Treatment of acute myocardial infarction in Peru and its relationship with in-hospital adverse events: Results from the Second Peruvian Registry ...
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Archivos Peruanos de Cardiología y Cirugía Cardiovascular
Arch Peru Cardiol Cir Cardiovasc. 2021;2(2):113-122.
Original Article
Treatment of acute myocardial infarction in Peru and its relationship
with in-hospital adverse events: Results from the Second Peruvian
Registry of ST-segment Elevation Myocardial Infarction (PERSTEMI-II)
Manuel Chacón-Diaz 1,a*; René Rodríguez Olivares 1,a; David Miranda Noé 1,a; Piero Custodio-Sánchez 1,b;
Alexander Montesinos Cárdenas 1,c; Germán Yábar Galindo 1,d; Aida Rotta Rotta 1,e; Roger Isla Bazán1,f; Paol Rojas de la Cuba 1,d;
Nassip Llerena Navarro 1,g; Marcos López Rojas1,f; Mauricio García Cárdenas 1,h; Akram Hernández Vásquez 2,i
Received: April 17, 2021
Accepted: may 19, 2021 ABSTRACT
Authors’ affiliation Background. ST-segment elevation myocardial infarction (STEMI), is an important cause of morbidity and mortality
1
Cardiologist
2
Research physician worldwide, and myocardial reperfusion, when adequate, reduces the complications of this entity. The aim of the study
a
National Cardiovascular Institute
was to describe the clinical and treatment characteristics of STEMI in Peru and the relationship of successful reperfusion
INCOR, EsSalud, Lima, Peru.
b
Almanzor Aguinaga Asenjo Na- with in-hospital adverse events. Materials and methods. Multicenter, prospective cohort of STEMI patients attended
tional Hospital, EsSalud, Chiclayo,
Peru. during 2020 in public hospitals in Peru. We evaluated the clinical and therapeutic characteristics, in-hospital adverse
c
Adolfo Guevara Velasco National events, and the relationship between successful reperfusion and adverse events. Results. A total of 374 patients were
Hospital, EsSalud, Cusco, Peru.
d
Guillermo Almenara National included, 69.5% in Lima and Callao. Fibrinolysis was used in 37% of cases (pharmacoinvasive 26% and fibrinolysis
Hospital, EsSalud, Lima, Peru.
alone 11%), primary angioplasty with < 12 hours of evolution in 20%, late angioplasty in 9% and 34% did not access
e
Cayetano Heredia National
Hospital, MINSA, Lima, Peru. adequate reperfusion therapies, mainly due to late presentation. Ischemia time was longer in patients with primary
f
Alberto Sabogal National Hospi-
tal, EsSalud, Callao, Peru. angioplasty compared to fibrinolysis (median 7.7 hours (IQR 5-10) and 4 hours (IQR 2.3-5.5) respectively). Mortality was
g
Carlos Alberto Seguín Escobedo 8.5%, the incidence of post-infarction heart failure was 27.8% and of cardiogenic shock 11.5%. Successful reperfusion
National Hospital, EsSalud,
Arequipa, Peru was associated with lower cardiovascular mortality (RR:0.28; 95%CI: 0.12-0.66, p=0.003) and lower incidence of heart
h
Hipólito Unanue Hospital, MINSA, failure during hospitalization (RR: 0.61; 95%CI: 0.43-0.85, p=0.004). Conclusions. Fibrinolysis continues to be the most
Lima, Peru.
i
San Ignacio de Loyola University, frequent reperfusion therapy in public hospitals in Peru. Shorter time from ischemia to reperfusion was associated
Lima, Peru.
with reperfusion success and, in turn, with fewer in-hospital adverse events.
*Correspondence
Coronel Zegarra street 417, Jesús
María, Lima, Peru.
Keywords: Myocardial Infarction; Fibrinolysis; Angioplasty; Mortality; Heart Failure; Peru.
Mail
manuelchacon03@yahoo.es
Conflicts of interest
None.
RESUMEN
Financing
Self-financing.
DOI: 10.47487/apcyccv.v2i2.132 Tratamiento del Infarto Agudo de Miocardio en el Perú y su Relación Con
Eventos Adversos Intrahospitalarios: Resultados del Segundo Registro
Peruano de Infarto de Miocardio con Elevación del segmento ST (PERSTEMI-II)
Antecedentes. El infarto de miocardio con elevación del segmento ST (IMCEST), es una de las principales
causas de morbimortalidad a nivel global, la reperfusión adecuada del miocardio consigue disminuir las
complicaciones de esta entidad. El objetivo del estudio fue describir las características clínicas y terapéuticas
del IMCEST en el Perú y la relación de la reperfusión exitosa con los eventos adversos intrahospitalarios.
Materiales y métodos. Cohorte prospectiva, multicéntrica de pacientes con IMCEST atendidos durante el
año 2020 en hospitales públicos del Perú. Se evaluaron las características clínicas, terapéuticas y eventos
adversos intrahospitalarios, además de la relación entre la reperfusión exitosa del infarto y los eventos
adversos. Resultados. Se incluyeron 374 pacientes, 69,5% en Lima y Callao. La fibrinólisis fue usada en
37% de casos (farmacoinvasiva 26% y sola 11%), angioplastia primaria con < 12 h de evolución en 20%,
angioplastia tardía en 9% y 34% no accedieron a terapias de reperfusión adecuadas, principalmente por
presentación tardía. El tiempo de isquemia fue mayor en pacientes con angioplastia primaria en comparación
a fibrinólisis (mediana 7,7 h [RIQ 5-10] y 4 h [RIQ 2,3-5,5] respectivamente). La mortalidad fue de 8,5%, la
incidencia de insuficiencia cardiaca posinfarto fue de 27,8% y de choque cardiogénico de 11,5%. El éxito de
la reperfusión se asoció con menor mortalidad cardiovascular (RR: 0,28; IC95%: 0,12-0,66, p=0,003) y menor
incidencia de insuficiencia cardiaca (RR: 0,61; IC95%: 0,43-0,85, p=0,004). Conclusiones. La fibrinólisis sigue
siendo la terapia de reperfusión más frecuente en hospitales públicos del Perú. El menor tiempo de isquemia
a reperfusión se asoció con el éxito de esta y, a su vez, a menores eventos adversos intrahospitalarios.
Palabras clave: Infarto de Miocardio; Fibrinólisis; Angioplastia; Mortalidad; Insuficiencia Cardiaca; Perú.
EsSalud | 113Treatment of acute myocardial infarction in Peru
W
orld Health Organization (WHO) establishes that the during 2020, in whom the clinical, diagnostic and treatment
leading cause of death worldwide is atheroesclerotic characteristics of infarction, as well as complications and in-
disease, and that around 30% of reported deaths are hospital mortality were evaluated. Patients with non-ST elevation
caused by ischemic cardiomyopathy , the impact is greater than
(1)
myocardial infarction (NSTEMI), non-persistent STEMI and
those produced by infections and cancer, with mortality predicted patients with Takotsubo syndrome were excluded.
to increase by 36% by 2030 (1,2). Within this etiology, one of its most
Data collection (prior informed consent) was made
frequent presentations is the ST-segment elevation myocardial
directly from the medical record to an electronic database
infarction (STEMI). In the United States, STEMI represents 25-40%
of all myocardial infarction cases (3), with an in-hospital mortality of designed for this purpose (http://40.77.71.10/www/Perstemi2/).
5-6% and 7-18% one year after the event. Approximately 30% are The study variables included: general variables (age, sex, home
women, 23% have diabetes mellitus and up to 7% do not receive city); epidemiological (pathological history, cardiovascular risk
reperfusion therapy (4). factors); clinical (symptoms, electrocardiogram characteristics,
Killip Kimball classification); access to reperfusion, type of
Myocardial reperfusion in the acute phase modified natural reperfusion, times to first medical contact and time from
history of STEMI due to reduction of mortality and the prevention or
ischemia to reperfusion, in-hospital treatment and on discharge,
reduction of the occurrence of heart failure secondary to myocardial
in-hospital complications and mortality (in-hospital and 30 days’
necrosis. The accepted time window for reperfusion of STEMI is up
mortality).
to 12 hours from the onset of symptoms; in special clinical situations
like hemodynamic instability or very extensive myocardial areas at We considered reperfusion therapy as the administration
risk it extends beyond 12 h . There are two basic reasons why many
(5) of some therapy of this type in the first 12 h of symptons, late
patients do not receive reperfusion: first the delay in treatment reperfusion if primary percutaneous coronary intervention
and loss of the adequate time window to obtain reperfusion, and (pPCI) was performed between 12 to 48 h, and patient without
second the lack of an adequate diagnosis (6). access to reperfusion if a case did not receive any reperfusion
treatment (6). Reperfusion success with fibrinolysis was defined
In Latin America, according to the ARGEN-IAM-ST registry
as the ST segment fall > 50% after ninety minutes of starting the
(Argentina), 83.5% of patients with STEMI received reperfusion
drug, and in case of pPCI as the post-intervention TIMI 3 flow
therapy (78.3% with primary angioplasty and 16% with fibrinolytics)
of the infarct related artery (IRA). Both cases were considered
with an in-hospital mortality of 8.8% (7). On the other hand, the
as “reperfused” cases for statistical analysis, patients without
RENASICA-II study (Mexico), identified that reperfusion therapy
was 32% with coronary angioplasty and 37% with fibrinolytics, access to reperfusion was considered “non-reperfused”.
with a hospital mortality of 10% (8). In Peru, in 2016, the PERSTEMI Categorical variables were expressed in frequency and
registry found that fibrinolysis was used in 38% of cases (12.9% percentages, numerical variables in means and medians and their
pharmacoinvasive strategy), primary angioplasty in 29% and 33% respective measures of dispersion according to their distribution.
did not receive reperfusion during the first 12 h of STEMI evolution The evaluation of association between two categorical variables
and in-hospital mortality was 10.1% (9).
was carried out using chi-square test, and between numerical
Given these data, the second national registry of variables using student’s t test (normal distribution) or Man-
myocardial infarction PERSTEMI-II, sought to evaluate the evolution Whitney U test (non-parametric distribution). Generalized
of the epidemiological profile of STEMI in Peru four years after the linear models of the binomial family with log link function were
first registry, to know the most prevalent reperfusion strategies performed to estimate the crude and adjusted relative risk (RR)
in our country, the main complications of STEMI and the adverse and their respective CI 95% of the factors associated to successful
events at one-year follow-up. This article describes the presentation reperfusion and its impact on the frequency of in-hospital
characteristics and treatment of STEMI, and the relationship of adverse events. Statistical evaluation was performed using Stata
successful reperfusion with in-hospital adverse events. 14.0 program (StataCorp, College Station, Texas, USA).
Materials and methods Results
PERSTEMI-II is a multicenter and prospective cohort Twenty-five hospitals from the public health system
of patients with STEMI treated in Peruvian public hospitals in Peru, were invited to participate in the registry, 17 of them
(Ministerio de Salud and EsSalud). The study protocol included all actively participated in the data collection. From January 1 to
patients older than 18 years with diagnosis of STEMI according December 31, 2020; 405 cases were registered in the system, of
to the fourth universal definition of myocardial infarction, treated which, incomplete cases or those with erroneous diagnosis were
114 | EsSaludArch Peru Cardiol Cir Cardiovasc. 2021;2(2):113-122.
excluded, leaving 374 patients as study population. Most (69.5%)
were registered in Lima and Callao cities, 88.5% were attended Table 1. Antecedents and risk factors of study population
in hospitals of EsSalud social security and 11.5% in hospitals of
Antecedents n %
the Ministerio de Salud (MINSA). A 67.4% of cases were referred
Arterial hypertension 198 52,9
to hospitals with higher resolution level to complete their
Dyslipidemia 198 52,9
reperfusion therapy.
Type 2 Diabetes mellitus 111 29,7
The number of cases decreased during the year due to Smoking 81 21,6
the influence of SARS-CoV-2 pandemic (Figure 1). The 85% of Myocardial infarction 28 7,5
cases were men and the median age was 66 years (IQR: 58-74 Chronic kidney disease 28 7,5
years); the age of presentation in women was higher than that Chronic coronary syndrome 24 6,4
of men (71 and 65 years, respectively, p=0.01). The most frequent Cerebrovascular event 18 4,8
risk factors were arterial hypertension and dyslipidemia (Table 1). Hyperuricemia 12 3,2
Myocardial revascularization 12 3,2
Clinical presentation Heart failure 9 2,4
Typical angina was found in 93.8%, dyspnea in 29%,
atypical chest pain in 5.3%, syncope in 4% and cardiac arrest in
3.2%. Women had a higher proportion of atypical symptoms
than men (dyspnea 36.4% vs 27.9%; syncope 5.5% vs 3.8% and KK II in 27.3%; KK III 2.9% and KK IV in 4.3%. In the following hours,
atypical chest pain 9.1% vs 4.7%, respectively), although without 59.4% of patients remained in KK I; 27% KK II; 4% worsened to KK
statistical significance. III and 9.6% to KK IV. In general, time to first medical contact was
2.5 h (RIQ: 1-6) and time from ischemia to reperfusion was 5.3 h
The first electrocardiogram found 92.5% of cases in sinus
(RIQ: 3-9).
rhythm, 4.5% with high degree auricular-ventricular block and
2.9% with auricular fibrillation. The most frequent localization of
Reperfusion strategies (Main figure)
infarction was the anterior wall (antero-septal, anterolateral and
anterior) in 38.2%, followed by inferior wall (26.5%), extensive Two hundred five patients (55% of the study population)
anterior wall (18.7%), inferolateral (14.2%) and lateral (2.4%). The received some type of reperfusion in the first 12 hours: 131 (64%)
clinical condition at admission was Killip Kimball (KK) I in 65.5%; fibrinolysis and 74 (36%) pPCI.
70
60
50
40
30
20
10
0
Figure 1. Number of STEMI cases reported by month during 2020.
EsSalud | 115Treatment of acute myocardial infarction in Peru
Thirty-two patients (8.2%) received late reperfusion 12 to with alteplase), and was the most frequent reperfusion therapy
24 hours after the infarction (3 fibrinolysis and 28 pPCI), mainly (56%). The success rate was 66% (90 patients).
due to: heart failure (15 cases), large myocardial infarctions
As part of a pharmacoinvasive strategy after a successful
(extensive anterior or inferolateral) without heart failure (8 cases)
fibrinolysis, 77% (69 patients) underwent coronary angiography
and unknown reason (8 cases). In 6 patients (1.6%), the pPCI
and percutaneous coronary intervention (PCI) between 3 to 24
was performed after 24 h to 48 h of evolution (in 5 patients with
h (routine early PCI strategy), which means 50% of all patients
post-infarction heart failure). In four cases, ischemia time was not
who underwent fibrinolysis and 18% of the cohort. The success
registered (3 fibrinolysis and 1 pPCI). One hundred twenty-eight
patients (34%) did not receive any reperfusion therapy, mainly due of PCI in this group was 99%. In the 47 cases where fibrinolysis
to late presentation (Figure 2). was unsuccessful, rescue PCI was performed in 60% (7.5% of
total cohort).
Fibrinolysis
From above, it can be deduced that 29% of patients who
One hundred thirty-seven patients (37% of the underwent fibrinolysis (40 cases) did not received a subsequent
population) received fibrinolysis as first reperfusion strategy (all invasive therapy (the majority from the interior of the country
STUDY POPULATION IN-HOSPITAL ADVERSE EVENTS
Lima and Callao
Metropolitan Area
69.5 % Rest of the
country
30.5% Death Cardiogenic Heart Failure
8.5% Shock 27,5%
11.5%
REPERFUSION STRATEGY
No reperfusion No reperfusion 34
Fibrinolysis + PCI 25.9
Primaria PCI 19.8
Fibrinolysis alone 11.0
PCI 12 - 48 hours 9.3
Reperfusion 0 5 10 15 20 25 30 35 40
%
TIME DELAY TO TREATMENT
Total time until fibrinolysis (Expressed as median)
4h
Symptoms First Medical
Onset Contact
1.5 h Fibrinolysis PCI capable center
arrival
2.5 h
Primary
3.5 h 1.2 h PCI
7.2 h
Total time until Primary PCI
Main figure. Reperfusion, delays in care attention and in-hospital events in STEMI - PERSTEMI II Registry. Peru 2020.
116 | EsSaludArch Peru Cardiol Cir Cardiovasc. 2021;2(2):113-122.
35
30.9
30
25
20.3
20
15 13.8
12.2 12.2
10 8.1
6.5
5 3.2
1.6
0
Presentation Lack of Presentation Presentation Lack of Error Contraindication Refusal of Others
24 - 72 h angiographer > 12 h > 72 h fibrinolytic diagnosis to fibrinolysis patient
Figure 2. Reasons for not applying reperfusion therapies in STEMI (values expressed as percentages).
and in hospitals of MINSA) that represented 11% of the study 5 due to cardiogenic shock, 4 due to high risk anatomy for PCI
population. and 2 for mechanical complication.
Primary percutaneous coronary intervention A 26% of patients did not have success in reperfusion
therapy, when added to the patients without access to any
pPCI during the first 12 h of evolution was performed reperfusion, we found 192 patients (51.3% of the population)
in 74 patients (19.8% of the population) and its success rate who did not achieve optimal myocardial reperfusion. Analyzing
by coronary arteriography was 73%. In 34 patients (9% of the the factors associated with successful reperfusion in the adjusted
population), it was performed late pPCI and its success rate was model, we found that two factors were associated with it: treatment
54% (p=0.078). Time to first medical contact, time from ischemia in a hospital from EsSalud (RR: 2.12, p=0.006, CI95%: 1.23-3.65) and
to pPCI and Door-To-Balloon Time are detailed in Table 2. total time from ischemia to reperfusion 12 h) (Table 3).
anterior descending artery in 62%, right coronary artery in
31%, circumflex artery in 6%, and no IRA was found in 1%
(myocardial infarction with nonobstructive coronary arteries Table 2. Delays in reperfusion treatment according to the
(MINOCA)). The percentages of pre-PCI TIMI flow 0,1,2 and strategy used in the first 12 h of evolution.
3 was 33%, 18%, 21% and 28%, respectively; post-PCI was Fibrinolysis Primary PCI
4%, 7%, 13% and 76%, respectively. Stents were placed in Median Median
IQR IQR
92% of cases that underwent coronary arteriography, mainly (hours) (hours)
drug-eluting stents (96%). A 51% of patients (104 cases) had TFMC 1.5 0,7-3 2 1-4
multivessel coronary disease, of them, 65% had intervention TTI 4 2.3-5.5 7.7 5-10
performed in non-IRA vessels: 26% in the same procedure and DNT/DBT 1.5 0.7 – 2.6 1.2 1-1.5
73% deferred before medical discharge (97% routine and only PCI: percutaneous coronary intervention. TFMC: Time to first medical con-
tact time. TTI: total from ischemia to reperfusion. DNT: Door-to-needle-
3% based on ischemia/viability assessment). Only 17 cases time. DBT: Door-to-balloon time. IQR: Interquartile range.
(4.5%) underwent cardiac surgery, 6 due to unsuccessful PCI,
EsSalud | 117Treatment of acute myocardial infarction in Peru
Medication and in-hospital adverse events cardiogenic shock during hospitalization after the admission, a
value higher than that reported by Farré et al. during the Code
The mean length of hospital stay was 7 days (IQR:5-11).
IAM registry (20)
. Due to the high mortality associated with this
Double antiplatelet therapy was used in 95%, beta-blockers in
81%, ACE inhibitors/angiotensin receptor blocker in 69%, statins condition, especially in our country as reported by a recent
in 94%, diuretics in 21% and antialdosteronic agents in 25%. national single-center registry, it is important to identify, prevent
and follow-up this patients (21,22).
In-hospital mortality was 8.6% (32 cases), 6.7% due to
cardiac cause and 1.8% non-cardiac cause. Incidence of post- In relation to PERSTEMI I, there was a reduction in the
infarction heart failure was 27.8%, cardiogenic shock 11.5%, post- number of patients undergoing some type of reperfusion
infarction angina 7.8%, mechanical complication 2.9%, cardiac therapy during the first 12 h (55% vs 67%), and late presentation
arrest 8.5%, cerebrovascular event 0.8% and major bleeding was the main recurrent cause. This reperfusion rate was
2.9%. The mortality at 30-day follow-up was 9.1% (34 cases). It is lower than reported by the FAST AMI registry with 77% or
important to mention that 16 patients (4.2%) were attended with ARGEN-IAM-ST (88%), but higher than reported by other Latin
active SARS-COV2 infection. American registries such as RESISST (40.7%) and RENASICA
Reperfusion success was the variable that notably III (52.6%) . These differences express the different
(15,16,18,23)
influenced the presence of in-hospital adverse events, both in the organizational realities of health system and logistical aspects
crude analysis and in analysis adjusted for age, sex and underlying to offer reperfusion therapy. In Peru, there is only one public
diseases (Table 4). hemodynamic room with permanent care for management of
patients with STEMI, in the National Cardiovascular Institute
(INCOR), reality that has not been changed since 4 years ago.
Discussion
In PERSTEMI I, the time to first medical contact was 2 h (IQR:
The information obtained from the clinical records and 1- 4.5) while in PERSTEMI II was 2.5 h (IQR: 1 - 6), a result that could
their temporal comparison have become fundamental tools with be interpreted as an expression of the absence of educational
the aim of improving the quality of care of patients with STEMI (10). programs at national level about the early recognition of infarction
The percept that you cannot improve what you cannot measure, symptoms and search for medical attention, as well as due to the
describes the central role of registries in reducing mortality in
COVID-19 pandemic that motivated the late presentation to the
patients with STEMI worldwide (11). The PERSTEMI II registry lets
hospital due to fear of contagion (24,25). The delay in the application
us know and compare the epidemiological characteristics and
of fibrinolysis (1.5h) and pPCI (4.7h) after the first medical contact
clinical outcomes of patients with STEMI with respect to that
(delay in the system), showed the ineffectiveness of the public
reported by PERSTEMI (2016-2017) (9).
health system in the management of STEMI.
We found a reduction in the number of patients attended
Similar to that reported by PERSTEMI I, fibrinolysis in the
during the study year, which occurred during the COVID-19
first 12 h remained the most used reperfusion strategy (37% vs
pandemic that has led to a reduction of cases of STEMI worldwide,
38%). However, we found a decrease in the percentage of pPCI
especially at the beginning of the pandemic (decreasing of 59%
(19.8% vs 29%), which can be explained by the influence of the
in the number of admissions at the beginning of the emergency
COVID-19 pandemic on the decision of type of reperfusion,
state in Peru) and probably related to patients’ fear of being
since the fibrinolysis needs lower logistical demand and has
admitted to the hospital (12-14). The majority of cases were reported
in the cities of Lima and Callao and in centers of the EsSalud social been recommended by some scientific institutions (26). Similar to
security, similar to what was observed in PERSTEMI I. what was reported by De Luca et al. (27) who found a reduction of
19% in pPCI during the COVID-19 pandemic in 40 high-volume
Typical angina and dyspnea remained the most frequent European centers.
presentations and atypical symptoms were prevalent in women.
Regarding the location of the infarction, anterior wall remained In addition to the reduction of pPCI as reperfusion
the most frequent, similar to what was reported by the RENASICA therapy, the percentage of patients with TIMI 3 flow in coronary
III and PHASE-MX registries, but different to what was evidenced arteriography decreased markedly in relation to PERSTEMI I (67%
by the ARGEN-IAM-ST and RESISST registries (Argentine and vs 82%), which can be explained by the intervention of more
Brazilian respectively), where the compromise of the inferior wall patients with late presentation (> 12h after the first symptoms)
was the most frequent (15,16,18,19). in this registry.
We highlight the progression of hemodynamic Fibrinolysis success rate remained close to 70%, which
deterioration in almost 10% of patients who developed reaffirms the usefulness of this strategy in the current context.
118 | EsSaludArch Peru Cardiol Cir Cardiovasc. 2021;2(2):113-122.
Table 3. Factors associated with the success of reperfusion therapy in STEMI
Crude model Adjusted model*
Characteristic
RR (CI 95%) p value RRa (CI 95%) p value
Sex
Female Reference
Male 0.76 (0.53-1.08) 0.122 0.95 (0.74-1.24) 0.718
Age (years-old) 1.00 (0.99-1.00) 0.405 Not included
Smoking
No Reference
Yes 1.33 (1.07-1.65) 0.009 1.07 (0.92-1.23) 0.381
Diabetes mellitus
No Reference
Yes 0.82 (0.64-1.06) 0.127 1.02 (0.87-1.21) 0.728
Arterial Hypertension
No Reference Reference
Yes 0.83 (0.68-1.02) 0.084 0.97 (0.83-1.12) 0.640
Chronic Kidney Disease
No Reference Not included
Yes 0.87 (0.56-1.36) 0.544
Chronic Heart Failure
No Reference Not included
Yes 0.68 (0.27-1.72) 0.416
Place of health establishment
MINSA Reference Reference
EsSalud 2.50 (1.38-4.51) 0.002 2.12 (1.23-3.65) 0.006
Place of care
Outside Lima city Reference Reference
Lima city 1.26 (0.98-1.62) 0.069 1.04 (0.86-1.27) 0.676
Transfer/reference
No Reference Reference
Yes 1.35 (1.05-1.73) 0.018 0.93 (0.76-1.14) 0.505
Ischemia time
< 6 hours 1.46 (1.11-1.92) 0.007 1.60 (1.12-2.28) 0.010
6-12 1.29 (0.96-1.75) 0.096 1.34 (0.95-1.89) 0.099
>12 hours Reference Reference
Time to first contact 0.91 (0.88-0.94)Treatment of acute myocardial infarction in Peru
Table 4. Association between successful reperfusion in STEMI and in-hospital outcomes
Non Adjusted
Reperfused Crude model
reperfused model*
Characteristic
n=182 (48,7) n=192 (51,3) RR (CI 95%) p value RRa (CI 95%) p value
General mortality 6 (3.3) 26 (13.5) 0.24 (0.10-0.58) 0.001 0.28 (0.12-0.66) 0.003
Cardiovascular mortality 5 (2.8) 20 (10.4) 0.26 (0.10-0.69) 0.007 0.31 (0.13-0.74) 0.009
Non cardiac mortality 1 (0.6) 6 (3.1) 0.18 (0.02-1.45) 0.106 0.17 (0.02-1.55) 0.116
Symptomatic heart failure 36 (19.8) 68 (35.4) 0.56 (0.39-0.79) 0.001 0.61 (0.43-0.85) 0.004
Cardiogenic shock 10 (5.5) 33 (17.2) 0.32 (0.16-0.63) 0.001 0.35 (0.18-0.68) 0.002
Post-infarction angina 7 (3.9) 22 (11,5) 0.34 (0.15-0.77) 0.010 0.33 (0,14-0.80) 0.014
Mechanical complications 2 (1.1) 9 (4.7) 0.23 (0.05-1.07) 0.062 0.36 (0.08-1.65) 0.188
Cardiac arrest 9 (5.0) 23 (12.0) 0.41 (0.20-0.87) 0.020 0.47 (0.23-0.96) 0.038
Major bleeding** 4 (2.2) 7 (3.7) 0.60 (0.18-2.03) 0.414 0.85 (0.25-2.91) 0.802
* Adjusted for age, sex, smoking, diabetes mellitus, arterial hypertension, and chronic kidney disease.
**Major bleeding: TIMI definition: intracranial hemorrhage. Decrease of hemoglobin > 5 g/dL., decrease of hematocrit > 15%.
RR: relative risk.
The percentage of patients with this strategy was higher in this constant training at the first level of care, to have a single integrated
study compared to 12.9% in PERSTEMI I, which finally makes health system for management of STEMI with referral centers
the systematic early percutaneous coronary intervention and more complex centers for intervention, all connected by an
consolidated as an effective strategy for the reality of our country. adequate transportation system; this is the only way to achieve
higher successful reperfusion rates and fewer adverse events.
As reported by multiple international registries, we
confirmed that reduction in total ischemia time and time to first As limitations of the study we can say that, although
medical contact were statistically significantly associated with the PERSTEMI II registry was proposed to be applied at national
successful coronary reperfusion . Late presentation and the
(28)
level, the data was mainly obtained from public hospital centers
absence of integrated networks for the management of STEMI are in the city of Lima and Callao, so its conclusions not necessarily
problems associated with prolonged times in our country, and in reflect the situation of patients treated by STEMI at national level.
developing countries in general, which prevent improving clinical
Likewise, it is important to consider the influence of the COVID-19
outcomes (29).
pandemic in the care attention and clinical outcomes of patients
In-hospital mortality was lower than reported by with STEMI in this registry.
PERSTEMI I (8.6% vs 10.1%), which is comparable to that
observed by other registries such as ARGEN-IAM-ST (8.7%), Rio
Grande Brazil (8.9%) and RENASICA III (8.7%), but higher than that Conclusions
reported by PHASE-MX with 6.2% for CPI and 4.8% for systematic
STEMI in Peru is presented with more frequency in
early percutaneous coronary intervention (15,17,18,19). Mortality from
men in the seventh decade of life and the most prevalent risk
cardiac cause remained the most frequent.
factors were arterial hypertension and dyslipidemia. The most
More than half of study population did not receive frequent reperfusion therapy was fibrinolysis. The reason
reperfusion or it was not successful, which in the regression analysis for lack of reperfusion therapy administration remained the
was interpreted as more adverse events including death in the late admission of patients in health services with capacity to
evolution. Therefore, it is necessary to reduce the times of attention perform reperfusion. Success of reperfusion was associated
of STEMI, which includes education for general population, with lower cardiovascular mortality, heart failure, post-infarction
120 | EsSaludArch Peru Cardiol Cir Cardiovasc. 2021;2(2):113-122.
angina and cardiac arrest. It is necessary to create an integrated Guillermo Almenara -Lima), Aida Rotta (Hospital Cayetano
program for management of STEMI at national level to get better Heredia - Lima), Javier Chumbe (Hospital Arzobispo Loayza
clinical outcomes. - Lima), Rubén Azañero (Hospital 2 de mayo, Lima), Mauricio
García (Hospital Hipólito Unanue, Lima), Carlos Barrientos
Authors‘ contribution: MCHD: conception of the article, data
(Hospital MINSA-Huancayo), Jorge Martos (Hospital MINSA
collection, analysis, writing. RRO, DMN, PCS: data collection,
Cajamarca), Alexander Montesinos, Fernando Gamio
analysis, writing. AMC,GYG,ARR,RIB,PRC,NLN,MLR,MG: data
(Hospital Adolfo Guevara-Cusco), Nassip Llerena (Hospital
collection, writing. AHV: analysis, writing.
Carlos Seguín-Arequipa), Piero Custodio (Hospital Almanzor
Acknowledgement: Dr. Carlos Pereda for the central image. Aguinaga-Chiclayo), Julio Uribe (Hospital Essalud- Iquitos),
Walter Saavedra (Hospital Essalud- Tumbes), Fernando Allende
(Hospital Essalud- Puno), Pamela Mejía (Hospital Essalud-
PERSTEMI II investigators: Roger Isla, Luis López (Hospital Tacna), René Rodriguez, David Miranda y Manuel Chacón
Alberto Sabogal - Callao), Paol Rojas, Germán Yabar (Hospital (Instituto Nacional Cardiovascular, INCOR).
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