IJCS | Volume 31, Nº5, September / October 2018

522 Table 1 - Comparison of door-to-angiography time (DAT) between patients seen at the referral hospital patients seen in other healthcare units Referral hospital * Others** Total Initial care 16 96 112 DAT < 90 min 7 (43.7%)* 43 (44.3%)** 50 (44.2%) DAT > 270 min 4 (25%)* 45 (46.3%)** 49 (43.3%) DAT > 720 min 3 (18.7%)* 36 (37%)** 39 (34.8%) Maximum DAT 15.695 48.439 48.439 Minimum DAT 19 10 10 Mean DAT 1,433 2,132 2,033 (+/-5,542) Angioplasty 14 (87.5%) 78 (80.41%) 92 (82.1%) *Pearson X 2 = 2.124; P = 0.145 /Fisher`s Exact Test 0.169; ** Pearson X 2 = 0.436/Fisher´s Exact Test 0.511. Hoepfner et al. Myocardial infarction in Joinville Int J Cardiovasc Sci. 2018;31(5)520-526 Original Article Discussion In 2001, Gibson posed a question he was often asked: “what do we need to do to improve mortality by another 1% in the setting of acute myocardial infarction?” and then answered that this could not be achieved exclusively with new drugs and devices but also by reducing the time to treatment. 4 Our results suggest that we are far from achieving these objectives. When mentioning the Assessment of the Safety and Efficacy of a New Thrombolytic (ASSENT 2) report, 5 Gibson emphasized the importance of performing electrocardiography for the diagnosis and a time to treatment < 2 hours. In the ASSENT-2 trial, the investigators assessed electrocardiographic changes and 1-year mortality in 13,100 patients undergoing primary thrombolysis. In- hospital mortality and late mortality were proportional to pain duration and inversely proportional to ST-T resolution (lower and upper limits of 3.8 and 13%) in one year. 5 In our study, analysis of the medical records revealed that results of cardiac enzyme tests for diagnosis and treatment decisions are still lacking in many of them. Acute coronary syndrome, notably AMI, is the major cause of cardiac deaths in Brazil. 1,2 A considerable percentage of deaths occur quickly and unexpectedly before patients get medical care. 1-3 Until 1980, there were insufficient medical resources to achieve significant reductions in in-hospital and late mortality. In 1979, Rentrop published the first results of intracoronary injection of streptokinase. Coronary angiography performed during and after STEMI showed spontaneous recanalization in nearly 40% of patients, increased to 70% with thrombolytic therapy. These findings were confirmed by Ganz in 1982. The potential of reperfusion therapy with thrombolytic drugs and angioplasty in reducing mortality has already been shown; 1-17 nevertheless, a significant reduction inmortality depends on how early reperfusion therapy is performed. 5-19,21 In Stemi, the therapy should be started within the first four hours of the event. 5,12,15,17-19 A mean reperfusion time < 180min has been reported in attempt to provide adequate assistance to patients before (by administration of thrombolytic drugs) and during hospitalization (primary angioplasty). Systematic reviews by Keeley et al., 13 updated by Asseburg et al., 14 including short term and six-month outcomes, showed that compared with thrombolytic agents, reduction in mortality and in non-fatal outcomes with primary angioplasty was only significant when time delay was shorter than 45 minutes and 90 minutes, respectively. 15,16 The use of thrombolytic therapy was even more efficient in reducing mortality according to six randomized studies by Morrison et al. 15 In-hospital thrombolysis and prehospital thrombolysis decreased the mean duration of pain until reperfusion by 162 and 104 minutes, respectively. Thrombolytic therapy followed by short-term angioplasty is efficient in reducing short-term and long-term events, regardless of the presence of multi-vessel or one-vessel injury. 16 Many factors can influence the rescue of patients with STEMI – the patient, who should seek medical assistance as soon (and if) he perceives the symptoms; healthcare professionals who should diagnose the condition and provide the patient with adequate treatment as early as possible, and performance of reperfusion therapy. In Joinville, the SUS offers three emergency care units and three public hospitals (including one referral center for coronary angiography and angioplasty). The efficacy of this systemwas unknown, although there were reports of difficult accessibility of paramedics to the referral hospital and delayed arrival of patients to the catheterization laboratory. With the permission of the catheterization laboratory, we identified the patients with ACS seen at the unit, their “front door” to medical care, and the time from the first assistance to reperfusion with angioplasty. Patients’ transportation depends on the experience of the