary care services with the capacity for PCI (hubs) is very scarce, especially in public facilities. Considering this reality, new strategies for the diagnosis and interconnection between primary and secondary care services (spokes) to the hubs is needed in order to reduce these times, with the impact of precocity of revascularization, costs, and hospital mortality. [7][8][9] In this way, it is possible to reduce the inability of these individuals that generally are at a productive age.
In the public health system, hospital mortality due to STEMI is still high. In the year 2000, it corresponded to 16.2%, in 2005 to 16.1%, and in 2010, to 15.3%. [10][11][12] However, we are still very distant from the North American reality, where mortality varied between 5% and 6% in 2009. 1 Based on the rationale we describe, the Latin America Telemedicine Infarct Network (LATIN) program was implemented in the city of Aparecida de Goiânia, in the metropolitan region of Goiânia, located in the state of Goiás, which has only one cath lab service.
The objective of the current study was to analyze the implementation of the program, as well as the characteristics of the population and the time involved in treatment and transfer, besides hospital mortality.

METHODS
This is a cohort study carried out in the city of Aparecida de Goiânia, in which data collection was done at the Hospital Encore, by means of the LATIN platform (https://latin. telemedicina.com/index.php/login). The electronic me dical records of patients received by means of the LATIN system from November 2015 to August 2018 were analyzed. Patients seen by the platform came from five of the emergency care units (ECU), the spokes.
Data relative to the times of admission and transfer were recorded electronically by LATIN and Tasy (medical record system of the hub). The time of the original ECG determined the first care given, and at hospital reception or at the cath lab, hospital admission would be determined. The moment of the PCI was defined by means of the time recorded in the procedure media, containing an inflated balloon in the culprit lesion, aiming to minimize registration biases in the records. This study was approved by the Research Ethics Committee of the Hospital de Urgência de Goiânia -linked to Plataforma Brasil (CAAE: 94882318.7.0000.0033).
The five spokes were all located in the city of Aparecida de Goiânia and varied from 2.7 to 21.3km distance to the tertiary care service (cath lab). According to what was evaluated in ideal conditions by the Google Maps electronic tool, the transfer time could vary from 8 to 37 minutes, using an automotive vehicle (Table 1). None of the spokes had a cardiology service, so that ECG results were reported by cardiologists who were part of the International Telemedical Systems (ITMS), a component of the LATIN system. Thus, the electrocardiographic diagnosis of the STEMI was established and the spoke was informed; right away, an e-mail and a direct call were sent to the cardiologist on call at the hub for the case to be described, a vacancy verified, and immediate transport provided. Patients with an evolution greater than 12 hours were excluded from the protocol.

3
The Emergency Medical Services (SAMU, acronym in Portuguese) was triggered by the spoke team after release of a vacancy in an intensive therapy unit (ICU) at the hub, as well as the confirmation of infarction by the cardiology team. The SAMU provided feedback on the time of departure from the point of origin, so the cath lab team could get prepared.
At the time of diagnosis and after the release of the vacancy, the hub's hemodynamic service was contacted regarding the transfer. At hospital admission, invariably the patient was admitted to the cath lab service without going through the emergency department, to proceed with the coronary angiography.
Considering the presentation of the data in the results, the categorical variables were expressed as absolute numbers and percentage. The continuous variables were expressed as mean±standard deviation. For tabulating the data, Microsoft Excel 365®, version 2016 was used.

RESULTS
The program was implemented at the end of 2015 and had its first STEMI case on November 30, 2015. During the entire program, until mid August 2018, 55,827 ECGs were generated. During the period described, 465 (0.8% of total) patients were diagnosed with STEMI, and 119 (25%) were characterized as progressed (more than 12 hours), 12 (2.5%) died at the spoke, 44 (9.4%) were not admitted due to insufficient beds, 176 (37.8%) were reclassified as another diagnosis, and 110 (23.6%) were admitted to the hub. The characteristics of the treated group are displayed on table 2.    After admission, six patients (5.5%) were reclassified as evolved infarction, and the early invasive strategy was chosen for two of them (within 24 hours). On table 3, the characteristics of admission to cath lab, times of treatment, and pre-and post-PCI complications were described.
Of all patients treated, in only 52 (47.7%) no supplementary treatment was proposed from the coronary point of view, such as additional PCI or coronary artery bypass grafting.

DISCUSSION
The implementation of telemedicine, within the framework of the myocardial infarction, affords a quick diagnosis, based on the documentation of a 12-lead ECG and the interconnection with a reporting center, favoring rapid contact with tertiary care services and the possible referral of the patient to more effective treatment, or the performance of fibrinolytic therapy at the point of origin. 1,3,8,11,13 The LATIN program is the first with such characteristics in the state of Goiás, seeking, as main therapy, the performance of a primary PCI and the consequent reduction of times for diagnosis and transfer to the hub. Nevertheless, within our reality, we observe a great difficulty in obtaining these internationally established goals due to the large delay in transfers (mean 126.3±75.5 minutes). It is believed that the use of exclusive ambulances would lead to an advance in this statistics, since other measures implemented were not capable of improving this parameter, despite the tendency to improve the time of transfer between 2015 and 2018 (p=0.09). In comparison with similar studies, we noted lower M2B times relative to our study − 1 hour on average −, reinforcing the need for improving agility of the transport systems. Nonetheless, it is important to point out that the said service only had one large spoke facilitating allocation to the transport service. 10 The mean door-balloon time at the hub was 54.3±37.7 minutes, with a median of 46 minutes; however, not considering the reclassified patients as evolved infarction, it was 51±31.3 minutes with a median of 44 minutes. Such values are closed to the means of a similar study, 10 but based on literature, 9 there is still space for improvements, especially in the communication between transport teams and hubs teams, optimizing the cath labs, avoiding idleness, and making access of infarcted patients easier.
Mortality due to STEMI in the in-hospital period was 8.3%, characterizing a significant reduction when compared to the mortality rates in the public service, which reached 26.1% 11 and 15.3%, 10 in 2009 and 2010, respectively. In the region studied the rate is estimated to be even higher, because of difficult access to thrombolysis − a fundamental approach which should be guaranteed. 5,11 One should also consider that before the current program presented in this article, there was no access to primary PCI by the public health service in the said city.
As demonstrated at other services, the timely pharmacological strategy proves to be as important as the primary PCI, according to studies that demonstrate reduction in mortality of up to 18.8%, in services with prevalence varying from 34% to 81% of individuals treated initially with pharmacological treatment, followed or not by a pharmacological-invasive or rescue strategy. 4,11 Implementation of the pharmacologic therapy at the spokes is paramount to treat the population described, with proven reduction in mortality. 1,3,4,11 We reiterate that the guaranteed access to thrombolytics, by means of the Ministry of Health ordinance number 2,994, of December 13, 2011, that "approves the line of care of the myocardial infarction and the acute coronary syndromes protocol," which guarantees the supply of alteplase and tenecteplase. 14 Lastly, we should highlight the need for actions in health education, considering that the impact of delay in seeking medical care in infarction cases is high. In the sample observed, we point out the group with approximately 25% of individuals who entered the spoke more than 12 hours from the beginning of symptoms, a fact similar to other studies in which the incidence varied from 22% to 43%. 4,15 The present study has a limitation, which should be pointed out. Since it is an observational study, our survey was based only on the collection of data present in medical records, which even when filled out carefully, make their information subject to completion biases by the absence of adequate methodological control in the day-to-day welfare routines. Despite the limitation, we believe it is possible, based on the data found, to compare the reality demonstrated in similar investigations, providing evidence of how to carry out treatment of individuals affected by STEMI in Brazil.

CONCLUSION
The implementation of the telemedicine service in a city in the Midwestern Region, in Brazil, resulted in systematization and integration between the public and private services, enabling agility to make diagnosis and the possibility of adequate percutaneous coronary intervention for the treatment of infarction. In addition to the improving and expediting diagnosis, comparatively with the reality of public services in Brazil, we can infer a significant improvement in the mortality rate related to infarction. However, we also note the need for improvement in the transport system, and the implementation and training of the teams at the emergency care units to perform fibrinolytic therapy.